2. INTRODUCTION
When treating injured patients, clinicians rapidly assess injuries and institute
life preserving therapy. Because timing is crucial, a systematic approach that
can be rapidly and accurately applied is essential. This approach, includes the
following elements:
• Preparation
• Triage
• Primary survey (ABCDEs) with immediate resuscitation of patients with life-
threatening injuries
3. • Secondary survey (head-to-toe evaluation and patient history)
• Continued post-resuscitation monitoring and re evaluation
• Definitive care
The primary and secondary surveys are repeated frequently to identify
any change in the patient’s status that indicates the need for additional
intervention.
4. PREPARATION
• Preparation for trauma patients occurs in two different
clinical settings
1. Prehospital phase: events are coordinated with the clinicians at the
receiving hospital.
2. Hospital phase: preparations are made to facilitate rapid trauma
patient resuscitation.
5. PRE HOSPITAL PHASE
• Coordination with prehospital agencies and personnel can greatly
expedite treatment in the field.
• It is set up to notify the receiving hospital before personnel transport
the patient from the scene.
• This allows for mobilization of the hospital’s trauma team members
so that all necessary personnel and resources are present in the
emergency department (ED) at the time of the patient’s arrival.
6. During the prehospital phase, providers
emphasize
• airway maintenance,
• control of external bleeding and shock,
• immobilization of the patient, and immediate
• transport to the closest appropriate facility
• Prehospital providers must make every effort
to minimize scene time Prehospital Phase. During the prehospital phase,
personnel emphasize airway maintenance, control of external
bleeding and shock, immobilization of the patient, and
immediate transport to the closest appropriate facility,
preferably a verified trauma center.
7. Hospital Phase
• Advance planning for the arrival of trauma patients is essential.
• Critical aspects of hospital preparation include the following:
1. A resuscitation area is made available for trauma patients.
2. Properly functioning airway equipment (e.g., laryngoscopes and endotracheal
tubes) is organized, tested, and strategically placed to be easily accessible.
3. Warmed intravenous crystalloid solutions should be immediately available for
infusion.
4. Appropriate monitoring devices should be made available.
8. • Due to concerns about communicable
diseases, particularly hepatitis and acquired
immunodeficiency syndrome (AIDS), the
Centres for Disease Control and Prevention
(CDC) and other health agencies strongly
recommend the use of standard precautions
(e.g., face mask, eye protection, water-
impervious gown, and gloves) when coming
into contact with body fluids. Trauma team members are trained to use standard precautions,
including face mask, eye protection, water-impervious gown,
and gloves, when coming into contact with body fluids.
9. TRIAGE
• Triage involves the sorting of patients based on the resources
required for treatment and the resources that are actually available.
• The order of treatment is based on the ABC priorities (airway with
cervical spine protection, breathing, and circulation with
haemorrhage control)
• Other factors that can affect triage and treatment priority include the
severity of injury, ability to survive, and available resources.
10. Primary Survey with Simultaneous Resuscitation
• The primary survey encompasses the ABCDEs of trauma care and
identifies life-threatening conditions by adhering to this sequence:
• Airway maintenance with restriction of cervical spine motion
• Breathing and ventilation
• Circulation with haemorrhage control
• Disability(assessment of neurologic status)
• Exposure/Environmental control
11. • Clinicians can quickly assess A, B, C, and D in a trauma patient (10-
second assessment) by identifying themselves, asking the patient for
his or her name, and asking what happened.
• An appropriate response suggests that there is no major airway
compromise , breathing is not severely compromised , and the level
of consciousness is not markedly decreased.
• Failure to respond to these questions suggests abnormalities in A, B,
C, or D that warrant urgent assessment and management.
12. AIRWAY MAINTENANCE WITH
RESTRICTION OF CERVICAL SPINE MOTION
• Upon initial evaluation of a trauma patient, first assess the airway to
ascertain patency.
• This rapid assessment for signs of airway obstruction includes
inspecting for
foreign bodies;
identifying facial, mandibular, and/or tracheal/laryngeal fractures and
other injuries that can result in airway obstruction;
13. • Suctioning to clear accumulated blood or secretions that may lead to
or be causing airway obstruction.
• Measures to establish a patent airway while restricting cervical spine
motion are done.
• Initially, the jaw-thrust or chin-lift manoeuvre often helps as an initial
intervention.
14.
15.
16. • In addition, patients with severe head injuries who have an altered
level of consciousness or a Glasgow Coma Scale (GCS) score of 8 or
lower usually require the placement of a definitive airway (i.e., cuffed,
secured tube in the trachea).
• Establish a definitive airway if there is any doubt about the patient’s
ability to maintain airway integrity.
17. • While assessing and managing a patient’s airway, take great care to
prevent excessive movement of the cervical spine.
• Based on the mechanism of trauma, assume that a spinal injury
exists.
• The spine must be protected from excessive mobility to prevent
development of or progression of a deficit.
18. Cervical spine motion restriction technique.
When the cervical collar is removed, a member of the trauma team
manually stabilizes the patient’s head and neck.
The cervical spine is protected with a cervical
collar.
When airway management is necessary, the
cervical collar is opened, and a team member
manually restricts motion of the cervical spine.
If c-spine protection is not done then the
patient may have breathing difficulties due to
phrenic nerve injury which supplies the
diaphragm.
19.
20. Non surgical Intubation
Sequence of non surgical intubation:
• Pre-oxygenate
• Administer cricoid pressure
• Administer 1-2 mg/kg succinylcholine, IV
• Intubate
• Inflate cuff and confirm tube placement
• Release cricoid pressure
21.
22. • The surgical cricothyroidotomy is the preferred means of establishing
an emergent airway.
23.
24. Breathing and Ventilation
• Airway patency alone does not ensure adequate ventilation.
• Adequate gas exchange is required to maximize oxygenation and
carbon dioxide elimination.
• Ventilation requires adequate function of the lungs, chest wall, and
diaphragm.
25. • To adequately assess jugular venous distention, position of the
trachea, and chest wall excursion, expose the patient’s neck and
chest.
• Perform auscultation to ensure gas flow in the lungs.
• Visual inspection and palpation can detect injuries to the chest wall
that may be compromising ventilation.
• Percussion of the thorax can also identify abnormalities.
26. If the patient is not breathing after establishment of an airway, artificial ventilation should be provided
with a bag-valve mask or a bag attached to an endotracheal tube.
The thumb and index finger are placed over the mask to hold the mask securely over the mouth and
nose, and the other fingers are curled beneath the inferior border of the mandible
27. • Injuries that significantly impair ventilation in the short term include
tension pneumothorax, massive hemothorax, open pneumothorax,
and tracheal or bronchial injuries.
• These injuries should be identified during the primary survey and
often require immediate attention to ensure effective ventilation.
• Because a tension pneumothorax compromises ventilation and
circulation dramatically and acutely, chest decompression should
follow immediately when suspected by clinical evaluation.
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29.
30.
31. Hemothorax
Hemothorax is the collection of blood in the pleural cavity.
result of penetrating injuries that disrupt the vasculature or result from blunt trauma that tears the
vasculature.
Massive hemothorax usually results from injuries to the aortic arch or pulmonary hilum.
A hemothorax may dangerously reduce the vital capacity of the lung and contribute to hypovolemic
shock.
A hemothorax is usually associated with a pneumothorax, and the subsequent blood loss causes
hypotension, a decreased cardiac output which when combined with the ventilatory
compromise, results in hypoxia
Treatment of a hemothorax consists of restoration of the circulating blood volume with transfusion of
fluids, volume expanders, blood, or blood products through large-bore intravenous lines; control of
the airway and support of the ventilation as required; and drainage of the accumulated blood from
the pleural cavity.
32. • Every injured patient should receive supplemental oxygen.
• If the patient is not intubated, oxygen should be delivered by a mask-
reservoir device to achieve optimal oxygenation.
• Use a pulse oximeter to monitor adequacy of hemoglobin oxygen
saturation.
33. Circulation
• Following establishment of an adequate airway and breathing in the
injured patient, the cardiovascular system of the patient must be
assessed and control of baseline circulation to the tissues must be
quickly restored.
• The most common cause of shock in the traumatized patient is
hypovolemia caused by hemorrhage, either externally or internally
into body cavities.
• Assessment of the degree of shock is important because inadequate
tissue perfusion can cause irreversible damage to vital organs such as
the brain or kidneys in a short time period.
34. Blood Volume and Cardiac Output
• Hemorrhage is the predominant cause of preventable deaths after injury.
Identifying, quickly controlling hemorrhage, and initiating resuscitation are
therefore crucial steps in assessing and managing such patients.
• Once tension pneumothorax has been excluded as a cause of shock, consider that
hypotension following injury is due to blood loss until proven otherwise.
• Rapid and accurate assessment of an injured patient’s hemodynamic status is
essential.
• The elements of clinical observation that yield important information within
seconds are level of consciousness, skin perfusion, urine output and pulse.
35. • Level of Consciousness— When circulating blood volume is reduced,
cerebral perfusion may be critically impaired, resulting in an altered
level of consciousness.
• Skin Perfusion— This sign can be helpful in evaluating injured
hypovolemic patients. A patient with pink skin, especially in the face
and extremities, rarely has critical hypovolemia after injury. Conversely,
a patient with hypovolemia may have ashen, gray facial skin and pale
extremities.
36. • Pulse— A rapid, thready pulse is typically a sign of hypovolemia. Assess a
central pulse (e.g., femoral or carotid artery) bilaterally for quality, rate, and
regularity. Absent central pulses that cannot be attributed to local factors
signify the need for immediate resuscitative action.
• The rate and character of the pulse is a good measure of the cardiac rate.
• The pulse rate is a more sensitive measure of hypovolemia than is the blood
pressure.
37. URINE OUTPUT
• Decreased intravascular volume is immediately reflected in decreased
urinary output because the compensatory mechanisms of the body
decrease blood flow to the kidneys in favor of blood flow to the heart
and brain.
• Any patient with significant trauma should always have an indwelling
urinary catheter inserted to monitor urine volume every 15 minutes.
• A minimally adequate urine output is 0.5 mL/kg/h, and fluid therapy
should be initiated to maintain at least this level of urinary output
38. Bleeding
• Acute loss of circulating blood.
• Identify the source of bleeding as external or internal.
• External hemorrhage is identified and controlled during the primary survey.
• Rapid, external blood loss is managed by direct manual pressure on the wound.
• Because of the rich blood supply to the face and neck, significant haemorrhage
may be associated with large scalp wounds, nasal or midface fractures, and
penetrating neck wounds
39. • In a short period of time the scalp may lose a large amount of blood,
which oozes from the loose connective tissue layers. The wound can
be approximated rapidly with 2-0 nonresorbable sutures without
regard to cosmetic closure.
• Direct pressure should then be placed over the wound to control the
hemorrhage and minimize hematoma formation.
• Most hemorrhages from facial injuries can be controlled with direct
pressure or packing.
• Liquid epinephrine may be added to the gauze packing, and the
patient’s head may be elevated to assist with hemostasis.
40. • Definitive bleeding control is essential, along with appropriate
replacement of intravascular volume.
• Vascular access must be established; typically two large-bore
peripheral venous catheters are placed to administer fluid, blood, and
plasma.
• Shock associated with injury is most often hypovolemic in origin. In
such cases, initiate IV fluid therapy
41. Hypovolemic Shock in the Patient with Multisystem Injuries
The most common cause of shock seen in the patient with multisystem injuries is
hypovolemia caused by hemorrhage.
42. Management
• The initial intravenous resuscitation fluid used in most hospitals is a
balanced electrolyte solution such as lactated Ringer’s solution or
normal saline.
• During prolonged shock, isotonic fluid is lost from the intravascular
and interstitial spaces to the extracellular space.
• Initially, the patient should be given 2 L of intravenous fluid (20 mL/kg
for a pediatric patient) rapidly over 10 to 15 minutes and then
observed.
• If this maneuver does not raise the systolic blood pressure to at least
80 to 100 mm Hg, the patient requires additional fluid, blood, and
control of blood loss.
43. Disability (Neurologic Evaluation)
• A rapid neurologic evaluation establishes the patient’s level of
consciousness and pupillary size and reaction; identifies the presence
of lateralizing signs; and determines spinal cord injury level, if
present.
• The GCS is a quick, simple, and objective method of determining the
level of consciousness.
• The motor score of the GCS correlates with outcome.
44.
45. • A decrease in a patient’s level of consciousness may indicate
decreased cerebral oxygenation and/or perfusion, or it may be caused
by direct cerebral injury.
• An altered level of consciousness indicates the need to immediately
re evaluate the patient’s oxygenation, ventilation, and perfusion
status.
46. • Primary brain injury results from the structural effect of the injury to
the brain.
• Prevention of secondary brain injury by maintaining adequate
oxygenation and perfusion are the main goals of initial management.
• Because evidence of brain injury can be absent or minimal at the time
of initial evaluation, it is crucial to repeat the examination.
47. Exposure and Environmental Control
• During the primary survey, completely undress the patient, usually by
cutting off his or her garments to facilitate a thorough examination
and assessment.
• After completing the assessment, cover the patient with warm
blankets or an external warming device to prevent him or her from
developing hypothermia in the trauma receiving area.
• Intravenous fluids are warmed before infusing them, and a warm
environment maintained.
48. Summary
• The primary assessment of the patient with multiple
injuries requires evaluation and maintenance of an
adequate airway with cervical protection, adequate
breathing(including the placement of chest tubes to
correct alterations in normal lung and chest wall
physiologic conditions), and adequate circulation and
hemodynamics, with the placement of two large-bore
intravenous lines peripherally and insertion of a Foley
catheter.
• The patient should be totally exposed so that the entire
body can be examined for injuries.
49. REFERENCES
• Advanced trauma life support manual for doctors.
• Oral and maxillofacial surgery, fonseca
• Peterson's principles of oral and maxillofacial surgery
