The document discusses trauma management and the primary and secondary surveys. It describes a case of a 25 year old male who fell 20 feet and is complaining of abdominal pain. It then covers the mechanisms of trauma, the three peaks of death from trauma, and the steps in advanced trauma life support. It provides details on the primary survey to assess the ABCDEs (airway, breathing, circulation, disability, exposure/environment). It then discusses performing the secondary survey to fully examine the patient and obtain their history.

1. +
TRAUMA
PRIMARY AND SECONDARY SURVEY

2. +
CASE:
A 25 year old is brought
to casualty with history of
fall from a height of 20
feet. He landed on a pile
of bricks. Fortunately
there was no head injury.
He is complaining of
severe abdominal pain.
On examination he is
conscious; his pulse is
110/minute, BP 90/60
mmHg. There is no
external wound. However
has abrasions in left
upper quadrant and left
lower chest.

3. +
MECHANISMS OF
TRAUMA
Trauma can be classified
in type by causation and
by effect
Blunt , e.g. car bonnet
Penetrating , e.g. Knife
Blast , e.g. Bomb
Crush , e.g. building
collapse
Thermal

4. +
Deaths from trauma show three
peaks:
 Immediate
death :
o
Occurs within seconds
o
Cause : head injury , heart injury or aortic injury
o
These deaths are not preventable

5. +

Early death:
o
Begins an hour or two after injury
o
Cause: subdural and epidural hematomas , hemo or
pneumothorax , organ rupture or blood loss
o
Often preventable
o
This period is called the GOLDEN HOUR during which
prompt intervention can save a life

6. +
 Late
death:
o
Occurs many days after injury
o
Cause: sepsis or multi-organ failure
o
Prompt treatment of shock and hypoxemia during GOLDEN
HOUR can reduce these deaths

7. STEPS IN ADVANCED
TRAUMA LIFE SUPPORT:

Prehospital care
Primary survey with simultaneous resuscitation:
identify and treat what is killing the patient

+
Secondary survey : proceed to identify all other
injuries

Definitive care: develop a definitive management
plan


8. +
PREHOSPITAL CARE

9. Airway
maintenance
 Control of
external bleeding
& shock
 Immobilization
of the patient
 Communication
with receiving
hospital &
immediate
transport to the
closest,
appropriate
facility
 History taking

+

10. +
Prior to arrival:

Ensure senior emergency medical and nursing staff are aware of all
available details of the case.

Call Trauma Team (Trauma surgeon , Anaesthetist , Nurses ,
Emergency physician , Respiratory therapist , Radiologist ,
Surgical subspecialists)

Delegate specific tasks to appropriate individuals.

Check the resuscitation equipment and prepare intravenous lines and
fluids.

If possible, estimate the patient's weight using the formula (Age + 4) x 2
(or 3 x Age for those over 9 years) and calculate:
1) The amount of fluid bolus at 20 ml/kg
2)The endotracheal tube size (age/ 4) + 4
3)Any other drugs likely to be needed

11. +
On arrival:

Immediately perform a primary survey by assessing and
managing the patient's airway, with cervical spine
stabilisation, breathing and circulation.

Obtain a history, if possible, from the attendents or
ambulance officers e.g. type of trauma, speed of the vehicle,
height of the fall, restraints or safety equipment used,
whether other people were injured.

Obtain information regarding any treatment or interventions
to date.

12. + PRIMARY
SURVEY

13. +
Identified the life-threatening conditions
and simultaneously manage:
 A: Airway maintenance with cervical spine protection
 B: Breathing and ventilation
 C: Circulation with hemorrhage control
 D: Disability ( Neurologic status )
 E: Exposure / Environmental control: Undress the patient &
prevent hypothermia

14. +
A : Airway and C- spine
* Talk to the patient

A patient who can speak clearly must have a clear airway

Unconscious patient may require airway and ventilatory
assistance.

The cervical spine must be protected during endotracheal
intubation if a head, neck or chest injury is suspected.

Airway obstruction is most commonly due to obstruction by
the tongue in the unconscious patient.

Hoarsness or pain with speaking indicate
laryngeal injury.

15. +
* Assess airway
The signs of airway obstruction may include:

snoring or gurgling ( foreign body , aspiration )

stridor or abnormal breath sounds

agitation (hypoxia)

using the accessory muscles of
ventilation/paradoxical chest movements

cyanosis.

16. +
* Consider need for advanced airway
management

Indications for advanced airway management techniques for
securing the airway include:
o
persisting airway obstruction
o
penetrating neck trauma with haematoma (expanding)
o
Apnoea
o
Hypoxia
o
severe head injury
o
chest trauma
o
maxillofacial injury

17. Advanced airway
management:
*
* If obstruction persists:
- Chin lift and Jaw thrust
- Consider C-spine injury in
every patient until proven
otherwise
+
•Endotracheal intubation if:
- above don’t help
unconscious patient
- airway swelling or burns
-GCS less than 8
* Surgical Cricothyrotomy (if
there is severe facial or neck
injury)

18. +
B: Breathing and ventilation
* Inspection (LOOK) of respiratory rate is
essential. Are any of the following present

Cyanosis

penetrating injury

presence of flail chest

sucking chest wounds

use of accessory muscles

19. + * Palpation (FEEL) for

tracheal shift

broken ribs

subcutaneous emphysema

percussion is useful for diagnosis of haemothorax (dull)
and tension pneumothorax (hyper-resonant)

20. + * Auscultation (LISTEN) for

pneumothorax (decreased breath sounds on site of
injury)

Detection of abnormal sounds in the chest.

Give 100% oxygen (if available, via self-inflating bag or
mask)
 injury




1.
2.
3.
4.
that may acutely impair ventilation
Tension pneumothorax
Flail chest with pulmonary contusion
Massive haemothorax
Open pneumothorax

21. + Tension
pneumothorax
* Respiratory distress
* Over inflated hemithorax and
visibly splayed ribs
* Ipsilateral Hyperresonant
percussion note
* Ipsilateral reduce or absent breath
sounds
* Treacheal deviation
* Distended neck veins
Management: Immediate needle
decompression in second Intercostal
space midclavicular line

22. + Open
pneumothorax
* Ipsilateral reduced breath sounds
* Ipsilateral resonant percussion note
* Decreased expansion
* Penetrating chest wall injury
Management:
Cover defect - Sterile waterproof three
sided dressing secured on two sides to act
as a flutter valve.
Intercostal drain placed away from open
wound.
Surgical debridement and closure later.

23. + Massive
Hemothorax
* Hypotension due to blood loss
* Ipsilateral dullness to percussion
note
* Ipsilateral absent or reduced
breath sounds
* Ipsilateral decreased chest
movements
Management:
Infusion of fluids through large bore
IV cannula before draining
Large bore intercostal drain for
adults

24. + Flial Chest
* Segment of chest looses bony
continuity with thoracic cage
* Moves paradoxically with
respiration and reduces tidal volume
Management: Analgesia for pain
Fluid management
Ventilatory support

25. C: Circulation and hemorrhagic
+
control
* Hemorrhagic control

Direct pressure for external hemorrhage

No tourniquet unless other methods are not effective in
controlling bleeding

Long bones splinted with external fixation

Pelvic binding or pneumatic anti-shock garment

Watch out for hypothermia, acidosis and coagulopathy

26. +
* Assessment for hypovolaemia

Check skin: color , clamminess and capillary refill time

Heart rate

Blood pressure

Pulse pressure

Conscious level

Connect an automatic BP recorder and ECG
Hypovolaemia is the commonest cause of shock in trauma
patients

27. +
*Vascular cannulization

Two Large bore IV cannulas: peripheral i.e. Femoral Vein
Central – Subclavian or Internal Jugular
Intraosseous in children
Draw
20ml blood for grouping and cross matching , analysis of
electrolytes and full blood count

28. + * Fluid resuscitation

Bolus of warm crystalloids

Surgical control of hemorrhage is better than aggressive
fluid resuscitation

Fluid resuscitation inhibits platelet aggregation , dilutes
clotting factors and raises BP

Altered cardiovascular response to hemorrhage in trauma
pts

Enough warm crystalloids to maintain a radial pulse

Blood may also be required

29. +
D : Disability

Glasgow Coma Scale

Pupilary reflexes
Monitor frequently to detect deterioration
Common causes for
deterioration

Hypoxia

Hypovolaemia

Hypoglycemia

Raised intracranial pressure

30. +
E : Exposure

Clothes should be cut to remove

Pt kept warm and covered with blankets

Log roll

Assess spine from base of skull to coccyx

Examine back for any signs of injury

Digital Rectal Examination:
Boney fragments
Rectal wall
Bleeding
Prostate

31. +
SECONDARY SURVEY

32. +
HISTORY

A. Allergies

M. Medications currently used + tetanus status

P. Past illness / pregnancy

L. Last meal / LMP

E. Events / Environment related to injury

33. +
HISTORY : MECHANISM OF INJURY
 Blunt
 Automobile collisions
 Seat belt usage
 Steering wheel deformation
 Direction of impact
 Ejection of passenger form the vehicle
 Burns and Cold injury
 Inhalation injury and
 Hazardous
CO. intoxication in fire field
environment

34. +
 Penetrating
 Anatomy factors
 Energy transfer factor
 Velocity and caliber of bullet
 Trajectory
 Distance

35. PHYSICAL
EXAMINATION
+

36. +
HEAD

Scalp: lacerations, bruising, depressions or irregularities in
the skull, Battles sign (bruising behind the ear indicative of a
base of skull fracture).

Mouth: lacerations to the lips, gums, tongue or palate.

Teeth: subluxed, loose, missing or fractured.

Nose: deformities, bleeding, nasal septal haematoma, CSF
leak

Ears: bleeding, blood behind tympanic membrane.

Eyes: foreign body, subconjunctival haemmorhage,
hyphaema, irregular iris, penetrating injury, contact lenses.

Jaw: pain, trismus, malocclusion.

37. +
NECK

Cervical spine: pain, tenderness, deformity, inability to
move neck;

Soft tissues: bruising, pain and tenderness;

Trachea: deviation, crepitus;

Neck veins: distention.

38. +
CHEST

Chest wall: bruising, lacerations, penetrating injury,
tenderness, flail segment.

Lung fields: percussion note, lack of breath sounds,
wheezing, crepitations.

Heart: Apex beat, presence and quality of heart sounds.

39. +
ABDOMEN

Abdo wall: bruising, lacerations, penetrating injury,
tenderness.

Viscera: splenic, hepatic or renal tenderness, bladder
tenderness or enlargement.

Bowel: abdominal tenderness or rebound, absent bowel
sounds.

Pelvis: pain on springing.

40. +
LIMBS

Soft tissues: bruising, lacerations, muscle, nerve or tendon
damage.

Bones: tenderness, deformities, open fractures.

Joints: penetrating injuries, ligament injuries.

41. +
BACK
 Soft
tissues: bruising, lacerations
 Bones: tenderness, space
between vertebrae.

42. +
BUTTOCKS AND PERINIEUM
Soft
tissues: bruising,
lacerations.

43. +
GENITALIA
 Soft
tissues: bruising, lacerations.
 Urethra: bleeding.
 Introitus: bleeding.

44. +
NEUROLOGIC
 Determine
GCS score
 Re-evaluate pupils
 Sensory / motor evaluation
 Maintain immobilization
 Prevent secondary CNS injury ( keep stable vital
signs, avoid increased ICP and treat IICP )
 Early neurosurgical consultation

45. +


INVESTIGATIONS
CBC
Urine output

Urinanalysis

Xray

CT

MRI

46. +