MOHAMED RIAD LECTURER OF GENERAL SURGERY

Trauma

Injury to the human body occurs when it is exposed to sudden transfer of high energy that the body can’t withstand.

Mechanisms of Injury Physical Agents;○ Kinetic. ○ Electrical.○ Thermal. ○ Radiation.Chemical.

Kinetic Energy Forces:

Blunt Trauma: Acceleration/Deceleration: mostly during Motor Vehicle

Accidents (MVA). Crushing: In this type of trauma, the priority is to save

patient’s life, then think about patient’s limb.Falling from height: Significant trauma occurs if the

victim fall >10 feet or 3 times the person’s height. Type of trauma depends on the body area striking the ground first.

Penetrating Trauma:High velocity → long & short Guns.Low velocity → Knives and rifles.

Management of poly-traumatized patient

There are many protocols for management of poly-trauma, the most universally accepted one is the protocol of ATLS (ADVANCED TRAUMA LIFE SUPPORT) which described by the American College of Surgeons, which consists of 3 steps:

Primary survey.Secondary survey.Definitive treatment.

Another protocol is the 5 Rs, as followsWhat are the 5 R’s?R1: Rapid Evaluation = Triage.R2: Resuscitation.R3: Radiology and Other Investigations.R4: Re-Evaluation.R5: Repair and Rehabilitation.

R1: Rapid Evaluation = Triage

Within few seconds you have to be able to put your patients in one of the following categories;

Black (White) Zone: for those who are dead or dying (e.g. brain fungation).

Red Zone: for those who needs urgent interference within 5-10 minutes (e.g. those with external hemorrhage and respiratory compromise).

Yellow Zone: for those who needs also urgent intervention but could withstand for 1-2 hours within which some resuscitation and investigations could be done (e.g. Internal hemorrhage patients).

Green Zone: for those who needs intervention within 1-2 days (e.g. patients with fractures).

R2: Resuscitation

Including the urgent measures that should be done for the patient immediately after the accident ( in the field of the accident ) to save his life during the first minutes or hours (the golden hours ), they should be done in the order of priority A B C D E as follows :

A-Airway: B-Breathing:C-Circulation: D-Disability (Neurological Assessment):E-Exposure:

A-Airway:

The patient’s airway should be evaluated and protected. In general, if the patient is capable of unstrained speech, his airway is patent. All patients should receive supplemental oxygen by mask till they reach the hospital.

Asses for: obstruction, facial fractures, tracheal injuries, tracheal deviation,…. etc.

Apply hard cervical collar.Open airway by doing jaw thrust maneuver (chin lift). Open the mouth, remove the obstruction or secretion.

Do suction to remove any obstruction (e.g. secretions, blood, vomitus or any foreign body).

Insert oro-pharyngeal or naso-pharyngeal airway to maintain patency of airway and to prevent falling back of the tongue in an unconscious patient. This method is contra-indicated in conscious patients (stimulates gag reflex and vomiting)

Endo-tracheal Intubation (indicated in cases of apnea, head injuries, air way compromise like maxillofacial injuries, fracture cervical spine and if there is risk of aspiration).

Cricothyroidotomy, if there is upper airway obstruction, and it is impossible to pass an endo-tracheal tube .

B-Breathing:

Check for spontaneous breathing for 10 sec;

If patient is breathing satisfactorily & PO2 above 90% → just observe.

If patient is breathing satisfactorily but PO2 below 90% → provide 02 therapy via mask 6 L/min, 60% O2 concentration.

If patient is not breathing or PO2 still declining → manually ventilate patient with 15L/min, 100% oxygen concentration & Prepare for intubation and mechanical ventilation.

C-Circulation:

Check peripheral pulsations: tachy- or brady- cardia .

Check Blood Pressure: be rapid and accurate in its measurement.

Check neck veins: is it Collapsed →→→ Hypovolemia. Distended →→→ Impaired Venous Return due to: Tension Pneumothorax; treat it immediately. Cardiac Tamponade; treat it immediately by Pericardiocentesis . Myocardial Contusion & Infarction .

If the patient in case of shock (neurogenic, oligaemic or cardiogenic), start immediately anti-shock measures (arrest of bleeding, infusion of lactated Ringer’s sol., and blood transfusion once available).

Class I Class II Class III Class IVBlood Loss mL Up to 750 750-1500 1500-2000 >2000

Blood Loss%

Up to 15% 15-30% 30-40% >40%

Pulse rate <100 >100 >120 >140

Systolic blood pressure

Normal Normal Decreased Decreased

Pulse pressure Normal Decreased Decreased Decreased

Respiratory rate 14-20 20-30 30-40 >35

Urine output >30 20-30 5-15 Negligible

Mental status Slightly anxious

Mildly anxious

Anxious, confused

Confused, lethargic

Fluid(3:1 rule)

Crystalloid Crystalloid Crystalloid and blood

Crystalloid and blood

D-Disability (Neurological Assessment):

Level of consciousness. AVPU scale;

Awake. Verbal response. Pain response. Unresponsive.

For assessment, apply any scale e.g Glasgow Coma Scale.

Glascow Coma Scale

3 – 15 point scale to assess mental status onlyBest observed responseGCS ≤ 8 is a “coma” and requires intubation

for airway protection

Eye opening• None = 1• To painful stimuli only = 2• To voice only = 3• Spontaneously open = 4

Verbal response• None = 1• Incomprehensible sounds = 2• Incomprehensible words = 3• Confused = 4• Oriented = 5

Motor response• None = 1• Decerebrate (extension) posturing = 2• Decorticate (flexion) posturing = 3• Withdraws to pain = 4• Localizes pain = 5• Follows commands = 6

E-Exposure:

Remove clothing. Observe the chest for bruises, penetrations,

and symmetry. Auscultate breath sounds. Auscultate heart sounds.For total assessment.After exposure you may find:Ecchymosis at site of trauma.Grey-Turner sign.

R3: Radiology & Other Investigations.

I- Basic X- Ray Films have to be done for every case of Polytrauma depends largely on the suspected site and the doctor who is going to request it. Every specialty has its own interest;

General Surgery: erect abdomenCardiothoracic Surgery: chest x-rayNeurosurgery: skull and spinesOrthopedic Surgery: pelvis, spine and

fractures

II- Focused Assessment with Sonography for Trauma (FAST):

PerihepaticPerisplenicPericardiumPelvis

III-CT Scans: Brain and Spine, Abdomen & Pelvis and

Chest are usually needed for assessment of most of cases.

IV - DPL (Diagnostic Peritoneal Lavage):This is an invasive diagnostic tool that should be preserved

in cases where diagnosis of intra-abdominal injury is very doubtful.

It should be done in the OR (Operating Room) under complete aseptic precautions and with all facilities ready for abdominal exploration if needed (even blood).

Through a stab incision just above the umbilicus, a Ryle tube is passed to the intra-peritoneal space and one liter of normal saline infused intra-peritoneal through it. Then we leave the fluid to come back and we analyze its content.

Positive result is considered when; 10cc gross blood. RBC >100,000/mm2 . , WBC >500/mm2 Amylase >175 IU/dL. Bile, bacteria, or food.

This means that this patient is candidate for immediate exploration.

Contraindications of DPL: Those with clear decision of exploration. Prior abdominal surgeries. Pregnancy & Obesity.

R4: Re-Evaluation(Secondary survey)

Now, this is the time of re-evaluation of the patient. It is done in two steps:

I-History taking: this includes; SAMPLE; → Symptoms.→ Allergies.→ Medications.→ Past history.→ Last meal.→ Events related to injury.

II-General Examination from Hair to Heal:

1. Head: search for sub-galeal hematoma, sub-conjunctival hemorrhage, facial fractures,…etc.

2. Neck: pain or tenderness, tracheal deviation, jugular vein, impaled objects and open wounds, Expanding neck hematoma.

3. Chest and Heart: rib fractures, pneumo- or hemo-thorax,…etc.

4. Abdomen & Pelvis: Cullen’s sign, Grey-Turner sign, Kher’s sign,…etc.

5. Extremities: Fractures, peripheral pulsations, soft tissue injuries,…etc.

6. Back: bruising, impaled objects, pain and tenderness.

R5: Repair & Rehabilitation.(Definitive treatment of individual injuries )

Finally, the patient is admitted to the hospital in one of the following destination sites:

General Surgery Department.Neurosurgery Department.Orthopedic Surgery Department.Cardiothoracic Surgery Department. ICU.