TRAUMADone by:

Hamoud AlshayaMohammed AmouriAbdulaziz A Al-anzy

Supervised by:Dr. Abed alrahman Manasrah

• Definition• Classification• Scoring Systems• Trauma Management Initial assessment Primary survey Secondary survey Definitive care

WHAT IS TRAUMA?

Trauma is the study of medical problems associated with physical injury. The injury is the adverse effect of a physical force

upon a person.

The third most common cause of death overall

CLASSIFICATIONTrauma classified by the type of force applied to the body to: ▪ Blunt trauma▪ Penetrating trauma▪ Blast trauma▪ Thermal trauma

Major trauma is sometimes classified by body area:▪ polytrauma 40% ▪ head injuries 30% ▪ chest trauma 20% ▪ abdominal trauma10% ▪ extremity trauma 2%

LEADING CAUSES

• Road traffic accidents• Falls from a height• Crimes and acts of violence• Domestic injury –Burn• Industrial injury

INJURY ASSESSMENT (SCORING SYSTEMS)

Anatomical scoring systemGlasgow Coma ScoreSystolic Blood Pressure

Respiratory rate

Revised trauma score Trauma score

Respiratory expansion

Capillary Refill

ISS/A1S (ANATOMICAL SCORING SYSTEM)

• The severity of injury is assessed in six different areas on a scale from 0 to 5.

• 1. External-contusions, burns 0-----5• 2. Extremities fractures 0-----5• 3. Abdomen 0-----5• 4. Thorax 0-----5• 5. Face 0-----5• 6. Head/Neck 0-----5

GCS

TRIAGE

According to trauma scores & ISS

Dead•(CPR)

Critical• (Resuscitation)

serious•(Admit to the hospital)

slight• (wait)

sorrowful•(wait)

According to trauma scores & ISS

Dead• Who have a trauma score of 0-2 and are beyond help

Priority 1• Who have a trauma score of 3-10 and need immediate

attention

Priority 2• Who have a trauma score of 10-11 can wait for short time

Priority 3• Who have a trauma score of 12and Can be delayed

Immediate deaths 50%• Within the first few minutes of injury

Early deaths 30%• 15 min – 6 hrs

Late deaths 20%• Days to weeks

• Pattern of trauma deaths :

TRAUMA MANAGEMENT

Initial evaluation Objectives:

1. To stabilize the trauma patient.

2. To identify life threatening injuries & to initiate adequate supportive therapy.

3. To efficiently & rapidly organize either

definitive therapy or transfer definitive therapy center.

ATLS PROTOCOL

ATLS Advanced Trauma Life SupportThe three main elements in trauma management

- Primary survey - Secondary survey- Definitive care

Primary survey

• C spine stabilization• A Airway• B Breathing• C Circulation• D Disability• E Exposure and Environment

“ c A B C D E “

C-SPINE

• Maintain the cervical spine in the neutral position• Problem : Unstable fracture• Assume it if : - unconscious - head injury - face injury• Interfere : - Semi-rigid collar - Sandbags/tape - Manual in-line immobilisation

AIRWAY

• Problem :

- direct trauma - obstruction : - foreign body

- blood or vomits

- soft tissue edema

- Deteriorating consciousness

• Assume if : cyanosis , tachypnoea , stridor , respiratory distress , no chest movement

AIRWAY INTERVENTIONS

1. Check verbal response2. Remove foreign bodies (dentures , plastic,

food)3. Suction of secretions or vomitus4. Chin lift/jaw thrust 5. oropharyngeal/nasopharyngeal airways maintain the airway by orotracheal or nasotracheal tube

5. Cricothyroideotomy or emergency tracheostomy.

6. ETI (endotracheal intubation) for comatose patients (GCS<8)

OROPHARYNGEAL AIRWAY

NASOPHARYNGEAL AIRWAY

TRACHEOSTOMY

CRICOTHYROIDOTOMY

A cricothyrotomy is usually done in an emergent situation when you are unable to intubate someone and need to get access to someone's airway in a hurry. It's done through the cricothyroid membrane (through your adam's apple). Landmarks are easy to identify, and you avoid the vocal cords and the person's thyroid gland & associated vessels. A tracheostomy is placed lower down in the trachea, between the tracheal rings. It can be placed in an operating room or at the bedside in an ICU setting, and is much more elegant than a cricothyroidotomy. It is usually placed if someone is going to need the support of a ventillator for a long time This allows the patient to talk and not have the extreme discomfort of a tube going down his mouth into his trachea.

CRICOTHROTOMY VS. TRACHEOSTOMY

B - BREATHING

• Airway patency alone does not ensure adequate ventilation , i.e the patient may stay cyanosed or apnoeic after the airway has been

cleared.• Assess the work of breathing and

its efficacy by conducting the following:

1. Inspection : For chest wall movement and injury , asymmetric chest expansion , cyanosis , tracheal shift , jugular venous distention , using accessory muscles, respiratory rate.

2. Palpation : for presence of subcutaneous

emphysema , flail segments .

3. Percussion : For hyperresonance or dullness .

4. Auscultation : for equal and symmetrical breath

sounds.

5. CXR to evaluate lung fields

SUBCUTANEOUS EMPHYSEMA

•Life threatening conditions :

WHAT WOULD WE DO FOR THIS PATIENT WHO IS HAVING DIFFICULTY BREATHING?

CHEST TUBE

PNEUMOTHORAX

• Injury to the lung resulting in release of air into the pleural space .

• Tension pneumothorax - diagnosed clinically and managed by rapid thoracostomy incision or immediate decompression by needle thoracostomy in the second intercostal space midclavicular line followed by chest tube placed anterior midaxillary line in the fourth intercostal space

MASSIVE HEMOTHORAX

• Diagnosis : - unilaterally decreased or absent breath sounds , dullness on percussion , CXR and CT scan , chest tube output “ blood “ .

• Treatment : - volume replacement - chest tube • Massive hemothorax : - > 1500 cc of blood on initial placement of chest tube - persistent > 250 cc of blood per hour * 3 hours

MASSIVE FLAIL CHEST

• Two separate fractures in three or more consecutive ribs .• Diagnosis : - history of pulmonary contusions . - flail segments of chest wall that sucks in with inspiration and pushes out with expiration .

• Treatment : - Intubation with positive pressure ventilation - Conservative therapy with emphasis on pain relief with thoracic epidural analgesia

BREATHING INTERVENTIONS

• Mouth to mouth resuscitation• Facemask• Ambu bag• Ventilate with 100% oxygen• Needle decompression if tension pneumothorax

suspected• Chest tubes for pneumothorax / hemothorax• Occlusive dressing to sucking chest wound• If intubated, evaluate ETT position

C - CIRCULATION

• Hemorrhagic shock should be assumed in any hypotensive trauma patient

• Rapid assessment of hemodynamic status Level of consciousness Skin color Pulses in four extremities Blood pressure and pulse pressure

CIRCULATION INTERVENTIONS :• Apply pressure to sites of external

hemorrhage• Establish IV access , The ATLS advice a

2000-cc crystalloid volume challenge 2 large bore IVs Central lines if indicated

• Cardiac tamponade decompression if indicated

• Volume resuscitation Have blood ready if needed Foley catheter to monitor resuscitation

CENTRAL VENOUS LINE

the catheter can be inserted via the subclavian or internal or external jugular vein.

There is good evidence to show that the safest means of establishing central venous access is by insertion of lines under ultrasoundguidance.

Indications:1-CVP monitoring provides Right Atrial and Right Ventricle

pressures2-Advanced Cardiopulmonary disease + major

operation3-Secure vascular access for drugs, fluids & traumatic

pts4-Inadequate peripheral IV access

1-Bleeding2-Injury to surrounding structures as carotid

artery3-Pneumothorax

4-Arrhythmia

Complications

SELDINGER TECHNIQUE

• Access vessel with needle under US/ aspiration

• Guide wire through needle 10cm /j-tip

• Remove the needle /leaving wire in place

• Skin incision /dilation tract / remove

• Advance catheter over wire

• Removal of wire

D - DISABILITY

• Abbreviated neurological exam Level of consciousness Pupil size and reactivity Motor function GCS

• Utilized to determine severity of injury , mental status

• Guide for urgency of head CT and ICP monitoring

DISABILITY INTERVENTIONS

• Spinal cord injury High dose steroids if within 8 hours

• ICP monitor- Neurosurgical consultation

• Elevated ICP Head of bed elevated Mannitol Hyperventilation Emergent decompression

E - EXPOSURE

• Complete disrobing of patient• Logroll to inspect back• Rectal temperature• Warm blankets/external warming

device to prevent hypothermia

ALWAYS INSPECT THE BACK

Ongoing monitoring :

• Urinary catheters are mandatory, however,

precautions are taken for pelvic trauma and for those with blood at the urethral

meatus.

• Gastric tubes inserted into:1. All patients requiring

endotracheal intubation.2. Children are prone to gastric

dilatation, which can impair their respiration.

SECONDARY SURVEY

• The secondary survey does not begin until after the primary survey has been completed, and all potentially life-threatening injuries have been dealt with (stable pt )

• The purpose of the secondary survey is to identify all other injuries and perform a more thorough ‘head to toe’ examination. (look & palpate everywhere!!! )

• If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present.

Secondary survey• Head-to-toe evaluation

• Complete history and PE• Reassessment of all VS

• Indicated x-rays are obtained.

• Special procedures• Tubes and fingers in every

orifice

Complete history

• History can be taken from the patient “conscious, cooperative “ family , paramedics , other victims/injured people .

AMPLE hx

Allergy

Medications currently used

Past medical/surgical hx + pregnancy

Last meal

Events &Environment related to the injury

PHYSICAL EXAM Examine each region of the body for signs of injury, bony instability and tenderness to palpation.

❑ Head and face

• Penetrating injuries / depressed fractures• Evidence of bleeding /discharge from the ears • Maxillofacial fractures and ocular injury.• Exclude midfacial injury and potential airway compromise

❑ Neck

• Hematomas / crepitus / tenderness . • The spine is held immobilized until formally cleared clinically and

radiographically .

❑ Chest

Full palpation and auscultation of the chest wall, including the clavicle, sternum and ribs.

❑ Neurological

• GCS regularly. • Full neurological examination

❑ Abdomen and pelvis

• Distension/ bruising /penetrating wounds. Tenderness /signs of peritonism.

• Perineum for evidence of ecchymosis or bleeding• A rectal examination is needed

❑ Extremities

• Tenderness / crepitation /abnormal movement.• Ask him or her to move the limbs • Adequately splint any injuries• Reassess after splints, traction or manipulation

❑ Log roll• One member of the team is responsible for maintaining

in-line spinal stabilization , Three other trained staff hold the patient steady through the turn.

• Inspect and palpate the entire spine • Tenderness / bony abnormalities/ penetrating injuries or

exit wounds from gunshot . • Percuss, palpate and auscultate the posterior chest wall.

❑ Frequent reassessment of vitals

• During the examination, any injuries detected should be accurately documented, and any urgent treatment required should occur, such as covering wounds, bleeding management and splinting fractures.

• Appropriate analgesia, antibiotics or tetanus immunization should be ordered.

• The priorities for further investigation and treatment may now be considered and a plan for definitive care established 

ADJUNCTS TO PRIMARY SURVEY

• ECG Monitoring.• Urinary Catheter• NGT • Monitoring - ABG - Pulse oximeter(O2 sat) - Blood pressure• X-rays - AP CXR - AP pelvis - C-spine• Diagnostic peritoneal lavage• Abdominal ultrasonography (FAST)

❑ Standard trauma labs• Blood group &cross matching • ABG• CBC • Urine analysis • Blood sugar• KFT, LFT, Coagulation profile

Standad truama investigations

• X-rays• CT scans “ spine , chest , abdomen , head” • FAST/DPL

FAST EXAM FOCUSED ASSESSMENT WITH SONOGRAPHY

FOR TRAUMA

❑ Rapid bedside ultrasound examination performed to evaluate for free fluid “blood”

❑ It includes 4 views: • The hepato-renal recess (Morison

pouch)• The peri-splenic view • The sub-xiphoid pericardial window• The suprapubic window (Douglas pouch)➢ (E-FAST) examination views: (1) the bilateral hemithoraces (2) the upper anterior chest wall should also be obtained

DIAGNOSTIC PERITONEAL LAVAGE(DPL)

❑ Diagnostic peritoneal lavage (DPL) may help in determining the presence of blood or enteric fluid.

❑ It was recently replaced by ultrasound (rarely performed )

❑ Contraindications:• Previous abdominal surgery ” (adhesions) ”• Pregnancy• Morbid obesity• Coaglobapthy • Pelvic fractures• Operator in-experience

+ve test • 10 cc/blood

• 100,000 RBCs/mm3

• 500 WBCs/mm3• Presence of bile, bacteria or

food particles

• Using local anesthesia, the surgeon makes a small incision in the abdomen just below the umbilicus.

A catheter is introduced through the incision into the abdomen. Saline is

infused into the abdomen through the catheter, and then removed. If

blood is present in the saline after

removal, it is highly probable that there is

a serious intra-abmoninal injury.

CT FAST DPL

variable 2-4 min 10-15 min Time

Yes Easy Possible, rarely done Repeatability

Obesity , movement Operator dependent Not organ specific Reliability

High Medium High Sensitivity

High High Low Specificity

Noninvasive, highly

accurate ,fixed, expensive

Noninvasive, rapid,

mobile ,Moderately inexpensive

Inexpensive, mobile , detects

bowl injuryAdvantages

Misses diaphragm, small bowel and pancreatic injury;

radiation

Hampered by subcutaneous

tissue/intra abdominal air, obesity, pelvic

fractures

Invasive, misses retroperitoneal injury Disadvantages

To conclude :

❑ In the absence of a reliable physical examination, the main diagnostic choice is between CT scanning or FAST (with CT scanning in a complementary role).

❑ Hemodynamically unstable patients may be initially evaluated with FAST or DPL

RESULTS: Two hundred patients with a mean age of 28.3 years were studied, 98 in FAST and 102 in DPL group. 104 sustained blunt trauma and 76 sustained penetrating trauma due to stabbing. In addition, 38 (38.7%) were FAST positive and 48 (47%) were DPL positive (p=0.237, not significant).

As a guide to therapeutically beneficial laparotomy, negative DPL was better than negative FAST. For non-operative decisions, positive FAST was significantly better than positive DPL. DPL was significantly better than FAST in detecting as well as not missing the bowel injuries. DPL took significantly more time than FAST to perform

.CONCLUSION:

Although DPL requires significantly more time to perform, it is better than FAST as an adjunct for the initial assessment of a patient suspected to be having intra-abdominal injury.

ADJUNCTS TO THE SECONDARY SURVEY

These specialized tests should not be performed until the patient’s hemodynamic status has been normalized .

• Additional x-rays of the spine and extremities• CT of the head, chest, abdomen, and spine• Contrast urography• Angiography• Bronchoscopy• Esophagoscopy

SPECIAL SUBGROUP CONSIDERATIONS

❑ The initial management of any traumatized individual initially follows the same methodical ‘ABCDE’ pathway. However, there are three very important subgroups which require special consideration:

➢ The pediatric age group➢ The elderly ➢ The pregnant

PEDIATRIC TRAUMA

This age- group have :

❑ Smaller body mass ” greater force applied per unit surface

area for a given injury”. ❑ Body with less fat / less connective tissue❑ Immature skeleton “injuries to more than one organ ❑ High surface area to body volume “hypothermia is a higher risk”

❑ Airway and cervical spine control

• Nasotracheal intubation in children <9 y should not be performed “damage to the cranial vault and to the fragile soft tissues causing bleeding.”

• Cuffed tubes are rarely indicated for children <9y because of the delicate structures within the airway.

• Trachea is relatively short ”not to intubate the right main bronchus.

❑ Breathing and ventilatory control

• The respiratory rate in the child decreases with age.• Flail chest and aortic rupture are uncommon in children due to the

elastic nature underlying structures.• Pulmonary contusions are not evident in the early chest x-ray, but as

before, re-evaluation is necessary for the following 24–48 hours.

❑ Circulation with hemorrhage control

• Vital signs vary with age.• High capacity and ability of children to compensate for fluid loss ” hypotension is a very late and ominous sign of hypovolemic shock.”• If IV access has failed after two attempts, consideration should be given

to intraosseous access “proximal tibia/ distal femur”

❑ Disability

• Head injury• Diffuse axonal injury

❑ Secondary survey

• Liver and spleen are the most common organs to be injured in the abdomen.

• Duodenal haematoma /pancreatic injury • “underdeveloped anterior abdominal

muscels “• Small bowel perforation and mesenteric injuries• Bladder injury “pelvic shallowness”❑ Child abuse

TRAUMA IN THE ELDERLY POPULATION

❑ Trauma in the elderly population presents many challenges for the treating physicians due:

• fragility of physiological status • co-morbidities❑ It does not require high velocity or high-

energy trauma to put the elderly life at risk

❑ Airway and cervical spine control

• Dentition status

• Nasopharyngeal fragility & macroglossia

• Stiffness in the cervical spine

❑ Breathing and ventilation

• Mortality rates following chest injuries in the elderly are higher

• rib fractures and pulmonary contusion

• Pulmonary complications “atelectasis, pneumonia ,pulmonary edema”

Circulation• Cardiac reserve and maximum potential heart rate • Masking of compensatory tachycardia following trauma, “b-blockers”• kidney is also more susceptible to damage from hypovolemia,• Retroperitoneal hemorrhage “minor pelvic or hip fractures”

Disability• Confusion “ assessment of head injury ”• Osteoporosis “spinal fractures with minor injury”• Spinal injury “stiffness and spinal stenosis.”

Secondary survey in the elderly• Musculoskeletal injury • The most common fracture is in the proximal femur followed by the

humerus and wrist.

TRAUMA IN PREGNANCY

❑ Pregnancy must be considered and excluded in all women of child-bearing age.

❑ Anatomic and physiological changes must be considered when assessing and resuscitating a pregnant woman.

❑ The trauma team + obstetrician + pediatrician

❑ Can lose significant amounts of blood before they display the usual signs of hypovolemia.”high intravascular volume “

❑ Mother may appear relatively stable while the fetus is in distress “lack of placental perfusion”

❑ During the primary survey, the uterus of the third trimester pregnant patient should be manually displaced to the left side in order to take pressure off the inferior vena cava.

❑ Feto-maternal hemorrhage “anti-D”

COMMON FINDINGS IN TRAUMA PATIENTS

BATTLE’S SIGN : BRUISING BEHIND THE EAR SUGGESTS A FRACTURE IN THE POSTERIOR CRANIAL FOSSA

RACOON EYES :EXTENSIVE PERI-ORBITAL EXTRAVASATIONS OF BLOOD FROM BASAL SKULL FRACTURE.

HEMOTYMPANI

SEATBELT SIGN

REFERENCES

1) Courtney M. Townsend , R. Daniel Beauchamp , B. MARK EVERS And KENNETH L. Mattox(2012) Sabiston Textbook Of Surgery :The Biological basis Of Modern surgical Practice

12th Ed 2) Norman S. Williams , Christopher J.K. Bulstrode , P. Ronan O’Connell(2013)

  Bailey & Love's Short Practice of Surgery 26th Ed

3) Jill S Whitehouse & John A Weigelt (2009) Diagnostic peritoneal lavage: a review of indications, technique, and Interpretation , Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine .

4) Sunil K, Abhay K, Mohit K and Vinita R (2014) Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as an adjunct to primary survey in torso trauma:a prospective randomized clinical trial Turkish Journal of Trauma and Emergency Surgery

5) John P. McGahan, & John Richards(2002) The Focused Abdominal Sonography for Trauma Scan , the American Institute of Ultrasound in Medicine

6) William S. Hoff (2002) Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma: The EAST Practice Management Guidelines Work Group , The Journal of TRAUMA Injury, Infection, and Critical Care

7)http://www.medscape.com

THANK YOU