Management of the Trauma

Patient

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 GOLDEN HOUR
The first hour following a trauma during
which aggressive resuscitation can improve
the chances of survival and restore the
normal functions.

Early pre-hospital care, early transport,

aggressive resuscitation and interventions

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HOSPITAL PHASE

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 Primary Survey
Advanced Trauma Life Support
Assess and address life threatening
injuries in order
ABCDE of trauma
Airway
Breathing
Circulation
Neurologic deficit
Exposure of patient
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 AIRWAY MAINTENANCE WITH
CERVICAL SPINE CONTROL
Suspect cervical spine injury in all
patients unless other vise proven

High chance in high speed impact,

and in patients with altered
consciousness

15% patients with supraclavicular

injuries and 5 % with head injury 5
 Assessment of airway
As a general rule if patient talks properly
airway is patent (A) breathing is
adequate (B) sufficient delivery of
oxygen through circulation (C) to
transport the oxygen to the brain (D)

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 Look, Listen, and Feel
Look
Agitated or obtunded.
Agitation suggests hypoxia, and
obtundation suggests hypercarbia.
Pattern of breathing and use of accessory
muscles of ventilation

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 Listen
Abnormal sounds.
Noisy breathing, Snoring, gurgling - partial
obstruction of the pharynx or larynx.
Hoarseness laryngeal obstruction.
Abusive patient -hypoxic

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 Feel
location of the trachea and determine
whether it is in the midline

foreign objects (e.g.,fractured teeth,

fillings, dentures) should be removed.

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 Reasons for airway obstruction
Tongue fall
aspiration of foreign bodies
regurgitation of stomach contents
facial, mandibular, tracheal and laryngeal
fractures
retropharyngeal hematoma resulting from
cervical spine fractures
Traumatic brain injury
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 JAW THRUST OR CHIN LIFT
PROCEDURE
JAW THRUST
knuckles of the index fingers are placed behind the
angle of the mandible with thumbs apply pressure on
the cheek bones at the same time lifts and
displaces the mandible forward.
Breathing spontaneously high-flow oxygen via
the facemask
Not breathing a facemask with a bag-valve
device (AMBU bag) and is continuously bagged

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CHIN LIFT
mandible is gently lifted upward using the
fingers of one hand placed under the chin.
The thumb of the same hand lightly
depresses the lower lip to open the mouth

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 AIRWAY
Suction should be used to clear any
secretions
Oral or nasal airway - keep the airway
patent
Nasal airway is better tolerated in an
awake patient.

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 OROPHARYNGEAL AIRWAY
OPA should extend from the corner of
the mouth to the angle of the mandible.
introduced upside down so that its
concavity is directed upward, until the
soft palate
the device is rotated 180 degrees to
direct the concavity down and the
airway is slipped into place over the
tongue

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 Definitive Airway
Defined as an inflated cuffed tube in the trachea.
Orotracheal
Naso tracheal
Contra indicated - frontal sinus fractures, base of skull
fractures, and ant cranial fossa fractures
Surgical Airway
Needle Cricothyroidotomy
Cricothyroidotomy
Tracheostomy

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 Breathing
Identify life threatening deficits in breathing
mechanism
Simple pneumothorax
Tension pneumothorax
Massive hemothorax
Open pneumothorax (sucking chest wound)
Flail chest
Ventilation is compromised not only by airway
obstruction but also altered ventilatory
mechanics or CNS depression.
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LIFE-THREATENING THORACIC INJURIES

A: Airway obstruction
T: Tension pneumothorax
O: Open pneumothorax
M: Massive hemothorax
F: Flail chest
C: Cardiac tamponade

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 Tension Pneumothorax
Air accumulation within the pleural
space
Collapse of affected lung
Pushing of other contents of
mediastinum to the opposite side
Compression of heart and major
vessels and reduced venous return
CF:
chest pain
Management:
air hunger
respiratory distress Immediate decompression by
tachycardia insertion of a large-bore needle into
Hypotension
tracheal deviation
the second intercostal space followed
unilateral absence of breath sounds by Chest Tube Insertion
hyper resonant percussion note

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 MASSIVE HEMOTHORAX
Rapid accumulation of more than 1500 ml of
blood in the chest cavity.
Damage to great vessels
Dull percussion note
Hypovolemia

Drainage followed by
thoracotomy

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 FLAIL CHEST
Result of trauma associated
with multiple rib fractures
with a number of ribs being
fractured in two places
Chest wall loses bony
continuity with the rest of
the thoracic cage
Disruption of the normal
chest wall movement
Rx
Adequate ventilation
Splinting the area
Humidified oxygen
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Good analgesia
 C: CIRCULATION AND
HEMORRHAGE CONTROL
Or, identification of shock
Definition of shock inadequate organ
perfusion
Causes of shock
Hemorrhage/hypovolemia
Compressive
Cardiogenic
Neurogenic
Sepsis
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 CIRCULATION
General Clinical Features Of Shock
Hypotension (Systolic BP<70mmHg)
Tachycardia (>100/min)
Cold , Clammy Skin
Rapid,Shallow Respiration
Drowsiness,Confusion,Irritability
Oliguria (Urine Output<30ml/hour)
Multi-Organ Failure
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 Circulation
Treatment of shock
Direct pressure on external bleeding
Initial 2 liter bolus of crystalloid fluid RL
Responder:
vital signs return toward normal
Loss of less than 20% of circulating volume and are not actively
bleeding
Transient responder:
The vital signs initially improve but then deteriorate.
Still actively bleeding from an occult site.
Require transfusion with blood
Identify source of bleeding 26
 Circulation
Nonresponders:
The vital signs do not improve.
Blood loss is continuing at a rate at least equal to the rate of fluid
replacement.
Central line
Immediate surgery and transfusion

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 D: DISABILITY
Level of
consciousness
Best indicator of
central perfusion &
deterioration of
patient status
Pupils
GCS
AVPU
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 E-EXPOSURE
Head to toe examination of the patient for injury
Pitfalls
Maintenance of spine precautions
Prevention of heat loss
Under cervical collar
Back and flanks

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 Adjuncts to the Primary Survey
Exams during or after primary survey to
aid in identifying life-threatening injuries
Chest x-ray
Pelvis x-ray
Focused abdominal sonogram for trauma
(FAST)
Diagnostic peritoneal lavage (DPL)

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 Secondary Survey
and Definitive Treatment
The secondary survey is a complete head
to toe evaluation of the patient
Adjuncts to the secondary survey include
CTs, plain radiographs, blood tests
Treatment plans, especially for multiple
injuries, based on clinical status and
specific injuries

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 Resuscitation
Aim is to Restore Organ Perfusion
How much is enough? What are the endpoints of
resuscitation?
Heart rate, blood pressure, urine output
May lead to compensated shock
Global indicators of perfusion
Lactic acid, base deficit
Cardiac output, oxygen delivery, oxygen consumption
Mixed venous O2 saturation (SvO2)

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 Resuscitation
Maintain Airway
Restore Breathing
Restore Circulation
2 wide bore IV Cannula
Ringers Lactate
Blood
Analgesics
Antibiotics
Tetanus Toxoid
Splint Fractures
Pass Foley

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 Resuscitation Initial
Management of Head Injury
Maintain Airway
Give Oxygen
IV Line
Inf Ringers
Inf Mannitol
Maintain adequate MAP and Brain Perfusion
Analgesics
Antibiotics
Tetanus Toxoid
Prop Up by 30 Degrees
Skull X Ray/CT Scan Brain
Neuro-observation
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Questions?

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