1. Dr. Faiez Alhmoud
Department of Surgery
Albashir Teaching Hospital – MOH – Amman
Jordan

2. • Trauma epidemiology & the burden of trauma
• Rapid & accurate assessment of the patient‟s
condition (the concept of triage )
• How to identify common life-threatening
injuries (Primary Survey)
• Adequate resuscitation, stabilization and re-
evaluation of patients according to the priority.
• Performing a secondary survey and planing the
next stage of care

4. Our Roads is a cause
Our Attitude as a cause
13-11-2013 08:12 AM
…..
[8/11/2013 12:35:08 AM]
16/11/2013
17/11/2013

5.  The leading cause of death in age group
2-40 years (great impact on family)
 The third leading cause of death all over
the world in all age group & in 2020 may
be second cause of death
 420 million injured / year worldwide
 5.8 million deaths / year worldwide (>9
people/min. )
 3 patients permanently disabled / death
 >15% of hospital beds are consumed by
injury
 Great economic & social loss (2% of
budgets for health or $ 750 bil. ).
 Most expensive medical problem in
terms of lost wages, initial care,
rehabilitation, and lifelong maintenance
 The neglected disease of modern
developing nations
Epidemiology Overview

6. Can this outcome be better?
How…?
TRAUMA DEATH FACTS
•1 in 3 traumatic deaths occurred in
hospital could have been prevented
•Some deaths might be due to failure of
simple early management (golden hour)

7. 1.Early pre-hospital
care
2.Early transport
3.Aggressive
resuscitation and
interventions in ED
4.Continued care in
ICU if needed
Golden hour
• If you are critically
injured, you‟ll have
less than 60 minutes
to survive.
You might not die right
then; it may be three
days or two weeks
later -but something
has happened in your
body that is
irreparable” .
Dr. R. Adams Cowley
“Father of Trauma Medicine”

9.  The first
peak……within
minutes
 50% - Death at the time of injury
 apnea due to severe brain injury,
high spinal cord injury
 Primary injury to vital organs
such as brain, heart, great
vessels..
 The injuries are nonsurvivable
but rapid treatment and transfer
may salvage some patients
 Primary prevention

10. • 30% - Hours from the first peak
• Patients have the best chance
for survival if definitive care is
available within an hour after
injury
• Morbidity and mortality are prevented
by avoidance of a secondary injury
due to :
hypoxia, hemorrhage, (intracranial
hematoma, major hemorrhage from
viscera, bones fractures and vessels
or hemothorax)
• ATLS [Advanced Trauma Life
Support] →9%
• Prehospital and ER care
Hero
Or Zero?

11.  20%
 Death occurs days or
weeks after the injury in
the ICU
 Sepsis and or multi-organ
failure is the usual cause
 Advances in intensive care
reduce some deaths
Improvements in initial management on admission
reduce the 3rd peak morbidity and mortality

12. Patients have the
1st & best chance
for survival if
definitive care is
available within an
hour after injury

13. Conflict Evacuation
time (hour)
Mortality rate (%)
World War I 18 18
World War II 4-6 3.3
Korea 2-4 2.4
Vietnam
Iraq and Afghani..
1-2
30`-60`
1.8
1
WW I: 1914World War II: 1939Korean War: 1951
Viet Nam War
: 1965-1972
Emergencies don‟t give us a
second chance…..

14.  Physiologic approach
 Time is of the essence
 Treat greatest threat to life first
 Definitive diagnosis less important
 Do no further harm
 Teamwork required to succeed
Logical Sequence 1- Preparation 2- Triage
3- Primary Survey 4- Resuscitation
5- Secondary Survey
6- Definitive Management
With frequent repetition of the primary & secondary
surveys to confirm pt‟s response to therapy
ATLS
"When I can
provide better
care with
limited
resources”
James K. Styner
1978

15. ATLS provides a
common language
These guidelines seek to set achievable
standards for trauma treatment services
which could realistically be made
available to almost every injured person

16. •On the scene, the EMS action is to prevent
any further harm to victims
•The “primary survey” reveals obvious
injuries .It includes limited interventions
Airway control
Oxygenation and ventilation support
Hemorrhage control
Spinal Immobilization
Rapid Transport to appropriate facility
Victim is placed on a long back-board
Anti-shock trousers placed
IV lines if time allows
History taking ( include events )

17. “Triage : a sorting of injured
people according to their need
for emergency medical attention
to get the :
Right……….. patient to the
Right……….. place at the
Right……….. time with the
Right……….. care provider“
Simple triage & rapid treatment
“START” assesses RPM:
• Respiration
• Pulse
• Mental Status

18. • The approach In dealing with the trauma
victim cannot be routine “history, exam
,tests, diagnosis ,then treating the patient.”
•Therapeutic interventions must be made “on
the fly,” before the full evaluation can be
completed.(Primary Survey)
• A trauma surgeons have “threshold of
action” a point at which the physician will
aggressively intervene even without
traditional “proof” of the diagnosis.
• For example, the combination of low blood pressure,
unilaterally decreased breath sounds, and respiratory distress
Triggers a response from the physician. A chest tube is placed
immediately, rather than waiting until an x-ray
can “prove” the diagnosis

19.  Airway obstruction
 Tension pneumothorax
 Sucking chest wound
 Cardiac tamponade
 Massive hemothorax
 Massive bleeding
 Large scalp lacerations
 Pelvic and other long bone fractures

20. Priorities are the same for all !!!!

21. • A quick look tells you a lot about the patient‟s
status.
 Is he breathing?
 Does he look at you?
 Is the C-spine immobilized?
• Address the patient directly. If the patient gives
any meaningful answer, you will know that:
1) There is an intact airway
2) Ventilation is occurring
3) Circulation is present.
4) The brain is reasonably functional
If the C-spine is not
immobilized in any patient
at risk ask someone to
stabilize it now

22. Look for :
- Snoring, gurgling, stridor or hoarseness
- Use of accessory muscles or “seesaw “
breathing.
- Agitation or obtundation
- F.B ( airway debris, blood, vomitus, teeth….
- Unconscious.
- Cyanosis.
- The likehood of difficult airway
(Possible airway compromise)

23.  Continuous observation and “high
index of suspicion” in patients with :
- Maxillofacial injury
- Soft-tissue injury of neck
- Facial or neck burns
- Neck surgical emphysema
- Laryngeal pain with swallowing or talking

24. Assume C -spine injury in any pt. with ;
 -Multi-trauma patient
 -Blunt injury above clavicle
 -Pain of neck with or without
neurologic deficit.
 -Unconscious patient
(Immobilizing devices or special
maneuvers are recommended)

25. -Chin lift / modified
jaw thrust
-Remove F.B &
suctioning
-Oropharyngeal or
Nasopharyngeal
airway
-Laryngeal mask
airway
-Definitive airway
-Reassess frequently
Jaw Thrust
If no gag reflex,
prepare for
intubation
-All patients with
GCS <9 need
intubation
- IN Suspected C-
spine injury do not
head tilt chin lift

27. Three
Varities:
1-Orotracheal tube
2-Nasotracheal
tube
3-Surgical airway.
-Cricothyroidotomy
-Tracheostomy

28. Consider the need for advanced airway
management techniques in:
• Persisting airway obstruction
• Penetrating neck trauma with (expanding)
haematoma
• Apnoea
• Hypoxia
• Severe head injury
• Severe chest trauma
• Maxillofacial injury.
Indications for advanced
( definitive) airway

29. (LOOK)
• Penetrating injury
• Presence of flail chest
• Sucking chest wounds
• Use of accessory muscles?
• Cyanosis
(FEEL)
• Tracheal shift
• Broken ribs
• Subcutaneous emphysema
• Percussion is useful for diagnosis of haemothorax and
pneumothorax.
(LISTEN)
• Pneumothorax (decreased breath sounds on site of injury)
• Detection of abnormal sounds in the chest.
The respiratory rate
and effort are sensitive
indicators of chest
trauma. They should
be monitored and
recorded at frequent
intervals.
expose the
patient
adequately
without causing
hypothermia

30. Pericardiocentesis
oxygen and
analgesics
insert a CTTDCover the defect.
& Insert (CTTD)
Urgently decompress
-If available,
maintain the
patient on oxygen
until complete
stabilization is
achieved.

31.  Quickly re-check airway patency, breathing and
oxygen supply before assessing circulation.
Assess the features of
hypovolemia
-Cold, clammy extremities
-Poor capillary refill
-Tachycardia (>120 beats /minute)
-Low blood pressure (systolic
blood pressure <80mmHg)
-Altered consciousness
(hypovolemia alone can cause
decreased conscious level)

32. • Children
• Elderly
• Athletes
• Pregnancy
• Medications

33. Blood pressure (SBP) can be
estimated from peripheral pulse
presence
Largest blood loss
in thorax, abdomen, pelvis, extremities
Non-hemorrhagic shock
 -Cardiogenic shock
 -Tension pneumothorax
 -Neurogenic shock
60
7080
90

34. Circulation and haemorrhage control treatment
options include:
 Warm fluids (crystalloids) up to 2lit. Or 20ml/kg
 Arrest bleeding by direct local pressure
 Arrest bleeding by splinting bones & pelvis
 Avoid tourniquets and if they must be used, the
duration of application must be monitored
 Central line if inotropes / vasopressors are needed
 Urinary catheter
 Warm blood and
 Blood products
 Surgery („damage control‟ or definitive)

35.  There is a rapid neurological assessment
 Assessing AVPU is quick and easy to do
 ALERT - GCS 14-15
 VERBAL STIMULATION RESPONSE - GCS 9 – 13
 RESPONDS TO PAIN ONLY - GCS 4 – 8
 UNRESPONSIVE - GCS 3
 It is a baseline for more detailed
neurological examination carried out in the
secondary survey

36.  Fully expose the patient whilst assuming that other
injuries are present
 Prevent hypothermia by controlling room temperature or
covering the patient with blankets immediately after
examination.
 To expose the patient, use scissors to cut along the seams
of clothes to avoid worsening any injury and ensure
minimal movement of the patient.
 Do not forget to do a rectal examination whilst log rolling
the patient
Findings on rectal examination
• Rectal bleeding or bone spicules suggest a pelvic fracture
• A high riding prostate suggests urethral injury
You may miss injuries if you do not fully expose the patient

37. Almost every patient with severe trauma should
have a cross-table C-spine x-ray, chest x-ray, and
pelvis x-ray. The rationale:
Neck pain may be missed in
a massively-injured patient, and the
cost of missing a cervical fracture is great.
The chest may have significant
internal injury without external tenderness.
Pelvic fractures are often present in
patients with trunk trauma, and are
often missed.
Order these important x-rays before the patient
leaves the emergency department for other care

38.  Stable hemodynamics.
 Stable oxygen saturation.
 Normal temperature.
 Urinary output > 1ml /kg/hr.
 No requirement of inotropic
support.
 Lactate level below 2 mmol / L.
 No cogaulation disturbance.

39.  Is the airway patent and secure?
 Is the patient receiving high flow oxygen?
 Is the cervical collar in place?
 Are all the tubes in place? i.e. urinary catheter,
nasogastric tube and intravenous lines
 Have blood samples been sent to appropriate
laboratories?
 Are the vital signs being recorded every 5 minutes?
 Have the X-ray forms been filled?
Only then can you consider a secondary survey

40. Key Components
 History
 Physical examination: Head-to-toe
 “Tubes and fingers in every orifice”
 Complete neuro-exam
 Special diagnostic tests and X-rays
 Monitoring and resuscitation
 Special procedures
 Re-evaluation

41. The history must include…….. Remember
“SAMPLE”
 S Symptoms
 A Allergies
 M Medications
 P Previous medical/ surgical history
 L Last meal (Time)
 E Events / Exact circumstances

42. Examination of all body regions:
Head & Face
Neck
Chest
Abdomen
Pelvis
Extremities
Neurological examination + pupils +
sensation
Region by region, look for:
•Deformities , swellings &
movements limitations
•Contusions
, abrasions, lacerations, punctures
& penetrations
•Burns
•Tenderness
•Pulses
•Tone, power, motor

43.  Blood for lab tests can be drawn through
the second IV catheter. This insures that
there is no delay in starting fluids via the
first
 At a minimum, the victim of trauma should
have a baseline blood count and urinalysis.
 Severely injured patients should have a
CBC, KFT, UA, electrolytes, blood gases,
clotting studies, and type & crossmatch.

44.  Common special procedures for trauma are
1) FAST
2) CT of the brain,
3) CT of the abdomen and pelvis
4) Laparoscopy ??!
5) DPL
• Special procedures should only be ordered
when:
the patient is sufficiently stable that
there is little likelihood of
deterioration during the time of the
testing
the information desired from the
procedure cannot be obtained in other
ways
the test is necessary to
determine the next
appropriate step of therapy

45.  During and after the secondary survey, the
physician monitors the effects of prior
resuscitation efforts.
This is primarily through patient color, skin
temperature, mental status, blood
pressure, respiratory rate, and pulse rate.
 If the patient does not respond to fluid
infusion, a CVP monitoring catheter must be
placed.A low CVP (less than 6
indicates
the need for further
fluidA high CVP
raises suspicion of
obstructive shock
The combination of
inappropriate
bradycardia with systolic
pressures of around 80,
warm extremities,
and a normal CVP
reading is typical of
spinal shock.

46. The pulse oximeter provides a useful,
rapid method of monitoring oxygenation
in the patient with severe pulmonary
injury.
Progressive respiratory distress, or
hypoxemia despite supplemental
oxygen, warrants endotracheal
intubation

47. Paracentesis is a rapid method of determining the need for
abdominal surgery.
Paracentesis (peritoneal lavage) is not needed for patients
who:
1) Have a reliable and normal abdominal exam .
2) Are fully stable to wait for CT scanning, or
3) Urgently need abdominal surgery based on other
findings.
Assuming no contraindication, perform paracentesis on the
potentially unstable trauma victim with possible
abdominal injury who does not already have indications
for abdominal surgery
Assume that any trauma patient with decreased level of
consciousness has abdominal injury until excluded by
paracentesis ,FAST or CT scan
Any patient with a gunshot wound requires exploration, so
paracentesis is not indicated. However, peritoneal lavage
may be helpful in the stabbing victim to rule out bowel
perforation

48.  Obstructed airway is opened and maintained before hypoxia
leads to death or permanent disability.
 Impaired breathing is supported till the pt.is able to breath
without assisstance
 Bleeding is promptly stopped
 Shock is recognized and treated
 The consequences of brain injury are lessened
 Intestinal and other abdominal injuries are promptly recognized
and repaired.
 Potentially disabling extremity injuries are corrected.
 Potentially unstable spinal cord injuries are recognized and
managed
 Medications for the above services and for the minimization of
pain are readily available when needed
 What resources are available in the hospital?
 Then may require surgery and/or intensive care or transfer

49. The patient does not leave the
emergency department for
definitive care (whether to the
operating room or to a higher
care facility or to ICU) until the
secondary survey and critical
testing are complete

50. Many of trauma related
deaths are
preventable, and its
time to realize this fact.