assessment + management

2. TRAUMA MANAGEMENT

3. Presented by:
Dr. M. RIZWAN
PG Scholar
Dept of surgery
NIUM, Bangaluru

4. TODAYS DISCUSSION…….
 DEFINITION OF TRAUMA
 EPIDEMIOLOGY OF TRAUMA
 A BRIEF DESCRIPTION OF TRAUMA
 GOLDEN HOURS IN TRAUMA
 MANAGEMENT OF TRAUMA
 ASSESSMENT IN TRAUMA
 INDICATION OF ICU ADMISSION
 TAKE HOME MESSAGE

5. WHAT IS TRAUMA?????
• THE TERM TRAUMA IS DERIVED FROM A GREEK WORD
WHICH MEANS A WOUND/A HURT
• In simple word-any BODILY INJURY is referred as TRAUMA
• TRAUMA MAY BE DEFINED AS, AN INJURY TO THE LIVING TISSUE CAUSED BY
AN EXTRINSIC AGENT.
• AN EXTRINSIC AGENT
• mechanical, thermal, electrical, electromagnetic or nuclear

6. EPIDEMIOLOGY OF TRAUMA
leading cause
of death in age
group 2-40
years of age.
420 million
people are
injured / year,
worldwide
5.8 million
deaths / year,
worldwide,
>9
people/min
60% of
preventable
deaths occur
in the first
24 hours.

7. ARE YOU AWARE?
• 3.2% MORE DEATHS
THAN HIV ,TB
,MALARIA, all
combined together
• WHO predicted, by
2020, RTA will be 2nd
leading cause of death

8. Hospitalisation & deaths in trauma victims

9. A brief
description Some Facts
about trauma

10. COMMON CAUSE OF TRAUMA
RTA/ MVA
FALLING FROM HEIGHT
STABE INJURY
BOXING/ PUNCH
GUNSHOT
FIR
BOMB BLAST
INJURY DUE NATURAL CALAMITIES

11. Mechanism of Traumatic Injury
BLUNT TRAUMA
PENETRATING TRAUMA

12. BLUNT TRAUMA
TISSUES ARE NOT PENETRATED BY EXTERNAL OBJECT
Results from Distributed dissipation of kinetic energy
Leads to direct contusive injury, shearing, vascular disruption, & indirect
laceration secondary to fractures
commonly results from road traffic collisions, falls and sports-related
accident.

13. PENETRATING TRAUMA
DISRUPTION OF SKIN AND TISSUES IN A LOCALISED AREA.
More focal dissipation of a projectile’s kinetic energy Leads to direct impact
laceration and fractures
Associated with knife, firearm, farming, traffic or other accidents.

14. IMPACT PATTERNS IN MOTOR VEHICLE CRASHES
FRONTAL OR HEAD ON IMPACTS LATERAL OR SIDE IMPACTS ROLL OVERS
Pedestrian Vs. CarOpen Vehicle or Motorcycle/Moped

15. FALLS FROM HEIGHT
SEVERITY OF INJURIES IMPACTED BY
o Height
o Position
o Surface
o Physical condition
Indication for the transfer to trauma centre
 Falls from a height of >6 m (>20 ft) in adults and
 Falls from a height of >3 m (>10 ft) in children

16. GUNSHOT WOUNDS
SEVERITY DEPENDS ON
Distance of victim
Types of tissue struck

17. Indication for the transfer to trauma centre
 High-risk automobile crash
Penetrating injuries to head, neck, torso and extremities
proximal to elbow or knee.
 Chest wall instability or deformity
 Two or more proximal long bone fractures
 Crushed, degloved, mangled or pulseless extremity
 Amputation proximal to wrist or ankle
 Pelvic fractures
 Open or depressed skull fracture
 Paralysis

18. High-risk automobile crash
 Car deformity with intrusion of the car body (including the roof)
of >30 cm (>12 inch) at the occupant site or >45 cm (>18 inch) at
any site
 Ejection of passenger (partial or complete) from automobile
 Death in same passenger compartment
Auto vs. pedestrian/ bicyclist thrown, run over or with significant
(>30 km/h; >20 mph) impact
 Motorcycle crash >30 km/h (>20 mph)

19. Special precaution or system considerations
Older adults
 Risk of injury related death increases with the age >55 years
 Systolic blood pressure of <110 mmHg may represent shock in
patients aged >65 years.
 Low-impact mechanisms (e.g. ground level falls) may result in severe
injury.
Concurrent use of anti-thrombotic drugs, which makes them vulnerable
to bleeding e.g. intracranial haematomas.
Children
 should be triaged to trauma centres with high level paediatric facilities.
Pregnancy: >20 weeks

20. Death following trauma (TRIMODAL DISTRIBUTION)
30%
20%
50%
Immediately Hours Days/Weeks
 Three peaksareobserved
 80% of deaths occurs in 1st hour
afterinjury(goldenhour)

21. Golden hour
IT’S THE FIRST ONE HOUR FROM THE TIME OF
TRAUMA
80% of death can be prevented by:
 early recognition of life threats and their immediate
management
 early Transportation to an APPROPRIATE facility trauma centre

22. • APNOEA DUE TO SEVERE BRAIN INJURY,
HIGH SPINAL CORD INJURY
• PRIMARY INJURY TO VITAL ORGANS
SUCH AS BRAIN, HEART, GREAT VESSELS..
• THESE INJURIES ARE NON-SURVIVABLE
BUT RAPID TREATMENT AND TRANSFER
MAY SALVAGE SOME PATIENTS
50% -
Death
occurs at
the time
of injury
1st PEAK ..within minutes

23. 2nd PEAK within an hour
30% -OF DEATHS
OCCURS-
WITHIN 1 HOURS
FROM THE FIRST PEAK
SUB DURAL
HEMATOMA,HEM
O/PNEUMO
THORAX
BEST CHANCE FOR
SURVIVAL - IF CARE IS
AVAILABLE WITHIN AN
HOUR
MORBIDITY AND
MORTALITY
PREVENTED - BY
AVOIDING SECONDARY
INJURY DUE TO:
HYPOXIA AND
HAEMORRHAGE

24. USUAL CAUSE-
SEPSIS AND MULTI
ORGAN FAILURE
BEST TREATED
BY APPLYING
PRINCIPLES OF
ATLS
ADVANCE
INTENSIVE CARE
REDUCES THE
MORBIDITY AND
MORTALITY
IMPROVEMENTS IN
INITIAL
MANAGEMENT ON
ADMISSION
REDUCE THE 3RD
PEAK MORBIDITY
AND MORTALITY
3rd PEAK- days or weeks after

25. 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 if it not happen,
something un-repairable. might
happen to your body
Dr. R. Adams Cowley

26. DIFFICULTIES IN MANAGEMENT
ATTITUDE OF
NEGLIGENCE
NON-AVAILABILITY
OF TRAINED
MANPOWER
NON-AVAILABILITY
SUITABLE
INFRASTRUCTURE

27. Management of trauma requires
Broad
knowledge
Sound
judgme
nt
Technical
skills and
Leaders
hip
capabilit
y
Better management depends
on assessment skills
An organized
approach
Clearly defined
priorities
Understanding
of available
resources
Good assessment results from

28. Principles of Trauma Management
Organized team approach
Assumption that most serious injury has occurred
Treatment before diagnosis
Thorough examination
Frequent assessment
Don’t get distracted with ugly injuries

29. ASSESSMENT IN TRAUMA
Objectives
To know the correct sequence of TRIAGE
To perform primary and secondary survey
To know history of trauma incident and
thus the type of injury received
To set a Guidelines for initial resuscitation
and definitive treatment

30. • Pre-hospital phase
• In hospital phase
1. Preparation
2. Triage
3.Primary Survey ( ABCDEs)
4.Resuscitation
5.Secondary (Survey head to
toe evaluation)
6.Definitive Management
ATLS® has following components
Advanced Trauma Life Support (ATLS®)
A systematic approach should always be practiced

31. Preparation
Pre-hospital Phase :
The receiving hospital should be notified about the patients condition for- Advanced
planning
Pre- hospital
Preparation
Airway control
Oxygenation
and ventilation
support
Haemorrhage
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

32. In-hospital Phase
Bleep the trauma team to keep ready with;
Airway equipment
Warmed IV fluids (crystalloids/colloids)
Monitoring facilities with lines etc.
Procedural equipment
Information to Laboratory department
Information to Radiology department
Bed made available for transfer
Transfer agreements with other hospital
Universal precaution gear (mask, gloves, gown, etc)

33. TEAM LEADER CHECKLIST
• TRAUMA TEAM ACTIVATION PRIOR TO
ARRIVAL
• UNIVERSAL PRECAUTION IN PLACE
• LEAD AND GOWNS IN PLACE
• WARMED IV FLUID HANGING
• O-ve BLOOD READY,BLOOD WARMER
&RAPID INFUSER READY
• ORTHO RESIDENT NOTIFIED
• RADIOLOGY NOTIFIED

34. PRE HOSPITAL INFORMATION AT THE TIME OF HANDOVER
M-I-S-T
• MECHANISM OF INJURY
• INJURIES SUSTAINED OR SUSPECTED
• SIGNS- VITALS ON SCENE AND DURING
TRANSPORT
• TREATMENT INITIATED

35. ON PATIENT’S ARRIVAL
AIRWAY
DOCTOR
CIRCULATION
NURSE
AIRWAY
NURSE
CIRCULATION
DOCTOR
ORTHO
REGISTRAR
SOCIAL
WORKER
TEAM
LEADER
SCRIBE
NURSE
RADIOGRAPHER

36. 2. Triage
It is sorting of injured people according to their need for immediate
resuscitation
Simple triage
for rapid
treatment
RPM
•Respiration
•Pulse
•Mental Status
•Treat greatest threat to life first
•Definitive diagnosis is less important
•Do, no further harm to the patient

37. Priorities of triage for Resuscitation
High-Priority Areas
· Airway/breathing
· Shock/external haemorrhage
· Impending cerebral herniation
· Cervical spine
Low-Priority Areas
· Neurological
· Abdominal
· Cardiac
· Musculoskeletal Soft tissue injury

38. 3. Primary Survey
Objectives
To find and correct the threats to the life
If it can’t be corrected Support oxygenation, ventilation and perfusion
Transport to centre with appropriate facilities !!
Most obvious or dramatic injury usually is not what is killing the patient

39. PRIMARY SURVEY
Rapid clinical assessment should be done systematically (following
the ‘A-B-C-D-E’ approach
• ABCDEs of trauma care
• A Airway and c-spine protection
• B Breathing and ventilation
• C Circulation with hemorrhage control
• D Disability/Neurologicstatus
• E Exposure/Environmental control

40. • Assume C-SPINE injury in all patients with multisystem trauma
so stabilise the C-spine first.
• Examine for stridor, hoarseness, gurgling
• Assess for patency of Airway, if not establish the patency.
• Inspect for any foreign body and the remove it.
• Examine for pooled secretions or blood in oro-pharyngeal
cavity.
A-AIRWAY ASSESSMENT AND C-SIPNE CONTROL

41. MILS- MANUAL IN LINE STABILISATION
• INDEX FINGERS IN THE
EXTERNAL AUDITORY CANAL
• PALMS ON THE
PARIETAL BONE
• THUMBS ON THE FORE HEAD
• REMAINING FINGERS UNDER
THE MASTOID PROCESSES
• WITHOUT APPLYING
AXIAL TRACTION

42. C-spine Immobilization
Return the head to neutral position
Correctsized CervicalSpinalCollar is applied
Stabilizethe positionofheadand neckwithBlocks/
tape/Sandbags
 Longrigidspinalboardorimmobilizationonflate
surfacesuchas stretcher=T/LSpine
19

43. Impending cerebral herniation
In C. herniation brain tissue, cerebrospinal fluid, and blood vessels
are moved or pressed away from their usual position inside the skull.
Require immediate recognition and treatment to prevent irreversible
injury and death
Signs and symptoms of cerebral herniation
 High blood pressure.
 Irregular or slow pulse.
 Headache.
 Weakness.
 Cardiac arrest (no pulse)
 Loss of consciousness, coma.
 Loss of all brainstem reflexes (blinking, gagging, and pupils reacting to light)
 Respiratory arrest (no breathing)

44. Treatment of cerebral herniation
 The goal of treatment is to save the person's life.
 Increased Intra-cranial pressure, treated through the Medication such
as Mannitol or other diuretics.
 Placing a drain into the brain to help removal of excessive
cerebrospinal fluid (CSF)
 Endo-tracheal intubation
 Removal of blood or blood clots
 If pressure is raising inside the skull and causing herniation, remove a
part of the skull to give the brain for more room

45. Obstructions of Airway can be partial or complete
signs of partial obstruction
Weak cough
High-pitched wheezing
Increased straining while breathing
Clutching at the throat
Slight cyanosis (blueness)
Signs of complete airway obstruction
Inability to speak, groan, cough, or cry out
Absence of breath sounds
Labored use of muscles used in breathing
Progressive restlessness, anxiety, and
confusion
Unresponsiveness

46. OPENING, THE AIRWAY
A. Head-Tilt/Chin-Lift
B. Jaw Thrust Technique

47. Head-tilt/Chin-lift Maneuver
1. Place one hand on the patient’s forehead and
gently tilt their head back.
2. Place the fingertips of the other hand under the
point of the patient’s chin and gently lift up to
stretch the anterior of the neck structures.
CAUTION:
 Do not use the thumb to lift the lower jaw.
Do not press deeply into the soft tissue under the chin with the fingers.
Do not completely close the casualty’s mouth. If you see something inside it

48. Jaw-thrust Maneuver
 Kneel behind the casualty’s head, steady and support
the head in the neutral position, head, neck and spine
are aligned.
 Place your hands on each side of the face with your
fingertips at the angle of the jaw (mandible)
 Gently lift the jaw to open the airway. Take care not to
tilt the neck.
 The movement of the jaw moves the tongue forward
in the mouth opening the airway
Caution: Do not put the fingers in the mouth to assist the jaw thrust.

49. Removal of foreign body

50. PATIENT
CONSCIOUS
ORIENTED
FAILS TO RESPOND
APPROPRIATELY(DROWSY
OR UNCONSCIOUS)
THREATENED
AIRWAY
MANDATORY
INTUBATION
1. GCS<9
2. SEVERE FACIAL
INJURY OR BLEED
3. SEVERE FACIAL
OR NECK BURNS
CONSIDER INTUBATION
1. COMBATIVE
PATIENTS
2. GCS -9-12
3. FACIAL OR
INJURY
IMPENDING
NECK
WITH
AIRWAY
COMPROMISE(PENET
RATING INJURY)
YES (VOCALISES
NORMALLY)
ASK TO TAKE DEEPBREATHS
ASSESS UPPERAIRWAY,
CHEST EXPANSION
SUPPLEMENTAL O2
CERVICALCOLLAR

51. • PRE-INTUBATION-
• SUPPLEMENT OXYGEN
• OROPHARYNGEAL SUCTION
• JAW THRUST
• ORO-PHARYNGEAL AIRWAY
• RAPID SEQUENCE INDUCTION AND ENDO-TRACHEAL INTUBATION
• DIFFICULT AIRWAY ANTICIPATED-
• AIRWAY INJURY
• HEAD AND NECK INJURY
• SHORT NECK
• REDUCED MOUTH OPENING
• SURGICAL AIRWAY
• CAN’T INTUBATE
• DISTORTED ANATOMY
• IN FAILED INTUBATION – LMA AS BRIDGE

52. • FOB
• specialized laryngoscopes
• Bougies
• double lumen tubes
• Laryngeal injury-immediate tracheostomy
• Perform a surgical cricothyroidotomy, if above measures
fails
ADVANCED AIRWAY TECNIQUES

53. B-BREATHING WITH SUPPLEMENTATION OF OXYGEN
 Rapid assessment of
• RR
• SPO2
 INSPECT:Equal chest rise, paradoxical chest
movements,sucking chest wound, distended neck veins
 PALPATE: position of Trachea,chest wall tenderness,
subcutaneous emphysema, sternum and rib fracture
 PERCUSS:dullness,hyperresonance
 AUSCULTATE: equal breath sounds, absence of breath
sounds
 Patent airway does not mean equal and adequate
ventilation
 Do not confuse airway problem for ventilation problem.

54. Respiratory Distress: Signs and Symptoms

55. TENSION PNEUMOTHORAX
• RESPIRATORY DISTRESS
• HYPERINFLATED CHEST
• DEVIATED TRACHEA
• DECREASED MOVEMENT
• DECREASED BREATHSOUND
• TACHYCARDIA
Needle thoracostomy via 2nd ICS in MCL followed by definitive chest
tube (4th- 5th ICS just anterior to mal connected to water under seal
drain)

56. MASSIVE HEMOTHORAX
• SIGNS SIMILAR TO TENSION
PNEUMOTHORAX EXCEPT
DULLNESS ON PERCUSSION
• SHOCK
• T R E AT M E N T - TUBE
THORACOSTOMY
• THORACOTOMY IN
• >1500ml DRAIN IMMEDIATELY
• >200ml/hr FOR 4 HOURS
• CONTACT CTVS EARLY.

57. FLAIL CHEST
• >2 RIB FRACTURES IN 2 OR MORE
PLACES
SYMPTOMS AND SIGN
• PAIN
• SHORTNESS OF BREATH,
• PARADOXICAL CHESTWALL
MOVEMENT
 BLOOD OXYGEN LEVELS DROP AND
CARBON DIOXIDE LEVELS INCREASE
• T/T: ADEQUATE VENTILATION
• REEXPAND LUNGS: INTUBATION,
IPPV, CTVS CONSULTATION

58. C-CIRCULATION AND HEMORRHAGECONTROL
ASSESS-
• PULSE RATE AND CHARACTER
• SKIN COLOUR AND TEMPERATURE
• CONSCIOUSNESS LEVEL(GCS)
• CAPILLARY REFILL TIME
• DECREASED URINE OUTPUT
• HYPOTENSION-A LATE SIGN WHEN≥ 30% BLOOD VOLUME
LOST.
• Stopping the bleeding is most important priority

59. IDENTIFY
• External hemorrhage
• Apply direct pressure
• Be aware of possible sources of internal
bleeding both from blunt and penetrating
trauma

61. Primary Survey - Circulation

62. MANAGEMENT OF CIRCULATION
• Control bleeding with direct
pressure
• Splint limb fractures
• Insert 2 large bore IV cannulas in
adults
• Send off blood-cross match,
coagulation screen, Hb, hct,
biochemistry, blood alcohol level
if req
• Intraosseous needle in children up
to 1 0 yrs.

63. • Fluid replacement: adults up to
2 - 3 lt
crystalloid/colloid,
• Children 20 ml/kg
• Blood replacement
• O neg,group specific or fully
cross matched packed cells
• Remember other blood product
requirements: ffp, cryoppt,
platelets

64. D-DISABILITY AND NEUROLOGIC STATUS
DISABILITY ASSESSEMENT:by AVPU SCALE
• A- Alert i.e. Obeys commands
• V- vocalizes-inappropriate or incomprehensible
• P- Responds to pain
• U- Unresponsive
No spinal tenderness
Normal conscious state
Normal neurological examination
No major distracting injury- Collar may be removed and no further
investigation required
NEUROLOGIC ASSESSMENT BY - GCS SCALE

65. GLASGOW COMA SCALE
Variables Score
Eye opening Spontaneous
To speech
To pain
None
4
3
2
1
Verbal response Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Best motor respons Obeyscommands
Localizes pain Normal
flexion
abnormal flexion
Extension
None
6
5
4
3
2
1
(E+M+V).
Score 3-8 points = severe head injury
Score 9-12 points = moderate head injury
Score 13-15 points = mild head injury

66. Disability Interventions
• Spinal cord injury
• High dose steroids, within 8 hours
• ICP monitor- Neurosurgical consultation
• Elevated ICP
• Head of bed elevated
• Mannitol
• Hyperventilation
• Emergent decompression

67. E- Exposure
You can’t treat what you don’t find!
If you don’t look, you won’t see!
Logroll the patient to examine patient’s back
Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine
Minimum of 3 people, often more providers required
Avoid hypothermia
Apply warm blankets after removing clothes
Hypothermia = Coagulopathy
Increases risk of hemorrhage

68. Trauma Logroll
• One person = Cervical
spine
• Two people = Roll main
body
• One person = Inspect
back and
palpate spine

69. Always Inspect the Back

70. 3.RESUSCITATION
• Protect/Secure airway & protect C-spine
• Breathing/Ventilation/Oxygenation
• Vigorous shock therapy
• At least two large - caliber IV line
• Crystalloid solution ( Ringer’s lactate 2~3 litter)
• Type-specific blood
• surgical intervention
• Protect from Hypothermia : 39oC warm IV fluid
• Urinary/gastric catheters unless contraindication

71. 4.PRIMARY SURVEY ADJUNCTS
• MONITOR VITALS
• ECG
• FOLEY’S CATHETER
• GASTRIC TUBE
• ABG
• PULSE OXIMETER
• URINE OUTPUT

72. Apply appropriate
monitoring device

73. GASTRIC TUBE
• RELIEVE GASTRIC DILATATION
• DECOMPRESS STOMACH BEFORE
DPL
• REDUCE RISK OF ASPIRATION
• N.G TUBE

74. DIAGNOSTIC PROCEDURES

76. Secondary survey
Key Components.
AMPLE History
Physical examination: Head-to-toe
Tubes and fingers in every orifice”
Complete neurological-exam
Special diagnostic tests and X-rays
Monitoring and resuscitation
Special procedures
Re-evaluation

77. “AMPLE HISTORY
“AMPLE” History
• A:Allergies
• M:Medication currently being taken by the
patient
• P:Past illness and operations, pregnancy
• L:Last meal
• E:Event/Environment related to the injury

78. • HEAD
• Signs of skull base fracture
• Pupillary size
• Hemorrhages of
conjunctiva/fundi
• Visual acuity
• Penetrating injury
• Contact lens
• Dislocation of lens
• Ocular movement
• Posterior scalp laceration

79. • MAXILLOFACIAL
• Associated with airway obstruction or major bleeding
• Fracture
• No NG tube [performed oral route]

80. • NECK
• Cervical tenderness, subcutaneous emphysema
• Esophageal injury
• Tracheal/laryngeal injury
• Carotid injury (penetrating/blunt)

81. • CHEST
• Inspect
• Palpate
• Percuss
• Auscultate
• Obtain x-rays

82. • ABDOMEN
• Inspect
• Auscultate
• Palpate
• Percuss
• Reevaluate
• Special studies

83. • Musculoskeletal
• Contusion, deformity
• Pain
• Perfusion
• Peripheral neurovascular status
• X-ray

84. 6.ADJUNCTS TO SECONDARY SURVEY
Some diagnostic tests as indicate
• Contrast x-ray studies
• Extremity x-ray
• CT
• Endoscopy
• Ultrasound
Choice of imaging modality depends on nature of injuries
and stability of patient.
Knowledge of injury mechanism and index of suspicion most
important

85. 8.DAMAGE CONTROL
• Multi trauma pt. triad of
coagulopathy,hypothermia,metabolic
acidosis-interfernce with surgical mgt
• Goal- 1.control hmg
•
•
•
2. prevent contamination
3. protect pt. from further
injury
• Proceed to definitive surgery once pt
stabilizes
• Clear communication between surgeon,
anesthesiologist and intensivist

86. PAIN CONTROL
• Relief of pain is an important part of the management of
the trauma patient
• Titrate IV opiates and anxiolytics
• Be aware that these agents can cause hypotension and
respiratory depression

87. Definitive treatment
Definitive treatment is based on specificity of the injuries received
and diagnosis at the end secondary survey
Definitive care involves:
􀂃 Specific investigations
􀂃 Consultation with speciality teams
􀂃 Documentation of all injuries and treatment
􀂃 Specific management plans from all appropriate teams
􀂃 Definitive placement to appropriate speciality team
• Or Referred to ICU

88. Indications for ICU Admission
-A GCS score of 8 or lower after resuscitation
-Airway protection and mechanical ventilation
- Cardiovascular resuscitation
- Severe head injury
- Organ support
- Correct coagulopathy
- Invasive monitoring
- Active re-warming of hypothermic patients

89. Take home message
Outcomes of the trauma management can be better?
Early pre-hospital
care
Early
transportation
Aggressive
resuscitation and
interventions in ED
Continued care in
ICU, if needed

90. OPEN FOR DISCUSSION