initial assessment and primary management in trauma

1. DR.ARUN V
PG OMFS1

2. contents
 Golden hour
 ABCDE
 Airway management
 Shock management
 AMPLE history
2

3. 3

4. 4

5. 5

6. TIME AND TIDE WAITS FOR
NONE
6

7.  Accurate and systematic approach
 25% to 30% of deaths caused by trauma
can be prevented
7

8. GOLDEN HOUR
 AR Cowley
 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
8

9. PLATINUM MINUTES
“THE PLATINUM TEN MINUTES”
9

10. Three categories
 severe -5% of all injuries, but more than 50%
of all trauma deaths
 urgent - 10% to 15%
 Non urgent – 80 %
10

11. Assessment principles – American
College of Surgeons
1. Preparation and transport
2. Primary survey and resuscitation,
including monitoring and radiography
3. Secondary survey, including special
investigations,such as CT scanning or
angiography
4. reevaluation
5. Definitive care
11

12. PREHOSPITAL PHASE
 The trauma ambulance and paramedics
 Convey the status and number of
victims to the hospital
 Provide on site care
 ventilation and spine stabilization
12

13.  Pneumatic antishock garments and the
establishment of intravenous lines
 administration of fluid should be
reserved for transport times greater than
30 minutes or patients bleeding in
excess of 50 mL per minute.

 Long bone fracture – traction splint
13

14. Multiple casualties
 No. of patients and the severity of their
injuries do not exceed the ability of the
facility to provide care.
 MASS CASUALTIES
 The no. of patients and the severity of
their injuries exceed the ability of the
facility to provide care.
14

15. TRIAGE
 A method of quickly identifying
victims who have immediately life-
threatening injuries AND who have
the best chance of surviving
15

16.  red - Immediate (critical)
 yellow - Delayed (urgent)
 green - Minor (ambulatory)
 White – those who do not require
treatment
 Black - Deceased
16

17. START system
 Simple Triage And Rapid Transport
 respiratory status, perfusion status, and
mental status
 "immediate," "delayed," or "minor" category
17

18. HOSPITAL PHASE
18

19. Primary Survey
 A - Airway (with C-spine precautions)
 B – Breathing and ventilation
 C – Circulation and hemorrhage
control
 D – Disability + neurological status
 E – Exposure + environment
 F- Frequent reassessment
19

20. 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
20

21.  Hyperextension or hyperflexion
of the patient’s neck should be
avoided
 Cervical collars or neck
support
 Neuronal deficit and paralysis
 SUSPECT,PROTECT&
DETECT
21

22. 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)
22

23. 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
23

24. Listen
 abnormal sounds.
 Noisy breathing, Snoring, gurgling -
partial obstruction of the pharynx or
larynx.
 Hoarseness laryngeal obstruction.
 abusive patient -hypoxic
24

25. Feel
 location of the trachea and determine
whether it is in the midline
 foreign objects (e.g.,fractured teeth,
fillings, dentures) should be removed.
25

26. 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
26

27. 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
27

28. 28

29.  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
29

30.  suction should be used to clear any
secretions
 nasogastric tube or soft suction catheter
may be used in patients without suspected
midface or cranial base - tubes
inadvertently passed into the cranial vault.
 oral or nasal airway - keep the airway
patent
 nasal airway is better tolerated in an
awake patient.
30

31. Airway devices
 Supraglottic
 Infra glottic
31

32. 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
32

33. Nasopharyngeal airway
 inserted in the nostril that appears to be
unobstructed
 and passed gently into the posterior
oropharynx
 approximate distance between the end of the
patient’s nose and the ear lobe
33

34. laryngeal mask airway
 if orotracheal intubation has failed or bag-mask
ventilation is not maintaining sufficient
oxygenation
 No cuff – chances of gastric distension and
aspiration
34

35. multilumen esophageal
airway
 two tubes, - occlusion of the esophagus
to reduce the risk of aspiration.
 does not have a cuffed tube in the
trachea -not a definitive airway
35

36. 36

37. injuries to the larynx and
trachea
 neck swelling, dyspnea, voice alteration, or
frothy hemorrhage
 tenderness, and laryngeal or tracheal crepitus
 Endotracheal intubation / surgical airway
37

38. 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
38

39. indications
Oral & Maxillofacial trauma – Fonseca Walker 39

40. Contraindications
 ability to maintain a patent airway in a less
invasive manner
40

41. LEMON
41

42. Oral & Maxillofacial trauma – Fonseca Walker 42

43. Oral & Maxillofacial trauma – Fonseca Walker 43

44.  Rapid-sequence induction with
anesthetic agents, neuromuscular
blocking drugs, and esophageal
occlusion by cricoid pressure
44

45. 7 Ps
 Preparation
 Pre oxygenation
 Pre medication
 Paralysing
 Pressure (Cricoid)
 Placement
 Position
 Post intubation care
45

46. Premedication - LOAD
 L: Lidocaine
 O: Opioids (typically fentanyl)
 A: Atropine
 D: Defasciculating agent
46

47. Laryngoscopy
 flexion of the neck, to align the pharyngeal and
laryngeal axes.
 head is extended at the atlanto-occipital joint
so that the oral axis is in line with the other two
47

48. STOP MAID
 S: Suction
 T: Tools (e.g., blade, handle.)
 O: Oxygen
 P: Positioning
 M: Monitors (electrocardiogram [ECG], O2,
CO2, blood pressure [BP])
 A: Assessment, airway devices, assistant
 I: IV access
 D: Drugs
48

49. 49

50. 50

51. Surgical Airway
 Needle Cricothyroidotomy
 Insertion of a wide-bore needle (or IV
cannula) via the crico-thyroid membrane
into the airway
 Intermittent insufflation (1 second on
and 4 seconds off)
 Maximum 30-45 minutess
 Inadequate ventilation
51

52. 52

53. 53

54. Surgical
Cricothyroidotomy
54

55. Surgical
Cricothyroidotomy
 3 cm long skin incision
 Cut down through the cricothyroid membrane
 tracheal dilator is inserted to open up the
incision, separating the thyroid and cricoid
cartilages and enabling visualization of the
trachea
 tracheostomy tube is inserted
55

56. 56

57. tracheostomy
 laryngotracheal trauma
 fractures of the thyroid or cricoid
cartilage or hyoid bone
 Prolonged ventilation
 upper airway obstruction
57

58.  Thyroid cartilage, cricoid cartilage and
tracheal rings are palpated
 skin incision should be marked while the
patient’s head is in a normal position
 Vertical/horizontal skin incision
58

59. 59

60. BREATHING
 Assess breathing and ventilation
 Ventilation is compromised not only by airway
obstruction but also altered ventilatory
mechanics or CNS depression.
60

61.  Direct trauma to the chest - # ribs -
rapid, shallow breathing and hypoxemia
 Intracranial injury - abnormal patterns
 spinal cord injury – paralysis of
intercostal muscles – unable to meet
increased demand
61

62. life-threatening thoracic injuries
 A: Airway obstruction
 T: Tension pneumothorax
 O: Open pneumothorax
 M: Massive hemothorax
 F: Flail chest
 C: Cardiac tamponade
62

63. 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
63

64. Tension Pneumothorax
64

65.  positive-pressure ventilation worsens
tension pneumothorax
 Maybe seen as complication of central
line insertion in polytrauma
65

66. C/F
 chest pain
 air hunger
 respiratory distress
 tachycardia
 Hypotension
 tracheal deviation
 unilateral absence of breath sounds
 hyper resonant percussion note
66

67. Collins J, Stern EJ. Chest Radiology: The Essentials. Lippincott Williams & Wilkins;
2012. 360 p.
67

68.  immediate decompression by insertion
of a large-bore needle into the second
intercostal space
 Definitive treatment - insertion of a chest
drain into the fifth intercostal space
68

69. Needle Thoracocentesis
 Identify the second intercostal space in the
midclavicular line on the affected side
 Insert large bore catheter (12-14 gauge) over the
top of rib into ICS
 Puncture the parietal pleura and push 1 cc of air
so as to remove tissue tag at the end of catheter
 Remove the plunger of syringe attached to
catheter
 Sudden escape of air happens
69

70. Chest Drain Insertion
 Identify the insertion site at the nipple level (fifth
intercostal space) anterior to the midaxillary line on the
affected side.
 Make a 3-cm transverse incision and bluntly dissect
through the subcutaneous tissue just above rib.
 Puncture the parietal pleura
 perform a finger sweep with a gloved finger through
the incision, to avoid injury to other organs and to clear
adhesions and clots.
 Insert the tube and advance into the pleural space to
the desired length
70

71. 71

72. 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
72

73. 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
73

74.  injury to the underlying lung parenchyma -
pulmonary contusion
 paradoxical breathing
 asymmetrical and uncoordinated movement
of chest wall
 Crepitus
74

75. Treatment
 adequate ventilation
 Splinting the area with sandbag/ iv fluid
bag
 administration of humidified oxygen
 fluid resuscitation
 Good analgesia
75

76. Cardiac Tamponade
 Penetrating/ blunt injury
 pericardium fills with blood from the
heart, great vessels
 interfere with cardiac filling
 Beck’s triad
 distended neck veins
 decline in arterial pressure
 muffled heart sounds
76

77.  Kussmaul’s sign (a rise in venous
pressure with inspiration when breathing
spontaneously)
 Aspiration of pericardial blood -
pericardiocentesis
77

78.  Puncture the skin 1 to 2 cm inferior and to the
left of the xiphochondral junction, at a 45-
degree angle to the skin.
 Carefully advance the needle upward, aiming
toward the tip of the left scapula
 Once needle enters the blood-filled pericardial
space, withdraw as much blood as possible
78

79. C: CIRCULATION AND
HEMORRHAGE CONTROL
 Acute blood loss - 0% to 40% of trauma
deaths
 Leads to Shock
 Clincal state of cardiovascular
collapse characterized by acute
reduction of effective circulating blood
volume, inadequate perfusion of cells
& tissues.
79

80. Shock is of 2 types
Primary (initial)
Secondary (true)
 Primary –
 transient attack resulting from sudden reduction
of venous return
 It occurs immediately following trauma, severe
pain, emotional over reaction
 pale & clammy limbs, weak & rapid pulse& low
BP
 Secondary- due to hemodynamic
derangements with hypoperfusion of cells.
80

81.  PRIMARY (Initial Shock)
 SECONDARY (True Shock)
 HEMATOGENIC/HYPOVOLAEMIC/OLIGAMI
C SHOCK
 OBSTRUCTIVE SHOCK / TRAUMATIC
SHOCK
 NEUROGENIC SHOCK
 CARDIOGENIC SHOCK
 SEPTIC SHOCK
81

82. CLINICAL FEATURES
General Clinical Features Of Shock
o Hypotension (Systolic BP<70mmHg)
o Tachycardia (>100/min)
o Cold , Clammy Skin
o Rapid,Shallow Respiration
o Drowsiness,Confusion,Irritability
o Oliguria (Urine Output<30ml/hour)
o Multi-Organ Failure
82

83. STAGES IN SHOCK
3 STAGES
INITIAL SHOCK
PROGRESSIVE SHOCK
IRREVERSIBLE SHOCK
83

84.  inadequate tissue perfusion and oxygenation and
anaerobic glycolysis results in lactic acid
production
 coagulation factor and platelet dysfunction
combined with coagulation factor consumption
a profound coagulopathy
 Triad of
 Metabolic acidosis
 Hypothermia
 coagulopathy
84

85.  stop hemorrhage
 minimize contamination
 restore near-normal physiology
85

86. 86

87. Initial Management of
Hemorrhagic Shock
 Prevention of further blood loss and
 the earliest restoration of tissue perfusion
 External hemorrhage is identified and
controlled by direct manual pressure
 Occult bleeding -thoracic and abdominal
cavities, the pelvis, the retroperitoneal space
 pneumatic antishock garment (PASG)
87

88.  Long bone fractures – approx 750 ml
blood loss
 Femur fracture – approx 1500 ml
 Pelvic fracture – 2000-2500ml
88

89. 89

90. Management
 Peripheral cannulae – large bore
cannulae  rate of flow proportional to
4th power of radius
 venous cut-down, made 2 cm anterior
and superior to the medial malleolus into
the greater saphenous vein
 central line into the femoral or
subclavian vein
90

91.  Crossmatch,full blood count; RFT,LFT
and electrolytes; ABG
91

92. Fluid Replacement
 restore critical organ perfusion
 2 L of RL / 20 ml/kg RL
 3 type of responses
 Responder:vital signs return toward
normal
 Loss of less than 20% of circulating
volume and are not actively bleeding
92

93.  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
 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
93

94. Crystalloid, colloid and
blood
 Colloids - larger molecular weight, and hence
expand the intravascular compartment more
effectively – 1:1 ratio
 improve oxygen transport, myocardial
contractility and cardiac output
 More risk of anaphylactic complications
 Crystalloids are cheap and safe
 3-4 times greater volume is required
 Causes hypothermia and dilution of clotting
factors
94

95. Isotonic saline
 Corrects both water and electrolyte imbalance
1. Water and salt depletion as in vomiting, diarrhoea
2. Hypovolemic shock.
 CONTRA-INDICATIONS :
1. Hypertensive patients
2. Patientswithedema due to CCF
95

96. RL
 Rapidlyexpandsintravascular volume.
 Themostphysiological IVfluid.
 Sodium lactatemetabolisestoprovide
bicarbonate
1. severehypovolemia.
2. For replacingfluidin post-oppatients
3. For diarrhoeainducedhypovolemia.
4. Diabeticketoacidosis.
96

97.  CONTRA-INDICATIONS
1. In severeCHF.
2. Severe metabolicalkalosis.
97

98. colloids
 ADVANTAGES :
i. More effectivein treatinghypotension thancrystalloids.
ii. Increase in plasma volume is for a prolonged period.
iii. Improve thehemodynamicstatus.
iv. Highersystemic oxygen delivery.
98

99.  DISADVANTAGES:
i. Expensive.
ii. Anaphylacticreactions
 INDICATIONS:
i. To treatsudden hypotension due tomajorbloodloss, tillblood is
awaited, or to avoidblood transfusion.
99

100. Type of fluid Effective plasma
volume
expansion/100ml
duration
5% albumin 70 – 130 ml 16 hrs
25% albumin 400 – 500 ml 16 hrs
6% hetastarch 100 – 130 ml 24 hrs
10% pentastarch 150 ml 8 hrs
10% dextran 40 100 – 150 ml 6 hrs
6% dextran 70 80 ml 12 hrs
100

101.  Crystalloids – recommended as the initial fluid of
choice in resuscitating patients from hemorrhagic
shock
Svensen C, Ponzer S… Volume kinetics of Ringer solution after
surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 :
133 - 141
 COCHRANE Collaboration in critically ill patients –
“ No evidence from RCT that resuscitation with
colloids reduces the risk of death, compared with
crystalloids in patients with trauma or burns after
surgery”
Roberts I, Alderson P, Bunn F et al : Colloids versus
crystalloids for fluid resuscitation in critically ill patients..
Cochrane Database Syst Rev(4) : CD 000567, 2004
101

102. Blood transfusion
102

103.  Hb concentrations below 6 g/dL
 no significant differences were found in 30-
day mortality rates between those in whom
‘restrictive’ transfusion therapy was used
and those in whom the transfusion therapy
was applied ‘liberally’ (triggering Hb values
between 7-8 g/dL and around 10 g/dL,
respectively
103
Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for
the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

104. Blood transfusion
104

105. MABL = (Starting pt Hct – 25) X
Estimated blood vol
Starting pt Hct
MABL= [EBV x (H initial- H final)]/H initial
H final = 30
Estimatedbloodvolume –males75ml/kg
females65 ml/kg
105
Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for
the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

106.  Incompatible fluids Electrolyte and
colloid solutions containing any calcium
(e.g. Haemaccel, lactated Ringer’s
solution)
 5 % dextrose hemolyses RBCs
106
Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for
the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

107. Adverse reactions
 1. Immediate
 acute haemolytic reactions
 febrile non-haemolytic reactions
 Anaphylaxis
 transfusion-related acute lung injury – TRALI
 2. Delayed
 delayed haemolytic reactions
 3. Immediate non-immunological
 bacterial contamination
 circulatory overload
 Air embolism/hypothermia
107

108. hypotensive resuscitation
 target mean arterial pressure (MAP) of 50
mm Hg
 decrease postoperative coagulopathy and
lower the risk of early postoperative death
and reduce the amount of blood product
transfusions and overall IV fluid
administration.
108

109. D: DISABILITY
 Level of consciousness
– Best indicator of central perfusion &
deterioration of patient status
 Pupils
 GCS
 A: Alert
 V: responds to Vocal stimuli
 P: responds to Painful stimuli
 U: Unresponsive to all stimuli
109

110. 13-15  mild head injury
8-12 moderate
<8  severe
110
revised in 1976- sixth point -
“withdrawal from painful stimulus
Jennett and Teasdale in the early 1974

111. Infants & children
111

112. AVPU/ACDU
Alert
Confused
Drowsy
Unresponsive
112

113. MAYO HEAD INJURY CLASSIFICATION
SYSTEM FOR TRAUMATIC BRAIN INJURY
 Category A moderate to severe (definite) TBI:
1. Death caused by this TBI
2. LOC of 30 minutes or longer
3. Post-traumatic anterograde amnesia of 24 hours or
longer
4. Worst GCS full score in the first 24 hours less than 13
5. One or more of the following present: EDH, SDH,
Contusion
 Category B
1. Loss of consciousness of momentary to less than 30 minutes
2. Post-traumatic anterograde amnesia of momentary to less
than 24 hours
3. Depressed, basilar or linear skull fracture
113

114. 114

115. Injury Severity Score
115
Abbreviated injury score

116. Revised Trauma Score (RTS)
116
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR
range 0 to 7.8408 RTS < 4 – severe injury
1981 by Champion et al.

117. Mainz score
117

118. Acute Physiology and Chronic Health
Evaluation Score (APACHE) II
 clinical decision-making particularly for
ICU patients
118

119. EXPOSURE
 Complete exposure is a must  avoid
hypothermia
 warm ambient room, overhead heating,
and warmed IV fluids
119

120. ADJUNCTS TO THE
PRIMARY SURVEY
 assessment of pulse and respiratory
rates;
 systolic and diastolic blood pressures;
 pulse oximetry;
 Temperature
 ECG monitoring
 urinary catheter recording of urine
output
 NG tube aspiration
120

121. SECONDARY SURVEY
 complete and comprehensive head to- toe
evaluation
 history and circumstances leading to the injury
 physical examination of the patient
 reassessment of all vital signs.
 Six potentially lethal injuries that should be evaluated
 Pulmonary contusion
 aortic disruption
 tracheobronchial disruption
 esophageal disruption
 traumatic diaphragmatic hernia
 myocardial contusion 121

122. HISTORY
 A: Allergies
 M: Medications currently used
 P: Past illnesses and Pregnancy
 L: Last meal
 E: Events and Environment related to
the injury
122

123. Physical examination
 Scalp
 Lacerations
 Contusions
 hematomas
 bone surface irregularities
123

124. Eyes
 pupillary response - shape, equality, and light
reaction of the pupils
 eye injury - blunt or penetrating
 Direct injury to the optic nerve
124

125. 125

126. Neck and Cervical Spine
 unstable cervical spine injury –
unless otherwise proven
 Cervical spine tenderness,
subcutaneous emphysema
 laryngeal fracture
 Lateral and AP views -seven
cervical vertebrae and the first
thoracic vertebra (C1- C7/T1
junction)
126

127. Chest
 Pain, dyspnea, and hypoxia
 pneumothorax and
 large flail segments
 Contusions and hematomas occult
pulmonary or cardiac injury
 Distended neck veins  cardiac
tamponade or tension pneumothorax
127

128. Abdomen
 Intra abdominal bleed should be
suspected if there are fractures of the
ribs that overlie the liver and the spleen
 Blunt/penetrating trauma
 Lap belts
 Focused assessment with sonography
for trauma - FAST
128

129. Perineum, Rectum, and
Vagina
 contusions,hematomas, lacerations, and
urethral bleeding.
 Must before catheterization
129

130. Musculoskeletal
Assessment
 Contusions, lacerations, deformities
 Peripheral pulses
 Motor and sensory impairement
 Pelvic fractures are suggested by:
 ecchymosis over the iliac wings, pubis, vagina, or
scrotum.
 pain on palpation.
 mobility of the pelvis in response to gentle
anteroposterior pressure in the unconscious patient
130

131. Spinal Cord Assessment
 electrical shock–like pain radiating down
the spine or into the limbs nerve root
compression
131

132. 132

133. 133

134. Conclusion
 With meticulous and rapid assessment
and management it is possible to add
years to peoples life
134

135. References
 Oral & Maxillofacial Trauma – Fonseca
Walker – 4th edition
 Maxillofacial trauma and esthetic facial
reconstruction – Wardbooth, Eppley
135

136. 136