1. +
TRAUMA
PRIMARY AND SECONDARY SURVEY

2. +
CASE:
A 25 year old is brought
to casualty with history of
fall from a height of 20
feet. He landed on a pile
of bricks. Fortunately
there was no head injury.
He is complaining of
severe abdominal pain.
On examination he is
conscious; his pulse is
110/minute, BP 90/60
mmHg. There is no
external wound. However
has abrasions in left
upper quadrant and left
lower chest.

3. +
MECHANISMS OF
TRAUMA
Trauma can be classified
in type by causation and
by effect
Blunt , e.g. car bonnet
Penetrating , e.g. Knife
Blast , e.g. Bomb
Crush , e.g. building
collapse
Thermal

4. +
Deaths from trauma show three
peaks:
 Immediate
death :
o
Occurs within seconds
o
Cause : head injury , heart injury or aortic injury
o
These deaths are not preventable

5. +

Early death:
o
Begins an hour or two after injury
o
Cause: subdural and epidural hematomas , hemo or
pneumothorax , organ rupture or blood loss
o
Often preventable
o
This period is called the GOLDEN HOUR during which
prompt intervention can save a life

6. +
 Late
death:
o
Occurs many days after injury
o
Cause: sepsis or multi-organ failure
o
Prompt treatment of shock and hypoxemia during GOLDEN
HOUR can reduce these deaths

7. STEPS IN ADVANCED
TRAUMA LIFE SUPPORT:

Prehospital care
Primary survey with simultaneous resuscitation:
identify and treat what is killing the patient

+
Secondary survey : proceed to identify all other
injuries

Definitive care: develop a definitive management
plan


8. +
PREHOSPITAL CARE

9. Airway
maintenance
 Control of
external bleeding
& shock
 Immobilization
of the patient
 Communication
with receiving
hospital &
immediate
transport to the
closest,
appropriate
facility
 History taking

+

10. +
Prior to arrival:

Ensure senior emergency medical and nursing staff are aware of all
available details of the case.

Call Trauma Team (Trauma surgeon , Anaesthetist , Nurses ,
Emergency physician , Respiratory therapist , Radiologist ,
Surgical subspecialists)

Delegate specific tasks to appropriate individuals.

Check the resuscitation equipment and prepare intravenous lines and
fluids.

If possible, estimate the patient's weight using the formula (Age + 4) x 2
(or 3 x Age for those over 9 years) and calculate:
1) The amount of fluid bolus at 20 ml/kg
2)The endotracheal tube size (age/ 4) + 4
3)Any other drugs likely to be needed

11. +
On arrival:

Immediately perform a primary survey by assessing and
managing the patient's airway, with cervical spine
stabilisation, breathing and circulation.

Obtain a history, if possible, from the attendents or
ambulance officers e.g. type of trauma, speed of the vehicle,
height of the fall, restraints or safety equipment used,
whether other people were injured.

Obtain information regarding any treatment or interventions
to date.

12. + PRIMARY
SURVEY

13. +
Identified the life-threatening conditions
and simultaneously manage:
 A: Airway maintenance with cervical spine protection
 B: Breathing and ventilation
 C: Circulation with hemorrhage control
 D: Disability ( Neurologic status )
 E: Exposure / Environmental control: Undress the patient &
prevent hypothermia

14. +
A : Airway and C- spine
* Talk to the patient

A patient who can speak clearly must have a clear airway

Unconscious patient may require airway and ventilatory
assistance.

The cervical spine must be protected during endotracheal
intubation if a head, neck or chest injury is suspected.

Airway obstruction is most commonly due to obstruction by
the tongue in the unconscious patient.

Hoarsness or pain with speaking indicate
laryngeal injury.

15. +
* Assess airway
The signs of airway obstruction may include:

snoring or gurgling ( foreign body , aspiration )

stridor or abnormal breath sounds

agitation (hypoxia)

using the accessory muscles of
ventilation/paradoxical chest movements

cyanosis.

16. +
* Consider need for advanced airway
management

Indications for advanced airway management techniques for
securing the airway include:
o
persisting airway obstruction
o
penetrating neck trauma with haematoma (expanding)
o
Apnoea
o
Hypoxia
o
severe head injury
o
chest trauma
o
maxillofacial injury

17. Advanced airway
management:
*
* If obstruction persists:
- Chin lift and Jaw thrust
- Consider C-spine injury in
every patient until proven
otherwise
+
•Endotracheal intubation if:
- above don’t help
unconscious patient
- airway swelling or burns
-GCS less than 8
* Surgical Cricothyrotomy (if
there is severe facial or neck
injury)

18. +
B: Breathing and ventilation
* Inspection (LOOK) of respiratory rate is
essential. Are any of the following present

Cyanosis

penetrating injury

presence of flail chest

sucking chest wounds

use of accessory muscles

19. + * Palpation (FEEL) for

tracheal shift

broken ribs

subcutaneous emphysema

percussion is useful for diagnosis of haemothorax (dull)
and tension pneumothorax (hyper-resonant)

20. + * Auscultation (LISTEN) for

pneumothorax (decreased breath sounds on site of
injury)

Detection of abnormal sounds in the chest.

Give 100% oxygen (if available, via self-inflating bag or
mask)
 injury




1.
2.
3.
4.
that may acutely impair ventilation
Tension pneumothorax
Flail chest with pulmonary contusion
Massive haemothorax
Open pneumothorax

21. + Tension
pneumothorax
* Respiratory distress
* Over inflated hemithorax and
visibly splayed ribs
* Ipsilateral Hyperresonant
percussion note
* Ipsilateral reduce or absent breath
sounds
* Treacheal deviation
* Distended neck veins
Management: Immediate needle
decompression in second Intercostal
space midclavicular line

22. + Open
pneumothorax
* Ipsilateral reduced breath sounds
* Ipsilateral resonant percussion note
* Decreased expansion
* Penetrating chest wall injury
Management:
Cover defect - Sterile waterproof three
sided dressing secured on two sides to act
as a flutter valve.
Intercostal drain placed away from open
wound.
Surgical debridement and closure later.

23. + Massive
Hemothorax
* Hypotension due to blood loss
* Ipsilateral dullness to percussion
note
* Ipsilateral absent or reduced
breath sounds
* Ipsilateral decreased chest
movements
Management:
Infusion of fluids through large bore
IV cannula before draining
Large bore intercostal drain for
adults

24. + Flial Chest
* Segment of chest looses bony
continuity with thoracic cage
* Moves paradoxically with
respiration and reduces tidal volume
Management: Analgesia for pain
Fluid management
Ventilatory support

25. C: Circulation and hemorrhagic
+
control
* Hemorrhagic control

Direct pressure for external hemorrhage

No tourniquet unless other methods are not effective in
controlling bleeding

Long bones splinted with external fixation

Pelvic binding or pneumatic anti-shock garment

Watch out for hypothermia, acidosis and coagulopathy

26. +
* Assessment for hypovolaemia

Check skin: color , clamminess and capillary refill time

Heart rate

Blood pressure

Pulse pressure

Conscious level

Connect an automatic BP recorder and ECG
Hypovolaemia is the commonest cause of shock in trauma
patients

27. +
*Vascular cannulization

Two Large bore IV cannulas: peripheral i.e. Femoral Vein
Central – Subclavian or Internal Jugular
Intraosseous in children
Draw
20ml blood for grouping and cross matching , analysis of
electrolytes and full blood count

28. + * Fluid resuscitation

Bolus of warm crystalloids

Surgical control of hemorrhage is better than aggressive
fluid resuscitation

Fluid resuscitation inhibits platelet aggregation , dilutes
clotting factors and raises BP

Altered cardiovascular response to hemorrhage in trauma
pts

Enough warm crystalloids to maintain a radial pulse

Blood may also be required

29. +
D : Disability

Glasgow Coma Scale

Pupilary reflexes
Monitor frequently to detect deterioration
Common causes for
deterioration

Hypoxia

Hypovolaemia

Hypoglycemia

Raised intracranial pressure

30. +
E : Exposure

Clothes should be cut to remove

Pt kept warm and covered with blankets

Log roll

Assess spine from base of skull to coccyx

Examine back for any signs of injury

Digital Rectal Examination:
Boney fragments
Rectal wall
Bleeding
Prostate

31. +
SECONDARY SURVEY

32. +
HISTORY

A. Allergies

M. Medications currently used + tetanus status

P. Past illness / pregnancy

L. Last meal / LMP

E. Events / Environment related to injury

33. +
HISTORY : MECHANISM OF INJURY
 Blunt
 Automobile collisions
 Seat belt usage
 Steering wheel deformation
 Direction of impact
 Ejection of passenger form the vehicle
 Burns and Cold injury
 Inhalation injury and
 Hazardous
CO. intoxication in fire field
environment

34. +
 Penetrating
 Anatomy factors
 Energy transfer factor
 Velocity and caliber of bullet
 Trajectory
 Distance

35. PHYSICAL
EXAMINATION
+

36. +
HEAD

Scalp: lacerations, bruising, depressions or irregularities in
the skull, Battles sign (bruising behind the ear indicative of a
base of skull fracture).

Mouth: lacerations to the lips, gums, tongue or palate.

Teeth: subluxed, loose, missing or fractured.

Nose: deformities, bleeding, nasal septal haematoma, CSF
leak

Ears: bleeding, blood behind tympanic membrane.

Eyes: foreign body, subconjunctival haemmorhage,
hyphaema, irregular iris, penetrating injury, contact lenses.

Jaw: pain, trismus, malocclusion.

37. +
NECK

Cervical spine: pain, tenderness, deformity, inability to
move neck;

Soft tissues: bruising, pain and tenderness;

Trachea: deviation, crepitus;

Neck veins: distention.

38. +
CHEST

Chest wall: bruising, lacerations, penetrating injury,
tenderness, flail segment.

Lung fields: percussion note, lack of breath sounds,
wheezing, crepitations.

Heart: Apex beat, presence and quality of heart sounds.

39. +
ABDOMEN

Abdo wall: bruising, lacerations, penetrating injury,
tenderness.

Viscera: splenic, hepatic or renal tenderness, bladder
tenderness or enlargement.

Bowel: abdominal tenderness or rebound, absent bowel
sounds.

Pelvis: pain on springing.

40. +
LIMBS

Soft tissues: bruising, lacerations, muscle, nerve or tendon
damage.

Bones: tenderness, deformities, open fractures.

Joints: penetrating injuries, ligament injuries.

41. +
BACK
 Soft
tissues: bruising, lacerations
 Bones: tenderness, space
between vertebrae.

42. +
BUTTOCKS AND PERINIEUM
Soft
tissues: bruising,
lacerations.

43. +
GENITALIA
 Soft
tissues: bruising, lacerations.
 Urethra: bleeding.
 Introitus: bleeding.

44. +
NEUROLOGIC
 Determine
GCS score
 Re-evaluate pupils
 Sensory / motor evaluation
 Maintain immobilization
 Prevent secondary CNS injury ( keep stable vital
signs, avoid increased ICP and treat IICP )
 Early neurosurgical consultation

45. +


INVESTIGATIONS
CBC
Urine output

Urinanalysis

Xray

CT

MRI

46. +