2. TRAUMA
• Trauma is the study of medical problems
associated with physical injury
• The injury is the adverse effect of a physical
force upon a person
• There are variety of forces that can lead to
injury
3. PRINCIPLES OF TRAUMA
MANAGEMENT
– Treat the greatest threat of life first
– Definitive diagnosis is not immediately important.
– Time matters (“golden hour” emphasizes
urgency).
– Do no further harm.
– Assess, intervene, reassess
4. TRIAGE
A process for sorting injured people into groups
based on their need for or likely benefit from
immediate medical treatment.
5.
6.
7. Initially
• 1 assess basic physiology
• 2 assess anatomy of injury
• 3 assess mechanism of injury
• 4 assess special patients or system
considerations
9. PRIMARY SURVEY
To identify life and limb threatening
injuries
Airway with cervical spine protection.
Breathing and Ventilation
Circulation with hemorrhage control
Disability / neurological status
Exposure / environmental control
10. Airway with cervical spine protection
• Brief history: age, gender, mechanism of injury
• Airway with cervical spine control
– Upper airway (above vocal cords) managed
adjunctively with chin lift/jaw thrust,
– suctioning, oral airway, nasopharyngeal airway,
and
– laryngeal mask airway.
– The most common cause of airway obstruction in
the unconscious patient is the tongue.
11. – Lower airway managed definitively with a cuffed
tube in the trachea (orotracheal intubation,
nasotracheal intubation, or surgical airway—
cricothyroidotomy)
– Assume cervical spine injury in patients sustaining
any blunt injury or penetrating injury above the
chest.
17. • Tension pneumothorax (pneumothorax with hypotension)
with needle decompression (second intercostal space, mid-
clavicular line), followed by 32-36 French anterior chest tube
• Simple pneumothorax with 32-36 French anterior chest
tube
• Open pneumothorax with occlusive chest wall dressing and
36 French anterior chest tube
• Massive hemothorax with 36 French posterior chest tubes
en route to operating room
• Simple hemothorax with 36 French posterior chest tube
• Flail chest/severe pulmonary contusion with intubation and
mechanical ventilation
18.
19. Circulation with haemorrhage control
• Treatment of bleeding is to stop it.
• Pressure over bleeding site.
• Look for clinical signs of shock
• 2 wide bore 14 – 16g peripheral lines should
be started
• Resuscitate with crystalloids/colloids
20. Disabiity
• Rapid neurological evaluation using
– A Alert
– V Responds to verbal
stimulus
– P Responds to pain
– U Unresponsive
21. – Brief neurologic exam
• Level of consciousness: Glasgow Coma Scale
• Pupil symmetry and reaction to light
• Lateralizing signs
– Maintain airway, breathing, and circulation to prevent
secondary brain injury.
– Temporize for evidence of increased intracranial
pressure.
• Elevate head of bed.
• Mild hyperventilation to paCO2 = 35
• Mannitol (1 gm/kg)
• Neurosurgical consultation
22.
23. Exposure and environmental control
– Assess temperature.
– Remove all clothing to facilitate access and
examination.
– Maintain normothermia/prevent hypothermia:
warm room, warm fluids, warm blankets
24. Adjuncts to primary survey and
resuscitation
• Blood :CBP,urea
&electrolytes,glucosetoxicology,clotting
screening,cross match
• ECG
• Two wide bore cannule for IVF
• Urinary and gastric catheters
• Radiographs of the cervical spine&chest
25. Radiographs
• AP chest, to assess for tube and line placements, as
well as subclinical hemopneumothoraces
• Pelvis, to assess for pelvic fracture as a source of
hidden bleeding
• Cervical spine, to assess for source of neurogenic
shock. As long as the cervical spine is protected with
immobilization, this radiologic evaluation can be moved
to the secondary survey
26. – Assessment for intraperitoneal injury
• Focused Assessment by Sonography in Trauma (FAST)
–Looks for fluid in 4 areas (hepatorenal,
splenorenal, pelvic, and pericardial spaces)
–Assumes that fluid represents blood and can
detect 200 cc or more
–Can be rapidly repeated for follow-up
–Not designed to find injuries unassociated
with mild to moderate intraperitoneal fluid
loss
27. Secondary survey
– Begins after primary survey & resuscitation have
been completed .It consists of:
Complete medical history
– Head to toe evaluation
– Complete neurological examination
– Radiological evaluation
– Laboratory Studies
– Formulate management plan
28. Medical history
A Allergies
M Medication
P Past illnesses /pregnancy
L Last meal
E Events / Environment
related to injury
29. Mechanism of injury
– Blunt
» Motor vehicle
» Pedestrian
» Fall
» Crush
– Penetrating
» Gunshot
» Shotgun
» Stab
– Environmental
» Burn
» Cold
» Chemical, radiological, biological
– Primary pressure wave (blast)
– Explosions combine all four mechanisms of injury
30. Examination
• Head
– Mental status: GCS
– Scalp
» Lacerations and avulsions
» Open skull fractures
– Eyes
» Visual acuity: the vital sign of the eye
» Pupil size & reactivity
» Globe integrity & foreign body assessment
» Extraocular muscle movement
– Ears
» Pinna
» External auditory canal
» Hemotympanum and tympanic membrane
45. Causes of blunt injury
• Motor vehicle crashes
• Motor cycle crashes
• Vehicle Pedestrian Collision
• Direct blows to Abdomen
• Falls
46. Seat belt injury
• Tear /avulsion of mesentry
• Rupture of small bowel/colon
• Seat belt sign– appearance of transverse
,linear ecchymosis on Anterior
abdominal Abdomen.
• Chance fracture– presence of lumbar
distraction in X-ray.
• Thrombosis of iliac artery or abdominal aorta.
49. Up and forward movement
• In this sequence the body’s forward motion carries it
up and over the steering wheel with the head being
the lead body portion striking the windshield frame
or roof.
• Once impacted head stops movement but torso is still
in movement until the force is absorbed by spine and
transmitted back, through spine ( cervical spine) is the
least protected part in the body
• And injuries can be caused by compression
(lungs,heart) or shearing force due to fixed kidney
tearing at IFC or aorta
55. Auscultation
• Bowel sound if present after a while after the
injury – almost excludes serious injury.
• Bowel sounds if present in the chest –
diaphragmatic rupture.
58. USG abdomen
– Good for solid organs
– Portable
– Fast
– 100 cc detection blood
– No radiation
– No contrast need
– Not seen well: solid parenchymal, retroperitoneal,
diaphragm
– Problem if: obesity, gas
– Less sensitive than DPL for hemoperitoneal
– Operator dependant
59. CECT abdomen
– Able to define organ injury
– Good for retroperitoneal & vertebral column
– Non-invasive
– Not Operator dependant
– Not great for hollow viscus
– Stable patient
– Cost $$$
– Complications: IV or oral contrast
64. – Criteria for Evaluation of Peritoneal Lavage Fluid.
– Positive
– 20 mL gross blood on free aspiration (10 mL in children)
– 100,000 red cells/ L
– 500 white cells/ L (if obtained 3 hours or more after injury)
– 175 units amylase/dL
– Bacteria on Gram-stained smear
– Bile (by inspection or chemical determination of bilirubin
content)
– Food particles
65. • Intermediate :
• pink fluid on free aspiration
• 50,000-100,000 red cells/L in blunt trauma
• 100-500 white cells/L
• 75-175 units amylase/dl
• Negative :
• clear aspirate,100 white cells/L
• 75 units amylase/dl
66. FAST
Initial diagnostic
evaluation
FAST
Focused Assessment
with Sonography for
Trauma
X-ray pelvis and
chest
FAST negative
Diagnostic peritoneal
lavage
Positive DPL and Unstable
Explorative
laprotomy
FAST positive
US abdomen
CT abdomen
FAST negative and unstable
Exploratory laprotomy
67. • Identification of abnormal collection of fluid
or blood.
• Standard FAST, four areas:
• Rt upper quadrant
• Subxiphoid area
• Lt upper quadrant
• Pelvis
68. • The technique focuses on only 4 areas:
pericardial
splenic
hepatic
pelvic
Disadvantages:
• It will not reliably detect less than 100ml of free
blood
• it does not identify injury to hollow viscus
• It cannot reliably exclude injury in penetrating trauma
70. • blunt or penetrating injury
• mortality: 10 - 20%
• may be associated with right lower rib fracture
• Signs / Symptoms
– RUQ pain abdominal wall spasm ,guarding
hypoactive or absent BS signs of hemorrhage
71. • Repeat CT rule out possible complications:
– Parenchymal infarction
– Hematoma
– Biloma
• Extrahepatic bile drained percutaneously.
• Intrahepatic collections of blood and bile
resolve spontaneously.
72. GRADE TYPE OF
INJURY
DESCRIPTION OF INJURY
I Hematoma
laceration
Subcapsular tear<10%surface area
Capsular tear <1cm parenchymal tear
II Hematoma
laceration
Sc tear,10-50%;intra parenchymal<10cm in diameter
Ct ,1-3 cm parenchymal depth,10cm in length
III Hematoma
laceration
Sc tear >50% surface area of ruptured sc/parenchymal
hematoma ,ip hematoma>10cm or expanding
>3cm parenchymal depth
IV Laceration Parenchymal disruption 25-75%hepatic lobe or 1 to3
segments
V Laceration
vascular
PD involving >75% of hepatic lobeor more thanone
couinaud segment within a single lobe
Juxtahepatic venous injuries
VI vascular Hepatic avulsion
74. • Blunt or Penetrating
• Signs / Symptoms
– LUQ pain
–Kehr’s sign
– involuntary guarding hypoactive or absent
BS
–signs of hemorrhage
– point tenderness
75. GRADE TYPE OF
INJURY
DESCRIPTION OF INJURY
I Hematoma
Laceration
Subcapsular tear <10%surface area
Capsular tear <1cm parenchymal depth
II Hematoma
Laceration
10-50%,intraparenchymal <5cm in depth
1-3cm,does not involve trabecular vessels
III Hematoma
laceration
>50% expanding/ruptured /ip hematoma> 5cm or
Expanding
>3cm with trabecular vessels involvement
IV Laceration Segmental/hilar vessels producing major
devascularisation
V Hematoma
Laceration
Completely shattered spleen
Hilar vascular injury devascularizes spleen
77. • Stomach & Small Bowel
– Blunt vs penetrating
• Diagnosis
– Pneumoperitoneum or free fluid on CT scan
– small bowel injury may be difficult to detect
– Found at laparotomy
79. • Colon
– Diagnosis
• Pneumoperitoneum or free fluid on CT scan
• injury may be difficult to detect
• Found at laparotomy
• Rectum
– Intraperitoneal- treat as colon injury
– Extraperitoneal- primary repair with
diversion
• +/- presacral drains
81. • Diagnosis
– often delayed diagnosis
– frequently seen together
– most often contused due to blunt injury
– Seen on CT Scan or at laparotomy
– intramural hematoma in wall of duodenum
obstruction bilious vomiting severe abdominal
pain distention
82. PELVIC INJURY
• Introduction
– significant blood loss if bilateral
–may settle in retroperitoneal space
–3% of all fractures
–mortality 8 - 50%
–2nd most common cause of traumatic
death
86. – The small bowel occupying the large portion is
more prone.
– Injury to the major vessels or liver- early shock.
– Patient presenting with shock in penetrating
injury- exploration.
– Hollow visceral injuries – sepsis.
87. – Increasing tenderness, total count elevation, fever
several hours after injury – surgery.
– Local wound exploration.
– Laproscopy.
– Gun shot wounds must be explored
88. Stab wounds
involve the chest in up to 10% of cases.
Most stab wounds do not cause an
intraperitoneal injury
The incidence varies with the direction of entry
into the peritoneal cavity
The liver, followed by the small bowel, is the
organ most often damaged by stab wounds.
89. Gun shot
• the degree of injury depends .
• amount of kinetic energy imparted by the
bullet to the victim
• mass of the bullet and the square of its
velocity
• Distance .
90. • type I wounds: long range (>7 yards) , a
penetration of subcutaneous tissue and deep
fascia only.
• Type II wounds: distance of 3 to 7 yards and may
create a large number of perforated structures.
• Type III wounds occur at point-blank range (<3
yards) and involve a massive destruction of tissue
