Principles of Trauma Management

TraumaPrehospital phase and triagePrimary SurveyABCDEResuscitationAdjuncts to primary survey and resuscitationSecondary Survey Records, Consent, Forensic evidence

Primary SurveyAirway and cervical spine controlBreathingCirculation with control of hemorrhageDisabilityExposure/environment (expose patient, but avoid hypothermia)

ResuscitationOxygenation and VentilationShock managementIV linesNormal SalineManagement of life-threatening problems

Adjuncts to Primary Survey and ResuscitationMonitoring:ABGs and ventilatory rateEnd-tidal CO2EKGPulse oximetryBlood pressure

Adjuncts to Primary Survey and ResuscitationUrinary and gastric cathetersX-rays and diagnostic studiesChestPelvisC-spineFAST / CT SCAN / DPL

Trauma Mortality35 per 100,000 populationMost common cause of death in children

Airway and VentilationThese are first priorities!!!!Risks for obstruction:ComaAspirationMaxillofacial traumaNeck trauma

Airway and ventilationNeck trauma: disruption of the larynx or trachea-or compression by soft tissue injuryLaryngeal trauma:HoarsenessSubcutaneous emphysemaPalpable fracture

Airway and ventilationObstruction:Agitation or obtundationAbnormal airway soundsTrachea not in midline

Airway and ventilationInadequate ventilationAsymmetric chest riseAsymmetric chest soundsPoor oxygenation

Airway and ventilationAirway MaintenanceChin liftJaw thrustOropharyngeal airwayNasopharyngeal airwayDefinitive AirwayEndotracheal tubeCricothyroidotomy

Airway and ventilationPaO2 Levels

90 mm Hg60 mm Hg30 mmHg27 mmHgO2 Hgb Saturation

100%90%60%50%

Pulse OximetryLED absorbed differently between oxygenated and non-oxygenated HgbAffected by:Poor perfusionAnemiaCarboxyhemoglobin or methehemoglobinCirculating dyePatient movement, ambient light or signals

ThoraxBreathing:Tension pneumothoraxOpen pneumothorax (sucking wound)Flail chestMassive hemothorax

ThoraxTension PneumothoraxCollapse of affected lungDecreased venous returnDecreased ventilation of opposite lung

ThoraxTension pneumothorax:Respiratory distressDistended neck veinsUnilateral decrease in breath soundsHyperresonanceCyanosisNeeds immediate decompression!

ThoraxOpen pneumothorax:Occlusive dressingFlail chest:Trauma principles and ventilationMassive hemothoraxChest decompression

ThoraxCirculation:Massive hemothoraxFlat v. distended neck veinsShock with no breath soundsTreat with decompression

ThoraxCirculation:Cardiac tamponadeDecreased arterial pressureDistended neck veinsMuffled heart soundsPEA (pulseless electrical activity)Treat with decompression

ThoraxResuscitative thoracotomy:Penetrating traumaPulseless with myocardial activityEvacuate bloodStop bleedingCardiac massageCross clamp of aortaInfusion of fluids and blood

ThoraxSecondary SurveySimple pneumothoraxHemothoraxPulmonary contusionTracheobronchial tree injuryBlunt cardiac injuryAortic disruptionDiaphragm injuriesMediastinal traversing woundsEsophageal ruptureRib, sternum, scapular fractures

ShockHemorrhage is the most common cause of shock in the injured patient!!

ShockHemorrhagic shockNon-hemorrhagic shock:CardiogenicTension pneumothoraxNeurogenic shockSeptic shock

ShockBlood volume:5 liters in the 70 kg adult80-90 ml/kg in the childClasses of Hemorrhage (% loss)I: 40%

ShockInitial Therapy:Stop the bleeding!Vascular Access lines2 large bore IV linesIntraosseous linesCentral linesFluid bolus 2 Liters NS: adult20ml/kg: Child

ShockAssess:Capillary refill (should be < 2 sec)Peripheral pulsesHeart rateTemperature and color of skinSensoriumPulse pressure

ShockSigns of hemodynamic recovery:Slowing of pulseDecrease in skin mottlingIncrease in extremity temperatureClearing of sensoriumUrinary output > 1ml/kg/hourIncreased systolic blood pressure

AbdomenMechanisms:BluntPenetratingSpaces:Peritoneal cavityPelvisRetroperitoneum

AbdomenPhysical exam:InspectionAuscultationPercussionPalpationEvaluate penetrating wounds Local exploration of stab wounds

AbdomenPhysical exam:Assess pelvic stabilityGenital and rectal examGluteal exam

AbdomenDiagnostic studies:CT scanUltrasound DPLUrethrography/cystography

AbdomenIndications for exploration:Blunt trauma with instability and positive US or DPLBlunt trauma with recurrent hypotensionPeritonitisHypotension from penetrating woundBleeding from stomach/rectum/GU (penetrating)Gunshot woundEvisceration

AbdomenSpecial considerations:DiaphragmDuodenumPancreasLiver/SpleenGUSmall bowel

Left: Massive hemothoraxRight: Chest tube decompression

Tension pneumothoraxChest tube placed and pneumo-thorax resolved

CirculationHeart rate Systolic BP Urineml/kg/hr Infants 100-160 60 2Preschool 80-140 80 1.5School age 80-140 90 1-1.5Adolescent 60-120 100 0.5-1

Head Trauma500,000 cases per year in US10% die prior to hospital

Head TraumaCerebral Perfusion PressureCPP=MAP-ICPMAP =Mean arterial pressureICP = Intracranial pressureCerebral Blood Flow50ml/ 100g of brain/minute

Head TraumaMechanism:Blunt v. PenetratingSeverity:Mild: GCS 14-15Moderate: GCS 9-13Severe: GCS 3-8Morphology:Skull fracturesIntracranial lesions

Head TraumaSkull fractures:Battles SignRacoon eyesRhinorrhea/otorrheaLinear vault fractures400 X risk hematoma in awake patients20 X risk in comatose patients

Head TraumaIntracranial lesionsEpidural hematomasSubdural hematomasContusions/hematomasConcussionDiffuse axonal injuries

Head TraumaManagement;ABCs! (GCS < 8 intubate patient)Hypotension is never presumed to be from head traumaCT scanHyperventilationMannitol/lasixSteroidsBarbiturates

Spinal InjuriesLevelSeverityC-spine-protect always!!10% have another vertebral fractureRespiratory function may be lostSpinal shockHigh dose methylprednisolone in first 8 hoursPediatric considerations (SCIWORA)SCIWORA Spinal Cord Injury WithOut Radiographic Abnormality

Subluxation C-5 on C-6

Musculoskeletal InjuriesMay have significant bleeding sourceEvaluate vascular and neurologic statusImmobilize/tractionPelvic fractureStabilizeEmbolize

Musculoskeletal InjuriesCrush injuries:MyoglobinuriaOpen fracturesImmobilizeAntibiotics/tetanus

Musculoskeletal InjuriesCompartment Syndrome:Pain (especially with passive stretching)ParesthesiaDecreased sensation or functionParalysis or loss of pulse are LATE changes and loss of limb is imminentTissue pressures >35-45 mm Hg threaten limb

Cerebral contusion with cerebral swelling and skullfracture

Tear drop fracture anterior C-4

Massive left hemothorax with compressed lung

Tension pneumothorax on right with shifted mediastinum

Fractured vertebral body on CT scan view

Stomach herniated through diaphragm

Epidural hematoma

Massive facial trauma

Contusion of right lobe of liver

Fracture through body of pancreas

Intra-osseous access

Technique for pericardiocentesis

Lap belt abrasion-indicates force of injuryand high risk of internal injuries

View of normal vocal cords

Fractured larynx

MRI image of thoracicvertebral fracture and injured spinal cord

Subdural hematoma

Lines of escarotomy in burn injuries