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TRAUMA OVERVIEW
Mark E. Armstrong, M.D.
Overview
1. Preparation2. Triage3. Primary Survey4. Resuscitation5. Secondary Survey6. Continued postresuscitation monitoring and re-evaluation
7. Definitive care
PreparationPrehospital
Notify receiving hospital Closest appropriate facility Report pertinent information
Inhospital Warmed IV solutions Ancillary departments notified Equipment made readily available Hospital personnel protection
Primary Survey
AirwayBreathingCirculationDisability: Neurologic Evaluation
Exposure/Environmental Control
Primary SurveyAirway
PatencyForeign bodiesFacial FracturesProtect C-spine
Primary SurveyBreathing
Patency does not equal adequate ventilation Expose chest Auscultate Conditions that may acutely impair ventilation Tension pneumothorax Massive hemothorax Flail chest Rib fractures Open pneumo Pulmonary contusion
Primary SurveyCirculation
Hemorrhage controlTwo Key Elements 1. Level of Consciousness -AVPU -Glasgow Coma Score 2. Pulse
Bleeding
ControlNo hemostatsConsider occult sources
Primary SurveyDisability
AVPU
Glasgow Coma
Verbal Response Motor response Oriented 5 Obeys
6 Confused 4 Localizes
5 Inappropriate words 3 Withdraws 4 Incomprehensible sounds 2 Decortication 3 None 1 Decerebration
2 None
1
Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1
Primary SurveyExposure
Remove all clothesCover to prevent hypothermia
Resuscitation
Airway Oral Nasal- do not put in someone with facial trauma
Endotracheal Surgical
Breathing Supply O2 Ventilate alveoli
Resuscitation
Circulation Establish 2 large bore IVs Draw blood Vigorous IV therapy ECG monitoring Avoid hypothermia Evaluate PEA Other dysrhythmias
Class % bloodloss
Heart rate Bloodpressure
Pulsepressure
Resp rate Capillaryrefill
Urineoutput
Other Mortality
I 10 – 19(750 cc)
Normal
II 20 – 29(1250)
>100 Slightly Delayed
III 30 – 39(2000)
>120 (>30) VeryDelayed
Oliguria Acidosis 25%
IV >40 >140 Anuria 60%
Hemorrhage classification
Resuscitation
Catheters Urinary
Rectal first Check for other signs of urethral injury
Gastric Oral v.s. nasal placement
NGT Intracranial
Resuscitation
Monitoring ABG’s Pulse oximetery Blood pressure ECG
Roentgenograms
Should not delay resuscitationAP pelvisAP chestLateral C-spineOdontoid, AP C-spine
Other Imaging
FAST scan Focused Assessment Sonography in Trauma
Ultrasound1. Pericardial sac (epigastric area)2. Hepatorenal fossa3. Splenorenal fossa4. Pelvis or Pouch of Douglas (bladder)
Secondary Survey
Head-to toe evaluation Vital sign evaluation Detailed neuro exam if not done in primary survey
Special procedures“Tubes and fingers in every orifice”
Secondary SurveyHistory
A AllergiesM MedicationsP Past illnessesL Last mealE Events related to injury 1.Blunt 2.Penetrating 3.Burns 4.Hazardous Environment
Secondary SurveyHistory
A AllergiesM MedicationsP Past illnessesL Last mealE Events related to injury 1.Blunt 2.Penetrating 3.Burns 4.Hazardous Environment
Secondary Survey (PE)Head
ScalpEyesNoseMouthBite occlusion
Secondary Survey (PE)Head
PITFALLSHyphemaOptic nerve injuryLens dislocationHead injuryPosterior scalp laceration
Secondary Survey (PE)Maxillofacial
Midline facial fracturesBite occlusionBleedingFracture repair can wait
Midface FracturesLaFortI: Maxilla only transversely above the alveolar ridge
Most common isolatedII (pyramidal): Through nasal bone or nasal bone disarticulation with frontal bone
Most common when associated with other fractures
III (dislocated face): Through nasal bone, across floor of orbit, through lateral wall of orbit, zygomatic arch Rare
Secondary Survey (PE)Maxillofacial
PITFALLSPending airway obstructionChanges in airway statusCervical spine injuryExsanguinating midface fractureLacrimal duct lacerationsFacial nerve injuries
Secondary Survey (PE)C-spine and neck
Must be immobilizedInspection PalpationAuscultation (carotids)
Secondary Survey (PE)C-spine and neck
PITFALLSC-spine injuryEsophageal injuryTracheal or laryngeal injuryCarotid injury (blunt or penetrating)
Secondary Survey (PE)Chest
Visual evaluation (ant & post)Palpate rib cageSternal pressureAuscultation (heart & lungs)Chest xray
Secondary Survey (PE)Chest
PITFALLSTension pneumothoraxOpen chest woundFlail chestCardiac tamponadeAortic rupture (widened mediastinum)
Pneumothorax
Tension Pneumothorax
Secondary Survey (PE)Abdomen
Frequently repeated examsInspectionPalpationNormal initial exam does not rule out injury
Peritoneal lavage v.s. CT scan v.s. U/S (FAST)
Secondary Survey (PE)Abdomen
PITFALLSLiver or splenic flexureDeceleration injuries Hollow viscus, Lumbar spinePancreatic injuryMajor intraabdominal vascular injuryRenal injuryPelvic fractures
Secondary Survey (PE)Perineum/Rectum/Vagina
Contusions,Hematomas, Lacerations
Urethral bleedingRectal bloodHigh riding prostateSphincter toneVaginal vault injuries (pelvic fractures)
Secondary Survey (PE)Perineum/Rectum/Vagina
PITFALLSUrethral injuryRectal injuryBladder injury Vaginal injury
Retrograde urethrogram
Secondary Survey (PE)Musculoskeletal
ContusionDeformityPalpationPelvic pressure and compressionVascular examNeurologic exam
Secondary Survey (PE)Musculoskeletal
PITFALLSSPINE FRACTURESFractures with vascular compromise
Pelvic fracturesDigital fractures
Secondary Survey (PE)Neurologic
Immobilization of entire patient Reevaluate GCSCranial nerve examMotor examSensory examMonitor frequently for changes in neuro status
Assess O2 delivery if changes notedEarly neurosurgical consultation
Secondary Survey (PE)Neurologic
PITFALLSIncreased intracranial pressureSubdural hematomaEpidural hematomaDepressed skull fractureSpine injuryBeware of unconscious patient
Subdural Hematoma
Epidural Hematoma
Aftercare
Continuous reevaluationDefinitive care