Approach To Truama

APPROACH TO TRUAMA
Tesfanew Bekele, MD, Surgeon

OUTLINE
 Introduction
 Primary survey
 Secondary survey
 Head Injury
 Neck Injury
 Thoracic Injury
 Abdominopelvic injury
 Orthopedic emergencies
INTRODUCTION
 Trauma, or injury, is defined as cellular disruption caused by an
exchange with environmental energy that is beyond the body's
resilience.
 the most common cause of death for all individuals between the
ages of 1 and 44 years
 the third most common cause of death regardless of age.
 the number one cause of years of productive life lost
 trauma is a major public health issue

INITIAL EVALUATION AND
RESUSCITATION OF THE INJURED
PATIENT
Primary Survey: The Advanced Trauma Life Support (ATLS)
Rationale:
 Appropriate and timely care can significantly improve the outcome
for the injured patient
 ATLS provides a structured approach to the trauma patient with
standard algorithms of care
 it emphasizes the "golden hour" concept that timely prioritized
interventions are necessary to prevent death
 The ATLS course refers to the primary survey as assessment of the
"ABCs"
3 PEAKS OF DEATHS AFTER TRAUMA
 1st peak: at the scene
Atlantoaxial dislocation, major vascular injury, cardiac
injury
 2nd peak: minutes to hours
severe head injury, Airway obstruction, tension

pneumothorax, hemorhagic shock
 3rd peak: days
sepsis, thromboembolism
ATLS focuses on 2nd peak
A AIRWAY MANAGEMENT WITH C-
SPINE PROTECTION
 Ensuring airway patency
 All patients with blunt trauma require cervical spine
immobilization until injury is excluded by applying a hard collar or
placing sandbags on both sides.
 In general, patients who are conscious, do not show tachypnea,
and have a normal voice do not require early attention to the
airway
WHO NEED AIR WAY EVALUATION?
 Patients who have an abnormal voice, abnormal breathing
sounds, tachypnea, or altered mental status.
 patients with penetrating injuries to the neck and an expanding
hematoma; evidence of chemical or thermal injury to the mouth,
nares, or hypopharynx; extensive subcutaneous air in the neck;
complex maxillofacial trauma; or airway bleeding
WHAT COMPROMISES AIR WAY?
 Blood, vomit, the tongue, foreign objects, and soft tissue
swelling
 Comatose patient
 Maxillofacial injury
WHAT TO DO?
 Suctioning
 Chin lift or jaw thrust
 Air ways(nasal & oral)
 Endotracheal intubation(nasotracheal, orotracheal,

surgical cricothyrotomy, tracheostomy)
 Oropharyngeal or nasopharyngeal airway
Oral airway Nasal airway

ENDOTRACHEAL INTUBATION
TECHNIQUE OF INTUBATION
TRACHEOSTOMY TUBES
 Made of silver or plastic
 Cuffed tubes
PGMEDICALWORLD.COM
 Preventsaspiration
 Can give PPV
B BREATHING AND VENTILATION
Recognize!!
 tension pneumothorax,
 open pneumothorax, sucking chest wound
 Massive hemothorax
 flail chest with underlying pulmonary contusion,,
WHAT TO DO?
 All injured patients should receive supplemental oxygen and be
monitored by pulse oximetry
 Needle thoracostomy
 Tube thoracostomy
 Covering sucking chest wound with an occlusive dressing that is

taped on three sides(Pic)
 Presumptive intubation and mechanical ventilation for flial chest
(rarely)
C CIRCULATION WITH HEMORRHAGE CONTROL
 Recognizing the presence of shock and assessing its severity
 Shock in trauma is hemorrhagic unless proven otherwise!!
 External/internal bleeding
 Rapid assessment of hemodynamic status

 Level of consciousness
 Skin color
 Pulses in four extremities
 Blood pressure and pulse pressure
 Estimation of SBP i.e radial-> 80mmHg, femoral>70, carotid>60,

 If carotid pulse absent-> no apical pulse-> CPR
 SBP<90mmHg & HR>120bpm indicative of shock

C CIRCULATION WITH HEMORRHAGE CONTROL
 four life-threatening injuries that must be identified are(internal

bleeding)
(a) massive hemothorax, CXR
(b) cardiac tamponade, FAST
(c) massive hemoperitoneum, FAST
(d) mechanically unstable pelvic fractures, pelvic x-ray
CIRCULATION INTERVENTIONS
 Cardiac monitor
 Apply pressure to sites of external hemorrhage, avoid
torniques , massive dressing, blind clamping
 Establish IV access
2 large bore Ivs, 2L (adult) or 20 mL/kg (child) IV bolus of
isotonic crystalloid N/S vs R/L
 Intraoseous, saphenous cutdown
 Central lines if indicated
 Cardiactamponade decompression if indicated
 Volume resuscitation
 Have blood ready if needed
 Foley catheter to monitor resuscitation
NON-RESPONDERS TO
RESUSCITATION
 Patients with ongoing hemodynamic instability, whether
"nonresponders" or "transient responders," require systematic
evaluation and prompt intervention
 Consider ongoing internal bleeding
 cardiogenic shock & DDx: tension pneumothorax, pericardial

tamponade, blunt cardiac injury, myocardial infarction,
bronchovenous air embolism
D- DISABILITY
 Neurological exam
 Level of consciousness
 Pupil size and reactivity
 Motor function
 GCS
 Utilized to determine severity of injury
 Guide for urgency of head CT and ICP monitoring
GCS
EYE VERBAL MOTOR
Spontaneous 4 Oriented 5 Obeys 6
Verbal 3 Confused 4 Localizes 5
Pain 2 Words 3 Flexion 4
None 1 Sounds 2 Decorticate 3
None 1 Decerebrate 2
None 1
DISABILITY INTERVENTIONS
 Spinal cord injury
 High dose steroids if within 8 hours
 ICP monitor- Neurosurgical consultation
 Elevated ICP
 Head of bed elevated
 Mannitol
 Hyperventilation
 Emergent decompression
E- EXPOSURE/ENVIRONMENTAL CONTROL
 Complete uncovering of patient
 Logroll to inspect back
 Rectal temperature
 Warm blankets/external warming device to prevent

hypothermia
ALWAYS INSPECT THE BACK!!
SECONDARY SURVEY
 Obtain an AMPLE history (Allergies, Medications, Past
illnesses or Pregnancy, Last meal, and Events related to
the injury
 P/E: head to toe with special attention to the patient's
back, axillae, and perineum
 PR & PV
 Adjuncts to the physical examination include vital sign

and CVP monitoring, ECG monitoring, nasogastric tube
placement, Foley catheter placement, repeat FAST,
laboratory measurements, and radiographs (the big three)
TRAUMA II will
continue…..

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APPROACH TO TRUAMA

Tesfanew Bekele, MD, Surgeon

 the number one cause of years of productive life lost

 trauma is a major public health issue

severe head injury, Airway obstruction, tension

 Air ways(nasal & oral)

 Endotracheal intubation(nasotracheal, orotracheal,

Oral airway Nasal airway

 Covering sucking chest wound with an occlusive dressing that is

 Rapid assessment of hemodynamic status

 Estimation of SBP i.e radial-> 80mmHg, femoral>70, carotid>60,

 SBP<90mmHg & HR>120bpm indicative of shock

 four life-threatening injuries that must be identified are(internal

 cardiogenic shock & DDx: tension pneumothorax, pericardial

 Warm blankets/external warming device to prevent

 Adjuncts to the physical examination include vital sign

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