Management of the Injured com

8/14/2019 Management of the Injured com

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Dr. Mohamed El-GindyDr. Mohamed El-Gindy

Professor of SurgeryProfessor of Surgery

MansouraMansouracom.mansfans.www


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)2009 (

85% 15%

% 85% 10

% 5

5 26

6 25

23


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Trauma is the (neglected disease) of

modern society.

It is the number one killer under the

age of 40 years and the 4th cause of

death in all ages.

Significance of traumaSignificance of trauma

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The economic cost of trauma to the

nation is more than $

41 bilion annually.

It causes permanent loss of millions of

productive work years.

Economic cost of traumaEconomic cost of trauma

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The intent of any system of trauma care

must be to fulfil the" 3 Rs"

To get the Right patientTo the Right hospital

At the Right time.

Trauma careTrauma care

" 3 Rs"

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* It can Resuscitate the victim* It can Review (assessment, monitorin

and diagnosis)

* It can Repair (definitive treatment)

" 3 Rs"

The Right Hospital should fulfil

also

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It provides specialised trauma care

(Resuscitate, Review & Repair) .

Educate physicians and paraprofessionals in

trauma care.

Undertake trauma research.

Treat a certain number of severly injured

patient every year.

Level (I) Trauma

Hospital " 3 Rs"

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Trauma CategoriesTrauma Categories

l) Those with injuries that are rapidly fatal (5%)

Death is inevitable

2) Stable patients (80%)

They need little expertise

3)Those with life threatining injuries and required

urgent medical attention (15%).

They need more expertisecom.mansfans.www


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Mechanisms of InjuryMechanisms of Injury

Blunt mechanisms

ForcesCompression forces

Shearing forces

Deceleration forces

SourcesMVCs

Seat belt injury

Steering wheelinjuryFalls

Assaults

Blast

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Mechanisms of InjuryMechanisms of Injury

Penetrating mechanisms

Low velocityKnife

ice pick

Medium velocitygunshot/handgun

shotgun

High velocityhigh power hunting riflemilitary weapon

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Immediate measures at the

scene of accident.

Transportation

Emergency room care

TheThe 3 lines3 lines of managementof management

of theof the injured patient areinjured patient are

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* Handled as if severe injury has occurred.

* Protected from further trauma

* Treated by trained personnel.

the victim should bethe victim should be

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1) Is the victim breathing ?

2) Is there a pulse or heart beats ?

3) Is there gross external bleeding ?

4) Is there any question of spine injury ?

5) Is there any obvious fractures ?

55QQ ?? ??

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a. Airway obstructiona. Airway obstruction

Causes:

* Blood, mucus, vomitus.

* Foreign body (e.g. broken teeth)

* Fallen tongue in comatosed

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1. Simple manipulation of the

mandible

2. Immediate endotracheal intubation

3. Try to remove any foreign body.

Management of AirwayManagement of Airway

obstructionobstruction

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A

B

C

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4. One or two large-bore needles through

the cricothyroid membrane.

5. A lateral and slightly head down position

6. In respiratory arrest, mouth to mouth breathing

Management of AirwayManagement of Airway

obstructionobstruction

(CONT.)(CONT.)

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b. Acute Thoracic Injuryb. Acute Thoracic Injury

Flail Chest

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b. Acute Thoracic Injuryb. Acute Thoracic Injury

Open pneumothorax

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b. Acute Thoracic Injuryb. Acute Thoracic InjuryTension Pneumothorax

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*Absence of heart sounds and pulse*immediate action within 4 minutes.

Mouth to mouth breathing/5 cardiaccompressions.

* Place the victim on a hard surface.*Sharp blow with the Fist to the lower

end of the sternum

*4-5 cm toward the spine once/second.

2. Cardiac Arrest:2. Cardiac Arrest:

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3- HEMORRHAGE

*local pressure and elevation of the limb

*Tourniquet

*kept exposed*loosened / 20 m. for 2 m.

*write ( TK ) on forehead

*on uper arm or thigh

*It may cause vasc. & nerve damage

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ShockShock

*1 ry Shock*1 ry Shock ( pain and fright)( pain and fright)

*Hypovolemic shock*Hypovolemic shock ( loss of blood or plasma)( loss of blood or plasma)

*patient must be recumbent*patient must be recumbent

* Analgesics should be* Analgesics should be (I V(I V((

*fluids until blood trans.*fluids until blood trans.

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The lethal triadThe lethal triad

Bleeding coagulopathy

Acidosis hypothermia


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4- Fracture Spine 4- Fracture Spine


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Pelvic FracturesPelvic Fractures


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Patients should be transported in the supine

position.

Station wagon or truck is preferable

Resuscitation of injured patient should be

maintained

II.TransportationII.Transportation

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Is Pre hospital careIs Pre hospital care

significantly improve thesignificantly improve theoutcomeoutcome

** The answer is equivocalThe answer is equivocal bbecause of :ecause of :

1) Delay from receiving definitive1) Delay from receiving definitive

treatment in the hospitaltreatment in the hospital(2) It may have adverse effects and(2) It may have adverse effects and

compromise the patient furthercompromise the patient further ..


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is a new Aproachis a new Aproach

Except forExcept for

* Unavoidable delay due to entrapment.* Unavoidable delay due to entrapment.

* Inaccessible sites.* Inaccessible sites.* In rural locations* In rural locations..

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11((Size & demography of the populationSize & demography of the population 2)2)

Local geographical constraintsLocal geographical constraints

3) Rural or highly urbanized3) Rural or highly urbanized areaarea

The prehospital care directlyaffected by:

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**Fire and police services do the BASIC support .Fire and police services do the BASIC support .

** Emergency paramedics do the advanced skills andEmergency paramedics do the advanced skills and

communication links with the receiving hospital .communication links with the receiving hospital .

** Severely injured patient may bypass theSeverely injured patient may bypass the

nearest facility to the proper trauma centrenearest facility to the proper trauma centre

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com.mans

fans.ww

wcom.mansfa

ns.www

Hopping forHopping forcom.mansfans.www


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Hopping forHopping for

1-The Basic Care by the1-The Basic Care by the

police manpolice man

2- Augment the ambulance service2- Augment the ambulance service

3- Paramedic & physician in each3- Paramedic & physician in each

4- Advanced skills by the team inside4- Advanced skills by the team inside


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Transportation to theTransportation to the nearest hospital ??nearest hospital ??

Augment the communication linksAugment the communication links

7- Accident flying squads using Helicopters7- Accident flying squads using Helicopters

in inaccessible sitesin inaccessible sites

Hopping for

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III Emergenc Room CareIII Emergency Room Care


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III Emergency Room CareIII Emergency Room Care

1- General Principles :

1) Patient clothing (cut off).

3) History of :

a. medical diseases.

b. circumstances of the injury .

4) Findings should be "written records

(for medicolegal and follow up

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Do not remove the stab


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Do not remove the stab

except in OR.

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Impalement Injury


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2. Resuscitation

a. I.V catheters b. I.V Fluids

c. (C. V. P.) d. Foleys

catheter

e. Antitetanic, antigasgangrene serum if



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4. Radiological Study

* X-ray chest and abdomen in all cases of major injury.

* I.V.P. in abdominal and pelvic injuries with evidence of

urinary

tract injury

* X-ray skull, C.T. scanning of the head in most of head

injuries.


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Thermal Trauma

E t i Th l T


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Extensive Thermal Trauma

Special Bed for Extensive Thermal Trauma


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Special Bed for Extensive Thermal Trauma

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Bullet Injury of the

heart and abdomen

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Blunt Abdominal Trauma

Flank ecchymosis from internal bleeding

Blunt Closed Abdominal Trauma


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Blunt Closed Abdominal Trauma

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Certain injuries are so critical thatthatoperative treatment must be undertaken as

soon as the diagnosis is made ( penetrating

wound of the heart , abdominal wounds

involving the aorta and vena cava )

Cerebral injuries take priority in care

only when there is rapidly deepening coma and

evidence of extra dural bleeding .

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Laparotomy for abdominal injury and

craniotomy for cerebral injury can becarried out simultaneously .

Fractures of long bones can be treated on

a semiemergency bases unless

there is associated vascular

injury or open fractures

Hand injury should be treatment as early

If th ti t i t d


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Alcoholic intoxication . Cerebro vascular accident .

Diabetic coma .

Barbiturate Poisoning

Hypovolemic shook .

If the patient is comatosed :

The cause may be :


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Management of the Injured com