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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 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