Initial approach to

trauma

Dr.Shankar. Hippargi Consultant & HeadA & E Deptartment

TRAUMA

“The Neglected disease of modern developing nations”

Everyday we come across a story about

someone’s loved one dying on the road and

just ignore it, focusing on our day to day

life.

One day, it could be anyone of us! Someone from our family; some loved one!

Then What…?

Pitiable condition of our roads

Pitiable attitude of our people

Traumatic injury and death due to trauma is the third leading cause of death all over the world Leading cause of death in age group 20-40 years (great impact on family)Blunt injury due to motor vehicle crash is the leading cause of death in traumaTraumatic injury contributes to the highest medical costs and greatest incidence of life-long disability

Traumatic injuries are broadly classified into blunt and penetrating injuries

Time to Care vs Survival

Conflict EvacuationTime (hrs)

Mortality Rate (%)

World War I 18 18.0

World War II 4-6 3.3

Korea 2-4 2.4

Vietnam 1-2 1.8

What do these numbers suggest about trauma care strategies?

- Time is life -

What do these numbers suggest about trauma care strategies?

- Time is life -

Trimodal pattern of mortality

Pre Hospital- Devastating head & major vascular injuriesED- Major head, chest & abdominal injuriesICU- Organ hypoperfusion, SIRS, MOD

Trimodal distribution

<1 hour 1-3 hours 4 to 6 weeks

What can be done about these deaths?What role does EMS & ED play?

Golden hour

The first hour following a trauma during which aggressive resuscitation can improve the chances of survival, and restore the normal functionsEarly pre-hospital care, early transport, aggressive resuscitation and interventions in ED, continued care in ICU have a definite and significant roles in preventing deaths due to trauma

Role of ED

Portal of entry to all trauma patientsEarly triage, early recognition and rapid intervention of life / limb threatening injuriesMaintaining adequate ABCsEarly referral (understand your limitations)Co-ordinate other specialties

Indian scenario

No proper pre-hospital careNo trained emergency physiciansNo trained nursing / paramedical staffNo co-ordination between different specialties

Most of the trauma related deaths are preventable, and its high time to realize this fact.

The initial approach to trauma care is a process that consists of an initial primary assessment, rapid resuscitation and a more thorough secondary assessment, followed by diagnostic tests and disposition

Primary assessment

The goal is to identify and treat life & limb threatening conditionsAssessment and management should go hand in handRe-assess after each interventionAssess ABCDEs of trauma and do appropriate interventions as required

Treatable life threatening conditions

Airway obstructionTension pneumothoraxCardiac tamponadeMassive hemothoraxSucking chest woundMassive bleedingPelvic and other long bone fracturesScalp lacerations

ABCDEs of trauma…

Airway with C-spine controlBreathing with supplemental O2

Circulation with bleeding controlDeformity/ Disability Exposure

Airway with C-spine control Suspect C-spine injury in all unconscious patients, any injury above the clavicals, significant mechanism of injury (do not head tilt chin lift)Manually stabilize the C-spine, look for foreign bodies, bleeding, maxillo-facial injuriesAll patients with GCS <9 needs intubation Jaw Thrust

Manual in line stabilization of C-spine while doing intubationApply rigid neck collar after intubation (look for tracheal shift, distended neck veins, lacerations)Patients with severe Maxillo-facial injuries may need surgical airwayMaintaining adequate oxygenation is very important in preventing secondary injuries especially in head injury patients

Breathing with supplemental O2

Inspect- Equal chest rise, paradoxical chest movements, contusions, sucking chest wound, distended neck veinsAuscultate- Equal breath sounds, absence of BSPalpate- Tracheal shift, Chest wall tenderness, subcutaneous emphysema, sternum #, rib # Percuss- dullness, hyper-resonanceGive 100% O2 to all trauma patients

Important interventions

Tension pneumothorax- Needle decompression, followed by ICDOpen pneumothorax (Sucking chest wound) – 3 way occlusive dressingCardiac tamponade- PericardiocentesisMassive hemothorax- ICDPelvic fracture- pelvic binder

Tension pneumothorax

Open pneumothorax

Circulation with bleeding control

Hemorrhagic shock is common cause of post injury deathLook for S/O hypoperfusion- level of consciousness, PR, BP, capillary refill

(>2 sec), skin colour, urine outputAll hemorrhages do not produce shockS/O shock not seen until 30% of blood is lost

Anticipate shock depending on MOI and physical examinationControl obvious bleeding by direct pressure, splinting & limb elevationTry to find source of bleeding in hypotensive patient with no external bleeding

Pelvic fracture- pelvic binder

Cardiac Tamponade

Fracture & blood loss

Site of fracture Blood loss (approx)

Pelvic # 2500-4000ml

Femur # 1500-2000ml

Tibia & Fibula # 1000-1500ml

Humerus # 500-800ml

Forearm bones # 250-400ml

Classification of hemorrhagic shock

Rate of flow is fourth power of radius of cannula

α

Start 2 large bore iv lines, start crystalloids (avoid colloids for initial resuscitation)Give blood as soon as possible in hemorrhagic shocksLook for other causes of shock

Shock in trauma

Hypovolumic (hemorrhagic) most common- until proved otherwiseCardiac tamponadeTension pneumothoraxMyocardial contussionNeurogenic shock

Rule out by physical examination and USG

Disability

GCS, Pupils size and reaction, motor function

• GCS 13-14= mild head injury• GCS 9-12= moderate head injury• GCS <9= severe head injury (intubate)

Exposure

Primary assessment is incomplete without thorough examination of total body surface areaLog roll should be done in all unconscious patientsInspect & palpate entire spine & back, P/R for anal tone, blood & prostateMeatal bleed S/O urethral rupture, DO NOT CATHETERIZE

Primary survey...

Any derangement identified during primary assessment should be treated immediatelySecure airway & IV lines, catheterize, insert NG tubeContinuous monitoring (rhythm, HR, BP, RR, SpO2)

Secondary assessment

It is rapid but thorough head to toe physical examination for the purpose of identifying as many injuries as possibleResuscitation should be continued during secondary assessmentInspect & palpate for tenderness, crepitus, swelling, deformity, all peripheral pulses, motor & sensory function, scrotal hematoma

Do not in trauma

04/11/23

Never try to remove any impaled foreign object (may cause severe uncontrollable bleeding, tamponade and sudden death)

• Never insert anything nasally in head injury patients especially when there are signs of basal skull #

• Never try to put the intestinal loops back into abdomen in stab injuries (may cause strangulation)

Investigations

PCV (Hb)S. electrolytesCreatinine & ureaHIV, HbSAg, HCV

X-ray- Chest, C-spine,Pelvis & region of suspected #CT brain, thorax & abdomen as neededFAST (USG)

To summarise• Organised team approach

• Priorities in management & resuscitation

• Rule out of most serious injuries

• Treatment before diagnosis

• Thorough examination

• Frequent reassessment

• Monitoring

"A good beginning almost assures success"

Emergencies don’t give us

a second chance…..