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