TRAUMATRAUMA

• The `neglected disease of the modern The `neglected disease of the modern society`society`

• Commonest cause of death among people Commonest cause of death among people aged 1- 34 years.aged 1- 34 years.

• WHO – 1 in 10 deaths worldwide due to WHO – 1 in 10 deaths worldwide due to traumatrauma

• More than half young adults 15-44 years, 73% More than half young adults 15-44 years, 73% malesmales

• Most vulnerable – pedestrians, cyclists, Most vulnerable – pedestrians, cyclists, motorized two wheelers and passengers of motorized two wheelers and passengers of public transport. public transport.

TRAUMA - Indian scenarioTRAUMA - Indian scenario

• National Crimes Records Bureau National Crimes Records Bureau (NCRB) – 2004 –most accident prone (NCRB) – 2004 –most accident prone state – Maharashtra, 2state – Maharashtra, 2ndnd Kerala. Kerala.

• 3066 deaths out of 41306 accidents in 3066 deaths out of 41306 accidents in KeralaKerala

• 84000 die in India yearly84000 die in India yearly

• Loss of Rs.50000 crore annually.Loss of Rs.50000 crore annually.

Trauma mortalityTrauma mortality

Trimodal distribution of death in traumaTrimodal distribution of death in trauma• First peak - Within seconds or minutesFirst peak - Within seconds or minutes• Second peak – within hours about 30% Second peak – within hours about 30%

of deaths – half of these caused by of deaths – half of these caused by haemorrhage, the other half by CNS haemorrhage, the other half by CNS injuries. Can be averted by “golden injuries. Can be averted by “golden hour” treatment.hour” treatment.

• Third peak – after 24 hrs. due to Third peak – after 24 hrs. due to infection & Multiple Organ failure etc. infection & Multiple Organ failure etc.

PreventionPrevention

• Primary prevention – Educational e.g. Primary prevention – Educational e.g. anti drink campaign , legislative like anti drink campaign , legislative like enforcement of speed limits.enforcement of speed limits.

• Secondary prevention – Making Secondary prevention – Making vehicles and roads safer, wearing vehicles and roads safer, wearing helmets, seatbelts etc.helmets, seatbelts etc.

• Tertiary prevention – Better prehospital Tertiary prevention – Better prehospital and hospital care of the injured.and hospital care of the injured.

Causes of traumaCauses of trauma

• Blunt trauma – RTABlunt trauma – RTA

• Penetrating traumaPenetrating trauma

• Blast injuriesBlast injuries

• Crush injuriesCrush injuries

• Thermal injuriesThermal injuries

Initial assessment & Initial assessment & managementmanagement

Objectives:Objectives:• Identify the correct sequence of Identify the correct sequence of

priorities in assessing the polytrauma priorities in assessing the polytrauma ptpt

• Apply principles of primary & Apply principles of primary & secondary surveysecondary survey

• Apply guidelines & technique of Apply guidelines & technique of resuscitative & definitive careresuscitative & definitive care

Advanced Trauma Life Support Advanced Trauma Life Support (ATLS)(ATLS)

James Styner in 1976James Styner in 19761.1. PreparationPreparation2.2. TriageTriage3.3. Primay surveyPrimay survey4.4. ResusscitationResusscitation5.5. Secondary surveySecondary survey6.6. Continued monitoring & reevaluationContinued monitoring & reevaluation7.7. Definitive careDefinitive care

PreparationPreparation

• Prehospital phasePrehospital phase

• Inhospital phaseInhospital phase

Prehospital phasePrehospital phase

• Airway maintenanceAirway maintenance

• Control of external bleeding & shockControl of external bleeding & shock

• ImmobilizationImmobilization

• Transport to the immediate appropriate Transport to the immediate appropriate facility preferably a trauma centerfacility preferably a trauma center

Inhospital phaseInhospital phase

Proper trauma care facilities should be Proper trauma care facilities should be available. E.g.Facilities for taking available. E.g.Facilities for taking universal precautions, proper airway universal precautions, proper airway equipment, I/V fluids, monitoring equipment, I/V fluids, monitoring facilities, lab. & Imaging facilities, facilities, lab. & Imaging facilities, communication system etccommunication system etc

TriageTriage

• Sorting of patients based on the pts based Sorting of patients based on the pts based on the need for treatment and available on the need for treatment and available resources to provide that treatmentresources to provide that treatment

• Also sorting of pts in the prehospital phase Also sorting of pts in the prehospital phase to transport to trauma center.to transport to trauma center.

• Based on A,B,C prioritiesBased on A,B,C priorities• Quick assessment by monitoring vital signs Quick assessment by monitoring vital signs

viz., GCS,systolic B.P. & resp. rateviz., GCS,systolic B.P. & resp. rate

Triage – stepwise approach at Triage – stepwise approach at the sitethe site

Step 1: GCS <14/systoli BP <90mmHg/resp Step 1: GCS <14/systoli BP <90mmHg/resp rate<10 or >29- take pt to major hospitalrate<10 or >29- take pt to major hospital

Step 2: Assess anatomical extent of injuries – Step 2: Assess anatomical extent of injuries – pelvic #, flail chest, two or more long bone #, pelvic #, flail chest, two or more long bone #, amputation proximal to amputation proximal to wrist/ankle,burns>10%,all penetrating wrist/ankle,burns>10%,all penetrating injuries to head, neck, thorax, and injuries to head, neck, thorax, and extremities proximal to elbow & knee, any extremities proximal to elbow & knee, any neurological deficit > major hospitalneurological deficit > major hospital

Triage – stepwise approach at Triage – stepwise approach at the sitethe site

Step 3: Evaluate the mechanism of injury Step 3: Evaluate the mechanism of injury Death in the same passenger Death in the same passenger compartment/ pedestrian/ejection from compartment/ pedestrian/ejection from vehicle/deformity of the vehicle: >major vehicle/deformity of the vehicle: >major hospitalhospital

Step 4: Assess history: Age <10/>50yrs, Step 4: Assess history: Age <10/>50yrs, known medical condition > major known medical condition > major hospitalhospital

Advanced Trauma Life Support Advanced Trauma Life Support (ATLS)(ATLS)

James Styner in 1976James Styner in 19761.1. PreparationPreparation2.2. TriageTriage3.3. Primary surveyPrimary survey4.4. ResuscitationResuscitation5.5. Secondary surveySecondary survey6.6. Continued monitoring & reevaluationContinued monitoring & reevaluation7.7. Definitive careDefinitive care

Primary SurveyPrimary Survey

A. Airway maintenance with cervical A. Airway maintenance with cervical spine protection.spine protection.

B. Breathing & ventilationB. Breathing & ventilation

C. Circulation with haemorrhage controlC. Circulation with haemorrhage control

D. Disability: neurologic statusD. Disability: neurologic status

E. Exposure/Environment: completely E. Exposure/Environment: completely undress the patient, but prevent undress the patient, but prevent hypothermia. hypothermia.

Airway & cervical spineAirway & cervical spine

• Assessment – able to talk – unlikely to Assessment – able to talk – unlikely to be in jeopardy immediatelybe in jeopardy immediately

• Foreign bodies, secretions, facial, Foreign bodies, secretions, facial, mandibular, tracheal/laryngeal mandibular, tracheal/laryngeal #,unconscious pt > airway obstruction#,unconscious pt > airway obstruction

• Management – Perform a chin lift or jaw Management – Perform a chin lift or jaw thrust maneuver, clear airway of thrust maneuver, clear airway of FBs,insert FBs,insert oropharyngeal/nasopharyngeal airwayoropharyngeal/nasopharyngeal airway

Airway & cervical spineAirway & cervical spine

• Establish a definitive airwayEstablish a definitive airway 1. Orotraheal/nasotracheal intubation1. Orotraheal/nasotracheal intubation 2. Surgical cricothyroidotomy2. Surgical cricothyroidotomy 3. Needle cricothyroidotomy – 12 – 14 3. Needle cricothyroidotomy – 12 – 14

venflon > jet insufflation O2 at the rate of 12 venflon > jet insufflation O2 at the rate of 12 L/min. – temporary measure.L/min. – temporary measure.

• Maintain the cervical spine in the neutral position Maintain the cervical spine in the neutral position with manual immobilisation as necessary when with manual immobilisation as necessary when establishing airway establishing airway

• Reinstate immobilisation with appropriate Reinstate immobilisation with appropriate devices after establishing the airwydevices after establishing the airwy

BreathingBreathing

• Ventilation may be assessed by inspection Ventilation may be assessed by inspection &auscultation of the chest&auscultation of the chest

• Conditions that interfere with ventilation – Conditions that interfere with ventilation – tension pneumothorax, open pneumothorax, tension pneumothorax, open pneumothorax, large flail chest with pulmonary contusion large flail chest with pulmonary contusion and large haemothorax.and large haemothorax.

• Immediate decompression using I/V canula in Immediate decompression using I/V canula in the 2the 2ndnd I.C.space anteriorly in the case of I.C.space anteriorly in the case of tension pneumothorax.tension pneumothorax.

• Ventilation by Ambu bag / ventilator Ventilation by Ambu bag / ventilator

CirculationCirculation

• In a trauma pt, shock is assumed to be due to In a trauma pt, shock is assumed to be due to hypovolemiahypovolemia

• Diagnsis: tachycardia, skin color, mental Diagnsis: tachycardia, skin color, mental status, capillary refill and hypotension.status, capillary refill and hypotension.

• Management: Volume replacement after Management: Volume replacement after inserting two large bore I/V canula and inserting two large bore I/V canula and infusing 2L of ringer lactate fast long with infusing 2L of ringer lactate fast long with arresting any external bleeding .arresting any external bleeding .

• Monitoring, O2 and splinting of long bone # Monitoring, O2 and splinting of long bone # and tackling of internal bleeding urgently.and tackling of internal bleeding urgently.

Disability

A brief neurological examinationA brief neurological examination AA Alert Alert V Response to verbal commandV Response to verbal command P ,, pain - GCS 8P ,, pain - GCS 8 U Unresponsive - GCS 3U Unresponsive - GCS 3 ++ Status of the pupilStatus of the pupil

Expose & EnvironmentExpose & Environment

• Completely expose to examine from Completely expose to examine from head to foothead to foot

• Avoid hypothermiaAvoid hypothermia

Adjuncts to primary survey & Adjuncts to primary survey & ResuscitationResuscitation

1.1. Obtain arterial blood gas analysis & Obtain arterial blood gas analysis & ventilatory rateventilatory rate

2.2. Monitor the pt`s exhaled CO2 with an Monitor the pt`s exhaled CO2 with an appropriate deviceappropriate device

3.3. Attach ECG monitor Attach ECG monitor 4.4. Insert urinary catheter & N/G tube (CI – Insert urinary catheter & N/G tube (CI –

urethral rupture, basal skull#urethral rupture, basal skull#5.5. X-rays – Cervical spine – lateral, X-ray X-rays – Cervical spine – lateral, X-ray

chest - A-P, Pelvis- A-Pchest - A-P, Pelvis- A-P6.6. ? Abd. USG/ DPL ? Abd. USG/ DPL

Secondary surveySecondary survey

• History: AMPLEHistory: AMPLE

A = AllergiesA = Allergies

M = MedicationsM = Medications

P = Past illnessP = Past illness

L = Last mealL = Last meal

E = Events leading to the episodeE = Events leading to the episode

Secondary surveySecondary survey

• Head to foot evaluationHead to foot evaluation1.1. Head & Maxillofacial:Head & Maxillofacial: a.Glascow Coma Scale(GCS)- recorda.Glascow Coma Scale(GCS)- record b. Pupils b. Pupils c. Neurological deficit c. Neurological deficit d. Scalp & face – lacerations, contusions, fractures d. Scalp & face – lacerations, contusions, fractures

and burnsand burns e. Eyes- hemorrhage, penetrating injury, visual e. Eyes- hemorrhage, penetrating injury, visual

acuity, dislocation of lens & presence of contact acuity, dislocation of lens & presence of contact lenslens

f. Ears & nose for CSF leakagef. Ears & nose for CSF leakage g. Inspect mouth for evidence of bleeding, CSF,soft g. Inspect mouth for evidence of bleeding, CSF,soft

tissue lacerations, and loose toothtissue lacerations, and loose tooth

ManagementManagement

• Maintain airway, continue ventilation Maintain airway, continue ventilation and oxygenation as indicated.and oxygenation as indicated.

• Control haemorrhageControl haemorrhage

• Prevent secondary brain injuryPrevent secondary brain injury

• Remove contact lensesRemove contact lenses

Cervical spine & NeckCervical spine & Neck

• Inspect > signs of blunt/ penetrating injury, Inspect > signs of blunt/ penetrating injury, tracheal deviation, use of accessory tracheal deviation, use of accessory muscles of aspiration.muscles of aspiration.

• Palpate> tenderness, deformity, swelling, Palpate> tenderness, deformity, swelling, subcut. Emphysema, tracheal deviation, & subcut. Emphysema, tracheal deviation, & symmetry of pulsesymmetry of pulse

• Auscultator > bruits.Auscultator > bruits.• Obtain a lateral cross table cervical spine X- Obtain a lateral cross table cervical spine X-

ray.ray.• Management:Management: adequate immobilization & adequate immobilization &

protection of cervical spineprotection of cervical spine

ChestChest

• Inspect: Ant., Lat., and post chest wall for Inspect: Ant., Lat., and post chest wall for signs of blunt and penetrating injury, use of signs of blunt and penetrating injury, use of accessory breathing muscles, and bilat. accessory breathing muscles, and bilat. Resp excursionsResp excursions

• Auscultate the ant chest wall and post bases Auscultate the ant chest wall and post bases for bilat breath sounds and heart sounds.for bilat breath sounds and heart sounds.

• Palpate the entire chest wall for blunt & Palpate the entire chest wall for blunt & penetrating injury, subcut emphysema, penetrating injury, subcut emphysema, tenderness and crepitations.tenderness and crepitations.

• Percuss for evidence of hyper resonance & Percuss for evidence of hyper resonance & dullness.dullness.

ManagementManagement

• Needle decompression / tube Needle decompression / tube thoracostomy & underwater seal thoracostomy & underwater seal drainage.drainage.

• Open wound to be dressedOpen wound to be dressed

• Pericardiocentesis as indicatedPericardiocentesis as indicated

• Transfer the pt. to the operating theatre Transfer the pt. to the operating theatre if indicatedif indicated

AbdomenAbdomen

• Inspect: ant. & post. Abdomen – signs Inspect: ant. & post. Abdomen – signs of blunt and penetrating injuries.of blunt and penetrating injuries.

• Auscultate: presence/ absence of Auscultate: presence/ absence of bowel sounds.bowel sounds.

• Percuss: rebound tenderness.Percuss: rebound tenderness.• Palpate: tenderness/ involuntary Palpate: tenderness/ involuntary

muscle guard/ gravid uterusmuscle guard/ gravid uterus• Pelvic X- ray/ USG / DPL/ CTPelvic X- ray/ USG / DPL/ CT• Transfer to O.T. if requiredTransfer to O.T. if required

Perineum/Rectum/VaginaPerineum/Rectum/Vagina

• Perineum: contusions, haematomas, Perineum: contusions, haematomas, lacerations, urethral bleeding.lacerations, urethral bleeding.

• Rectum: rectal blood,anal shincter Rectum: rectal blood,anal shincter tone, bowel integrity, bony fragments, tone, bowel integrity, bony fragments, prostate position.prostate position.

• Vagina: Presence of blood in the Vagina: Presence of blood in the vaginal vault, vaginal lacerations. vaginal vault, vaginal lacerations.

MusculoskeletalMusculoskeletal

• Inspect: Contusions/ lacerations/ deformity.• Palpate: tenderness/ crepitation/ abnormal

mobility.• Peripheral pulses• Pelvis – #/ haemorrhage.• Thoracic & lumbar spine –

contusion/laceration/tendernes/deformity/sensation

• X – ray pelvis/ other suspected regions.

ManagementManagement

• Apply/Readjust appropriate splinting devices Apply/Readjust appropriate splinting devices for extremity #s.for extremity #s.

• Maintain immobilisation of thoracic & lumbar Maintain immobilisation of thoracic & lumbar spines.spines.

• Administer tetanus immunisation.Administer tetanus immunisation.• Appropriate medications like antibiotics.Appropriate medications like antibiotics.• Consider the possibility of compartment Consider the possibility of compartment

syndrome.syndrome.• Complete neuro vascular exam. of Complete neuro vascular exam. of

extremities. extremities.

NeurologicNeurologic

• Reevaluate pupils/level of Reevaluate pupils/level of consciousness.consciousness.

• Determine GCS score.Determine GCS score.• Evaluate extremities for motor & Evaluate extremities for motor &

sensory functions.sensory functions.• Observe lateralizing signs.Observe lateralizing signs.• Management: continue ventilation & Management: continue ventilation &

oxygenation/ maintain adequate oxygenation/ maintain adequate immobilization of the entire pt.immobilization of the entire pt.

Adjuncts to IIry surveyAdjuncts to IIry survey

• As the condition permits, Additional X – rays, CTs Contrast studies Angiography Bronchoscopy,esophagoscopy etc.• Pt. reevaluation.• Transfer to definitive care.