Trauma

Mohamed Mustafa MarzoukProf of Surgery Ain Shams University

RTA• Road traffic injuries cause more than 1 million deaths

annually and about 20 to 50 million significant injuries worldwide.

• More than 90% of car accidents occur in developing countries.

• In Egypt, road traffic deaths in 2010 were estimated to be 10,729 according to the annual report of World Health Organization (WHO).

• The total number of accidents in Cairo-Egypt and on its travel roads in 2013 is 13,957 with a 24% increase from 2012.

The wreckage of a minibus lies at the site of an accident near a railway crossing in Dahshur, Egypt, November 18, 2013.

Trimodal Death Distribution

Initial assessment

1. Primary survey (ABCDE).2. Resuscitation.3. Adjuncts to primary survey and resuscitation.4. Secondary survey (head- to- toe evaluation + AMPLE history.5. Adjuncts to secondary survey.6. Continuous monitoring and re-evaluation.7. Definitive care.

Primary Survey

• The patient is assessed for life-threatening injuries + starting management simultaneously.

• Adhere to the following sequence of priorities:1. Airway maintenance and protection of cervical

spine.2. Breathing and ventilation.3. Circulation with haemorrhage control.4. Disability; Neurological status.5. Exposure with prevention of hypothermia.

Airway maintenance

How do I know the air way is adequate?

Protection of cervical spine

Odontoid fracture

Life-threatening thoracic injury

1. Tension pneumothorax.2. Open pneumothorax.3. Flail chest and pulmonary contusion.4. Massive haemothorax.5. Cardiac tamponade.

Abdominal trauma

External Anatomy

Anteriorabdomen

Flank

Back

Penetrating wounds ?

Internal Abdominal Regions

Upper peritoneal cavity

Lower peritoneal cavity

Pelvic cavity

Diaphragm LiverSpleenStomachTransverse colon

Small bowelColon

Internal Abdominal Regions

Upper peritoneal cavity

Lower peritoneal cavity

Pelvic cavityIntraperitonealRetroperitoneal

Retroperitoneal space

AortaInferior vena cavaDuodenumPancreasKidneysUretersColon

Visceral Injuries are difficult to diagnose, why?

RectumBladderIliac vesselsUterusOvariestubes

Mechanism of Injury

It determines what organs are probably

injured.

Why is it important to know?

Compression

Crushing

Shearing

Deceleration (fixed organs)

Blunt Force Mechanism

How does it injure?

Liver and spleen

Blunt Force Mechanism 

Spleen (40 – 55%)

Liver (35 – 45%)

Small bowel (5 – 10%)

There is 15% incidence of retroperitoneal haematoma during laparotomy for blunt abdominal trauma

What organs are commonly injured?

Seat Belt abdominal injuries

• Rupture of upper abdominal viscera (shoulder harness)

• Tear or avulsion of mesentry.• Small bowel or colon.• Chance fracture of lumbar vertebrae.(hyper

flexion).• Pancreatic. • Duodenal.

Stab· Low energy· Lacerations

 Gunshot

· Transfer of kinetic energy· Cavitation (lateral damage)· falling· Fragments

Penetrating Mechanism

How does it injure?

· High energy

Penetrating Mechanism 

· Liver 40%· Small bowel 30%· Diaphragm 20%· Colon 15%·spleen

Low Energy High Energy

· Small bowel 50%.

· Colon 40%.

· Liver 30%.

· Vascular structures 25%.

Common injuries?

Explosive devices:1. Penetrating fragments2. Blunt injuries 3. Blast pressure injuries

Assessment: History

Blunt Speed Point of impact Intrusion Safety devices Position Ejection

 Penetrating Weapon Distance Number of woundsAmount of external bleeding.

Assessment: Physical Exam 

Inspection

Palpation

Percussion

Auscultation

Pelvic stabilityUrethralPerinealPRPVGluteal

Abdominal Trauma

What can compromise the exam?

Alcohol or other drugs

Injury to brain, spinal cord

Injury to ribs, spine, pelvis

Management: Gunshot Wound 

Early operation usually is

the best strategy.

Evidence of abdominal injury by mechanism, history, or evaluation

Hypotension

Positive FAST or grossly positive DPL

Absence of massive hemothorax on chest x-ray

Abdominal injury causes shock?

Adjunct: Gastric Tube

Relieves distention

Decompresses stomach before DPL.

To avoid aspiration.

Caution· Fracture skull base / facial fractures· May induce vomiting / aspiration·Blood in gastric secretions.

Adjunct: Urinary Catheter

Monitors urinary output Decompresses bladder before DPL Diagnostic

Caution

Do not insert the catheter if there is one of the following:1. Inability to void.2. Unstable pelvic fracture.3. Blood at the urethral meatus.4. Scrotal and perineal haematoma.5. High riding prostate.

Retrograde urethrography should be done first.

Adjuncts: X-ray Studies

Routine Blunt: AP chest, pelvis and cervical spine Penetrating: AP chest and abdomen with markers (if

hemodynamically normal) to all entrance and exit wound sites.

Adjuncts: Contrast Studies

Urethrogram Cystogram IVP GI

Abdominal CT

Special Studies in Blunt Trauma

Time

Transport

Sensitivity

Specificity

Eligibility

DPL FAST* CT

Rapid Rapid Delayed

No No Required

High High? High

Low Intermediate High

Allpatients

All patients Hemodyna-mically normal

* Operator dependent

Diagnostic Studies: Penetrating 

Lower chest wounds: Serial exams, thoracoscopy, laparoscopy, or CT scan

Anterior abdominal stab wounds: Wound exploration, DPL, or serial exams

Back and flank stab wounds: DPL, serial exams, or double- or triple-contrast CT scan

Indications for celiotomy? 

Blunt Trauma

BP, suspect visceral injury Free air Diaphragmatic rupture Peritonitis ve DPL, FAST, or contrast CT

Indications for celiotomy? 

Penetrating Trauma

Hypotension Peritoneal / retroperitoneal injury Peritonitis Evisceration ve DPL, FAST, or contrast CT

Remember…

…. a missed abdominal injury is a common

cause of a potentially preventable death.

Pelvic Fractures 

Mechanism

Lateral compression

AP compression

Vertical shear

Classification

Open

Closed

Pelvic Fractures 

Significant force applied Associated injuries

Pelvic bleeding

· Bone ends· Pelvic muscles

Veins / arteries

Pelvic Fractures 

Assessment

Inspection

Palpate prostate

· Leg-length discrepancy, external rotation · Pain on palpation of bony pelvic ring

Pelvic ring instability:

Pelvic Fractures 

Emergency Management

Fluid resuscitation (Hypovolaemic shock)

Determine if open or closed fracture

Splint pelvic fracture

Determine associated perineal / GU injuries

Determine need for transfer

Shock

• It is a systemic state of inadequate tissue perfusion and oxygenation.

• It is the most common cause of death among surgical patients.

• Hypovolaemic shock is the most common form of shock and is a component of other forms of shock.

Shock in trauma patient

Haemorrhagic . Non-haemorrhagic:• Tension pneumothorx.• Cardiogenic .• Neurogenic.• septic

In injured patient, haemorrhage is the most common cause of shock.

Pathophysiology

Triad of death

Classification

Any injured patient who is cool and has tachycardia is considered shock until proven otherwise.

Treatment

• Stop bleeding.• Restore blood volume:

1. Initial fluid infusion.2. Blood transfusion.

• Monitoring1. Urine output 2. Vital signs3. ECG4. CVP

Responses to fluid resuscitation

2000 ml of warm isotonic solution in adult and 20 ml/Kg of Ringer’s lactate in children given as fast as possible.

Blood Transfusion

Blood transfusion

1492 Pope Innocent VIII is said to have been given the world’s first blood transfusion by his Jewish physician who made him to drink blood of three 10-year-old boys.

1829 James Blundell makes the first successful human transfusion in women with post-partum haemorrhage.

1926 The British Red Cross institutes the first blood transfusion service in the world.

1939 The Rhesus system is identified and recognized as major cause of transfusion reaction.

James Blundell

Blood and blood products• Whole blood: rarely available.• Packed red cells:

– 330 ml and has haematocrit of 50-70%.– It is stored in SAGM (saline-adenine- glucose-mannitol). – Shelf time 5 weeks at 2-6°C.

• Fresh frozen plasma (FFP):• Rich in coagulation factors.• Stored at -40 to -50°C.• Shelf-time 2 years.• coagulopathy.

• Platelets:– Stored at 20 – 24 °C (room temperature).– Shelf time 5 days.– They are given in thrombocytopeic patients who are bleeding or undergoing surgery.

• Cryoprecipitate:• It the supernatent precipitate of FFP.• It is rich in factor VIII and fibrinogen.• Stored at -30°C with 2- yearsshelf –life.

• Prothrombin complex concentrates (PCCs):• It contains factors II, VII, IX and X.• Half life of factor II 60 – 72 h while others 6 – 24 h.• It is the reversal of oral anticoagulant (warfarin).

Indications for blood transfusion

• Acute blood loss.• Peri-operative anaemia:

• Symptomatic chronic anaemia.

Hg level (g dl¯¹ )

< 6 Indicated for transfusion.

6 - 8 Transfusion if there Is bleeding, impending surgery.

> 8 No indication for transfusion.

World wide distribution of blood groups

Massive blood transfusion

• It is the replacement of blood volume in 24 hours or > 50 % within 4 hours.

• Coagulopathy.• Hypocalcaemia.• Hyperkalaemia.• Metabolic alkalosis.• Hypothermia:

– Coagulopathy.– Hypocalcaeia.– Decrease O2 delivry to tissue (O2 diss. Curve to right).

• Acute lung injury

Management of coagulopathy

• FFP if PT and PTT > 1.5 of normal.• Cryoprecipitate if fibrinogen < 0.8 g/L.• Platelets if platelet count < 50 00 /cu mm.

Blood substitutes

• Haemoglobin-based oxygen carrier (HBOCs).• Per-florocarbon.

Glasgow Coma Scale (GCS)

Blast injury

Key concepts

1. Bombs and explosions can cause unique pattern of injuries rarely seen in civilian trauma.

2. Post explosion injuries involve both blunt and penetrating trauma.3. Expect half of all initial casualties to present in ER in one-hour

period.4. Most severely injured arrive after the less injured (upside-down

triage). 5. Explosions in confined spaces are associated with great morbidity

and mortality than that in open air.6. Blast lung is the most common fatal injury among initial survivors. 7. Repeatedly examine and assess the patients.

Explosives

High-order explosives (HE)• Manufactured • TNT, Nitroglycerine, ANFO,

dynamite.• supersonic over-perssurization

shock waves.• detonation

Low-order explosives (LE)• Improvised.• Molotov cocktails.• Subsonic wave.• Deflagration

Primary blast injury

Secondary blast injury

Tertiary blast injury

Quaternary blast injury

Primary Unique to HE.Results from the impact of the pressure wave with body surfaces.

(Blast wave)

Gas filled structures are most susceptible - middle ear -lungs. -GI tract.

- TM rupture and middle ear damage - Blast lung (pulmonary baro- traumas)- Abdominal hemorrhage and perforation - Globe (eye) rupture - Concussion without physical signs of head injury.

Secondary Results from flying debris and bomb fragments

Any body part may be affected

- Penetrating or blunt injuries -Eye penetration (can be occult)

Tertiary Results from individuals being thrown by the blast wind

Any body part may be affected

- Fracture and traumatic amputation - Closed and open brain injury

Quaternary - All explosion-related injuries, not due to primary, secondary or tertiary mechanisms. - Includes exacerbation or complications of existing conditions.

Any body part may be affected

- Burns. - Crush injuries - Closed and open brain injury - Respiratory problems from inhaling dust, smoke, or toxic fumes. - Angina - Hyperglycemia-Hypertension

Category Mechanism Body Part Affected Types of Injuries

Classification

Casualties

• Multiple casualties• Mass casualties• Triage :

– it is a process of determing the priority of patient treatment.– Priority was given to patients who has greatest chance of

survival.– Tags or markers– At different levels:

• At the scene of trauma• on arrival• Re-triage

Triage Scenario

• You are the only doctor available in ER with one nurse to assist you. 2 ambulance arrived with 5 patients who were passengers travelling in bus before it crashed in a collision

• The injured patients are:

• 6-year-old boy is crying from severe pain in his left thigh and asking for his mother.

• 45-year-old man. He is in severe respiratory distress. Multiple contusion over the chest wall he has Bp 120/80, pulse 120, RR40 and GCS 8.

• 38-year- old female thrown outside the bus and has unstable pelvis. The Bp 80/40, pulse 140, RR 25 and she is alert.

• 50-year-old man breathless and not moving. He has burst abdomen with intestines coming out and he lost considerable amount of his blood.

• Pregnant women in 3rd trimester who is shouting and has abdominal pain with normal vital signs.

Questions

• Give short account on causes, diagnosis and treatment of airway obstruction in trauma patient.

• Discusses the management of shocked in trauma patient. • Classification and management of hemorrhagic shock in

trauma patient.• Discuss the management of life-threatening injuries in

trauma patient.• Give short account in penetrating abdominal injury.• Mangement of traumatic fracture pelvis.• Give short account on blast injury.