Principles of Trauma

Management

Trauma

Prehospital phase and triage

Primary Survey
ABCDE
Resuscitation
Adjuncts to primary survey and resuscitation
Secondary Survey
Records, Consent, Forensic evidence

Primary Survey

Airway and cervical spine control

Breathing
Circulation with control of
hemorrhage
Disability
Exposure/environment (expose
patient, but avoid hypothermia)

Resuscitation

Oxygenation and Ventilation

Shock management
IV linesNormal Saline
Management of life-threatening
problems

Adjuncts to Primary Survey

and Resuscitation
Monitoring:

ABGs and ventilatory rate

End-tidal CO2
EKG
Pulse oximetry
Blood pressure

Adjuncts to Primary Survey

and Resuscitation
Urinary and gastric catheters
X-rays and diagnostic studies

Chest
Pelvis
C-spine
FAST / CT SCAN / DPL

Trauma Mortality
35 per 100,000 population
Most common cause of death in children

Airway and Ventilation

These are first priorities!!!!
Risks for obstruction:

Coma
Aspiration
Maxillofacial trauma
Neck trauma

Airway and ventilation

Neck trauma: disruption of the larynx or
trachea-or compression by soft tissue
injury
Laryngeal trauma:
Hoarseness
Subcutaneous emphysema
Palpable fracture

Airway and ventilation

Obstruction:
Agitation or obtundation
Abnormal airway sounds
Trachea not in midline

Airway and ventilation

Inadequate ventilation
Asymmetric chest rise
Asymmetric chest sounds
Poor oxygenation

Airway and ventilation

Airway Maintenance

Chin lift
Jaw thrust
Oropharyngeal airway
Nasopharyngeal airway

Definitive Airway
Endotracheal tube
Cricothyroidotomy

Airway and ventilation

PaO2 Levels
90 mm Hg
60 mm Hg
30 mmHg
27 mmHg

O2 Hgb Saturation
100%
90%
60%
50%

Pulse Oximetry
LED absorbed differently between
oxygenated and non-oxygenated Hgb
Affected by:

Poor perfusion
Anemia
Carboxyhemoglobin or methehemoglobin
Circulating dye
Patient movement, ambient light or signals

Thorax
Breathing:
Tension pneumothorax
Open pneumothorax (sucking wound)
Flail chest
Massive hemothorax

Thorax
Tension Pneumothorax
Collapse of affected lung
Decreased venous return
Decreased ventilation of opposite lung

Thorax
Tension pneumothorax:

Respiratory distress
Distended neck veins
Unilateral decrease in breath sounds
Hyperresonance
Cyanosis

Needs immediate decompression!

Thorax
Open pneumothorax:
Occlusive dressing
Flail chest:
Trauma principles and
ventilation
Massive hemothorax
Chest decompression

Thorax
Circulation:
Massive hemothorax
Flat v. distended neck veins
Shock with no breath sounds
Treat with decompression

Thorax
Circulation:
Cardiac tamponade
Decreased arterial pressure
Distended neck veins
Muffled heart sounds
PEA (pulseless electrical activity)
Treat with decompression

Thorax
Resuscitative thoracotomy:

Penetrating trauma
Pulseless with myocardial activity
Evacuate blood
Stop bleeding
Cardiac massage
Cross clamp of aorta
Infusion of fluids and blood

Thorax
Secondary Survey

Simple pneumothorax
Hemothorax
Pulmonary contusion
Tracheobronchial tree injury
Blunt cardiac injury
Aortic disruption
Diaphragm injuries
Mediastinal traversing wounds
Esophageal rupture
Rib, sternum, scapular fractures

Shock
Hemorrhage is the most
common cause of shock in the
injured patient!!

Shock
Hemorrhagic shock
Non-hemorrhagic shock:
Cardiogenic
Tension pneumothorax
Neurogenic shock
Septic shock

Shock
Blood volume:
5 liters in the 70 kg adult
80-90 ml/kg in the child

Classes of Hemorrhage (% loss)

I:
II:
III:
IV:

<15%
15-30%
30-40%
>40%

Shock
Initial Therapy:
Stop the bleeding!
Vascular Access lines
2 large bore IV lines
Intraosseous lines
Central lines
Fluid bolus
2 Liters NS: adult
20ml/kg: Child

Shock
Assess:
Capillary refill (should be < 2 sec)
Peripheral pulses
Heart rate
Temperature and color of skin
Sensorium
Pulse pressure

Shock
Signs of hemodynamic recovery:
Slowing of pulse
Decrease in skin mottling
Increase in extremity temperature
Clearing of sensorium
Urinary output > 1ml/kg/hour
Increased systolic blood pressure

Abdomen
Mechanisms:
Blunt
Penetrating

Spaces:
Peritoneal cavity
Pelvis
Retroperitoneum

Abdomen
Physical exam:

Inspection
Auscultation
Percussion
Palpation
Evaluate penetrating wounds
Local exploration of stab wounds

Abdomen
Physical exam:
Assess pelvic stability
Genital and rectal exam
Gluteal exam

Abdomen
Diagnostic studies:

CT scan
Ultrasound
DPL
Urethrography/cystography

Abdomen
Indications for exploration:

Blunt trauma with instability and positive US or DPL

Blunt trauma with recurrent hypotension
Peritonitis
Hypotension from penetrating wound
Bleeding from stomach/rectum/GU (penetrating)
Gunshot wound
Evisceration

Abdomen
Special
considerations:

Diaphragm
Duodenum
Pancreas
Liver/Spleen
GU
Small bowel

Left: Massive hemothorax

Right: Chest tube decompression

Tension pneumothorax

Chest tube placed and pneumothorax resolved

Circulation
Heart rate
Infants

Systolic BP

Urine
ml/kg/hr

100-160

60

Preschool

80-140

80

1.5

School age

80-140

90

1-1.5

Adolescent

60-120

100

0.5-1

Head Trauma
500,000 cases per year in US
10% die prior to hospital

Head Trauma
Cerebral Perfusion Pressure
CPP=MAP-ICP
MAP =Mean arterial pressure
ICP = Intracranial pressure

Cerebral Blood Flow

50ml/ 100g of brain/minute

<25-EEG activity disappears
5 brain death

Head Trauma
Mechanism:
Blunt v. Penetrating
Severity:
Mild: GCS 14-15
Moderate: GCS 9-13
Severe: GCS 3-8
Morphology:
Skull fractures
Intracranial lesions

Head Trauma
Skull fractures:
Battles Sign
Racoon eyes
Rhinorrhea/otorrhea
Linear vault fractures
400 X risk hematoma in awake patients
20 X risk in comatose patients

Head Trauma
Intracranial lesions
Epidural hematomas
Subdural hematomas
Contusions/hematomas
Concussion
Diffuse axonal injuries

Head Trauma
Management;
ABCs! (GCS < 8 intubate patient)
Hypotension is never presumed to be from
head trauma
CT scan
Hyperventilation
Mannitol/lasix
Steroids
Barbiturates

Spinal Injuries

Level
Severity
C-spine-protect always!!
10% have another vertebral fracture
Respiratory function may be lost

Spinal shock
High dose methylprednisolone in first 8 hours
Pediatric considerations (SCIWORA)
SCIWORA Spinal Cord Injury WithOut Radiographic
Abnormality

Subluxation
C-5 on C-6

Musculoskeletal Injuries

May have significant bleeding source

Evaluate vascular and neurologic status
Immobilize/traction
Pelvic fracture
Stabilize
Embolize

Musculoskeletal Injuries
Crush injuries:
Myoglobinuria

Open fractures
Immobilize
Antibiotics/tetanus

Musculoskeletal Injuries
Compartment Syndrome:

Pain (especially with passive stretching)

Paresthesia
Decreased sensation or function
Paralysis or loss of pulse are LATE changes
and loss of limb is imminent
Tissue pressures >35-45 mm Hg threaten
limb

Cerebral contusion with cerebral swelling and skull

fracture

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 injury

and high risk of internal injuries

View of normal vocal cords

Fractured larynx

MRI image of thoracic

vertebral fracture and
injured spinal cord

Subdural hematoma

Lines of escarotomy in
burn injuries