TRAUMA

Done by:
Hamoud Alshaya
Mohammed Amouri
Abdulaziz A Al-anzy
Supervised by:
Dr. Abed alrahman Manasrah

Definition

Classification

Scoring Systems
Trauma Management
Initial assessment
Primary survey
Secondary survey
Definitive care

WHAT IS TRAUMA?
Trauma is the study of medical problems
associated with physical injury. The injury
is the adverse effect of a physical force
upon a person.

The third most common cause of

death overall

CLASSIFICATION
Trauma classified by the type of force applied to the body to:

Blunt trauma

Penetrating trauma

Blast trauma

Thermal trauma

Major trauma is sometimes classified by body area:

polytrauma 40%

head injuries 30%

chest trauma 20%

abdominal trauma10%

extremity trauma 2%

LEADING CAUSES

Road traffic accidents

Falls from a height

Crimes and acts of violence

Domestic injury Burn

Industrial injury

INJURY ASSESSMENT
(SCORING SYSTEMS)
Anatomical scoring system
Glasgow Coma Score

Systolic Blood Pressure

Revised trauma score
Trauma score
Respiratory rate
Capillary Refill
Respiratory expansion

ISS/A1S (ANATOMICAL
SCORING SYSTEM)

The severity of injury is assessed in six different

areas on a scale from 0 to 5.

1. External-contusions, burns 0-----5

2. Extremities fractures 0-----5

3. Abdomen 0-----5

4. Thorax 0-----5

5. Face 0-----5

6. Head/Neck 0-----5

GCS

TRIAGE
According to trauma scores & ISS
Dead
(CPR)

Critical
(Resuscitation)

According to trauma scores & ISS

serious
(Admit to the hospital)

slight
(wait)

sorrowful
(wait)

Dead

Who have a trauma score of 0-2 and are beyond help

Priority 1

Who have a trauma score of 3-10 and need immediate

attention

Priority 2

Who have a trauma score of 10-11 can wait for short time

Priority 3

Who have a trauma score of 12and Can be delayed

 Pattern of trauma
deaths :
Immediate deaths 50%
Within the first few minutes of injury

Early deaths 30%

15 min 6 hrs

Late deaths 20%

Days to weeks

TRAUMA
MANAGEMENT

Initial evaluation Objectives:

1. To stabilize the trauma patient.
2. To identify life threatening injuries & to
initiate adequate supportive therapy.
3. To efficiently & rapidly organize either
definitive therapy or transfer definitive therapy
center.

ATLS PROTOCOL
ATLS Advanced Trauma Life Support
The three main elements in trauma
management

Primary survey

Secondary survey

Definitive care

Primary survey

cABCDE

C spine stabilization

Airway

Breathing

C Circulation

D Disability

Exposure and Environment

C-SPINE

Maintain the cervical spine in the neutral position

Problem : Unstable fracture

Assume it if :
- unconscious
- head injury
- face injury

Interfere :
- Semi-rigid collar
- Sandbags/tape
- Manual in-line immobilisation

AIRWAY

Problem :

- direct trauma
- obstruction :
- foreign body
- blood or vomits
- soft tissue edema
- Deteriorating consciousness

Assume if :
cyanosis , tachypnoea , stridor , respiratory distress , no chest movement

AIRWAY INTERVENTIONS
1.

Check verbal response

2.

Remove foreign bodies (dentures , plastic,

food)

3.

Suction of secretions or vomitus

4.

Chin lift/jaw thrust

5.

oropharyngeal/nasopharyngeal airways
maintain the airway by orotracheal or
nasotracheal tube

5.

6.

Cricothyroideotomy or
emergency tracheostomy.
ETI (endotracheal intubation) for
comatose patients (GCS<8)

OROPHARYNGEAL
AIRWAY

NASOPHARYNGEAL
AIRWAY

TRACHEOSTOMY

CRICOTHYROIDOT
OMY

CRICOTHROTOMY VS.
TRACHEOSTOMY

A cricothyrotomy is usually done in an emergent

situation when you are unable to intubate
someone and need to get access to someone's
airway in a hurry. It's done through the
cricothyroid membrane (through your adam's
apple). Landmarks are easy to identify, and you
avoid the vocal cords and the person's thyroid
gland & associated vessels.
A tracheostomy is placed lower down in the
trachea, between the tracheal rings. It can be
placed in an operating room or at the bedside in
an ICU setting, and is much more elegant than a
cricothyroidotomy. It is usually placed if
someone is going to need the support of a
ventillator for a long time This allows the patient
to talk and not have the extreme discomfort of a
tube going down his mouth into his trachea.

B - BREATHING

Airway patency alone does not

ensure adequate ventilation , i.e
the patient may stay cyanosed or
apnoeic after the airway has been
cleared.

Assess the work of breathing and

its efficacy by conducting the
following:

1.

Inspection :
For chest wall movement and injury ,
asymmetric chest expansion , cyanosis ,
tracheal shift , jugular venous distention ,
using accessory muscles, respiratory rate.

2. Palpation :
for presence of subcutaneous
emphysema , flail segments .
3.

Percussion :
For hyperresonance or dullness .

4.

Auscultation :
for equal and symmetrical breath
sounds.

5.

CXR to evaluate lung fields

SUBCUTANEOUS
EMPHYSEMA

Life
threa
tenin
g
cond
ition
s:

WHAT WOULD WE DO FOR THIS PATIENT WHO IS HAVING

DIFFICULTY BREATHING?

CHEST TUBE

PNEUMOTHORAX

Injury to the lung resulting in release of air

into the pleural space .

Tension pneumothorax
- diagnosed clinically and managed by rapid
thoracostomy incision or immediate decompression
by needle thoracostomy in the second intercostal
space midclavicular line followed by chest tube
placed anterior midaxillary line in the fourth
intercostal space

MASSIVE HEMOTHORAX

Diagnosis :
- unilaterally decreased or absent breath sounds , dullness on
percussion , CXR and CT scan , chest tube output blood .

Treatment :
- volume replacement
- chest tube

Massive hemothorax :
- > 1500 cc of blood on initial placement of chest tube
- persistent > 250 cc of blood per hour * 3 hours

MASSIVE FLAIL CHEST

Two separate fractures in three or more consecutive ribs .

Diagnosis :
- history of pulmonary contusions .
- flail segments of chest wall that sucks in with inspiration and
pushes out with expiration .

Treatment :
- Intubation with positive pressure ventilation
- Conservative therapy with emphasis on pain relief with thoracic
epidural analgesia

BREATHING INTERVENTIONS

Mouth to mouth resuscitation

Facemask

Ambu bag

Ventilate with 100% oxygen

Needle decompression if tension pneumothorax

suspected

Chest tubes for pneumothorax / hemothorax

Occlusive dressing to sucking chest wound

If intubated, evaluate ETT position

C - CIRCULATION

Hemorrhagic shock should be assumed in any

hypotensive trauma patient

Rapid assessment of hemodynamic status

Level of consciousness
Skin color
Pulses in four extremities
Blood pressure and pulse pressure

CIRCULATION
INTERVENTIONS :

Apply pressure to sites of external

hemorrhage

Establish IV access , The ATLS advice a

2000-cc crystalloid volume challenge

2 large bore IVs

Central lines if indicated

Cardiac tamponade decompression if

indicated

Volume resuscitation

Have blood ready if needed

Foley catheter to monitor resuscitation

CENTRAL VENOUS LINE

the catheter can be inserted via the subclavian
or internal or external jugular vein.
There is good evidence to show that the safest
means of establishing central venous access is
by insertion of lines under ultrasoundguidance.

Indications:
1-CVP monitoring provides Right Atrial and Right Ventricle
pressures

2-Advanced Cardiopulmonary disease + major

operation
3-Secure vascular access for drugs, fluids & traumatic
pts
4-Inadequate peripheral IV access

Complications
1-Bleeding
2-Injury to surrounding structures as carotid
artery
3-Pneumothorax
4-Arrhythmia

SELDINGER
TECHNIQUE

Access vessel with needle under US/ aspiration

Guide wire through needle 10cm /j-tip

Remove the needle /leaving wire in place

Skin incision /dilation tract / remove

Advance catheter over wire

Removal of wire

D - DISABILITY
Abbreviated neurological exam

Level of consciousness
Pupil size and reactivity
Motor function
GCS

Utilized to determine severity of

injury , mental status
Guide for urgency of head CT and
ICP monitoring

DISABILITY INTERVENTIONS
Spinal cord injury

High dose steroids if within 8 hours

ICP monitor- Neurosurgical

consultation

Elevated ICP

Head of bed elevated

Mannitol
Hyperventilation
Emergent decompression

E - EXPOSURE

Complete disrobing of patient

Logroll to inspect back

Rectal temperature

Warm blankets/external warming

device to prevent hypothermia

ALWAYS INSPECT THE BACK

Ongoing monitoring :

Urinary catheters are

mandatory, however,
precautions are taken for
pelvic trauma and for those
with blood at the urethral
meatus.

1.

Gastric tubes inserted into:

All patients requiring
endotracheal intubation.
Children are prone to gastric
dilatation, which can impair
their respiration.

2.

SECONDARY SURVEY

The secondary survey does not begin until after the primary
survey has been completed, and all potentially life-threatening
injuries have been dealt with (stable pt )

The purpose of the secondary survey is to identify all other

injuries and perform a more thorough head to toe examination.
(look & palpate everywhere!!! )

Secondary survey

Head-to-toe evaluation

If at any time during the secondary

Complete history and PE

Reassessment of all VS
survey the patient deteriorates,

Indicated x-rays are

obtained.
another primary survey is carried out
Special procedures

Tubes and fingers in every

as a potential life threat may be present.
orifice

Completehistory

History can be taken from the patient

conscious, cooperative family ,
paramedics , other victims/injured
people .
AMPLE hx
Allergy
Medications currently used
Past medical/surgical hx + pregnancy
Last meal
Events &Environment related to the injury

PHYSICAL EXAM
Examine each region of the body for signs of injury, bony instability and
tenderness to palpation.

Head and face

Penetrating injuries / depressed fractures

Evidence of bleeding /discharge from the ears

Maxillofacial fractures and ocular injury.

Exclude midfacial injury and potential airway compromise

Neck

Hematomas / crepitus / tenderness .

The spine is held immobilized until formally cleared clinically and

radiographically .

Chest

Full palpation and auscultation of the chest wall,

including the clavicle, sternum and ribs.

Neurological

GCS regularly.

Full neurological examination

Abdomen and pelvis

Distension/ bruising /penetrating wounds. Tenderness /signs of

peritonism.

Perineum for evidence of ecchymosis or bleeding

A rectal examination is needed

Extremities

Tenderness / crepitation /abnormal movement.

Ask him or her to move the limbs

Adequately splint any injuries

Reassess after splints, traction or manipulation

Log roll

One member of the team is responsible for maintaining

in-line spinal stabilization , Three other trained staff hold
the patient steady through the turn.

Inspect and palpate the entire spine

Tenderness / bony abnormalities/ penetrating injuries or

exit wounds from gunshot .

Percuss, palpate and auscultate the posterior chest wall.

Frequent reassessment of vitals

During the examination, any injuries detected should

be accurately documented, and any urgent treatment
required should occur, such as covering wounds,
bleeding management and splinting fractures.

Appropriate analgesia, antibiotics or tetanus

immunization should be ordered.

The priorities for further investigation and treatment

may now be considered and a plan for definitive care
established

ADJUNCTS TO PRIMARY SURVEY

ECG Monitoring.

Urinary Catheter

NGT

Monitoring
- ABG
- Pulse oximeter(O2 sat)
- Blood pressure

X-rays
- AP CXR
- AP pelvis
- C-spine

Diagnostic peritoneal lavage

Abdominal ultrasonography (FAST)

Standard trauma labs

Blood group &cross matching

ABG

CBC

Urine analysis

Blood sugar

KFT, LFT, Coagulation profile

Standad truama investigations

X-rays
CT scans spine , chest , abdomen , head
FAST/DPL

FAST EXAM
FOCUSED ASSESSMENT WITH SONOGRAPHY
FOR TRAUMA

Rapid bedsideultrasoundexamination
performed to evaluate for free fluid
blood

It includes 4 views:

The hepato-renal recess (Morison

pouch)

The peri-splenic view

The sub-xiphoid pericardial window

The suprapubic window (Douglas pouch)

(E-FAST) examination views:

(1) the bilateral hemithoraces

(2) the upper anterior chest wall should

also be obtained

DIAGNOSTIC PERITONEAL
LAVAGE(DPL)

Diagnostic peritoneal lavage (DPL) may help in determining the

presence of blood or enteric fluid.

It was recently replaced by ultrasound (rarely performed )

Contraindications:

Previous abdominal surgery (adhesions)

Pregnancy

Morbid obesity

Coaglobapthy

Pelvic fractures

Operator in-experience

+ve test

10 cc/blood

100,000RBCs/m
m3

500WBCs/mm3

Presence
ofbile,bacteria or
food particles

Using local
anesthesia, the
surgeon makes a
small incision in the
abdomen just below
the umbilicus.

A catheter is
introduced through
the incision into the
abdomen. Saline is
infused into the
abdomen through
the catheter, and
then removed. If
blood is present in
the saline after
removal, it is highly
probable that there is
a serious intraabmoninal injury.

CT

FAST

DPL

variable

2-4 min

10-15 min

Time

Easy

Possible, rarely
done

Repeatability

Not organ specific

Reliability

Yes

Obesity , movement Operator dependent

High

Medium

High

Sensitivity

High

High

Low

Specificity

Inexpensive,
mobile , detects
bowl injury

Advantages

Noninvasive, highly Noninvasive, rapid,

accurate ,fixed,
mobile ,Moderately
expensive
inexpensive
Misses diaphragm,
small bowel and
pancreatic injury;
radiation

Hampered by
subcutaneous
Invasive, misses
tissue/intra abdominal
retroperitoneal injury
air, obesity, pelvic
fractures

Disadvantages

To conclude :

In the absence of a reliable physical

examination, the main diagnostic choice is
between CT scanning or FAST (with CT
scanning in a complementary role).

Hemodynamically unstable patients may be

initially evaluated with FAST or DPL

RESULTS:
Two hundred patients with a mean age of 28.3 years were studied, 98 in
FAST and 102 in DPL group. 104 sustained blunt trauma and 76 sustained
penetrating trauma due to stabbing. In addition, 38 (38.7%) were FAST
positive and 48 (47%) were DPL positive (p=0.237, not significant).
As a guide to therapeutically beneficial laparotomy, negative DPL was
better than negative FAST. For non-operative decisions, positive FAST was
significantly better than positive DPL. DPL was significantly better than FAST
in detecting as well as not missing the bowel injuries. DPL took significantly
more time than FAST to perform
.
CONCLUSION:
Although DPL requires significantly more time to perform, it is better than
FAST as an adjunct for the initial assessment of a patient suspected to be
having intra-abdominal injury.

ADJUNCTS TO THE SECONDARY SURVEY

These specialized tests should not be performed until the

patients hemodynamic status has been normalized .

Additional x-rays of the spine and extremities

CT of the head, chest, abdomen, and spine

Contrast urography

Angiography

Bronchoscopy

Esophagoscopy

SPECIAL SUBGROUP
CONSIDERATIONS

The initial management of any

traumatized individual initially follows the
same methodical ABCDE pathway.
However, there are three very important
subgroups which require special
consideration:

The pediatric age group

The elderly

The pregnant

PEDIATRIC TRAUMA
This age- group have :

Smaller body mass greater force applied per unit surface

area for a given injury.

Body with less fat / less connective tissue

Immature skeleton injuries to more than one organ

High surface area to body volume hypothermia is

a higher risk

Airway and cervical spine control

Nasotracheal intubation in children <9 y should not be performed

damage to the cranial vault and to the fragile soft tissues causing
bleeding.

Cuffed tubes are rarely indicated for children <9y because of the
delicate structures within the airway.

Trachea is relatively short not to intubate the right main bronchus.

Breathing and ventilatory control

The respiratory rate in the child decreases with age.

Flail chest and aortic rupture are uncommon in children due to the
elastic nature underlying structures.

Pulmonary contusions are not evident in the early chest x-ray, but as
before, re-evaluation is necessary for the following 2448 hours.

Circulation with hemorrhage control

Vital signs vary with age.

High capacity and ability of children to compensate for

fluid loss

hypotension is a very late and ominous

sign of hypovolemic shock.

If IV access has failed after two attempts, consideration should be given

to intraosseous access proximal tibia/ distal femur

Disability

Head injury

Diffuse axonal injury

Secondary survey

Liver and spleen are the most common organs to

be injured in the abdomen.

Duodenal haematoma /pancreatic injury

underdeveloped anterior abdominal

muscels

Small bowel perforation and mesenteric injuries

Bladder injury pelvic shallowness

Child abuse

TRAUMA IN THE ELDERLY

POPULATION

Trauma in the elderly population presents

many challenges for the treating
physicians due:

fragility of physiological status

co-morbidities

It does not require high velocity or highenergy trauma to put the elderly life at
risk

Airway and cervical spine control

Dentition status

Nasopharyngeal fragility & macroglossia

Stiffness in the cervical spine

Breathing and ventilation

Mortality rates following chest injuries in the elderly are higher

rib fractures and pulmonary contusion
Pulmonary complications atelectasis, pneumonia ,pulmonary edema

Circulation

Cardiac reserve and maximum potential heart rate

Masking of compensatory tachycardia following trauma,

b-blockers

kidney is also more susceptible to damage from hypovolemia,

Retroperitoneal hemorrhage minor pelvic or hip fractures

Disability

Confusion assessment of head injury

Osteoporosis spinal fractures with minor injury

Spinal injury stiffness and spinal stenosis.

Secondary survey in the elderly

Musculoskeletal injury
The most common fracture is in the proximal femur followed by the
humerus and wrist.

TRAUMA IN PREGNANCY

Pregnancy must be considered and excluded in all women of childbearing age.

Anatomic and physiological changes must be considered when

assessing and resuscitating a pregnant woman.

The trauma team + obstetrician + pediatrician

Can lose significant amounts of blood before they display the usual
signs of hypovolemia.high intravascular volume

Mother may appear relatively stable while

the fetus is in distress lack of placental
perfusion

During the primary survey, the uterus of

the third trimester pregnant patient should
be manually displaced to the left side in
order to take pressure off the inferior vena
cava.

Feto-maternal hemorrhage anti-D

COMMON FINDINGS IN TRAUMA

PATIENTS

BATTLES SIGN : BRUISING BEHIND THE EAR

SUGGESTS A FRACTURE IN THE POSTERIOR
CRANIAL FOSSA

RACOON EYES :EXTENSIVE PERI-ORBITAL

EXTRAVASATIONS OF BLOOD FROM BASAL SKULL
FRACTURE.

HEMOTYMPANI

SEATBELT SIGN

REFERENCES
1) Courtney M. Townsend , R. Daniel Beauchamp , B. MARK EVERS And KENNETH L. Mattox(2012) Sabiston Textbook Of Surgery :The Biological
basis Of Modern surgical Practice
12th Ed
2) Norman S. Williams , Christopher J.K. Bulstrode , P. Ronan OConnell(2013)

Bailey&Love'sShort Practice of Surgery 26th Ed

3) Jill S Whitehouse & John A Weigelt (2009) Diagnostic peritoneal lavage: a review of indications, technique, and Interpretation , Scandinavian
Journal of Trauma, Resuscitation and Emergency Medicine .

4) Sunil K, Abhay K, Mohit K and Vinita R (2014) Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as
an adjunct to primary survey in torso trauma:a prospective randomized clinical trial Turkish Journal of Trauma and Emergency Surgery

5) John P. McGahan, & John Richards(2002) The Focused Abdominal Sonography for Trauma Scan , the American Institute of Ultrasound in
Medicine

6) William S. Hoff (2002) Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma: The EAST Practice Management
Guidelines Work Group , The Journal of TRAUMA Injury, Infection, and Critical Care

7)http://www.medscape.com

THANK YOU