PRIMARY TRAUMA

CARE
PRIMARY SURVEY
 OBJECTIVES

• TO INTRODUCE THE ELEMENTS OF THE

PRIMARY SURVEY

• TO UNDERSTAND WHEN TO PERFORM

THE PRIMARY SURVEY
 PRIMARY SURVEY
• A RAPID SEQUENTIAL LOOK

• 2 MINUTES

• TREAT AS YOU FIND

• REPEAT AT ANY TIME IF UNSTABLE

 PRIMARY SURVEY
• AIRWAY

• BREATHING

• CIRCULATION

• DISABILITY

• EXPOSURE
 AIRWAY: ASSESSMENT
• LOOK, LISTEN, FEEL

• COLOUR

• CONSCIOUS STATE

• ACCESSORY MUSCLE USE

 AIRWAY: BEWARE
• AIRWAY OBSTRUCTION

• CHEST INJURIES WITH BREATHING

DIFFICULTIES

• CERVICAL SPINE INJURY

 AIRWAY: MANAGEMENT
• CLEAR MOUTH

• CHIN LIFT/JAW THRUST

• GUEDEL / NASOPHARYNGEAL AIRWAY

• INTUBATION

• CERVICAL SPINE CARE

 BREATHING: ASSESSMENT
• AIR MOVEMENT

• RESPIRATORY RATE
 BREATHING: BEWARE
• TENSION PNEUMOTHORAX

• MASSIVE HAEMOTHORAX

• OPEN PNEUMOTHORAX

• FLAIL CHEST

• LUNG CONTUSION
 BREATHING: MANAGEMENT
• OXYGEN (IF AVAILABLE)

• ARTIFICIAL VENTILATION

• DECOMPRESS PNEUMOTHORAX

• DRAIN HAEMOTHORAX
CIRCULATION:ASSESSMENT
• CARDIAC OUTPUT

• BLOOD VOLUME

• EXTERNAL HAEMORRHAGE
 CIRCULATION: BEWARE
• INTRA-ABDOMINAL INJURY

• INTRA-THORACIC INJURY

• LONG BONE FRACTURE

• PELVIC FRACTURE

• PENETRATING INJURY

• SCALP WOUNDS
CIRCULATION:MANAGEMENT
• STOP BLEEDING

• LARGE BORE INTRAVENOUS ACCESS X 2

• BLOOD FOR CROSSMATCH AND HB

• ADMINISTER IV FLUID
 DISABILITY
• PUPILS

• CHECK AWARENESS

 A  AWAKE
RESPONDS TO VERBAL
 V 
COMMAND
 P  RESPONDS TO PAIN

 U  UNRESPONSIVE
 EXPOSURE
• UNDRESS FOR THOROUGH ASSESSMENT

• PREVENT HYPOTHERMIA
 PRIMARY SURVEY
X-RAYS ( IF AVAILABLE)
• CERVICAL SPINE (LATERAL)

• CHEST

• PELVIS
REASSESSMENT OF
ABCDE

IF PATIENT IS, OR BECOMES,

UNSTABLE
PRIMARY SURVEY

?
 PRIMARY SURVEY
SUMMARY
• A RAPID SEQUENTIAL LOOK

• 2 MINUTES

• TREAT AS YOU FIND

• REPEAT AT ANY TIME IF UNSTABLE

SECONDARY
SURVEY
 OBJECTIVES

• TO UNDERSTAND HOW AND WHEN TO

PERFORM THE SECONDARY SURVEY
 SECONDARY SURVEY

• THOROUGH HEAD TO TOE EXAMINATION

• ON COMPLETION OF PRIMARY SURVEY
• WHEN ABC’S ARE STABLE
• AIM TO FIND ANY INJURY THAT MAY
THREATEN LIFE OR LIMB
• RETURN TO PRIMARY SURVEY IF ANY
DETERIORATION
 HEAD EXAMINATION
• SCALP (BRUISING, LACERATIONS)

• SKULL (TENDERNESS, DEPRESSION)

• EYES (PUPILS, FUNDI, LENS, CONJUNCTVA)

• CSF OR BLOOD FROM EAR, NOSE, MOUTH

 NECK
• ASSUME NECK IS INJURED

• IMMOBILISE IN NEUTRAL POSITION

 NECK
• PENETRATING WOUNDS

• SUBCUTANEOUS EMPHYSEMA

• TRACHEAL DEVIATION

• NECK VEINS
 NEUROLOGICAL
EXAMINATION
• GLASGOW COMA SCORE

• MOTOR FUNCTION

• SENSATION

• REFLEXES
 CHEST
• INSPECTION

• PALPATION

• PERCUSSION

• AUSCULTATION

• CXR (IF NOT DONE, AND IF POSSIBLE)

• ECG ( IF AVAILABLE)
 ABDOMEN
• POTENTIALLY DIFFICULT

• BEWARE “HIDDEN HAEMORRHAGE”

• LOOK, LISTEN, FEEL

• REMEMBER RECTAL EXAMINATION

 ABDOMEN
• PENETRATING WOUND = SURGICAL
EXPLORATION

• BLUNT TRAUMA - NASO/OROGASTRIC

TUBE

• URINARY CATHETER IF NO MEATAL

BLOOD

• REASSESS FREQUENTLY
 EXTREMETIES
• LOOK
 DEFORMITY, BRUISING, LACERATION

• FEEL
 TENDERNESS, PULSES

• REMEMBER COMPARTMENTAL
COMPRESSION
SECONDARY SURVEY

DON’T FORGET THE BACK!

 LOG ROLL
• 4 PEOPLE

• AIRWAY/NECK CONTROLLER IN CHARGE

• CLEAR TIMING AND INSTRUCTIONS

• ALLOWS BACK EXAMINATION

 X-RAYS
• IN SECONDARY SURVEY IF NOT ALREADY
DONE

• CHEST

• CERVICAL SPINE - ALL 7 VERTEBRAE + T1

• PELVIS

• OTHERS AS INDICATED BY EXAMINATION

SECONDARY SURVEY

?
 SUMMARY
• THOROUGH HEAD TO TOE EXAMINATION

• RETURN TO PRIMARY SURVEY IF ANY

DETERIORATION

• DON’T FORGET THE BACK

 AIRWAY
AND BREATHING
 OBJECTIVES
• TO UNDERSTAND THE STRUCTURED
APPROACH TO AIRWAY AND BREATHING

• TO RECOGNISE AND MANAGE COMMON

AIRWAY AND BREATHING PROBLEMS
 AIRWAY MANAGEMENT
FIRST PRIORITY IS A PATENT AIRWAY

• TALK TO THE PATIENT

• GIVE OXYGEN (IF AVAILABLE)

• ASSESS THE AIRWAY

• CERVICAL SPINE
AIRWAY ASSESSMENT
• LOOK • COLOUR
• RESPIRATORY DISTRESS
• CONSCIOUS STATE
• CHEST MOVEMENT

• LISTEN
• BREATH SOUNDS
• FEEL • RESPIRATORY DISTRESS
 SIGNS OF OBSTRUCTION
• SNORING OR GURGLING

• STRIDOR

• AGITATION (HYPOXIA)

• USE OF ACCESSORY MUSCLES

• PARADOXICAL CHEST MOVEMENT

• CYANOSIS
 BASIC TECHNIQUES

• CHIN LIFT

• JAW THRUST
 ADJUNCTS TO
TECHNIQUES
• OROPHARYNGEAL AIRWAY

• NASOPHARYNGEAL AIRWAY
 ADVANCED TECHNIQUES
• ENDOTRACHEAL INTUBATION

• SURGICAL CRICOTHYROIDOTOMY
ENDOTRACHEAL INTUBATION
• IF
 FAILURE TO MAINTAIN AN AIRWAY BY
OTHER MEANS
 FAILURE OF VENTILATION BY OTHER
MEANS

• CONSIDER:
RISK OF ASPIRATION
CONTROL CO2 (EG HEAD INJURY)
 REMEMBER
• CERVICAL SPINE

• PATIENTS DIE FROM LACK OF OXYGEN

NOT LACK OF AN ETT
 SURGICAL
CRICOTHYROIDOTOMY
• CONSIDER IF:

 INTUBATION ATTEMPTED AND FAILED

AND STILL NEEDED

 PATIENT CANNOT BE VENTILATED

 BREATHING
(VENTILATION)
 BREATHING
ASSESSMENT

• INSPECTION (LOOK)

• PALPATION (FEEL)

• AUSCULTATION (LISTEN)

• RESUSCITATE
 BREATHING
Look
• Respiratory rate
• Accessory muscle use
• Cyanosis
• Penetrating injury
• Flail chest
• Sucking chest wound
 BREATHING
FEEL

• TRACHEAL SHIFT

• RIB FRACTURES

• SUBCUTANEOUS EMPHYSEMA

• PERCUSSION
 BREATHING
LISTEN

• BREATH SOUNDS

• HEART SOUNDS

• BOWEL SOUNDS
TENSION PNEUMOTHORAX
SIGNS

• RESPIRATORY • RESONANT
DISTRESS PERCUSSION NOTE

• TACHYCARDIA • TRACHEAL DEVIATION

• HYPOTENSION   AIR ENTRY

• DISTENDED NECK
VEINS
TENSION PNEUMOTHORAX
MANAGEMENT

• IMMEDIATE DECOMPRESSION

• LARGE BORE NEEDLE

• SECOND INTERCOSTAL SPACE

• MID CLAVICULAR LINE

• FORMAL CHEST DRAIN TO FOLLOW

TENSION PNEUMOTHORAX

• SHOULD BE A CLINICAL DIAGNOSIS

• TREAT BEFORE X-RAY

 BREATHING
MANAGEMENT

• HIGH FLOW OXYGEN IF AVAILABLE

• ASSIST VENTILATION IF NECESSARY

• TREAT PNEUMOTHORAX + HAEMOTHORAX

AIRWAY AND BREATHING

?
 SUMMARY
• OPEN THE AIRWAY

• CONSIDER INTUBATION

• DO NOT FORGET CERVICAL SPINE

• OXYGEN IF AVAILABLE

• ASSIST VENTILATION AS REQUIRED

CIRCULATION
 OBJECTIVES

• TO UNDERSTAND THE STRUCTURED

APPROACH TO CIRCULATION PROBLEMS

• TO RECOGNISE AND MANAGE SHOCK

 ASSESSMENT
• BLOOD PRESSURE

• HEART RATE

• CAPILLARY REFILL

• PERIPHERAL TEMPERATURE

• PERIPHERAL COLOUR
 TYPES OF SHOCK
 HYPOVOLAEMIC

 CARDIOGENIC

 NEUROGENIC

 SEPTIC

 ANAPHYLACTIC
 SITES OF BLOOD LOSS
• CLOSED FEMORAL #  1.5-2 LITRES
• CLOSED TIBIAL #  500 ML
• PELVIC #  3 LITRES
• RIB # (EACH)  150 ML
• HAEMOTHORAX  2 LITRES

• HAND SIZED WOUND  500 ML

• FIST SIZED CLOT  500 ML
CONCEALED BLOOD LOSS
• ABDOMINAL CAVITY

• PLEURAL CAVITY

• FEMORAL SHAFT

• PELVIC FRACTURES

• SCALP (CHILDREN)
 TYPES OF BLEEDING
• COMPRESSIBLE
 USUALLY PERIPHERAL

• NON-COMPRESSIBLE

 E.G. INTRA-ABDOMINAL

 SURGERY REQUIRED
 CLINICAL SIGNS IN SHOCK
• ALTERED MENTAL STATE : ANXIETY TO
COMA
• PULSE PRESENT ?
 RADIAL  SYSTOLIC > 80 MMHG
 FEMORAL  SYSTOLIC >70 MMHG
 CAROTID  SYSTOLIC > 60 MMHG
• TACHYCARDIA
• PULSE PRESSURE NARROWED
 CLINICAL SIGNS IN SHOCK
• SKIN - COLD, PALE, SWEATY, CYANOSED

• CAPILLARY REFILL TIME > 2 SECONDS

• BLOOD PRESSURE

• JVP

• URINE OUTPUT < 0.5 ML/KG/HR

• RESPIRATORY RATE
CLINICAL SIGNS IN SHOCK
BLOOD HEART BLOOD CAPILLL RESP MENTAL
LOSS RATE PRESSURE ARY RATE STATE
RETURN
< 750 < 100 NORMAL NORMAL NORMA NORMAL
L

750- > 100 SYSTOLIC PROLON 20-30 MILDLY

1500 NORMAL GED ANXIOUS

1500- > 120 DECREASE PROLON 30-40 ANXIOUS

2000 D GED CONFUSE
D
 BLOOD LOSS < 750ML
• HEART RATE  < 100
• BLOOD PRESSURE  NORMAL
• CAPILLLARY RETURN  NORMAL
• RESP RATE  NORMAL
• MENTAL STATE  NORMAL
BLOOD LOSS 750 – 1500ML
• HEART RATE  > 100
• BLOOD PRESSURE  SYSTOLIC
NORMAL
• CAPILLLARY RETURN  PROLONGED
• RESP RATE  20 - 30
• MENTAL STATE  MILD CONCERN
 BLOOD LOSS > 1500ML
• HEART RATE  > 120
• BLOOD PRESSURE  DECREASED
• CAPILLLARY RETURN  PROLONGED
• RESP RATE  > 30
• MENTAL STATE  ANXIOUS/
CONFUSED/
COMA
 CARDIOGENIC SHOCK
• MYOCARDIAL CONTUSION

• CARDIAC TAMPONADE

• TENSION PNEUMOTHORAX

• PENETRATING WOUND OF HEART

• MYOCARDIAL INFARCTION
 CIRCULATION
MANAGEMENT
• A + B, OXYGEN (IF AVAILABLE)
• TWO LARGE BORE INTRA-VENOUS
CANNULAE
• STOP OBVIOUS BLEEDING
• FLUID REPLACEMENT
• MAINTAIN TEMPERATURE
• ANALGESIA
 CIRCULATION
STOP BLEEDING
• CHEST
DRAIN TUBE AND RE-EXPAND LUNG
EMERGENCY THORACOTOMY RARELY
• ABDOMEN
LAPAROTOMY IF HYPOTENSIVE AFTER
FLUIDS
• LIMBS
PRESSURE DRESSING
TOURNIQUET IS LAST RESORT
 CIRCULATION
FLUID REPLACEMENT
• WARM FLUIDS IF POSSIBLE

• COLLOIDS OR CRYSTALLOIDS?

• CONSIDER HYPOTENSIVE
RESUSCITATION IF HAEMOSTASIS NOT
SECURE

• CONSIDER ORAL RESUSCITATION

 FLUID REPLACEMENT -
HOW MUCH?
• 1000-2000ML 0.9% SALINE OR RINGER’S
• REASSESS
• 1000-2000ML 0.9% SALINE OR RINGER’S
• REASSESS
• CONSIDER BLOOD
• CONSIDER SURGERY
• AIM FOR SYSTOLIC BP>90 + HR <100
 CONSIDER BLOOD TX
• HAEMODYNAMIC INSTABILITY IN SPITE
OF FLUIDS

 HAEMOGLOBIN <7G/DL AND PATIENT

STILL BLEEDING
CIRCULATION

?
 SUMMARY
• CAREFUL ASSESSMENT

• STOP THE BLEEDING

• REPLACE VOLUME
HEAD TRAUMA
 OBJECTIVES

• TO UNDERSTAND THE STRUCTURED

APPROACH TO THE PATIENT WITH HEAD
TRAUMA

• TO LEARN HOW TO IDENTIFY SERIOUS

AND LIFE-THREATENING HEAD INJURIES
 HEAD TRAUMA
• ACCOUNTS FOR 1/3-1/2 OF TRAUMA
DEATHS
• GOOD OUTCOMES ARE POSSIBLE
WITHOUT CT SCANS AND
NEUROSURGEONS
• AIM TO AVOID ANY FURTHER INJURY TO
THE BRAIN
• HYPOXIA AND HYPOTENSION DOUBLE
MORTALITY
 HEAD TRAUMA
APPROACH

• AIRWAY

• BREATHING

• CIRCULATION
 HEAD TRAUMA
PHYSIOLOGY

• CPP = MAP - ICP

 CPP = CEREBRAL PERFUSION

PRESSURE
 MAP = MEAN ARTERIAL PRESSURE

 ICP = INTRACRANIAL PRESSURE

 CEREBRAL BLOOD FLOW
DEPENDS ON:

• CPP (MAP-ICP)

• PACO2

• PAO2

• LOCAL METABOLITES
 HEAD TRAUMA
PATHOPHYSIOLOGY
• PRIMARY INJURY
 OCCURS AT TIME OF INJURY
• SECONDARY INJURY
 OCCURS AFTER INJURY

 MAY BE PREVENTABLE
 HEAD TRAUMA
PRIMARY INJURY

 DIFFUSE AXONAL INJURY

 ACCELERATION

 DECELERATION

 CEREBRAL CONTUSION

 PENETRATING INJURY
 HEAD TRAUMA
SECONDARY INJURY

 HYPOXIA

 HYPOPERFUSION (ICP, MAP)

 HYPOGLYCAEMIA

 HYPERTHERMIA (FEVER)

 SEIZURES
 HEAD TRAUMA
INITIAL ASSESSMENT

• AIRWAY (+ C-SPINE)

• BREATHING

• CIRCULATION

• DISABILITY (AVPU, PUPILS)

• EXPOSURE
 HEAD TRAUMA
EXAMINATION

• GLASGOW COMA SCORE

• PUPILS

• CORNEAL REFLEX

• EYE POSITION

• FUNDI
 HEAD TRAUMA
EXAMINATION

• TYMPANIC MEMBRANE

• SCALP AND SKULL

• RESPIRATORY PATTERN

• MUSCLE TONE

• POSTURE
 GLASGOW COMA SCORE
• GRADES SEVERITY OF HEAD INJURY

• SCORE OUT OF 15

• SUBJECT TO INTER-OBSERVER VARIATION

• TREND OF GCS OVER TIME VERY USEFUL

• IMPORTANT TO DESCRIBE RESPONSES ALSO

 GCS EYE OPENING
• OPEN SPONTANEOUSLY4

• OPEN TO COMMAND 3

• OPEN TO PAIN 2

• NONE 1
BEST VERBAL RESPONSE
• ORIENTED 5

• CONFUSED 4

• INAPPROPRIATE WORDS 3

• INAPPROPRIATE SOUNDS 2

• NONE 1
 BEST MOTOR RESPONSE
• OBEYS COMMAND 6

• LOCALISES TO PAIN 5

• WITHDRAWS TO PAIN 4

• ABNORMAL FLEXION 3

• EXTENSOR RESPONSE 2

• NONE 1
SEVERITY OF HEAD INJURY
• SEVERE GCS <8

• MODERATE GCS 9-12

• MINOR GCS 13-15

 PUPILLARY SIGNS
• SIZE

• REACTIVITY

• EQUALITY
 PUPILLARY RESPONSES
• FIXED, DILATED,  SEVERE HYPOXIA
UNRESPONSIVE
 HYPOTHERMIA

 SEIZURES

• UNILATERAL,  EXPANDING LESION ON

DILATED, SAME SIDE
UNRESPONSIVE
 TENTORIAL HERNIATION

 SEIZURES
 ACUTE EXTRADURAL
ACUTE SUBDURAL
• POTENTIALLY LIFE-THREATENING

• IMMEDIATE RECOGNITION ESSENTIAL

• REQUIRE BURR-HOLE DECOMPRESSION

 ACUTE EXTRADURAL
• LOC  LUCID INTERVAL  DETERIORATION

• MIDDLE MENINGEAL ARTERY BLEED

• OVERLYING SKULL FRACTURE

• CONTRALATERAL HEMIPARESIS

• FIXED PUPIL ON SIDE OF INJURY

 ACUTE SUBDURAL
• TEARING OF BRIDGING VEIN BETWEEN
CORTEX AND DURA

• SEVERE CONTUSION OF UNDERLYING

BRAIN

• USUALLY NO LUCID INTERVAL

• WORSE PROGNOSIS THAN EXTRADURAL

HAEMATOMA
 OTHER INJURIES
• BASE-OF-SKULL FRACTURES

• CEREBRAL CONCUSSION

• DEPRESSED SKULL FRACTURE

• INTRACEREBRAL HAEMATOMA

USUALLY DO NOT REQUIRE

NEUROSURGERY
 MANAGEMENT
• AIRWAY

• BREATHING (VENTILATION)

• CIRCULATION
+
• AVOID  ICP

AIM TO PREVENT SECONDARY INJURY

 SEVERE (GCS<8)
• INTUBATE

• NORMAL CO2

• TREAT HYPOTENSION WITH FLUID

• SEDATION +/- PARALYSIS

 SEVERE (GCS<8)
• NURSE HEAD UP 20O

• PREVENT HYPERTHERMIA

• COMPLETE SECONDARY SURVEY

• REASSESS FREQUENTLY
 BEWARE
• DETERIORATING CONSCIOUS STATE

• PENETRATING INJURY

• FOCAL NEUROLOGICAL SIGNS

 UNEQUAL, DILATED PUPILS

 SEIZURES

 POSTURING
HEAD TRAUMA

?
 SUMMARY
• ABCs

• Prevent secondary injury

• Isolated head trauma does not cause

hypotension

• Look for other injuries

• Deterioration  reassess
CHEST INJURIES
 OBJECTIVES

• RECOGNISE COMMON LIFE THREATENING

CHEST INJURIES

• UNDERSTAND PRINCIPLES OF MANAGEMENT OF

CHEST INJURIES
 INITIAL ASSESSMENT

• AIRWAY

• BREATHING

• CIRCULATION
 CHEST INJURIES
• CAUSE OF ~25% OF TRAUMA DEATHS

• IMMEDIATE DEATHS DUE TO MAJOR

DISRUPTION OF HEART AND GREAT
VESSELS

• EARLY DEATHS DUE TO AIRWAY

OBSTRUCTION, CARDIAC TAMPONADE
OR ASPIRATION
 CHEST INJURIES
• PNEUMOTHORAX (SIMPLE, TENSION,
OPEN)
• HAEMOTHORAX
• PULMONARY CONTUSION
• RIB FRACTURES
• FLAIL CHEST
• PERICARDIAL TAMPONADE
• MYOCARDIAL CONTUSION
 TENSION PNEUMOTHORAX
• AIR ENTERS THE PLEURAL SPACE BUT
CANNOT LEAVE

• INTRATHORACIC PRESSURE

• MEDIASTINAL SHIFT

  VENOUS RETURN +  CARDIAC OUTPUT

• RESPIRATORY DISTRESS AND HYPOXIA

 Chest Injuries
Tension Pneumothorax
Life threatening emergency

Clinical diagnosis

Urgent decompression
Tension Pneumothorax
Signs
• respiratory distress
• tachycardia
• hypotension
• distended neck veins
• resonant percussion note
• tracheal deviation
  air entry
Tension Pneumothorax
Management

• Immediate decompression
• Large bore needle
• Second intercostal space
• Mid clavicular line
• Formal chest drain to follow
 Chest Injuries
Simple Pneumothorax
• X-Ray to confirm and size

• Chest drain

• Treat if considering IPPV

 Chest Injuries
Open Pneumothorax

• “Sucking” chest wound

• Other signs of pneumothorax present
• Occlude wound (on 3 sides only)
• Air escapes on expiration
• Urgent insertion of chest drain
 Chest Injuries
Haemothorax

• More common in penetrating than in blunt trauma

• Hypovolaemic shock may occur
• Large bore chest tube
• Lung re-expansion may stop bleeding
• Consider thoracotomy if bleeding continues > 200-
300 ml/hr
 Chest Injuries
Pulmonary Contusion
• Potentially life threatening
• Occurs with blunt and penetrating trauma
• Suspect if rib fractures
• Onset often slow and progressive over 24 hours
 Chest Injuries
Rib Fractures

• Associated with pulmonary contusion

• Associated with pneumothorax
• May result from simple trauma in the
elderly
• Remember analgesia
 Chest Injuries
Flail chest

• Unstable segment
• Paradoxical movement with ventilation
• Severe respiratory distress may result
• Adequate analgesia is vital
• Give oxygen (if available)
• Consider intubation and IPPV
 Chest Injuries
Myocardial Contusion

• Common in blunt trauma

• May mimic myocardial infarction
• Can cause sudden death
• ECG monitoring (if available)
Chest Injuries
Other Injuries
Pericardial tamponade
Great vessel injury
Airway rupture
Oesophageal trauma
Diaphragmatic injury
Chest Injuries

?
 Chest Injuries
Summary
• Management is ABC

• Recognise life threatening problems in primary survey

• Surgical intervention rarely needed

LIMB TRAUMA
 OBJECTIVES
• TO UNDERSTAND THE STRUCTURED
APPROACH TO THE PATIENT WITH
PERIPHERAL INJURY

• TO LEARN HOW TO TREAT PERIPHERAL

INJURIES AND PREVENT FURTHER
INJURY
 LIMB TRAUMA
• PERIPHERAL HAEMORRHAGE IS A
PREVENTABLE CAUSE OF EARLY
DEATH.

• INFECTION OF LIMB WOUNDS IS A

CAUSE OF LATE DEATH.

• EARLY TREATMENT REDUCES LATE

DISABILITY.
 ASSESSMENT
• ABC

• LOOK - COLOUR, DEFORMITY,

WOUNDS, SWELLING

• FEEL - TENDERNESS, CREPITUS,

TEMPERATURE, MOVEMENT

• CHECK - DISTAL PULSES, SENSATION

 MANAGEMENT
• ABC

• CONTROL HAEMORRHAGE

• MAINTAIN PERIPHERAL PERFUSION

• PREVENT INFECTION AND SKIN

NECROSIS

• PREVENT DAMAGE TO PERIPHERAL

NERVES
 MANAGEMENT
• ANALGESIA

• DRESS WOUNDS

• ALIGN FRACTURES

• SPLINT AND IMMOBILIZE

• TRACTION IF APPROPRIATE
 CONTROL OF
HAEMORRHAGE
• DIRECT PRESSURE IS PREFERABLE
TOURNIQUET  IF ALL ELSE FAILS

 RELEASE FREQUENTLY

• TRACTION AND IMMOBILISATION WILL

REDUCE BLEEDING
 COMPARTMENT
SYNDROME
• DUE TO  PRESSURE IN FASCIAL
COMPARTMENTS

• CAUSES COMPRESSION OF VESSELS

AND NERVES

• MAY RESULT IN PERIPHERAL NERVE

DAMAGE AND MUSCLE NECROSIS
 COMPARTMENT
SYNDROME
• PAIN

• OEDEMA

• DECREASED SENSATION

• MUSCLE WEAKNESS

  PULSES AND  CAPILLARY REFILL ARE LATE

SIGNS
COMPARTMENT
SYNDROME
MANAGEMENT

EARLY FASCIOTOMY
 OPEN FRACTURES
• CONSIDER WOUND NEAR A JOINT TO BE
COMMUNICATING

• STOP EXTERNAL BLEEDING

• IMMOBILISE

• RELIEVE PAIN

• TETANUS PROPHYLAXIS
LIMB TRAUMA

?
 SUMMARY
• EARLY TREATMENT WILL PREVENT
DISABILITY

• AVOID TOURNIQUETS IF POSSIBLE

• BEWARE COMPARTMENT SYNDROME

• ANALGESIA
ABDOMINAL TRAUMA
 OBJECTIVES

• RECOGNISE COMMON LIFE

THREATENING ABDOMINAL INJURIES

• UNDERSTAND PRINCIPLES OF
MANAGEMENT OF ABDOMINAL INJURIES
 INITIAL ASSESSMENT

• AIRWAY
• BREATHING
• CIRCULATION
 ABDOMINAL TRAUMA
• COMMON SITE OF INJURY

• ASSESSMENT CAN BE DIFFICULT

• SITE OF “HIDDEN HAEMORRHAGE”

• CONTINUAL REASSESSMENT IMPORTANT

• SEEK EARLY SURGICAL CONSULTATION IF

POSSIBLE
 MECHANISM OF INJURY
• PENETRATING (GUNSHOT, STABBING)
-ENTRY/EXIT WOUNDS MAY NOT BE
OBVIOUS
-SURGICAL OPINION / LAPAROTOMY

• NON- PENETRATING
-GOOD HISTORY IMPORTANT
-COMPRESSION, CRUSH, SEAT BELT,
ACCELERATION, DECELERATION
 SITE OF INJURY
• LIVER

• SPLEEN

• GIT

• PANCREAS

• KIDNEY AND URINARY TRACT

 REMEMBER

INTRA-PERITONEAL CAVITY EXTENDS INTO

THORAX UP TO 4TH INTERCOSTAL SPACE

 LOOK
• LACERATIONS

• PENETRATING INJURY

• DISTENSION

• BRUISING MAY INDICATE SIGNIFICANT

INJURY

• EXTERNAL URETHRAL MEATUS

 FEEL
• BE GENTLE (ESPECIALLY CHILDREN)

• TENDERNESS

• RIGIDITY

• RECTAL EXAMINATION (BLOOD, TONE,

PROSTATE)
 MANAGEMENT
• AIRWAY
• BREATHING
• CIRCULATION
 IV ACCESS
 FLUID RESUSCITATION
 ? LAPAROTOMY
 MANAGEMENT
• GASTRIC DECOMPRESSION AND
ASPIRATION
- ESPECIALLY IN CHILDREN
- LOOK FOR BLOOD

• URINARY CATHETERISATION
- AFTER EXCLUSION OF URETHRAL
TRAUMA
 LAPAROTOMY ?

• PENETRATING TRAUMA

• HAEMODYNAMIC INSTABILITY WITH

 OBVIOUS INTRA-ABDOMINAL INJURY
 NO OTHER OBVIOUS CAUSE

SEEK EARLY SURGICAL ADVICE

 PELVIC INJURIES

• POTENTIAL FOR MASSIVE

HAEMORRHAGE
• CONSIDER UROLOGICAL INJURY
• FEEL FOR TENDERNESS, CREPITUS,
ABNORMAL MOVEMENT, PULSES
• X-RAY ESSENTIAL (IF AVAILABLE)
• IMMOBILISATION WILL HELP STOP
BLEEDING
 SPECIAL INVESTIGATIONS
• DIAGNOSTIC PERITONEAL LAVAGE

• CT SCAN

• ULTRASOUND SCAN

• INTRAVENOUS UROGRAPHY

• URETHROGRAPHY
ABDOMINAL TRAUMA

?
 SUMMARY
• COMMON SITE OF INJURY

• ASSESSMENT CAN BE DIFFICULT

• SITE OF “HIDDEN HAEMORRHAGE”

• CONTINUAL REASSESSMENT IMPORTANT

• SEEK EARLY SURGICAL CONSULTATION IF

POSSIBLE
SPINAL TRAUMA
 OBJECTIVES
• TO UNDERSTAND THE STRUCTURED
APPROACH TO THE PATIENT WITH SPINAL
TRAUMA

• TO LEARN HOW TO IDENTIFY SERIOUS

AND LIFE-THREATENING SPINAL INJURIES
 PRIMARY SURVEY
• AIRWAY + CERVICAL SPINE

• BREATHING

• CIRCULATION

• DISABILITY

• EXPOSURE
 SECONDARY SURVEY
• EXAMINE IN NEUTRAL POSITION
• LOG-ROLL TO EXAMINE BACK
• IMMOBILISE
 STIFF NECK COLLAR
 SANDBAGS + TAPES
 IN-LINE IMMOBILISATION
 SECONDARY SURVEY
• LOCAL TENDERNESS

• SWELLING

• DEFORMITY AND STEPPING

 ASSESSMENT OF LEVEL
• MOTOR RESPONSE
• SENSORY RESPONSE
 ESPECIALLY SACRAL SPARING

• REFLEXES
• AUTONOMIC FUNCTION
- BOWEL CONTROL
- BLADDER CONTROL
 HIGH RISK FOR C-SPINE
• HEAD INJURY
• PARADOXICAL (DIAPHRAGMATIC)
BREATHING
• FLACCID LIMBS
• NO REFLEXES (CHECK RECTAL
SPHINCTER)
• HYPOTENSION (+BRADYCARDIA)
 TRANSPORT
• NEVER TRANSPORT IN SITTING OR
PRONE POSITION

• STABILISE SPINE PRIOR TO MOVEMENT

• LOG ROLL FOR TRANSFER

SPINAL TRAUMA

?
 SUMMARY
• IMMOBILISE UNTIL INJURY IS EXCLUDED

• INITIAL MANAGEMENT IS ABC

• THOROUGH NEUROLOGICAL EXAM

BURNS
 OBJECTIVES
• TO UNDERSTAND THE STRUCTURED
APPROACH TO THE BURNT PATIENT

• TO RECOGNISE AND TREAT THE

CONSEQUENCES OF SEVERE BURNS
 APPROACH
• STOP THE BURNING

• ABCDE

• DETERMINE AREA OF BURN

• GOOD IV ACCESS

• EARLY FLUID REPLACEMENT

• PREVENT HYPOTHERMIA
 MORTALITY
• EARLY  AIRWAY OBSTRUCTION
DEATH
 RESPIRATORY FAILURE

 SHOCK

• LATE  RENAL FAILURE

DEATH
 SEPSIS

 MULTIPLE ORGAN
FAILURE
 AIRWAY
  HOARSENESS

• DIFFICULTY SWALLOWING
SECRETIONS

  RESPIRATORY DISTRESS

• TRANSFER REQUIRED
CONSIDER EARLY INTUBATION
 BREATHING
• FIRE IN ENCLOSED SPACE
•

• BURNS AROUND MOUTH, FACE, NASAL

HAIR

• RESPIRATORY DISTRESS

• HOARSENESS, COUGH, STRIDOR

• ASH IN SPUTUM
SUSPECT INHALATIONAL INJURY
 CIRCULATION
• TREAT SHOCK

• CALCULATE ONGOING FLUIDS ON SIZE

OF BURN

• ORAL REHYDRATION POSSIBLE IN

SMALLER BURNS

• MAINTAIN URINARY OUTPUT 0.5-1.0

ML/KG/HR
 AREA ASSESSMENT
• HEAD AND NECK 9%

• UPPER LIMB 9%

• FRONT OF TRUNK 18%

• BACK OF TRUNK 18%

• LOWER LIMB 9%

• PERINEUM 1%
 CIRCULATION - FLUID RESUSCITATION

• 2-4 ML CRYSTALLOID/KG/% BURN IN FIRST

24 HOURS

• 1/2 OF FLUID IN FIRST 8 HOURS

• 1/2 OF FLUID OVER NEXT 16 HOURS

• CALCULATIONS ARE ONLY A GUIDE

• REMEMBER MAINTENANCE FLUIDS

 EXPOSURE

COVER PATIENT TO PREVENT

HYPOTHERMIA
 ASSESSMENT OF DEPTH
• SUPERFICIAL
 PAIN, ERYTHEMA, NO BLISTERS
• PARTIAL THICKNESS
 PAINFUL, WEEPING, BLISTERS
MOTTLED
• FULL THICKNESS
 PAINLESS, MAYBE WHITE OR DARK
AND LEATHERY

DEPTH LESS IMPORTANT THAN SIZE

IN EARLY RESUSCITATION
 OTHER ISSUES
• ANALGESIA • CONSIDER
ESCHAROTOMY

• NASOGASTRIC • BEWARE OF
DRAINAGE OTHER INJURIES

• TETANUS • BEWARE
PROPHYLAXIS ELECTRICAL
BURNS
BURNS

?
 BURNS
• ABCDE

• BEWARE OF CO-EXISTING INJURIES (EG

AFTER EXPLOSIONS)

• CONSIDER EARLY INTUBATION

• BEWARE HYPOTHERMIA
TRAUMA IN
CHILDREN
 OBJECTIVES
• TO UNDERSTAND THE STRUCTURED
APPROACH TO THE INJURED CHILD

• TO RECOGNISE THE PHYSIOLOGICAL,

ANATOMICAL AND PSYCHOLOGICAL
DIFFERENCES BETWEEN CHILDREN AND
ADULTS
 CHILDREN VS ADULTS
• ANATOMICAL DIFFERENCES
(ESPECIALLY AIRWAY)

• PHYSIOLOGICAL DIFFERENCES

• PSYCHOLOGICAL DIFFERENCES

TRAUMA MANAGEMENT
PRICIPLES ARE THE SAME
 ANATOMICAL DIFFERENCES
• LARGE SURFACE AREA TO VOLUME
RATIO

• MINIMISE EXPOSURE TO PREVENT

HYPOTHERMIA

• WEIGHT = (AGE + 4) X 2
 AIRWAY DIFFERENCES
• HEAD + TONGUE LARGER

• LARYNX HIGHER + EPIGLOTTIS BIGGER

• CRICOID IS NARROWEST PART OF AIRWAY

• PARTICULARLY IN CHILDREN < 4

 AIRWAY DIFFERENCES
• UNCUFFED ENDOTRACHEAL TUBES
PREFERRED

• ETT SIZE = AGE/4 + 4

 BREATHING DIFFERENCES
• AIR SWALLOWING IS COMMON IN
DISTRESSED CHILDREN

• GASTRIC DISTENSION COMPROMISES

LUNG FUNCTION

• GASTRIC DECOMPRESSION IS USEFUL

 CIRCULATION DIFFERENCES
• NORMAL VALUES VARY WITH AGE

• WIDE RANGE OF NORMAL BP + HEART

RATE

• CAPILLARY REFILL TIME IS VERY USEFUL

SIGN
 CIRCULATION DIFFERENCES
• PULSE PALPATION
 FEMORAL ARTERY
 BRACHIAL ARTERY

• IV CANNULATION
 AVOID CVCS
 LONG SAPHENOUS VEIN (ANKLE)
 FEMORAL VEIN
 CIRCULATION DIFFERENCES - SHOCK

• TACHYCARDIA • AGITATION

• WEAK PULSE • DROWSINESS

• TACHYPNOEA •  URINE OUTPUT

• CAPILLARY REFILL > 2 SECONDS

CIRCULATION DIFFERENCES

HYPOTENSION MAY BE A LATE SIGN IN

CHILDREN
 INTRAOSSEOUS ACCESS
• RELATIVELY SAFE + EFFECTIVE

• ANTEROMEDIAL ASPECT OF TIBIA BELOW

TIBIAL TUBEROSITY

• OTHER LONG BONES OK

• AVOID EPIPHYSEAL GROWTH PLATE

• INTRAOSSEOUS NEEDLE OR SPINAL

NEEDLE
 FLUID RESUSCITATION
• INITIAL BOLUS IS 20ML/KG

• SECOND BOLUS IS 20ML/KG

• IF NO RESPONSE GIVE BLOOD

• AIM FOR URINE OUTPUT 1-2 ML/KG/HOUR

IN INFANT

• WARM FLUIDS IF POSSIBLE

 PSYCHOLOGICAL DIFFERENCES

• DISTRESS MAY NOT BE DUE TO PAIN

• UNHAPPY CHILD IS DIFFICULT TO

ASSESS

• CONSIDER PARENTAL PRESENCE AT ALL

TIMES
TRAUMA IN CHILDREN

?
 TRAUMA IN CHILDREN
SUMMARY

• PRINCIPLES OF MANAGEMENT ARE AS

FOR THE ADULT
• REMEMBER ANATOMICAL,
PHYSIOLOGICAL AND PSYCHOLOGICAL
DIFFERENCES