Principles of Trauma

Management
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 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 lines—Normal 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 O2 Hgb Saturation

90 mm Hg 100%
60 mm Hg 90%
30 mmHg 60%
27 mmHg 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: <15%
– II: 15-30%
– III: 30-40%
– IV: >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 pneumo-

thorax resolved
 Circulation
Heart rate Systolic BP Urine
ml/kg/hr

Infants 100-160 60 2
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:
– Battle’s 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