What is

trauma?
Real Life & Death
 What is
trauma?
 Trauma in the United States
• 2.7 million hospital admissions per year
• Leading cause of death for ages 1-44 years
• 100,000 deaths per year from traumatic
injuries
– Half die before they reach medical care
• Hemorrhage is second-leading cause of death
in trauma
Figure 6A: Number of Incidents by Age

Number of Incidents by Age

40,000

35,000
Number of Incidents

30,000

25,000

20,000

15,000

10,000

5,000

0
1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106
Age (years)
Figure 7A: Number of Incidents by Age and Gender
Number of Incidents by Age and Gender

30,000

25,000
Number of Incidents

20,000

Males
15,000
Females

10,000

5,000

0
0
6
12
18
24
30
36
42
48
54
60
66
72
78
84
90
96
102
Age (years)
Figure 8A: Case Fatality Rate by Age

Case Fatality Rate by Age

10.0

9.0

8.0

7.0
Case Fatality Rate

6.0

5.0

4.0

3.0

2.0

1.0

0.0
0 10 20 30 40 50 60 70 80
Age (years)
Figure 10A: Number of Incidents by Mechanism of Injury

Number of Incidents by Mechanism of Injury

600,000

500,000
Number of Incidents

400,000

300,000

200,000

100,000

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Mechanism of Injury
 Mechanisms of Injury:
Blunt Trauma

• MVC
• Pedestrian vs
Vehicle
• Falls
 Mechanisms of Injury:
Special Situations

• Explosions
– Blunt + penetrating + burns
• Burns
• Crush injuries
• Drowning
• Hypothermia/ exposure
Compression injury

• Frontal brain
contusion
• Pneumothorax
• Rupture of Left
hemidiaphragm
• Small bowel
rupture
• Chance fracture
Deceleration Injury
• Aortic tear
– Fixed descending aorta
– Mobile arch
• Acute subdural brain
hematoma
• Kidney avulsion
• Splenic pedicle
 Mechanisms of Injury: Penetrating
Trauma
• Gun shot wounds
• Stab wounds
• Impalement
 Gun Shot Wounds: Mechanism
• Energy transfer
– Shape/size of bullet
– Distance to target
• Velocity (most important)
– Kinetic energy = (Mass × Velocity2 )/2
• Surface area distributed
– Tumble and yaw
– Fragmentation
• Anatomy
– Viscoelasticity
• Muscle
• organs
 Stab wounds
• Mechanism
– Blunt: Crush injury
– Sharp:Tissue disruption
• Extent of Injury
– Weapon size, length,
sharpness, penetration
• Severe injury
– Chest and abdomen
– 4+ wounds
 What happens
when the
patient comes
to a Level I
Trauma Center?
 Trauma Team
“Doin it 24/7”
• ED Physicians
• Anesthesiology
• Surgeons
– General and Trauma and Critical Care
– Neurosurgery
– Orthopedics
• Medical Students
• Nurses
• Radiology Techs
• Radiologists
 What happens when
this patient comes to
the ER where you are
moonlighting?
What the heck
do I do now?
Don’t panic!
 Trauma is not
rocket science!
• Air goes in & out
• Oxygen is good
• Blood goes round & round
• Stop bleeding
• Put things back where and
how they belong
 Initial Assessment:
Prerequisites
• Wide-angled view

• Pattern recognition skills

• Ability to triage and set priorities

• Organized structure
 Trauma is not
rocket science!
ABCDEF
 Initial Assessment:
Primary Survey
• A = Airway
• B = Breathing
• C = Circulation
• D = Disability
• E = Exposure
• F = Fracture
 Initial Assessment: Airway

• Clear & establish a

good airway
– Consider intubation
for coma, shock, and
thoracic injuries

• C-spine stabilization
Airway: Cricothyrotomy
 Initial Assessment: Breathing
• Chest excursion & breath sounds
– Flail chest
• Pneumothorax
– Open
– Tension
• Massive Hemothorax
Initial Assessment: Circulation
• Perfusion (mental status, skin, pulse)
• Control bleeding with pressure
• Pericardial Tamponade
– Beck’s Triad
• Establish 2 large bore (16G or larger)
IV’s in upper extremity peripheral veins
• Resuscitate with Lactated Ringers
– After 4 L think about resuscitation with
blood
 Initial Assessment: Disability
• Neurologic status
– Glasgow Coma Scale
• Eye
• Motor-best predictor of long term
outcome
• Verbal
– Spinal Cord Injury
– GCS ≤ 8 is a “coma” and requires
intubation for airway protesction
Eye opening
» None = 1
» To painful stimuli only = 2
» To voice only = 3
» Spontaneously open = 4
Verbal response
» None = 1
» Incomprehensible sounds = 2
» Incomprehensible words = 3
» Confused = 4
» Oriented = 5
Motor response
» None = 1
» Decerebrate (extension) posturing = 2
» Decorticate (flexion) posturing = 3
» Withdraws to pain = 4
» Localizes pain = 5
» Follows commands = 6
 Initial Assessment: Exposure
• Remove clothes
• Temperature
– warm blankets
• Finger and tube in every orifice
• Maintain full spine precautions
– Log Roll
 Initial Assessment: Fracture
• Stabilize Fractures
• Relocate dislocated joints
• Reassess pulses
 Secondary Survey
• Patient history
• Head to toe physical exam
• Radiography
– Lateral C-spine, C-xray, pelvis
– One cavity above/below entrance/exit
wounds
– FAST (Focused abdominal sonogram for
trauma )
• Urinary bladder drainage
• NGT
• Blood sampling/monitoring
Does this patient
need to go to the
OR ?
Penetrating Abdominal Trauma
Penetrating Abdominal Trauma

GSW KSW

OR HD Unstable HD Stable/No peritonitis

OR Peritoneal Penetration

Positive Negative

OR Observation
Blunt Abdominal Injuries
Blunt Trauma

Peritonitis Indeterminate

OR HD Stable HD Unstable

CT FAST/DPL

Positive Negative

OR Keep Looking
Liver Injury
 Liver Injury
• blunt or penetrating injury
• mortality: 10 - 20%
• may be associated with right lower rib
fracture
• Signs / Symptoms
– RUQ pain abdominal wall spasm ,guarding
hypoactive or absent BS signs of hemorrhage
 Liver Injury: Management
Blunt Injury
• ICU monitoring
– For more severe injuries
– Serial HCT
• Floor Monitoring
– Less severe injuries
– Serial HCT
• OR if patient becomes unstable or requires
excessive blood transfusions
Surgical Management
Surgical Management
Surgical Management
Spleen Injury
 Splenic Injury
• Blunt or Penetrating
• Signs / Symptoms
– LUQ pain
– Kehr’s sign
– involuntary guarding hypoactive or absent
BS
– signs of hemorrhage
– point tenderness
 Splenic Injury Management
• ICU monitoring
– Serial Physical exams
– Serial HCT
• Floor Monitoring
– Not indicated at this time
• Further intervention needed if patient
becomes unstable or requires blood
transfusion
– Embolization vs Splenectomy
 Splenectomy
• Complications
– postsplenectomy infection
• Vaccination
– wound infection
– subdiaphragmatic abscess
– pulmonary complications
– hypovolemic shock
 Stomach and Small Bowel Injury

• Stomach & Small Bowel

– Blunt vs penetrating
• Diagnosis
– Pneumoperitoneum or free fluid on CT scan
– small bowel injury may be difficult to detect
– Found at laparotomy
• Management
– Primary repair or resection
 Colon and Rectal Injury
• Colon
– Diagnosis
• Pneumoperitoneum or free fluid on CT scan
• injury may be difficult to detect
• Found at laparotomy
– Management
• Colostomy vs primary repair
• Rectum
– Intraperitoneal- treat as colon injury
– Extraperitoneal- primary repair with
diversion
• +/- presacral drains
 Pancreas & Duodenum
• Diagnosis
– often delayed diagnosis
– frequently seen together
– most often contused due to blunt injury
– Seen on CT Scan or at laparotomy
– intramural hematoma in wall of duodenum 
obstruction bilious vomiting severe abdominal
pain distention
 Pancreas Injury
• Management
–if the result of blunt trauma
• nonoperative management NG/OG
decompression serial physical exams
monitoring signs of infection controversial
- 3 weeks of bowel rest with TPN
–Complications of nonoperative care
• pancreatic fistula pseudocyst formation
–Operative management is necessary if:
pain fever ileus elevated serum amylase
 Duodenal Injury
• Management
– For hematoma
• NG/OG decompression serial physical
exams monitoring signs of infection
– controversial - 3 weeks of bowel rest with TPN
– For perforation
• Primary repair with duodenal exclusion
• Efferent/Afferent Duodenal tubes
 Pelvic Injury
• Introduction
– significant blood loss if bilateral
– may settle in retroperitoneal space
– 3% of all fractures
– mortality 8 - 50%
– 2nd most common cause of traumatic
death
 Pelvic Fracture
• Signs & Symptoms
– pelvic instability
– pain (suprapubic also)
– crepitus
– bloody meatus
– neurovascular deficits
 Pelvis
• Interventions
– Stable patient
• analgesia
• Repair vs mobilization
– Unstable patient
• Immobilize
• Ex-fix
• Angiography
– embolization