02.

01-01
5 August 2013
Hazel Z. Turingan, MD, FPCS, FPSCS, DPBTCVS, DMCC TRAUMA AND
You’ll never know when you’ll get to an accident. You can be one of our patients. So
what to do? Wear nice panties and briefs! CRITICAL CARE
-Hazel Z. Turingan, MD, FPCS, FPSCS, DPBTCVS, DMCC
*[ Tra nscribe rs’ N ote: Those it alicized a re additio nal i nfo m ostly fr om Dr. Turinga n’s
lecture. Info under hea dings and tabl es wit h t hick or ange bor ders are the mus - knows
 hyperextended
(thos e t hat have sunshi ne m arks o n Dr. Turi nga n’s powe rpoint )]  rotated
OUTLINE – should be in the neutral position
Triage 1
Primary Survey & Resuscitation 1 1. Chin-Lift or jaw-thrust maneuver
– in chin-lift, put your hand in the chin to stabilize the
Adjuncts to Primary Survey 4
head, so in essence, you’re taking control
Secondary Survey 5 – in jaw-thrust, you pull the head upwards closing the
Adjuncts to Secondary Survey 12 mandible, hence elongating the neck so as not to impinge
Reevaluation 12 the blood vessels and nerves
Definitive Care 12
Records and Legal Considerations 12

TRIAGE
 process of determining the priority of patients' treatments
based on the severity of their condition resulting in
determining the order and priority of treatment, the order
and priority of emergency transport, or the transport
destination for the patient

PRIMARY SURVEY

What is a quick simple way to assess the patient in 10

seconds?
1. Airway maintenance with cervical spine protection
2. Breathing and ventilation
3. Circulation with hemorrhage control
4. Disability: Neurologic status
5. Exposure/Environmental control: undress, prevent
hypothermia

AIRWAY MAINTENANCE WITH CERVICAL SPINE

PROTECTION
STEP 1: ASSESSMENT 2. Clear airway of foreign body
 Ascertain patency 3. Insert oropharyngeal airway
 Assess airway obstruction
– Sign of Airway Obstruction
 foreign bodies
– eg. Dentures, gum, etc
 facial, mandibular, tracheal, laryngeal fx

Indications for Definitive Airway

Need for Airway Need for Ventilation or -when unconscious, tongue may fall backwards, obstructing
Protection Oxygenation then airway. Oropharyngeal airway is used so that this does
Apnea not happen
Unconscious  Neuromuscular paralysis -different colors that pertain to sizes
 Unconscious 4. Establish definitive airway
Inadequate respiratory efforts
 Tachypnea STEP 3
Sever maxillofacial
 Hypoxia Maintain cervical spine in neutral position with manual
fractures
 Hypercarbia immobilization as necessary when establishing an airway
 Cyanosis
Risk for aspiration Sever closed head injury with need STEP 4
 Bleeding for brief hyperventilation if acute Reinstate immobilization of the c-spine with appropriate
 Vomiting neurologic deterioration occurs devices after establishing an airway
Risk for obstruction
 Neck hematoma
Massive blood loss and need for
 Laryngeal or
volume resuscitation
tracheal injury
 Stridor

STEP 2: MANAGEMENT: Establish Patent Airway

 Head and Neck
– should not be:
 hyperflexed

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Page 1 of 13

 TRAUMA AND CRITICAL CARE

- Helmet removal. Rem oving a helm et prop erly is a two-pers on

procedure. While one pers on provides manual in-line s tabilization of
the head and n eck ( A), the s econd pers on exp ands the helmet
laterally. The s econd pers on removes the helmet ( B) with attention
paid to helmet clearing the n os e and occiput. Once r em oved, the
first pers on supports the weight of the patient ’s head (C) and the
s econd pers on takes over the s tabilization (D).
– Hit the tube on the 3 rd or 4 th ring of the trachea. If on the 1 st or 2 nd,
you might injure the vocal cords , hence, the patient may be alive
but unable/have difficulty talking. If you hit b elow the 4 th, c ephalic
vein might be injured, and m ake the patient bleed t o death.

BREATHING: VENTILATION AND OXYGENATION

STEP 1 ASSESSMENT
 Expose the neck and chest, ensure immobilization of head
& neck
 Determine rate & depth of respiration
 Inspect & palpate neck & chest tracheal deviation unilateral
or bilateral chest movement signs of injury
 Percussion: dullness, hyperresonance
 Auscultation
STEP 2 MANAGEMENT
 Administer high-concentration oxygen
 Mask ambu-bagging CIRCULATION WITH HEMORRHAGE CONTROL
 Alleviate tension pneumothorax
 Seal open pneumothorax STEP 1 ASSESSMENT
 CO 2 monitoring  Identify source of external exanguinating
 Pulse oxymeter hemorrhage
– is it a laceration from the extremities, abdomen?
 Identify potential source of internal hemorrhage
– How will you know if there is internal bleeding? If the
patient comes to you with a flat abdomen, then after a
while abdomen becomes bloated, suspect an internal
hemorrhage.
 Assess pulse: rate, rhythm
 Skin color
 Blood pressure

STEP 2 MANAGEMENT
 Direct pressure to external bleeding sites
– Direct pressure is not merely tapping the site of injury.
Using the BP app, measure the systolic BP. If it’s 100,
inflate the cuff proximal on the area of injury to
100mmHg to obliterate arterial bleeding eventually stop
the bleeding. If you inflate it to 300mmHg, you will
obliterate all the vessels. Pinatay mo na yung kamay ng
patiente mo.
 Consider internal hemorrhage & potential need for surgical
intervention
 Two large caliber IV catheters
 Blood extraction
 IV fluid warmed crystalloid, blood
 Prevent hypothermia

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 2 of 13

 TRAUMA AND CRITICAL CARE

Estimated Blood Volume loss

wt (kg) x 7% x 30% (estimate loss)
70 x 0.07 x 0.3 = 1.47L
Replacement 3:1 Rule
– 300ml electrolyte solution / 100ml blood loss
Fluid resuscitation begins with
2.0 Liters (adult)
20 ml/kg (child)
 IV bolus of isotonic crystalloid or Ringer's lactate
- These solutions don’t go in and out of the blood
vessels, they just stay there
Urine Output
-measured to know if you’ve resuscitated enough
Adult 0.5 ml/kg per hour
Child 1.0 ml/kg per hour
<1 y/o 2.0 ml/kg per hour

Estimated Blood Loss Based on Patient’s Initial

Presentation

CLA SS
Para met er I II III IV
Blood loss
<7 50 750-1500 1500-2000 >2 000
(mL)
Blood loss
<1 5 15-30 30-40 >4 0
(%)
Pulse Rate <1 00 100-120 120-140 >1 40
Blood
Pressure
N N ↓ ↓
Pulse
Pressure N / ↑ ↓ ↓ ↓
Respiratory
Greater Saphenous Vein access. 14-20 20-30 30-40 >3 5
Rate
- where it is located? 1cm anterior & 1cm superior to the Uri ne O utput
>3 0 20-30 5-15 Negligible
medial malleolus (mL/hr)
- it is the easiest vein to get CNS Slightly Mildly Anxious , Confus ed
Sy mptoms Anxious Anxious Confus ed L ethargic
Flui d Crystalloid Crystalloid
Crystalloid Crystalloid
Repla ce me nt and Blood and Blood
*For a 70 Kg Male
[Trans criber’s Note: Medyo iba ang adaptation nito from the lec ture on
s hoc k (T rans 01 .05 P age 7 ) where this table was first introduc ed. Kaso
may “Suns hine” eto s a s lide ni doc s o we c opied it verbatim. P lease be
guided.]

Hypotension
 not reliable early sign of hypovolemia
 loss >30% blood volume before hypotension occurs

RESPONSE TO RESUSCITATION
Femoral vein access.
 Responders
- medial to distal: Vein-Artery-Nerve  Transient Responders
- Eg. You gave 2L of fluid and the Px responded, but after
15mins, BP started to fall again. This means, there is still
bleeding that is not corrected
 Non Responders
- Non-responders and transient responders are hose
patients that need to be brought to the OR stat to locate
and correct the bleeding

Tra nsient Re sponde rs

Tibeal access. A dditional
- Especially used among children Ca use Physi cal Exa m Dia gnostic Interve ntion
Steps
U nder- - abnormal -DPL or - Surgical
How to estimate blood volume? es timation dis tention ultrasono- c ons ultation
of blood -Pelvic frac ture graphy -Volume
Normal adult blood volume loss or -E xtremity fracture infusion
≈ 7% body weight (adults) c ontinuing - obvious external - Blood
70kg (0.07) = 5L blood loss bleeding trans fus ion
≈ 8-9% body weight (children) -Apply
80-90ml/kg appropriate
s plints

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 3 of 13

 TRAUMA AND CRITICAL CARE

Non he morrha gi c Tra nsient EXPOSURE/ENVIRONMENTAL CONTROL

Cardiac - distended nec k - ec hoc ar- - thorac otomy
Tampo- veins diogram STEP 1 COMPLETELY UNDRESS THE PATIENT BUT
nade - decreased heart - FAST
AVOID HYPOTHERMIA
s ounds - peric ardio-
- normal breath centesis  ≤35OC = independent predictor of mortality
s ounds  Hypothermic patients are more likely to suffer:
Rec urrent/p - distended nec k -Clinic al - reevaluate o Cardiac arrhythmias
ers is tent veins diagnos is c hes t o Reduced cardiac output (CO)
tens ion - tracheal s hift - needle
o Increased systemic vascular resistance (SVR)
pneumothor - absent breath dec ompress ion
ax s ounds - tube o Alteration in O 2-Hgb dissociation curve
-H yperresonant thoracos tomy o Profound worsening of coagulopathy
c hes t percuss ion
Nonresponder Tools to prevent hypothermia
Mass ive -Abdominal -DPL or -I mmediate 1. Bair hugger: thermal blankets
Blood Loss dis tention ultrasono- intervention by
Class III or graphy s urgeon
IV -Volume
-I ntra- res toration
abdominal -O perative
bleeding res usc itation
Nonhe morrha gi c Nonresponde r
Tens ion - distended nec k -c linical - reevaluate
P neumothor veins diagnos is c hes t
ax - tracheal s hift - needle
- absent breath dec ompress ion
s ounds - tube
-H yperresonant thoracos tomy
c hes t percuss ion
Cardiac - distended nec k - ec hoc ar- - thorac otomy
Tampo- veins diogram -
nade - decreased heart - FAST
s ounds - peric ar- 2. Bair Paws: thermal gowns
- normal breath diocentesis
s ounds
Blunt -I rregular heart - ischemic -P repare for O R
Cardiac rate ECG c hanges - invasive
I njury -I nadequate -Ec hocar- monitoring
perfus ion diogram - inotropic
s upport
-c onsider
operative
intervention
- invasive
monitoring
maybe required

DISABILITY (BRIEF NEUROLOGIC EXAM)

Step 1: Determine level of consciousness using GCS 3. Rectal and nasal thermal probe to get an accurate
Step 2: Assess papillary size, equality, reaction. measurement of the central temperature

GLASGOW COMA SCALE ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION

Step 1: ABG analysis and ventilator rate
Assessment Area Score
Step 2: CO 2 monitoring
(E) Eye opening Step 3: ECG monitoring
 Spontaneous 4 Step 4: Urinary catheter, gastric catheter
 To speech 3 Step 5: Radiologic examination
 To pain 2 Step 6: FAST or DPL
 None 1
(V) Verbal response Initial Assessment & Shock Management
 Oriented 5
 Confused conversation 4 Condition A ssessment (PE) Ma na ge ment
 Inappropriate words 3 Tension  T rac heal deviation  N eedle decompression
 Incomprehensible sounds 2 pne umo-  D istended neck veins  T ube thorac ostomy
 None 1 thorax  Tympany
(M) Best motor response  Abs ent breath s ounds
 Obeys commands 6 Ma ssiv e  T rac heal deviation  Venous access
 Localizes pain 5 he mo-thorax  Flat neck veins  Volume replacement
 Perc ussion dullness  Surgical c ons ultation/
 Normal flexion (withdrawal) 4  Abs ent breath s ounds thoracotomy
 Abnormal flexion (decorticate) 3  T ube thorac ostomy
 Extension (decerebrate) 2 Ca rdi ac  D istended neck veins  Venous access
 None (flaccid) 1 tampona de  M uffled heart tones  Volume replacement
GCS score = E+V+M  Ultrasound  Pericardiotomy
Best possible score = 15  T horacotomy
 pericardioc entesis
Worst possible score = 3

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 4 of 13

 TRAUMA AND CRITICAL CARE

Condition A ssessment (PE) Ma na ge ment Vehicle is at complete stop and is struck from
Intra-  dis tended abdomen  Venous access behind by another vehicle
abdominal  uterine lift (if  Volume replacement Rear - First tendency of the neck is to move
he morrha ge pregnant)  Surgical c ons ultation
impact backwards then forward even when the seatbelt
 O PL/ ultras onography  D isplace uterus from
 Vaginal examination vena cava is on. So it is important not to remove the head
Obvious  I dentify s ource of  D irec t press ure part of the car seat.
externa l obvious external  Splints Quarter
Front or rear
blee ding bleeding  Clos ure of ac tive panel
bleeding scalp wounds - One side of the car is hit
impact
Unrestrained occupant can impact any part of
Chest X-ray Indications Roll over the passenger compartment
-happens in high speed cars (F1)
Findings Diagnoses to Consider
Respiratory distress without CNS injury, aspiration, Sustained injury: process of ejectionhits the
Ejection
ground. ↑300% ejected from vehicle
x-ray findings traumatic asphyxia
Pneumothorax, pulmonary Organ Collision
Any rib fracture
confusion  Anterior portion of torso ceases to move
Fracture of first 3 ribs or forward while posterior and internal
sternoclavicular fracture- Airway or great-vessel injury organs continue their motion
Compression
dislocation  organs compressed from behind by
injury
Fracture of lower ribs 9 to 12 Abdominal injury advancing posterior thoracoabdominal
2 or more rib fractures in 2 Flail chest, pulmonary wall and vertebral column, and in front by
or more places contusion the impacted anterior structure
Great-vessel injury,  Stabilizing portion of an organ ceases
Scapular fracture pulmonary contusion, forward motion with the torso while the
brachial plexus injury movable body part continues to move
Great-vessel injury, sterna forward.
Mediastinal widening
fracture, thoracic spine injury  May damage renal pedicle, ligamentum
Persistent large Deceleration teres, descending thoracic aorta
pneumothorax or air leak Bronchial tear injury - organs suspended by the ligaments like
after chest tube insertion liver, spleen and kidneys is affected if
Esophageal disruption, their ligaments are lacerated resulting to
Mediastinal air tracheal injury, significant beeding
pneumoperitoneum - most common cause of abdominal
GI gas pattern in the chest bleeding
Diaphragmatic rupture
(loculated air) Can be avoided by using:
Diaphragmatic rupture or  3-point restraints:
NG tube in the chest
ruptured esophagus Restraint use o 65-70% ↓fatalities
Hemopneumothorax or o 10x ↓serious injuries
Air fluid level in the chest
diaphragmatic rupture  Airbag deployments
Disrupted diaphragm Abdominal visceral injury
- Why do we have to know if it is frontal, lateral, etc.
Ruptured hollow abdominal
Free air under the diaphragm depending on the accident, you would know what the
viscus
injuries will be or how to assess it immediately

SECONDARY SURVEY AND MANAGEMENT Pedestrian injury

 90% pedestrian-auto collision <48kph
AMPLE HISTORY AND MECHANISM OF INJURY  Injury: thoracic > head > lower extremity
Step 1: Ample history from patient, family, prehospital  3 impacts: (1) vehicle bumper, (2) vehicle hood and
personnel. windshield, (3) ground
Step 2: Injury producing event: identify mechanism of
injury. Injury to cyclist
 Injury can be avoided/lessened through use of helmet:
A – Allergies redistribute the energy transmission and reduce intensity
M – Medications currently used  In the Phils, this is not true. Helmet is the first to be
P – Past illnesses and pregnancy broken, then the cyclist’s skull
L – Last meal
E – Events or environment related to injury Fall
 Abrupt change in velocity
 Ability of the stationary surface to arrest the forward
BLUNT TRAUMA
motion of the body
 Position of the body in relation to impact surface
Vehicular impact with patient inside vehicle
Blast Injury
Occupant Collision  A blunt injury since the primary injury comes from the
energy of the blast. Lacerations which are penetrating
Collision with an object in front of a vehicle that
Frontal trauma are only secondary.
suddenly reduces its speed
impact
- head-on collision
Collision against the side of a vehicle that
Lateral
accelerates the occupant away from the point
impact
of impact

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 5 of 13

 TRAUMA AND CRITICAL CARE

PENETRATING TRAUMA Morphology

– knife low energy -linear vs. stellate
Foreign Vault -depressed or nondepressed
– handgun  medium energy
object -open/closed
– military/hunting rifle  high energy
+/- CSF leak
Velocity – there are high and low velocity injuries Basilar
+/- 7th nerve palsy
wound at point of impact determined by:
Intracranial lesions
– shape of missile (e.g. mushroom)
– position of bullet relative to impact site (e.g. -epidural
tumble, yaw) Focal -subdural
– fragmentation (e.g. shotgun, bullet -intracranial
Bullet -concussions
fragments, special bullets)
shotgun wounds – whether short or long range Diffuse -multiple contusions
– lethal at close range -hypoxic/ischemic injury
– destructive potential dissipates w/ distance
Important to consider entrance and exit wounds INTRACRANIAL LESIONS
Epidural Hematoma
 Uncommon 0.5%
 Biconvex, lenticular (convex) -- Pushes dura away from
inner table
 Temporal or temporoparietal
 Tear middle meningeal artery due to fracture
 Life threatening
 Does not confirm the contour of brain
Subdural Hematoma
 30% Sunacute Brain Injury (SBI)
 Shearing bridging blood vessels cerebral cortex
 Conform contour brain
 More severe brain damage
Contusions & Intracranial Hematoma
 20%-30% SBI
 Contusions: frontal and temporal lobes
 May evolve intracerebral hematoma, coalesce
 Repeat scan 12-24 hr
Intraparenchymal Hemorrhage with RL midline shift
 Indication of surgery: At least 5mm shift
 Evacuate clot

STEP 4: MANAGEMENT
A. Maintain airway, continue ventilation
B. Control hemorrhage
C. Prevent secondary brain injury
D. Remove contact lenses
Algorithm for Management of minor Brain Injury

HEAD and MAXILLOFACIAL Patient is awake and may be oriented (GCS 13-15

STEP 3: Assessment
A. Inspect, Palpate head & neck: laceration, contusions,
History
fractures, thermal injuries
B. Reevaluate pupils -general examination to exclude systemic injuries
C. Reevaluate GCS level of consciousness -limited neurologic examination
D. Eyes -cervical spine and other X-rays as indicated
E. Cranial nerve function -blood-alcohol level and urine toxicology screen
F. Ears, nose -CT scan of head
G. Mouth, teeth

Classification of Brain Injury

Mechanism Observe or Admit Discharge from
to hospital hospital
-High velocity (automobile collision)
Blunt
-Low velocity (fall, assault)
-Gunshot wounds
Penetrating
-other penetrating injury
Severity
Minor GCS 13-15
Moderate GCS 9-12
Severe GCS 3-8

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 6 of 13

 TRAUMA AND CRITICAL CARE

Algorithm for Moderate Brain Injury (GCS 9-12)
Initial Examination (same as
in mild brain injury +
baseline blood work)
-CT scan in all cases
-Admit to facility capable of
definitive neurological care
After Admission
-frequent neurologic checks
-Follow-up CT scan if condition
deteriorates or preferably before
discharge
If patient improves
if patient deteriorates (10%)
(90%)
-discharge when -if the patient stops following
simple commands, repeat CT
appropriate
scan and manage per severe
-follow-up in clinic brain injury protocol
Management of Severe Brain Injury (GCS 3-8)
Patient is unable to follow simple commands
because of impaired consciousness (GCS 3-
8)
 20% solution 0.25-1.0 g/kg IV bolus
5mins
 osmotic diuretic - C/I hypotension
 I: acute neurologic deterioration 1g/kg
 dilated pupil, hemiparesis
 LOC (lost of consciousness) while being
observed
Steroids  not recommended in management of
Acute Brain Injury
Barbiturate  I: refractory to other measures to reduce
ICP
 C/I hypotension, hypovolemia, acute
resuscitative phase
Anti-  Post-traumatic epilepsy
convulsants  5% closed head injuries
 15% severe head injuries
 Main factors associated with high
incidence of late epilepsy:
o seizure within first week
o intracranial hematoma
o depressed skull fracture
 According to a study, prohylactic
phenytoin (antiepileptic drug) reduced
incidence of seizures in first week of
injury but not thereafter
o Used in acute phase
o Adults 1g IV at 50mg/min
o Maintenance: 100mg/8hrs titrated to
achieve therapeutic serum level
 Prolonged seizures
o add diazepam or lorazepam until
seizure stops
 Continuous seizures
o general anesthesia
 Prolonged seizures 30-60mins 2ndry
brain injury

BRAIN DEATH
 Implies no possibility of recovery of brain function
Assessment and Management
 Criteria:
-ABCDEs o GCS 3
-Resuscitation o Non-reactive pupils
-Ample history o Absent brainstem reflexes
− Oculocephalic
- Admit to facility
− Corneal
-Therapeutic agents − Doll’s eye
-neurologic evaluation − Gag
o No spontaneous ventilatory effort on formal apnea
testing
 Ancillary Studies may confirm diagnosis of brain death:
CT scan o EEG no activity at high gain
o ICP exceeds MAP for ≥ 1 hour
o cerebral angiography
MEDICAL THERAPY FOR BRAIN INJURY
NECK INJURY
Intravenous  Hypovolemia  harmful
Neck Zones
fluids  hypotonic fluid should not be used
Zone 1 Thoracic inlet to cricoid
(glucose containing causes further injury)
cartilage
 Recommend: LRS or NSS
Zone 2 Cricoid cartilage to
 hyponatremia → brain edema
mandible
Zone 3 Angle of mandible to
Hyperven-  ↓ PaC02 → cerebral vasoconstriction → base of skull
tilation cerebral ischemia (<30mmHg)
 use in moderation and limited period
 PaCO 2 maintained 25-30 mmHg
Mannitol  reduce elevated ICP (intracranial
Pressure)

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 7 of 13

 TRAUMA AND CRITICAL CARE

Cervical Spine X-ray Assessment

Assess Alignment:

 All 7 cervical vertebrae (A)

 Identify:
o Ant vertebral line (B)
o Ant spinal line (C)
o Spinous porcess (D)

Assess Bone:

 Examine all vertebrae

o Height preservation
NECK EXPLORATION o Bony cortex integrity
 Examine facets
 Examine spinous process

Look for Fractures:

 Jefferson fracture:
o Atlas fracture C1
SPINE & SPINAL CORD TRAUMA o 40% assoc with C 2 fx
o Burst fracture
STEP 5 ASSESSMENT
o Large load falls vertically on
A. Inspection: Blunt or penetrating injury
the head
B. Palpation
C. Auscultation: bruit
D. CT of cervical spine or later, cross table cervical spine x -
ray

 Odontoid fracture:
o 60% C2 fx involves odontoid
process
o Peg-shaped bony protuberance

 Hangman’s fracture:
o Post element of C2 pars
interarticularis
o 20% axis fracture extension
type injury

MUSCLE STRENGTH GRADING

Score Results of Examination
0 Total paralysis  Chance Fracture:
1 Palpable or visible contraction o Lap belt
2 Full range of motion with gravity eliminated o Transverse fracture through
3 Full range of motion against gravity vertebral body
4 Full range of motion, but less than normal strength
5 Normal strength
6 Not testable

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 8 of 13

 TRAUMA AND CRITICAL CARE

STEP 6 MANAGEMENT Diaphragmatic Rupture

 Blunt trauma produces
large radial tears that lead
to herniation, whereas
penetrating trauma
produces small
perforations that often
take some time to develop
 Maintain adequate in-line immobilization & protection of into diaphragmatic hernias
cervical spine Pericardial Tamponade

Four Person Log Roll

A C
STEP 8 MANAGEMENT
A. Thoracentesis, tube thoracostomy
B. Attach to underwater seal
C. Correctly dress open chest wound
D. Pericardiocentesis
E. Operating room as indicated
Chest Tube Thoracostomy

B D

CHEST
STEP 7 ASSESSMENT
A. Inspection: blunt or penetrating injury use of accessory
muscles
B. Auscultation
C. Palpation: crepitations, tenderness
D. Percussion: dullness, hyperresonance

Sucking Wound
Tension Pneumothorax
 Develops when a “one-
way valve” air leak occurs
from rhe lung or through
the chest wall
 Air is forced into the
thoracic cavity, completely
collapsing the affected
lung

Open Pneumothorax
 May resulted from large
defects of the chest wall
that remain open
Pericardiocentesis

Massive Hemothorax
 Results from rapid
accumulation of >1500mL
of blood or >1/3 of the
patient’s blood volume in
the chest cavity
 Initial chest tube output of
>1 L with ongoing output
of >200 mL/h

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 9 of 13

 TRAUMA AND CRITICAL CARE

EMERGENCY DEPARTMENT THORACOTOMY E. Pelvic x-ray

F. DPL or ultrasound
G. CT Scan hemodynamically stable

PENETRATING ABDOMINAL TRAUMA ALGORITHM

AASW = anteri or abd ominal s tab wound;

CT = c omputed t omogr aphy; DPL = diagnos tic peritoneal
lavage; G SW = guns hot wound; LWE = l ocal wound
explor ation; RUQ = right upper quadrant; SW = s tab
wound

FOCUSED ASSESSMENT SONOGRAPHY IN TRAUMA

Algorithm directing the us e of emerg ency department (FAST)
thoracot omy (EDT) in the injured patient undergoing
cardiopulmonary res us citation (CPR).
 Pericardial sac
ECG = el ectrocardiogr am; OR = oper ating room;
SBP = s ys tolic blood press ure  Hepatorenal fossa
 Splenorenal fossa
 Pelvis or pouch of Douglas
 Repeat scan after 30 minutes

E mergency department
thoracotomy is performed
T he peric ardium is opened
through the fifth interc ostal s pac e
anterior to the phrenic
using the
nerve, and the heart is rotated
anterolateral approac h
out for repair

ABDOMEN
STEP 9 ASSESSMENT
A. Inspection (anterior and posterior for blunt and
penetrating)
B. Auscultation
C. Percussion
D. Palpation Algorithm for the initial evaluation of a p atient with
s uspected blunt abdominal trauma .

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 10 of 13

 TRAUMA AND CRITICAL CARE

CT = c omputedtom ography; D PA = diagnos tic peritoneal KEY PHASES IN DAMAGE CONTROL

as piration;FAST = focus ed abdominal s onography for traum a; Hct =
hemat ocrit
DIAGNOSTIC PERITONEAL LAVAGE
 Invasive
 98% sensitivity for
intraperitoneal bleeding
Pre-operative
 Rapid transfer to hospital
 Activation of damage control in ER
 Stop the bleeding rather than resuscitate
 Prevent hypothermia
 Measure blood gases
 Rapid transfer to OR
Operative
 Control hemorrhage
 control contamination
 pack abdomen
 rapid closure techniques
 Improve perfusion (pH, base deficit)
 Prevent hypothermia
Rescucitation in OR/ICU
 Optimize perfusion & ventilation
 Monitor blood gases, pH, Hb
 Measure intra-abdominal pressure
 Re-warm
 Revise coagulopathy
Re-operate
 Consider early re-op if major blood losses continue
 Plan second look at 12-24 hours once physiology stabilized
 Perform definitive surgery
 Opt to close or leave abdomen open
 Splenectomy <2 minutes
 Nephrectomy through lateral approach <5 minutes

UNCONTROLLED HEMORRHAGE IN PROFOUNDLY

HYPOTENSIVE PATIENT
 digital control of the aorta
 aortic cross-clamping
 Proximal-distal control

AORTIC INJURY

DAMAGE CONTROL
 Indication: Manifestation of "bloody vicious cycle"
1. coagulopathy
2. hypothermia
3. metabolic acidosis
 Damage Control Laparotomy
o Primary objectives:
1. control bleeding
2. limit GI spillage
CONSIDERATIONS FOR DAMAGE CONTROL
 Penetrating abdominal injury with systolic BP <90 mmHg
 High velocity gunshot or abdominal blast injury PROXIMAL-DISTAL CONTROL
 Multi-system trauma with major abdominal injury
 Compound pelvic fracture with associated abdominal injury
 Multiple casualties with definite surgical requirement and
limited resources
 Military environment
LIVER INJURY
 Liver packing
 Four quadrant packing

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 11 of 13

 TRAUMA AND CRITICAL CARE

ABDOMINAL COMPARTMENT SYNDROME Pelvic stabilization using a sheet

 Causes of IAH and ACS include:
o intraperitoneal blood
o interstitial edema from fluid resuscitation peritonitis
o ascites
o gaseous bowel distention
 Bladder pressure
o Mildly elevated 10-20mmHg
o Moderately elevated >20mmHg
o Severely elevated >40mmHg
o Normal 0mmHg PERINEUM, RECTUM & VAGINA
o N after abdominal Surgery 0-15mmHg STEP 11 Perineal Assessment
A. Contusion and hematoma
B. Lacerations
C. Urethral bleeding

STEP 12 Rectal Assessment

A. Rectal blood
B. Anal sphincter tone
C. Bowel wall integrity
D. Bony fragments
E. Prostate position

STEP 13 Vaginal Assessment

A. Blood in the vaginal vault
PELVIC FRACTURE B. Vaginal lacerations

MUSCULOSKELETAL
STEP 14 Assessment
A. Inspection of upper & lower extremity
B. Palpation: crepitation abnormal
C. movement, temperature, sensation
D. Pulse
E. Pelvis
F. X-ray for suspected fracture site

Estimated Blood Loss

 Tibial fractures 300 to 500 ml
 Femur fractures 800 to 1000 ml
 Pelvic fractures >1000 mL

Compartment Syndrome

ABDOMEN

STEP 10 MANAGEMENT
A. Operating room
B. Pelvic compression: sheet or binder
 reduce pelvic volume
 control hemorrhage
Pelvic stabilization using a pelvic binder

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 12 of 13

 TRAUMA AND CRITICAL CARE

Peripheral Vascular

Signs and Symptoms of Peripheral Arterial Injury

Hard Signs Soft Signs
(Operation Mandatory) (Further Evaluation
Indicated)
Pulsatile hemorrhage Proximity to vasculature
Absent pulses Significant hematoma
Peripheral Nerve Assessment of Lower Extremities Acute ischemia Associated nerve injury
NERVE MOTOR SENSA TION INJ URY
A-A index of <0.9
Knee P ublic rami
Femoral Anterior knee Thrill or burst
extens ion fractures
A-A index = sys tolic blood press ure on the inquired s ide compared
O bturator ring
O bturator H ip adduction Medial thigh with that on the uninjured s ide.
fractures
Pos terior
Toe flexion Sole of foot Knee dis loc ation NEUROLOGIC
tibial
Fibular neck
Superficial L ateral dors um STEP 16 Assessment
Ankle eversion fracture, knee
peroneal of foot A.Reevaluate pupil & LOC
dis loc ation
Fibular neck B.GCS score
D orsal firs t to C.UE & LE motor & sensory function
D eep Ankle/toe fracture,
sec ond web
peroneal dors iflexion
s pac e
c ompartment D. Lateralizing signs
syndrome
Plantar Pos terior hip STEP 17 Management
Sc iatic nerve Foot
dors iflexion dis loc ation
A.Continue ventilation & oxygenation
Superior Acetabular
H ip abduction B.Maintain immobilization
gluteal fracture
G luteus
I nferior Acetabular ADJUNCTS TO SECONDARY SURVEY
maximus hip
gluteal fracture
extens ion STEP 18 As warranted
 Spinal x-rays
STEP 15 Management  CT head, chest, abdomen, spine
A.Apply/readjust splint  Contrast urography
B.Thoracic & lumbar spine immobilization  Angiography
C.Pelvic sheet wrap or binder  Extremity x-rays
D. Tetanus immunization  Transesophageal ultrasound
E. Medication  Bronchoscopy
F. Compartment Syndrome  Esophagoscopy
G. Complete neurovascular exam
REEVALUATION
 Trauma Px  The trauma patient must be reevaluated constantly to
w/ assure that new findings are not overlooked.
pneumatic  A high index of suspicion
tourniquet  Continuous monitoring of vital signs and urinary output is
essential.
 ABG/cardiac monitoring/ pulse oximetry
 Pain relive- IV opiates/anxiolytics.
DEFINITIVE CARE
Traction Splinting  Transfer to a trauma center or closest appropriate hospital.
RECORDS AND LEGAL CONSIDERATIONS
 Keep meticulous records (times for all entries, etc.).
Teamwork with timekeeping and recording of clinical
measurements, and observations can be helpful. Some
units have a member of the nursing staff whose sole role is
accurately to record and collate patient care information.
 Consent for treatment is not always possible with lifesaving
treatment and consent may have to be given later.
 Forensic evidence may be required in injuries caused by
criminal activity.

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Pag e 13 of 13