Trauma

Trimodal distribution of death Approach (initial assessment)

Immediate death 1. Preparation & triage
2. Primary survey (ABCDE) & resuscitation of vital functions
3. Re-evaluation of the patient
4. Secondary survey
5. Post-resus monitoring & re-evaluation
Early death Late death 6. Optimize for transfer & definitive care
Primary Survey
1. Airway assessment with cervical spine control 4. Disability / Intracranial mass lesion
• AVPUP
Assess for Establish Cervical • Glasgow Coma Scale (GCS)
Ascertain
airway a patent spine 5. Exposure / Environment
pathway
obstruction airway control

2. Breathing
Life-threatening ATOM TC
condition
3. Circulation with hemorrhage control
• Apply direct pressure to external site of bleeding
• Insert 2 large bore (14g/16g) IV branula
• Labs: GXM, FBC, RP, PT/APTT, ABG
• IV fluid therapy
• ECG, pulse oximeter, BP monitor
• CBD, NG tube
• Prevent hypothermia
• Reassess frequently
 Secondary Survey
Review patient history (SAMPLE) Subsequent physical examination
S: Symptoms Head/Face Any fracture, bleeding, open head injury, watery discharge from ear/nose
A: Allergy Neck Palpate neck ant & post for crepitus/hematoma/tenderness
M: Medication Chest Full palpation & auscultation for fracture/paradoxical chest mvmt/ diminished
P: Past medical history breath sound
L: Last meal Neurological GCS every 15 min & full neurological examination
E: Event of incidence Abdomen & Examine for abdominal distension, depth of wound, pelvic spring, perineum for
pelvis ecchymosis, bleeding, rectal examination
Extremities Fracture, neovascular condition
Log roll Spine fracture/deformity, open wounds

Abdominal Trauma
Classified into:
1. Hemodynamically ‘normal’ – ix can bd full & tx planned accordingly
2. Hemodynamically ‘stable’ – ix is more limited & is aimed at fixing the treatment modalities
3. Hemodynamically ‘unstable’ – immediate surgical intervention (laparotomy) after basic routine ix & primary resuscitation
Investigations:
1. Focused abdominal sonography for trauma (FAST)
Views
• Subcostal view
• RUQ view – Morison’s pouch
• LUQ view
• Suprapubic view – Pouch of Douglas
• E-FAST: add bilateral ant thoracic - pneumothorax
2. CT Scan
• Gold standard for dx of injury in stable patient
• Sensitive for retroperitoneal injury
3. Diagnostic laparotomy
• Evisceration, stab wound, gunshot wound
• Any penetrating injury
• Obvious signs of peritoneal irritation
• DRE fresh blood
 • Persistent fresh blood aspirated from NG tube
• Pneumoperitoneum / diaphragmatic rupture
4. Diagnostic peritoneal lavage (DPL)
• Used to assess the presence of blood in abdomen
• Done when FAST is not available
Head Trauma
AIM: prevention of secondary brain injury (from hypotension, hypoxemia, increase ICP) since neuronal death is irreversible
Concussion Intracranial Hemorrhage
• Physiological dysfunction without anatomical or radiological Extradural hemorrhage
abnormality • Lens-shaped hematoma: between skull & dura
• Usually recovers in 2-3 hours • Laceration of middle meningeal artery
Contusion: Small hematoma • Classically presents with ‘lucid interval’ which
Diffuse axonal injury precedes rapid deterioration
• A major cause of unconsciousness & persistent vegetative state
after head trauma Subdural hemorrhage
• Severe → punctate hemorrhage at the grey-white border • crescent shaped hematoma: between dura &
• Injury that causes rotational & shearing forces arachnoid
• Maximal effects at corpus callosum & brainstem • High speed acceleration/deceleration trauma which
Cerebral edema shears small bridging veins
1. Hypoxic/cytotoxic (cellular) • Underlying brain damage, expanding SOL
• Decrease blood supply (oxygenation) → loss of fx of Na-K Traumatic subarachnoid hemorrhage
pump as ATP decreases → increase intracellular sodium → • Star shaped appearance: at cisterns
cellular swelling • Usually only small amount of blood →conservative tx
• Not respond to medical tx sufficient
2. Interstitial
• Impaired absorption of CSF → increase in transependymal CSF Intraparenchymal hemorrhage
flow → acute hydrocephalus • Require immediate evacuation
• Not respond to medical tx
3. Vasogenic
• Breakdown of BBB → proteins enter interstitial space →
edema
• Seen in TBI, neoplasm, inflammatory condition
• Responsive to both steroid & osmotherapy

Monroe-Kelly doctrine
Fixed dilated pupil
Pathophysiology
• CPP = MAP – ICP
• When an intracranial mass is introduced, compensation must occur by a reciprocal decrease in the
volume of venous blood & CSF
Compensatory mechanism
- Hyperventilation → vasoconstriction of cerebral vessels due to decrease pCO2 →decrease blood
volume
- CSF pushed into spinal canal
• Early → gradual dilatation, sluggish response to light ipsilateral to the lesion
• Late → dilatation of ipsilateral pupil & non-reactive to light
• Final → bilateral pupil dilatation fixation

- In raised ICP, the uncus of temporal lobe herniates over the edge of tentorium, compressing the
fibers of the oculomotor nerve
- Fixed dilated pupil occurs on the side of the compression due to unopposed sympathetic supply
Cushing’s reflex • From Monroe-Kellie, increase MAP maintains cerebral perfusion pressure when ICP is raised
- Baroreceptors detect
Hypertension
Achieved by sympathetic abnormal BP → try to
overdrive: decrease it by triggering a
parasympathetic response via
Irregular - Increase HR
Bradycardia Increase blood pressure vagus nerve → decrease HR
breathing - Increase contractility
- Distortion and/or increase
- Increase vasoconstriction
pressure of brainstem →
irregular breathing/apnea

Managements

1. 3 important parameters: ABCs, GCS, pupil size

2. CT scan to look for causes, but stabilize patient first
3. Management of increase ICP:
- Medical: osmotic diuresis, loop diuretics
- Surgical: CSF diversion, decompression, removal of mass effect (craniectomy, craniotomy)
- Conservative: raised head of bed, intubate and hyperventilation
 Shock

Definition: inadequate tissue & organ perfusion to meet metabolic Recognition of shock:
demands leading to eventual global cellular hypoxia 1. Inadequate tissue perfusion
• Skin – cold, pale, decrease CRT
• Renal – decrease urine output
• CNS – anxiety, confusion, lethargy
2. Increase sympathetic tone
• Narrowed pulse pressure
• Tachycardia
 Types of shock
Shock classification Causes Signs & symptoms
Hypovolemic Acute hemorrhage (>20%), dehydration (burns), severe GE Pallor, cold-clammy skin, increase
Loss of circulating blood volume HR, CRT>2s
Others: acute pancreatitis, ruptured AAA, ruptured ectopic pregnancy
Cardiogenic Blunt cardiac injury, AMI Pallor, cold-clammy skin, increase
Intrinsic cardiac failure HR, pulmonary edema
Others: valvular stenosis, regurgitation, rupture, ischemia,
arrythmias, cardiomyopathy, AVSD
Obstructive Tension pneumothorax, cardiac tamponade, pulmonary embolism Increase JVP
Impaired venous return
Neurogenic Spinal injury Warm peripheries,
(distributive) normal/reduce HR, neuro deficit,
Loss of sympathetic tone Lack of sympathetic tone → decrease SVR → pooling of blood in decrease JVP
extremities → hypotension
Septic Infection - sepsis Fever, rigor, warm peripheries,
(distributive) increase HR
Anaphylactic Bites/stings Fever, rigors, warm peripheries,
(distributive) Allergens – drugs/food angioedema, bronchospasm

General managements

1. Recognize early features of shock

2. Airway & breathing
- Maintain airway – 100% with non-rebreather mask
- Consider intubation if necessary
3. Circulation
- 2 large bore branula (14G-16G): start IV fluid resus
- Inotropic support
o IV dopamine 5-10µg/kg/min
o IV dobutamine 5-10µg/kg/min (esp for cardiogenic shock)
o IV norepinephrine 5-20µg/kg/min (esp for septic shock)
4. Monitoring
 - Vitals – HR, BP, SpO2, RR, temperature
- ECG
- Urine output – CBD
5. Evaluate life-threatening causes
- Tension pneumothorax: decompress with 14G cannula over the 2nd intercostal space midclavicular line
- Cardiac tamponade: start IV fluid bolus with 500ml NS and/or IV dopamine infusion 5µg/kg/min & prepare for pericardiocentesis
6. Identifying underlying causes
• History, examination, investigation

Neurogenic shock Anaphylactic shock

Hx/PE Trauma – site, mechanism, force
Neuro exam, DRE – document initial
neurological deficits
Triad of hypotension, relative bradycardia,
hypothermia
Immobilize Immobilize spine in neutral position
Investigations - C-spine X-ray (AP & Lat)
- Swimmer’s view & open mouth view
- Thoracic & lumbar spine X-ray
- CT/MRI scan
Fluid Rx Titrate fluid resuscitate with urine output
Vasopressin if BP does not respond to fluid
challenge
IV high dose - 30mg/kg over 1st hour, followed by 5-
methylprednisolone 4mg/kg/h for next 23 hours
- Contraindications: <13yo, pregnancy, >8
hours after injury, brachial plexus injury
Disposition Refer ortho/neurosurgeon
Common symptoms:
Urticaria, angioedema, anaphylaxis, anaphylactoid reaction
Causes:
- Drugs – penicillin, NSAIDS, aspirin, TCA
- Food – shellfish, egg white, peanuts
- Venom – bees, wasp, hornets
- Environment – dust, pollen
- Infection – EBV, HBV, coxsackie virus, parasites
Stop Stop the drug, gastric lavage, activated charcoal
administration
Airway Intubation, cricothyroidotomy
Fluid rx 2L Hartman’s or NS bolus
Drugs rx Adrenaline, glucagon, antihistamine, cimetidine,
nebulized bronchodilator, corticosteroids
 Burns

Types of burns Burn depth

1. Thermal
2. Chemical
3. Radical
4. Electrical
Clinical features
Burn size

Managements
A. Lifesaving measures for patients with burn injuries include:
1. Establish airway control
• Burns can result in massive edema → upper airway is at risk of obstruction → ETT
• Factors that increase the risk of upper airway obstruction:
- Increasing burn depth & size
- Burns to the head & face
- Inhalation injury
- Burns inside the mouth
2. Stopping the burning process
• Remove all clothing, jewelry
• Brush dry chemical powders from the wound
• Rinse the wound with copious amount of tap water
• Cover the patient with warm, clean, dry linen
3. Get intravenous access
• Large bore
• Upper extremities are preferred
B. Primary survey
1. Airway
• Ensure that the airway is patent
• Clinical manifestation of inhalational injury may be subtle in the 1st 24 hours
• Consider prophylactic intubation
2. Breathing
• Supplemental oxygen
• Always assume carbon monoxide (CO) exposure in patients who were burned in enclosed areas → high-flow oxygen via
non-rebreathing mask
3. Circulation
• Fluid resuscitation with Ringer’s lactate: Parkland formula
• 4ml x body weight (kg) x % BSA burned
• Given half in 1st 8 hours (from onset of incident), half in the next 16 hours
• Fluid maintenance if patient cannot tolerate oral hydration
• Insert CBD to monitor hourly urine output
Care for minor burns Burn Center referral criteria
- Appropriate analgesics 1. Second degree burn >10% TBSA
- Cleanse burn with mild soap and water / diluted antiseptic 2. Burn involving face, hands, feet, genitalia, perineum, major joints
solution 3. 3rd degree burn in any age group
- Debride wound as needed 4. Electrical burns including lightning injury
- Apply topical antibiotic 5. Chemical burns
- Advise patient to return if sx of infection / uncontrolled pain 6. Inhalational injury
7. Burn injury in patients with preexisting comorbidities that could
complicate mx, prolong recovery or affect mortality
8. Circumferential burn