Management of poly traumatized patient

management ‫احنا بندرس المحاضرة ديه علشان يكون عندنا معلومات عامة و كدا كدا كل ال‬
....‫ هنتكلم عن اهم اسباب الوفاة‬trauma‫ بيعملها دكاترة بشري و علشان نعرف خطورة ال‬procedures
Leading causes of death
1- First leading cause is → strokes = vascular accidents either cerebro-vascular
or cardio-vascular.‫جلطة في القلب او المخ‬
2- 2nd leading cause is → malignancy
Most fatal type of cancer is lung and bronchial cancer, then in 2nd, 3rd, 4th place,
breast – colorectal -stomach – pancreas ‫بيتنفسوا علي المراكز ديه‬
3- 3rd leading cause is→ trauma
So, trauma is an issue representing 10% of causes of death worldwide with ratio
male : female (2:1).
Why is trauma an issue?
 People who die from stroke or cancer are mostly old aged and doesn’t
affect economic state.
 While, people who die from trauma are economically productive age (14-
44) which affects economic state in any society + cost of management of
traumatized patient.
Trauma is a challenge?
There are multiple associated injuries and these injuries could be fatal or life
threatening → which make it a challenge for diagnosis and management in
proper time.
‫ فالجراح‬,‫ دا كمل معانا لحد ما في السبعنيات عيلة جراح عظام ماتوا كلهم في حادثة طيارة‬challenge ‫ال‬
‫ و‬protocol for poly traumatized patient ‫ كرس حياته كلها يصمم‬James Styner ‫ده اللي هو‬
‫ و البروتكول دا بيتطبق في كل المستشفيات علي‬advanced trauma life support ATLS ‫سماه‬
‫ و احنا انهارده هنتكلم عن‬, ATLS ‫مستوي العالم و مفيش دكتور جراح بيشتغل من غير شهادة اتقان لل‬
.....‫البرتوكول دا‬
 Causes/ modes/ types of trauma

Why it is important to calcify trauma?

As we mentioned that trauma is a challenge to diagnose and treat in proper time.
Each type of trauma is characterized by certain pattern of injuries. If surgeon is
aware of mode of trauma he can predict injuries associated with it.
1- Blunt trauma
Def: Trauma not associated with penetration of body cavity (cranial – neck –
thoracic – abdomen).
Main incidence: is “sudden/ rapid deceleration” → when body is in motion it
gains momentum when deceleration occur this kinetic energy will be transferred
to internal organs causing damaged without penetration.
Types:
A) Road traffic accident
 Associated injuries: deceleration of a body that was in motion→ affect
internal organs causing..
1-head/ brain injury: concussion – hemorrhage – laceration – head edema.
2-Rib fracture that enter lung and pleura
3-any movable organ could be avulsed leading to injury of parenchymatous organ
(most commonly injured organ by bunt trauma is liver!!)
  Road traffic accidents could be..
Pedestrian who is hit by a Passenger not wearing Passenger wearing seat belt
car‫ماشي علي رجله‬ safety belt
1st incidence→ long bone 1st on rapid deceleration→ On rapid deceleration→ rib
fracture chest hits the wheel fracture and associated internal
2nd → fall on car head 2nd → head injury organ injury..
trauma If deceleration is severe→ pt. Pierce lung: pneumothorax
3rd→ fall on ground will e extruded out of the Spleen: traumatic rupture
fracture spine car→ with associated long if deceleration is
bone and spine injury severe→compress abdominal
cavity with associated rupture of
hollow organs (ex: cecum, rectum,
stomach)
Rule for surgeon: if seat belt is marking abdominal surface there is associated
internal organ injury and patient must undergo laparotomy.
B) Falling from height
 Severity of injury is affected by height.
 Associated: long bone fracture, spine fracture, internal organ injury.
2- Penetrating trauma
Def: trauma associated with penetration of body cavity.
Types:
Low energy trauma High energy trauma
 Ex: knives and  Ex: firearm injuries, bullet
bullets  Kinetic energy: massive
 Kinetic  Trauma: not limited to pathway of object it is more extensive.
energy: Mild While bullet is passing inside body the damage is enlarged (as we go
 Trauma: deeper damage increase).
Limited to A bone could be fractured and it is away from passage point of
pathway of bullet.
object  Inlet: usually very small and hard to be detected by surgeon.
 Outlet: if bullet gets out of the body the exit is obvious.
 3- Thermal trauma = thermal burn
4- Blast trauma
Def: it is a characterized type of trauma, collecting the above 3 modes.
Mode of injury:
when explosion happens 1st cause of injury is thermal burn→ due to heat
produced by explosion→ when ignition ‫احتراق‬continue air is consumed by
ignition causing pressure outside body < pressure inside body of patient→
causing blunt trauma and rupture of internal organs (ex:
pneumothorax – explosion of hollow organs as stomach,
colon, rupture of ear drum)→ when ignition is
completed it will produced gas and this gas will push the
surrounding objects causing→ penetrating trauma by
foreign particles.
5- Crush injury
Def: characterized by damage of large surface area of soft tissue ex: runover
injury (truck or train runs over victim) associated with 1-extensive soft tissue
damage associated with 2- metabolic disturbances (ex: shock- hyperkalemia-
acidosis- acute renal failure),,,,, crush injury an its metabolic consequences are
called “ crush syndrome”
Mode of injury:
 When there is extensive soft tissue damage , cellular damage, extensive
inflammatory mediators (causing extensive VD and hypotension→ shock.
 Intracellular k+ will be released in circulation causing→ hyperkalemia
 Hyperkalemia is associated with cardiac arrhythmias and arrest.
 Shock state leads to→ metabolic acidosis and extensive muscle damage.
 Extensive muscle damage with release of intracellular myoglobin will be
filtered by kidney→ urine will be red in color “myoglobinuria” → leading
to acute renal failure.
Note: this mode of injury can be associated with high voltage burn and
mismatched blood transfusion.

Level 1
 Regional trauma center.
 Teaching hospital.
 >500 bed.
 Separated ICU.
 On call consultant
Trauma represent 10% of deaths worldwide
50% (1st peak of death)
 Cause:
due to fatal injury where
victim dies at scene.
 Time of death:
within seconds to mins
 Injuries are non-treatable
but, predictable by safety
measures.
 Ex:
severe laceration- spinal cord
transection above c4- cardiac
injury and cardiac
penetration (external or into
pleura)- injury of major
vessels like (aorta- IVC)
Trauma centers
Level 2 Level 3
 Area wide trauma  Local trauma center.
center.  General surgeon is captain
of team.
30% (2nd peak of death) 20% (3rd peak of
death)
 Cause:  Cause:
Life threatening injuries, these pt. are Secondary to
our target trauma where
 Time of death: trauma is not 1ry
within mins to hours. cause of death.
 Injuries are treatable if  Time of
management starts properly death:
on time. Days to weeks
(First hour for poly traumatized pt. (within days of
is the golden hours→if surgeon trauma)
can detect and treat injury  Ex:
properly pt. will survive.) 1-infection: septic
 Patients of 2 peak of death
nd shock
have 1st priority for 2-multiple organ
management. failure: due to
 Ex: pulmonary
airway obstruction, intra cranial embolism
hemorrhage either extra(epi)dural- 3-organ failure:
subdural, pneumo/hemothorax, renal failure.
internal hemorrhage (due to non
major vessel injury or
parenchymatous organ injury),
multiple fracture.
 ➢ In order to manage a case of trauma it must be in a teaching hospital with…
1- Available staff: first team should be present 24/7 are (general surgeon-
vascular surgeon- neurosurgeon- cardiothoracic surgeon), second team (
orthopedic- plastic surgeon- naso-fascial surgeon).
2- Availability of blood bank: for blood transfusion in internal hemorrhage and
ICU for resuscitation and monitoring.
3- Radiology: nowadays no trauma management without CT scan
Triage
Def: concept of management of mass casualties as in war and earthquakes.
Where there is large no. of victims in limited time and space and no adequate
resources found for management.
Used in: high volume accident and disaster – section of victims hat best benefit
from management. ‫لما يكون فيه عدد كبير من المصابين في حوادث او المرضي هيعيشوا لو طبقت‬
‫عليهم البروتوكول‬
Priorities for disaster:
P1→pt. with treatable life-threatening injuries. (ex: conscious level: confused –
tachycardiac – hypertensive- increased respiration- multiple bone fracture)
P2→ pt. with serious but not life-threatening injuries. (ex: burn→ could die 2-4
days but not now)
P3→ walking wounded (ex: pt. is hemodynamic stable→ no hemorrhage and
conscious level is adequate)
P4→ dead or fatal injuries.
Guidelines:
Step 1 Step 2 Step 3
✓ Measure vital signs of ✓ If vital signs are normal→ ✓ Age <5 or >55
consciousness. assess anatomical and ✓ Known cardio
Ex of concerning vital signs: mechanism of injury. or pulmonary
✓ Glasgow coma scale <13 ✓ Penetrating injury, two or disease.
✓ Systolic BP<90mmhg more proximal bone fracture,
✓ Respiratory rate<10 or >29 burns>15%TBSA, flail chest,
high impact injury
 Management at scene

‫ الدولة صرفت فلوس كتير و مجهود كتير علشان تدرب‬trauma‫علشان نقلل الموت بسبب ال‬
‫ بس المجهودات ديه مدتناش نتايج فابلتالي اي مش من االسعاف‬first aid‫ ازاي يعمل‬community‫ال‬
‫ و دا‬management on scene is done by medics only‫هيعمل الثالث حاجات دول بس و ال‬
.‫ مش موجودة غير في المستشفي‬resources ‫ محتاج‬management‫علشان ال‬
Community members should:
1- Call 911.
2- If pt. is conscious→put in recovery position ‫نحط المريض علي جنبه‬
3- Stop bleeding by compression
Management on scene in only done by medics ensuring 3 main targets;
1- Proper airway.
2- Adequate breathing.
3- Support circulation.
Pt. will be transferred to ER(emergency
department) on a stretcher not a soft
matrix? To keep normal structure and
anatomy of spine, plus add neck collar,
canula and fluids and oxygen mask.

✓ When pt. arrive to hospital we call for coma team to evaluate the patient
and applying ATLS…

ATLS

Components of ATLS:
1- Primary survey.
2- Secondary survey.
3- Tertiary survey.
 ➢ Primary survey
Used for: patient resuscitation regardless type of injury, to diagnose and treat
life-threatening injuries.
ABC
A= ensure patent airway
This is the first priority, don’t jump for breathing until making sure that airway is
adequate (airway here means upper airway→ which extends from oral-nasal
upward to vocal cords downward)
➢ Indications of management:
If pt. is conscious and If pt. is conscious with obstructed airways If pt. is unconscious
responding
Airway is for sure There will be signs and symptoms… Any unconscious
patient 1-Stridor→high pitched sound related to patient should be
‫اسأل المريض عن اسمه و‬
inspiration. ‫صوت صفارة‬ considered to have
‫عمره و يرد عليا كده هو تمام‬
2-Tachypnea= rapid rate of respiration an obstructed airway.
3-Cyanosis central in mouth= bluish
coloration
4-Pt. struggling for air and working
accessory inspiratory muscles (scaleni and
sternocleidomastoid) + indrawing of
intercostal spaces with each inspiration
➢ Management:
1-Patient should be put I supine position with slight head extension.
Any unconscious pt. in supine position→tongue will be displaced backward→ by
saliva and gravity→ obstructing the pharynx→ so, doing slight extension by chin
lift (to displace tongue anteriorly) and jaw thrust maneuver (to open
airway)→this movement will re-open pharynx→ then, oropharyngeal airway will
take route/shape of upper airway and will prevent further the backward
displacement of tongue
 2-Oral toilet→ by suction of any saliva- vomitus- blood clots.
3-Airway obstruction
If pt. conscious If pt.is in deep coma
level is just
confused
-Patient can -patient can’t respond
localize/respond to pain.
to pain (doctor -oropharyngeal airway
squeeze the won’t be adequate??
nipple) Bec. While pt. is in deep
-Oropharyngeal coma there is CNS
airway will be suppression and all
adequate. reflexes will be
suppressed including
cough.
-losing cough reflex will
cause lost protection
against aspiration
-surgeon must apply
endotracheal tube
endotracheal tube‫ال‬
‫عبارة عن انبوبة فيها بالونة‬
beyond vocal ‫بندخلها‬
‫ و بعدين ننفخ البالونه‬cords
trachea‫ديه فهتقفل ال‬
aspiration‫فميحصلش‬
-Endotracheal tube
could be difficult in
emergency settings.
Cricothyroidotomy
If pt. has severe If endotracheal tube is
hypoxia or inaccessible
inhalation injury
-Apply -In cases of: severe laryngeal
endotracheal tube edema or extensive fascial
as a prophylactic injury.
method ‫وقاية‬ -apply surgical airway which
-In inhalation injury means creating an opening in
pt. is exposed to airway.
fire in a closed area, -example….
pt. inhale hot air→ 1-Crico-thyrodotomy→ make
causing burn to an opening in cricothyroid
pharynx and membrane (depression fond
laryngeal mucosa→ just below thyroid cartilage) +
leading to edema intubation
and asphyxia ‫اختناق‬ This is used in critical cases
-asphyxia: is where there is sterile sets.
hypoxia due to 2-More
obstruction of secure→tracheostomy
upper airway (opening in trachea) and
‫المريض دا كمان ساعة او‬ apply tube below 2nd,3rd,4th
asphyxia ‫اتنين هيجيله‬ tracheal tube
‫انا مش هستني لما يجيله و‬ ‫موجودة كتير في العناية فالزم نبقي‬
‫ فعلشان كدا‬tube‫احي ال‬ ‫عارفينها‬
‫بنحطها للوقاية و‬
obstruction ‫مبيحصلش‬
of airways
B= assess breathing
➢ Look, listen and feel.
➢ If there is hypoxia due to inadequate ventilation maybe due to rib fracture
➢ chest expansion (look for symmetry)
➢ listen to air sound
➢ look for ecchymosis
➢ look for emphysema (air in subcutaneous tissue)
➢ auscultation for breath sound
➢ percussion will be..
dull/ impaired → in hemothorax
tympanic/ hyper rhythmic → in pneumothorax
-If there is any sign or suspicion for
pnuemo/hemothorax we should insert intercostal tube
underwater seal.
-Oxygen can be delivered in mask ventori, nasal bronge or airway access, in some
instances we should apply +ve pressure ventilation by ambu-bag ventilate
‫ اللي‬ambu-bag‫ متوصل بال‬oxygen supply ‫ و فيه‬ambu-bag‫ماسك بيتحط علي الوش و ننفخ بال‬
.‫هيوصل اكسجين تحت ضغط‬

C = circulation
1-Assess vitals of pt. (heart rate- blood pressure).
Patient with internal hemorrhage heart rate will be high or blood pressure will be
low → according to severity
Young adults with cardio-vascular reserve can maintain blood pressure until
loosing one and half liter of blood.
 2- Apply canula in both arms → for hypotensive pt. or patient in shock
2 wide pore Venous cut down Central venous
canula
-Best way to give - If peripheral canula is difficult to apply as
-wrist option is much better
solution in case of obese or collapsed pt. than central venous line.
‫ندي بيها كمية كبيرة‬ -def: certain veins are anatomically -Def: catheter inserted into a
‫في وقت سريع‬ constant all surgeons know these sites of central vein like internal
these veins and can open on it blindly. jugular vein, femoral vein and
-Ex: subclavian vein.
1-if we can’t find peripheral line→most -Risk to apply catheter to
famous is long saphenous vein→ 1cm central vein is thrombosis……in
above and anterior to medial malleolus superficial vein will cause
thrombophlebitis but,
thrombosis in superficial vein
is not an issue.
-To prevent: apply thin canula
in central venous catheter? To
decrease incidence of central
2-if we found peripheral line → apply thrombosis, as this long and
canula in external jugular vein→ put head narrow catheter will not
of pt. downward close to clavicle, vein will permit diffusion of large
be apparent and we insert canula volume due to increased
resistance in tube.

Shock
Def: Systemic state of inadequate tissue perfusion‫حتي لو الضغط كويس‬
‫ مش شرط‬respiration of cell‫ لكن القصة اصال هي في ال‬circulatory failure ‫االول كان تعريفها‬
perfusion
Indicators of shock (diagnosis):
Only constant is high lactic acid “acidosis” which indicates inadequate tissue
perfusion and anerobic metabolism.
 Types:
Hypovolemic Cardiogenic Obstructive Distributive shock
shock shock shock hypovolemic‫انفصلت عن ال‬
‫انفصلت عن اللي‬
‫قبلها‬
Due to Due to heart Normal -Volume is normal but, surface area is widened.
volume loss failure… cardiac -To maintain perfusion there should be balance
as in.. 1-massive function with between volume and peripheral resistance.
1- infarction. impaired -If there is arteriolar or capillary VD→ net result
hemorrhgae. 2- filling as in… will be relative hypovolemia.
2-burn. arrhythmias. 1-massive Causes:
3-diarrhea. 3-arrest. pulmonary 1-Neurogenic shock: after spinal anesthesia,
4-vomitting. embolism spinal cord transection, vasovagal shock→ in all
5- (obstruction cases there is sympathetic paralysis → there is
dehydration. of pulmonary bradycardia and shock
arteries) -sympathetic is thoraco-lumbar while,
2-tension parasympathetic is brain stem and sacral.
pneumothora -Usually there is balance between sympathetic
x (severe and parasympathetic where parasympathetic
mediastinal normally overdrive and sympathetic control tone
shift) around capillaries.
3-cardiac -If parasymp. Is increased or symp. Is decreased→
tamponade this causes increase in blood vessel diameter as in
(blood within case of vasovagal tone (unpleasant smell or seen,
pericardium any emotional stress causing vagal overdrive and
preventing vagus nerve is sympathetic).
ventricular -Vasovagal tone cause (inc. tone and dec HR=
filling) bradycardia).
2-Anaphylactic shock→hypersensitization for
certain antigen cause antibody formation → on
re-exposure to antigen there will be antigen-
antibody reaction→ stimulating mast cell to
release histamine and serotonin → causing
peripheral VD and leading to shock
3-distributive shock could be cardiogenic shock??
Because inflammatory cytokines are cardiotoxic.
  hypovolemic, cardiogenic and obstructive shock are characterized by
manifestation of sympathetic overdrive ( pain- sweat- hypotension-
tachycardia)
 these where main 4 types of shock, other types…
5-Burn shock: hypovolemic + distributive + cardiogenic
6-Endocrine shock: according to cause…
a) adrenal cause “catecholamine” →distributive shock but, there is not
catecholamine only, there is cortisone and aldosterone which are
responsible for water reabsorption → causing hypovolemic shock
b) hyperthyroidism → causes cardiac arrhythmia→ cardiogenic shock
7-Traumatic shock.

Management of circulation and shock

1- assessment 2- two wide pore cannulas

3-Draw sample for investigation and cross matching → for blood transfusion
4-External hemorrhage should be controlled by….
a) No.1 by compression if failed..
b) Apply tourniquet
c) Restoration of blood volume (if there is hypotension)
 Hemorrhage def: loss of oxygen carrying capacity!!
 Best replacement for hemorrhage is blood!! But, this is not the 1st line !!
 We transfer blood after blood loss = 2L
 Initial resuscitation is not by blood but, by crystalloids!!
Factors controlling fluid shift across capillary membranes:
1- Hydrostatic pressure (intravascular and interstitial)
2- Oncotic pressure
Body fluids
I. 2/3 intracellular space of total body water.
II. 1/3 extracellular space …..
Intravascular space Interstitial space
5L Between blood vessels and cells called
internal environment
There is free communication between intravascular and interstitial space and
almost 99% equilibrium between them and this constant environment is
important for adequate cellular function ( Protein content, molecular content,
temperature, PH), all should be constant for cell to function adequately→ and this
mechanism or process to maintain this environment is called “homeostasis”
Homeostasis: physiological function to keep our internal environment constant.
So, passage across capillary membrane between intra-vascular and interstital is
guided by equilibrium between 4 forces: intravascular- hydrostatic- oncotic-
interstitial
In the arterial site of capillaries the main force is “HYDROSTATIC PRESSURE” that
overcome opposing forces→ 1-enhancing fluid to move 2- any particles smaller
than capillary pores to move and pass from capillaries to intersitium.
Parenteral fluid therapy
crystalloids colloids
-Def: solution with particles of small -Def: solution with particles of large
molecular weight molecular weight “complex particles”
-Ex: Na+, k+, cl-, HCO3- (bicarbonate) -Ex: starch and gelatin
-Maintain blood pressure for only -particles will be kept inside
about maximally 1H then, 2/3 of the intravascular space raising oncotic
volume will be passed to intersitium pressure considerably “ preventing
and lost from vascular compartment. fluid loss to interstium”→ it will keep
- used in initial resuscitation→ volume within intravascular space +
diagnose hypovolemia by challenge raising oncotic pressure draws fluid
test from intersitium to intravascular space
and this is called “plasma expanded”.
Notes:
 Crystalloid is fluid of choice for resuscitation??
1-resemble plasma composition like ringer lactate/ lactating ringer/Hartman’s
solution → contain Na, cl, HCO3 with lactic acid → concentration of these
elements represent their concentration in plasma could be considered a plasma
substitute.
2-during initial resuscitation I am still not diagnosing the cause of shock pt. with
passenger injury could have hemothorax and hypovolemic shock or it could be
cardiac tympanic with obstructive shock.
In case of using colloid with shock..
 Hypovolemic shock→ will improve blood pressure
 Obstructive shock→ will lead to pulmonary edema
So, when we use crystalloid in initial resuscitation we call it a challenge test → we
infuse a liter rapidly of crystalloid..
If blood pressure is raised→ cause of shock is hypovolemia
If blood pressure not raised→there is another cause of shock
with obstructive shock crystalloid is not a big deal?? As after 1 hour 2/3 of
volume will be moved out of intravascular compartment
while in colloid solution it will be an issue→ as fluid will remain for 12-24 hours
or more→ leading to pulmonary edema
‫ اللي‬crystalloid‫ ال‬,resuscitation ‫ نقدر نعمل بيهم‬fluid therapy‫باختصار عندنا نوعين من ال‬
‫قريبة جدا من تركيبة البالزما اللي موجودة عندنا في الدم بس بعد ساعة تلتين المحلول بتاعها بيفقد من الدم‬
,‫ ساعة‬24-12 ‫ فيها جزئات كبيرة فبالتالي بيفضل المحلول جوه االوعية الدموية مدة كبيرة‬colloid ‫و عندنا‬
‫ و دا الن انا وقته‬crystalloid‫ هو ال‬initial resuscitation‫بس رغم كده المحلول اللي بنشتخدمه في ال‬
‫ يعني لو مثال انا عندي‬, shock‫بكون لسا مشخصتش الحالة و ال عرفت دا انهي نوع من ال‬
‫ فانا كده هعمل ميه علي‬volume of blood‫ بسبب ان فيه انسداد و انا عليت ال‬obstructive shock
‫ مش هيحصل حاجة الن بعد ساعة‬crystalloid ‫ بس في حالة ان اديته‬, ‫الرئه مش هبقي بعالج المريض‬
‫ اللي هيفضل مدة‬colloid ‫ مشكلة المية علي الرئة دي هتحصل بس في حالة ال‬,‫هفقد المحلول كده كده‬
.‫طويلة في الدم‬
  When losing one liter of blood→ replace by 3 liters of Hartman solution
 If there is ongoing blood loss more than 1L→ start blood transfusion
 If pt. is severely shocked lost 3L of blood (grade 4 hemorrhage)→ give
colloid solution until availability of blood transfusion (half an hour – one
hour to prepare)
 Fluid therapy should be monitored.
General knowledge
Glucose 5% solution Ringer solution Saline solution
Just for water supply To replace loss in volume
To replace pressure.
‫عييان مبيشربش و عايز اديله‬ as in…. Mainly for distributive
‫مياه‬ 1-vomitting (vasovagal shock) as we
2-diarrhea inc. water retention in
3-bleeding intravascular
compartment.
Contain NaCl which is rhe
most abundant particle
cation of extracellular
fluid→determine volume
of osmosis
‫هو اللي بيتحكم في الضغط و‬
‫المياه‬
 Classes of hemorrhagic shock or hypovolemic shock
 In phase 1 and 2→blood pressure is normal ( loss of 1.5L)
 Blood pressure will be affected only when losing >1.5L of blood volume
✓ DISABILITY (AVPU) SCORING
• RAPID AND ROUGH NEUROLOGICAL ASSESSMENT
• A: ALERT
• V: VERBAL
• P: PAIN
• U: UNRESPONSIVE
✓ ENVIRONMENT
• KEEP THE PATIENT WARM
• NASOGASTRIC TUBE AND SUCTION
• URINARY CATHETER
✓ Initial resuscitation stop when we ensure adequate airway, oxygen
saturation is normal and blood pressure is normal now… we move on to
second phase of 1ry survey….
✓ After pt. is stable….
1- exposure
2- If there is a wound, →do dressing
3- If there is fracture→ splinting
4- Analgesia – antibiotic- antitetanic serum
5- Rapid overall assessment
 2ry survey

pt. is now stable → diagnose associated injury

1- Monitor: blood pressure, pulse, O2 saturation (process is continuous)
2- Glasmocoma score (GCS)→score assessment for consciousness and CNS
function
3- History talking AMPLE
A: allergies M: meds P: past medical history L: last meal E:events
4- Evaluate from head to toe (all body regions should be examined)
Skull – scalp wound – rib fracture – blood or CNS from ear or nose – facial fracture
– surgical emphysema – wounds/penetration – clavicle fracture – symmetry of
chest – movement of chest wall – paradoxical movement- abdominal rigidity/
ecchymosis/ tenderness – pelvic fracture – bleeding from urethra – long bone
fracture – peripheral pulsation
5- Investigation
➢ Classic→ Xray (skull – cervical spine – chest)
➢ Moreover→ FAST (focused abdominal sonography for peritoneal fluid
collection – liver injury – spleen injury)
➢ Then → CT (critical pt. goes to CT directly) for brain – chest – abdomen
Note: CT is done in 10 minutes!! But never put pt. on CT if unstable!! ‫في عشر دقايق‬
‫بعرف كل حاجه‬
GCS table (total score 4 + 5+ 6 = 15)

Jm

➢ Score:
1- 15 → normal conscious pt.
2- 3→nearly dead
3- 8 or below→ pt. severely suppressed → apply endotracheal tube
➢ incomprehensive wounds x → incomprehensive sounds ‫نصلحها‬
➢ unresponsive: eye only open for voice/pain
➢ confused: tells either…..
1- inappropriate sentence ‫جملة ملهاش عالقة باللي بيحصل‬
2- inappropriate words
3- incomprehensive voices (no words)
➢ localize pain ‫المريض يبعد ايدك‬
➢ withdraws with pain ‫يرفس‬
➢ abnormal flexion ‫جسمه يتني علي بعضه‬
 3ry survey

➢ Definitive management according to priorities.

➢ Priorities:
1- penetrating heart injuries.
2- Abdominal major vessel injury.
3- Cerebral unjury.
Ex1: pt. with extradural hemorrhage – fracture femur – rupture spleen
Prioritize: 1-intracranial hemorrhage 2-spleen 3-femur
Ex2: bullet and extra cardiac injury (bleeding in mediastinum)
Prioritize: 1-bleedng 2-bullet