APPROACH TO

TRAUMA PATIENT
By Dr Mohd Hadinur
Supervised by Dr Munirah
Outlines
◦ Objectives
◦ Trimodal Death Distribution and Trauma Death
◦ Initial assessment
◦ Preparation
◦ Triage
◦ Primary survey
◦ Life threatening injuries in primary survey
◦ Secondary survey
◦ Post resuscitation monitoring and reevaluation
◦ Definitive care
Objectives
 To use primary survey assessment technique to determine & demonstrate
ABCDE

 To establish resuscitation management priorities based on findings on

primary surveys
 To identify the injury producing mechanism and describe the injuries that may

have exists or anticipated as a result of mechanism of injury

 To use secondary survey techniques to assess patient head to toe
Trimodal Death Distribution
Trauma Death
•The Second Death Peak occurs within minutes to several hours after injury.
•Main focus of Trauma Life Support is in this peak.
•This period is referred to as the “Golden Hour”
•Concept of “Golden Hour - First Hour”
1. Rapid Transportation
2. Rapid assessment and stabilization
3. Rapid definitive care
Second Peak of Trauma Death
 Subdural / Extradural Haematoma.
 Haemo/Pneumothorax.
 Intraabdominal injury
 Ruptured Spleen/Liver lacerations.

 Pelvic Fractures.
 Multiple injuries associated with blood loss

“Preventable and manageable”

Initial Assessment
◦Preparation
◦Triage
◦Primary survey
◦Resuscitation
◦Adjuncts to primary survey & resuscitation
◦Consider need for transfer
◦Secondary survey
◦Adjuncts to secondary survey
◦Post resuscitation monitoring and reevaluation
◦Definitive care
Preparation
Pre-Hospital Phase
 Airway maintenance, control of bleeding & shock, Immobilization
 Coordination with the receiving hospital
 Communication
 Time of injury, Events related to injury,
◦ Patient’s history
 Minimize scene time (Immediate transport)
Hospital Phase
 Mobilization of hospital trauma team
& resources
High Energy Impact
 Falls
 Adult: > 20 ft (1 storey=10 ft)
 Child: >10 ft @ 2-3x height
 Auto Crash
 Intrusion > 12 inch, Occupant > 18 inch
 Ejection
 Death of same passenger
 Auto vs Pedestrian
 Thrown, run over
 Significant impact
>20mph @ 32km/h
 Motocycle crash
Triage
◦ Specific system of sorting out casualties
according to priorities of trauma
or evacuation
PRIMARY SURVEY
1. Airway and restriction of cervical spine motion

2. Breathing and oxygenation

3. Circulatory function & Hemorrhage control

4. Disability and Neurological status

5. Expose and Prevent hypothermia

AIRWAYS and C-SPINE CONTROL
◦ Aim: To ascertain the airways patency
◦ Observe how patient communicate. If able to communicate verbally, the airway is patent
AIRWAY MANAGEMENT
1. Blood/Secretions – suction/removal of debris
2. Floppy Tongue – oropharyngeal airways
3. Maxillo-facial injury – attempt reduction, intubation or cricothyroidotomy
4. Mechanical blockade – finger sweep and removal of object
5. Partially Airway Obst – jaw trust / gentle chin-lift

While assessing and managing airway, minimise cervical motion

◦ Use of cervical collar
◦ Cervical motion restriction technique
AIRWAYS and C-SPINE CONTROL
BREATHING AND VENTILATION
◦ Inspection – trachea deviated or centered? JVP raised or not? any open chest wound,
any implanted object, any inequality of chest raise
◦ Percussion – is the chest resonant / hyperresonant / dull
◦ Palpation – do you feel any abnormalities, any crepitus. Chest spring, any tenderness?
Apex beat, any displacement?
◦ Auscultation – air entry of lungs equal? Any muffled heart sound?

WHY IT IS IMPORTANT?
To diagnose life threatening conditions and treat imeediately
LIFE THREATENING CONDITIONS
ATOM TC
◦ AIRWAYS OBSTRUCTION
◦ TENSION PNEUMOTHORAX
◦ OPEN SUCKING CHEST WOUND
◦ MASSIVE HAEMOTHORAX
◦ TRACHEOBRONCHEAL DISTRUPTION
◦ CARDIAC TAMPONADE

WHERE MOST LIFE THREATENING CONDITIONS ARE.

CIRCULATION AND
HEMORRHAGIC CONTROL
◦ GENERAL ASSESSMENT
◦ CCTVR
◦ Color
◦ Capillary refill
◦ Temperature
◦ Volume of pulse
◦ Rate of pulse
◦ Blood pressure
◦ Identify source of bleeding and treat
◦ DON’T WAIT UNTIL THE BLOOD PRESSURE FALLS TO SUSPECT
SHOCK AND BEGIN TREATMENT
CLASS OF SHOCK
Suspect bleeding and heamorrhagic
shock?
◦ Find source of bleeding
◦ Intraabdoiminal – need for urgent referral to surgical team
◦ Pelvic fracture – pelvic binder
◦ Long bone fracture – splint
◦ Open bleeding – tourniquet
◦ Resus with 1L warm saline bolus. If still in shock, for blood transfusion.
◦ IV tranexamic acid 1g (if patient within 3 hours of injury)
DISABILITY AND NEUROLOGIC
STATUS
◦ Aim: To ascertain the state of consciousness
◦ COMPONENT

1.GCS: Glasgow Coma Score

◦ Mild head injury: 13 – 15
◦ Moderate head injury: 9 – 12
◦ Severe head injury: 3 – 8 (INTUBATE THIS PATIENT)

2.Pupillary Assesment

* All Head Injury Patients Should Be Given High Oxygen

Concentration *
EXPOSURE AND PREVENT
HYPOTHERMIA
◦ Need to undress the patient
◦ Thorough examination so as not to miss any injury at uncovered region:

- Pelvis
- Groin
- Genitalia
- Back
◦ Prevent Hypothermia – by cover back patient with blanket / warm device
ADJUCT TO PRIMARY SURVEY
◦ ECG, ABG
◦ FAST scan
◦ Xray: CXR and Pelvis xray
◦ CBD and Ryles tube
LIFE THREATENING CONDITION
◦ AIRWAYS OBSTRUCTION
◦ TENSION PNEUMOTHORAX
◦ OPEN PNEUMOTHORAX
◦ MASSIVE HAEMOTHORAX
◦ TRACHEOBRONCHEAL DISTRUPTION
◦ CARDIAC TAMPONADE
AIRWAY OBSTRUCTION
CAUSES OF AO
Soft tissue obstruction
 Floppy tongue (main cause of airway obstruction)
 Maxillofacial or airway injuries
 Oedema or haematoma occluding the airway
Foreign body obstruction
 Teeth
 Secretion
 Blood
 foreign debris
Laryngospasm / bronchospasm
AIRWAY OBSTRUCTION
SIGN OF AO
Agitated / Obtunded
 Agitation: Hypoxia
 Obtundation: Hypercarbia
Abnormal sounds
 Noisy Breathing
 Gurgling
 Snoring
 Hoarseness of voice
AIRWAY OBSTRUCTION
Floppy tongue is the main cause of airway obstruction
especially in patients with altered sensorium.
 Obstructed airway can often be cleared by:
1. Manual maneuvers
2. Airway adjuncts
3. Definitive airway
AIRWAY OBSTRUCTION
 Manual manoeuvres
 Chin lift
 Jaw thrust
 Airway adjuncts
 Oropharyngeal airway
 Nasopharyngeal airway
 LMA
 Multilumen esophageal airway (Combitube, Laryngeal tube)
 Definitive airway (tube placed in trachea with the cuff inflated below the vocal cord and connected to oxygen enriched
assisted ventilation)
 Endotracheal intubation

 Nasotracheal intubation

 Surgical airway
◦  Cricothyroidotomy
◦  tracheostomy
LIFE THREATENING CONDITION
◦ AIRWAYS OBSTRUCTION
◦ TENSION PNEUMOTHORAX
◦ OPEN PNEUMOTHORAX
◦ MASSIVE HAEMOTHORAX
◦ TRACHEOBRONCHEAL DISTRUPTION
◦ CARDIAC TAMPONADE
TENSION PNEUMOTHORAX
 Occurred when a one way valve air leak from lungs or through chest wall.
 Displaced mediastinum to opposite side
 Can cause obstructive shock – by reducing venous return
TENSION PNEUMOTHORAX
Clinical diagnosis
 Chest pain
 Air hunger
 Tachypnea
 Respiratory distress
 Tachycardia
 Hypotension
 Tracheal deviation away from the side of the injury
 Unilateral absence of breath sounds
 Hyperresonant
 Elevated hemithorax without respiratory movement
 Neck vein distention
 Cyanosis (late manifestation)
TENSION PNEUMOTHORAX
Immediate decompression of pleural space
 Needle thoracocenthesis
 Large branula at 5th intercostal space slightly anterior to midaxillary line
 Tube thoracotomy (definitive)
LIFE THREATENING CONDITION
◦ AIRWAYS OBSTRUCTION
◦ TENSION PNEUMOTHORAX
◦ OPEN PNEUMOTHORAX
◦ MASSIVE HAEMOTHORAX
◦ TRACHEOBRONCHEAL DISTRUPTION
◦ CARDIAC TAMPONADE
OPEN PNEUMOTHORAX
Sucking chest wound
 Wound size: 2/3 diameter of trachea
Flutter-valve dressings
 Plastic: taped 3 sides
 Definitive surgical closure
LIFE THREATENING CONDITION
◦ AIRWAYS OBSTRUCTION
◦ TENSION PNEUMOTHORAX
◦ OPEN PNEUMOTHORAX
◦ MASSIVE HAEMOTHORAX
◦ TRACHEOBRONCHEAL DISTRUPTION
◦ CARDIAC TAMPONADE
MASSIVE HEAMOTHORAX
Rapid accumulation of >1500ml blood @ 1/3 or more of
patients blood volume in pleural cavity
Features
 Decrease breath sounds
 Dullness to percussions
MASSIVE HEAMOTHORAX
MASSIVE HEAMOTHORAX
MANAGEMENT
Evacuation of blood: tube thoracotomy
Transfusion of type specific blood
or autotransfusion (use back the
blood collected)
DEFINITIVE: Resuscitative
thoracotomy by qualified surgeon
LIFE THREATENING CONDITION
◦ AIRWAYS OBSTRUCTION
◦ TENSION PNEUMOTHORAX
◦ OPEN PNEUMOTHORAX
◦ MASSIVE HAEMOTHORAX
◦ TRACHEOBRONCHEAL DISTRUPTION
◦ CARDIAC TAMPONADE
TRACHEOBRONCHIAL INJURY
 Majority occur within 1 inch of the carina
 SEVERE – majority patients die at scene
 Associated with
 Hemoptysis
 Subcutaneous emphysema
 Pneumomediastinum
 Pneumopericardium
 Persistent air leak from chest tube
 Persistent pneumothorax after chest tube
 Bronchoscopy
 Placement of more than one chest tube
 Temporary intubation of opposite mainstem bronchus
 Require operative repair
LIFE THREATENING CONDITION
◦ AIRWAYS OBSTRUCTION
◦ TENSION PNEUMOTHORAX
◦ OPEN PNEUMOTHORAX
◦ MASSIVE HAEMOTHORAX
◦ TRACHEOBRONCHEAL DISTRUPTION
◦ CARDIAC TAMPONADE
CARDIAC TAMPONADE
 Beck’s Triad
 Hypotension,
 Distended neck vein,
 Muffle heart sound

 Ultrasound
MANAGEMENT
 Fluid resuscitation
 Pericardiocentesis
 Heart surgery: repair
SECONDARY SURVEY
Does not begin until
 Primary survey completed

 Resuscitative efforts underway

 Normalization of vital signs demonstrated

Consists of HISTORY and PHYSICAL EXAMINATION

( head to toe)
HISTORY
(AMPLE)
A : Allergy
M : Medication
P : Past Medical history / Pregnancy
L : Last Meal
E : Events / Environment related to the injury
By knowing the event and mechanism
of injury, we can suspect the
anticipated injury of the patients
PHYSICAL EXAMINATION
 Head & Neck
 Face / Maxillofacial
 Cervical spine and Neck
 Chest
 Abdomen
 Pelvis
 Perineum, Rectum and Vagina
 Muscular-skeletal
 Neurological
Potentially Life Threatening Injuries In
Secondary Survey (HIDDEN 6)
1. Pulmonary contusion
2. Blunt cardiac injury
3. Aortic (Great vessel) disruption
4. Traumatic diaphragmatic hernia
5. Esophageal injury
6. Flail Chest
ADJUCT TO SECONDARY SURVEY
PERFORMED TO INDENTIFY SPECIFIC INJURY

CT scan: Head, Chest, Abdomen, Spine

X-rays: Spine (Cervical, Thorax, Lumbar)
X-rays: Extremities
Others:
 Angiography, Bronchoscopy, Esophagoscopy,
◦ Urography
REEVALUATION
Post Resuscitation Monitoring – need to be done continously
 Vital Signs
 Urine Output
 ABG
 EtCO2
 Pain relief

RE-EVALUATION !!!
If something wrong happen, need to repeat primary survey again.
Definitive Care
 Transfer
 If patient’s treatment need exceed the capability of hospital
 Eg: severe head injury – CT scan KIV craniotomy, Intraabdominal injury – CT scan KIV
Exploratory laparotomy
 URGENT TRANSFER – if patients is very unstable in HKN. Need to call EP HSB

 Communication
THANK YOU!