Acute Trauma--Initial assessment and management

Department of Emergency
Dr. Zong
1
2
 Case 1
• Male, 37y, motorcycle accident
• Transferred to the closest (40km) level 1 trauma center
• Injuries at ED: GCS 14, rib fractures (V-VIII, left), lung contusions,
left femur and bilateral tibial fracture, soft tissue contusions,
distorted splenic shape on FAST, suspected subcapsular
hematoma on CT
• Hemodinamicaly stabile, temporary immobilized
• Transferred to the specialized orthopedic hospital (80km) for
definitive repair 4 hours later
• Day 2: During preparation for surgery, patient becomes
tachycardic, tachypneic, anxious, hypoxic, complains on chest
and abdominal pain.....
 Case 1
• Anesthesiologist refuses to anesthetize him and requests
CTPA as pulmonary embolism was suspected
• CT at the nearby hospital (1h later): Diffuse ground- glass
opacities, abdominal free fluid, signs of splenic rupture
How many survival
• Transfer to the Emergency center (30 mins)
chances
• Emergency center were missed?
ED: somnolent, pale, Fr 135/min, TA 75/40,
tachypneic, hypoxic, intubated, immediately transferred to
OR
• OR: Splenectomy, massive transfusion
• ICU: Severe ARDS
• Died on the 3rd day due to MOF
 Case 2
• A 28-year-old woman was involved in a motor vehicle
accident (MVA) and suffered major trauma. The trauma
mechanism was a high speed MVA with head-on collision on a
motorway.
• Initial Glasgow Coma Scale (GCS) of 8.
• Complained about severe pain in her head, chest and right
leg. She was intubated, immobilized and transferred.
• After initial trauma management following the Advanced
Trauma Life Support (ATLS)-scheme, a whole body CT scan
was performed.
• Damage control concept-- stabilize open
tibial fracture (external fixator)--open
mandibular fracture surgery.
• Transferred to ICU--reassessment
showed an anisocoria (right > left).
• Reassessment--Additional diagnostics
were initiated. A CT angiography
revealed the suspicion of a bilateral
internal carotid artery (ICA) dissection.
Second CT scan with coronal
reconstructions of the bilateral
ICA dissection. “String sign”
indicated with an arrow.
• 48 h after the accident, the patient was transferred via
helicopter non-intubated to the emergency department of
our level I trauma center.
• GCS of 8 under sufentanil analgesia
• Transferred to the ICU. High-dose intravenous
heparinization was started immediately (PTT 60–80 s).
• MRI on the next day (3 days after trauma) revealed
bihemispheric, mainly left-sided, ischemic lesions near the
border zone.
• The high-dose heparinization was continued.

8
Axial T-2 sequences of a brain MRI scan of the 28-year-old patient. Left
posttraumatic bihemispheric, mainly left-sided, ischemic lesions near the
border zone, 3 days after trauma (indicated with arrows). Right 6 months
follow-up MRI scan with good recovery. 9
• 8 days after the accident and ICU treatment the patient was
referred to the stroke unit with a score of 8 on the National
Institutes of Health Stroke Scale(NIHSS, min. 0 points = no
neurological deficit, max.42 points = worst outcome).
• proximal tibial fracture was treated with osteosynthesis and the
intravenous heparinization was converted to oral
anticoagulation
• The patient was discharged to rehabilitation 22 days after the
trauma with a NIHSS of four points.
• 6 months later, besides slight concentration difficulties and fine
motor dysfunctions, no neurological deficiencies remained
(NIHSS = 0). The MRI scan showed good recovery.
10
Axial T-2 sequences of a brain MRI Angio scan of the 28-year-old
patient. Left posttraumatic intracranial dissection with intramural
hematomas of both internal carotid arteries 3 days after trauma (indicated
with arrows). Right 6 months follow-up MRI scan with good perfusion
of both internal carotid arteries.
11
 Epidemiology of Trauma
• Leading cause of death in ages 1-44
• 3rd leading cause of death for all ages
• 100,000 deaths/year
• 60 million injuries/year
 Epidemiology
 Road Traffic Accidents are major cause of long term morbidity and
mortality in developing nations
– In the first quarter of 2009, 372 deaths in Ghana from Road Traffic
Accidents
– 25% increase from previous year
 WHO predicts that by 2020, Road Traffic Accidents will be second
leading cause of loss of life for world’s population
 High Morbidity = Loss of income to society
 Challenges in Developing Countries
– Technological Advances in Trauma Care
– Lack of Infrastructure for Trauma Management
 EMS
 Pre-hospital notification
 MD/RN Training in trauma care

13
 Epidemiology
Trimodal Distribution of Trauma Deaths
 Immediate death
aortic rupture, lacerations of the brain stem, decapitating injuries
 Early death （ golden hour ）
tension pneumothorax, hemorrhagic shock （ intraabdominal or
intrathoracic bleeding ， pelvic ring disruptions with massive
retroperitoneal hemorrhage, or due to severe traumatic brain injury with
acute cerebral edema or intracranial hematoma ）
 Late death—days to wks
septic complications, multiple organ failure and due to untreatable increased
ICP associated with cerebral edema.

14
aortic rupture
lacerations of the brain stem
Decapitation/Internal
Decapitation
tension pneumothorax
hemorrhagic shock
pelvic ring disruptions
Traumatic brain injury(TBI)
 Epidemiology
Trimodal Distribution of Trauma Deaths

 Golden Hour = 80% of trauma

50% deaths in first hour after injury
 Rapid trauma care has greatest level
of impact in these patients

30%
20%

Immediately Hours Days/Weeks

22
Trauma topics
 Definition
1665 reports （ 1995-2008 ） A consensus yet to be
47 definitions established

Butcher,Balogh. Injury 2009

Butcher. J Trauma Acute Care Surg 2013
 Definition
POLYTRAUMA--definition according to Otmar Trentz
(2000).

A syndrome of multiple injuries exceeding a defined

severity (Injury Severity Score [ISS] > 17) with consecutive
systemic trauma reactions which may lead to dysfunction or
failure of remote – primarily not injured – organs and vital
systems

25
 Pathophysiological change
• Cardiovascular ： hypodynamic flow, the
hyperdynamic flow, and the recovery
• Immune system ： systemic inflammatory response
syndrome (SIRS) and the counter anti-inflammatory
response syndrome (CARS)

balanced SIRS unbalanced

recovery ARDS, MOD death

CARS
Decompensated CARS leading to immune supression
and early sepsis
Inflammation
SIRS
Pro-inflammatory Cytokines

Anti-inflammatory Cytokines

29
Trauma-induced
systemic inflammatory
response syndrome
(SIRS) and
complications
Host response to polytrauma

Keel M, Trentz O. Injury 2005

 Host response to polytrauma
Day 1: Surgery (DCS)
Day 2-4 (Hyperinflammation
Day 5-10: Window of opportunity
Day 11-21 (Immunodepression
From week 4: Reconstructive surgery.

Days 2-4: Hyperinflammatory phase (SIRS) / IL 6,8,12,18; TNFα

Days 11-21: Hypoinflammatory phase (CARS): IL 4,10,13, TGFβ
 MODS
 Severity of Initial Injury(First Hit)
SIRS/CARS MARS ；
 Two-Hit Theory
surgery/mass transfusion/missed injury

 Ischemia/Reperfusion Injury

Haber-Weiss
Fe （Ⅲ）＋ O2-→fe(Ⅱ) ＋ O2 　
Fe(Ⅱ)H2O2 →Fe(Ⅲ)+OH-+OH· 　
What really matters

34
 Acidosis
• Poor tissue perfusion is the main contributor in trauma patients
• Decreased cardiac output, hypoxia and anemia lead toward
cellular anaerobic metabolism and cause lactic acid accumulation
• Resuscitation with normal saline induces hyperchloremic acidosis
• Acidosis diminishes cardiac output leading to worse tissue
perfusion
• Aggravates coagulopathy
 PH drop from 7.4 to 7.0 reduces the effectiveness of coagulation cascade by 50-
75%
 Procoagulant drugs (rFVII) cannot work in acidotic environment

35
 Hypothermia
• The greatest contributor to hypothermia are environmental
temperature, cold crystalloids and PRBCs
• Tissue hypoperfusion and anaerobic metabolism exhaust ATP
which is required for maintenance of normothermia.
• Hypothermia causes coagulopathies:
 Coagulation cascade is temperature dependent
 Relative thrombocyopenia by plateled sequestration and dysfunction
• Induces shivering with further depletion of ATP and
progression of acidosis

36
 Coagulopathy
• Present at admission in 25% of trauma patients
• 4 fold increase in mortality

• Primary: Extrinsic coagulation • Secondary: Hemodilution/Consumption

Endotoxin
neutrophils ECs TF
cytokines macrophages

（ TF ） activate FX to FXa
FVIIa
converts prothrombin to thrombin
(FIIa)
FVII
activates FV, FVIII, and FXI thrombin formation

Fibrin clot
Surgical control of bleeding is unlikely to be successful!
 History of Trauma System Development
 Standardized Trauma Assessment
– Nebraska Cornfield, 1976
– Orthopedic Surgeon
– Lead to development of ATLS
 Trauma Systems Development
– First developed my military in wartime
 i.e. MASH Units Otisarchives1 (flickr)

– Expanded in US to Level 1, 2, 3 Trauma Centers

 Urban Systems
 Statewide networks of systems
 Level 1 – Highest level of care, Leaders in research, clinical
care and education
 Level 2 – Provides definitive care in wide range of complex
traumatic patients
 Level 3 – Provides initial stabilization and treatment. May
care for uncomplicated trauma patients
 Level 4 – Provides initial stabilization and transfers all
trauma patients for definitive care

38
 Mechanisms of Injury
 Blunt Trauma
– Compression Forces
 Cells in tissues are compressed and crushed
 E.g. Spleen
– Shear Forces
 Acceleration/Deceleration Injury
 E.g. Aorta
– Shearing force = Spectrum from Full thickness tear
(Exsanguination) to Partial tear (Pseudoaneurysm)
– Overpressure
 Body cavity compressed at a rate faster than the tissue
around it, resulting in rupture of the closed space
 E.g. Plastic bag
 E.g. in trauma = diaphragmatic rupture, bladder injury

39
 Mechanisms of Injury
 Frontal Impact Collisions
 Lateral Impact Collisions (T bone)
 Rear Impact Collisions
 Rollover Mechanism Nico.se (flickr)

 Open Vehicle or Motorcycle/Moped

 Pedestrian Vs. Car
 Penetrating Injury (Guns vs. Knives)

Vincent J Brown (flickr)

Juicyrai (flickr) Knockhill (flickr)

40
Nxtiak (flickr)
 Basics of Trauma Assessment
 Preparation
– Team Assembly
– Equipment Check
 Triage
– Sort patients by level of acuity (SATS)
 Primary Survey
– Designed to identify injuries that are immediately life threatening and to treat
them as they are identified
 Resuscitation
– Rapid procedures and treatment to treat injuries found in primary survey
before completing the secondary survey
 Secondary Survey
– Full History and Physical Exam to evaluate for other traumatic injuries
 Monitoring and Evaluation, Secondary adjuncts
 Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another facility

41
 Preparation for Patient Arrival

Organize Trauma
Response Team

Top and bottom images:

http://www.trauma.org/archive/resus/traumateam.html
42
 Trauma score systems
•Classification and characterizing heterogenous
trauma patients
•Triage, resourcing
•Prognosis
•Quality care assessment
•Research
•Communication improvement
Classification
 GCS

Mild ： 13-15
Moderate ： 9-12
Severe ： 3-8
CRAMS
Abbreviated Injury Scale(AIS)
 An example of the ISS calculation is shown below:
Region Injury AIS Square
Description Top Three

Head & Neck Cerebral Contusion 3 9

Face No Injury 0  

Chest Flail Chest 4 16

Abdomen Minor Contusion of 2  

Liver 5 25
Complex Rupture
Spleen
Extremity Fractured femur 3  
 
External No Injury 0  

Injury Severity Score:   50

ISS ranges from 1 to 75, an ISS of 75 is assigned to anyone

with an AIS of 6.
ISS---NISS
 Don’t get distracted with “ugly
injuries”
Mortality is decreased when

The RIGHT patient

Gets to

The RIGHT hospital

In the RIGHT AMOUNT of TIME

 General Assessment Pearls
• With restlessness and agitation, you must
consider
– hypoxia,
– shock,
– influence of alcohol and/or drugs
– need to assess for all reasons of restlessness.
– don’t not just stop when you discovered one cause
– there may be more than one pathology going on at a time
 Concepts of ATLS
• Treat the greatest threat to life first
• The lack of a definitive diagnosis should never
impede the application of an indicated treatm
ent
• A detailed history is not essential to begin the
evaluation
• “ABCDE” approach
 Initial Assessment and Management

• An effective trauma system needs the teamwo

rk of EMS, emergency medicine, trauma surge
ry, and surgery subspecialists
• Trauma roles
– Trauma captain
– Interventionalists
– Nurses
– Recorder
 Primary Survey
Airway and Protection of Spinal Cord
Breathing and Ventilation
Circulation
Disability
Exposure and Control of the Environment

53
 Primary Survey
Key Principles
– When you find a problem during the
primary survey, FIX IT.
– If the patient gets worse, restart from the
beginning of the primary survey
– Some critical patients in the Emergency
Department may not progress beyond
the primary survey

54
 Airway and Protection of Spinal Cord
 Why first in the algorithm?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ damage
 Airway Assessment
– Vital Signs = RR, O2 sat
– Mental Status = Agitation, Somnolent, Coma
– Airway Patency = Secretions, Stridor, Obstruction
– Traumatic Injury above the clavicles
– Ventilation Status = Accessory muscle use, Retractions, Wheezing
 Clinical Pearls
– Patients who are speaking normally generally do not have a need
for immediate airway management
– Hoarse or weak voice may indicate a subtle tracheal or laryngeal
injury
– Noisy respirations frequently indicates an obstructed respiratory
pattern
55
Airway Interventions
 Maintenance of Airway Patency
– Suction of Secretions
– Chin Lift/Jaw thrust Dept. of the Army, Wikimedia Commons

– Nasopharyngeal Airway
– Definitive Airway
 Airway Support
– Oxygen
– NRBM (100%) Ignis, Wikimedia Commons
– Bag Valve Mask
– Definitive Airway
 Definitive Airway
– Endotracheal Intubation
 In-line cervical stabilization
– Surgical Crichothyroidotomy
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons 56
 Protection of Spinal Cord
 General Principle: Protect the entire spinal cord until injury has been
excluded by radiography or clinical physical exam in patients with
potential spinal cord injury.
 Spinal Protection
– Rigid Cervical Spinal Collar = Cervical Spine
– Long rigid spinal board or immobilization on flat surface such as
stretcher = T/L Spine
 Etiology of Spinal Cord Injury (U.S.)
– Road Traffic Accidents (47%)
– High energy falls (23%)
 Clinical Pearls
– Treatment (Immobilization) before diagnosis
– Return head to neutral position
– Do not apply traction
– Diagnosis of spinal cord injury should not precede resuscitation
– Motor vehicle crashes and falls are most commonly associated with
spinal cord injuries
– Main focus = Prevention of further injury

57
 C-spine Immobilization
 Return head to neutral position
 Maintain in-line stabilization
 Correct size collar application
 Blocks/tape
 Sandbags

Paladinsf (flickr)

James Heilman, MD,

58
Wikimedia Commons
Breathing and Ventilation
 General Principle: Adequate gas exchange is required to
maximize patient oxygenation and carbon dioxide elimination
 Breathing/Ventilation Assessment:
– Exposure of chest
– General Inspection
 Tracheal Deviation
 Accessory Muscle Use
 Retractions
 Absence of spontaneous breathing
 Paradoxical chest wall movement
– Auscultation to assess for gas exchange
 Equal Bilaterally
 Diminished or Absent breath sounds
– Palpation
 Deviated Trachea
 Broken ribs
 Injuries to chest wall

59
 Breathing and Ventilation
 Identify Life Threatening Injuries
– Tension Pneumothorax
Air trapping in the pleural space
between the lung and chest wall
Sufficient pressure builds up and
pressure to compress the lungs and
shift the mediastinum
Delldot (wikimedia)
Physical exam
– Absent breath sounds
– Air hunger
– Distended neck veins
– Tracheal shift
Treatment
– Needle Decompression
 2nd Intercostal space, Midclavicular line
– Tube Thoracostomy
 5th Intercostal space, Anterior axillary line
Author unknown,
www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.ht
m 60
 Breathing and Ventilation
 Hemothorax
– Blood collecting in the pleural space and is
common after penetrating and blunt chest
trauma
– Source of bleeding = Lung, Chest wall
(intercostal arteries), heart, great vessels
(Aorta), Diaphragm
– Physical Exam
 Absent or diminished breath sounds
 Dullness to percussion over chest
Author unknown,  Hemodynamic instability
http://www.trauma.org/index.php/mai
n/images/C11/
– Treatment = Large Caliber Tube Thoracostomy
 10-20% of cases will require Thoracostomy for control of bleeding

61
 Breathing and Ventilation
 Flail Chest
– Direct injury to the chest resulting in an
unstable segment of the chest wall that moves
separately from remainder of thoracic cage
– Typically results from two or more fractures on
2 or more ribs
– Typically accompanied by a pulmonary
contusion
– Physical exam = paradoxical movement of chest
segment
http://images1.clinicaltools.com/images/trauma/
flail_chest_wounded.gif – Treatment = improve abnormalities in gas
exchange
 Early intubation for patients with respiratory
distress
 Avoidance of overaggressive fluid resuscitation

Author unknown,
http://www.surgical-tutor.org.uk/default-home.htm 62
?specialities/cardiothoracic/chest_trauma.htm~right
 Breathing and Ventilation
 Open Pneumothorax
– Sucking Chest Wound
– Large defect of chest wall
 Leads to rapid equilibration of
Author unknown, atmospheric and intrathoracic
http://www.trauma.org/index.php/main/image/
902/
pressure
 Impairs oxygenation and ventilation
– Initial Treatment
 Three sided occlusive dressing
 Provides a flutter valve effect
 Chest tube placement remote to site
of wound
 Avoid complete dressing, will create a
tension pneumothorax
Middle and bottom images:
Author unknown,
http://www.brooksidepress.org/Products/Ope
rationalMedicine/DATA/operationalmed/Pro 63
cedures/TreataSuckingChestWound.htm
 Needle Thoracostomy

 Needle Thoracostomy
– Midclavicular line
– 14 gauge angiocath
– Over the 2nd rib
– Rush of air is heard
Author unknown,
www.trauma.org/index.php/main/article
/199/index.php?main/image/95/

64
 Tube Thoracostomy
 Insertion site
– 5th intercostal space,
– Anterior axillary line
 Sterile prep, anesthesia with lidocaine
 2-3 cm incision along rib margin with #10 blade
 Dissect through subcutaneous tissues to rib margin
 Puncture the pleura over the rib
 Advance chest tube with clamp and direct posteriorly and
apically
 Observe for fogging of chest tube, blood output
 Suture the tube in place
 Complications of Chest Tube Placement
– Injury to intercostal nerve, artery, vein
Author unknown, – Injury to lung
http://www.trauma.org/images/image_lib – Injury to mediastinum
rary/chest0051a.jpg – Infection
– Allergic reaction to lidocaine
– Inappropriate placement of chest tube

65
 Shock
Circulation
– Impaired tissue perfusion
– Tissue oxygenation is inadequate to meet metabolic demand
– Prolonged shock state leads to multi-organ system failure and cell
death
 Clinical Signs of Shock
– Altered mental status
– Tachycardia (HR > 100) = Most common sign
– Arterial Hypotension (SBP < 120)
 Femoral Pulse – SBP > 80
 Radial Pulse – SBP > 90
 Carotid Pulse – SBP > 60
– Inadequate Tissue Perfusion
 Pale skin color
 Cool clammy skin
 Delayed cap refill (> 3 seconds)
 Altered LOC
 Decreased Urine Output (UOP < 0.5 mL/kg/hr)

66
 Circulation
 Types of Shock in Trauma
– Hemorrhagic
 Assume hemorrhagic shock in all trauma patients until proven
otherwise
 Results from Internal or External Bleeding
– Obstructive
 Cardiac Tamponade
 Tension Pneumothorax
– Neurogenic
 Spinal Cord injury
 Sources of Bleeding
– Chest
– Abdomen
– Pelvis
– Bilateral Femur Fractures
67
 Circulation
 Emergency Nursing Treatment
– Two Large IV Lines
– Cardiac Monitor
– Blood Pressure Monitoring
 General Treatment Principles
– Stop the bleeding
 Apply direct pressure
 Temporarily close scalp lacerations
– Close open-book pelvic fractures
 Abdominal pelvic binder/bed sheet
– Restore circulating volume
 Crystalloid Resuscitation (2L)
 Administer Blood Products
– Immobilize fractures
 Responders vs. Nonresponders
– Transient response to volume resuscitation = sign of ongoing blood loss
– Non-responders = consider other source for shock state or operating room
for control of massive hemorrhage

68
 Circulation
 Pericardial Tamponade
– Pericardium or sac around heart fills with
blood due to penetrating or blunt injury to
Pericardium
chest
Blood – Beck’s Triad
 Distended jugular veins
 Hypotension
He

 Muffled heart sounds

art

– Treatment
Epicardium  Rapid evacuation of pericardial space
 Performed through a pericardiocentesis
(temporizing measure)
Aceofhearts1968(Wikimedia)  Open thoracotomy

69
 Pericardiocentesis
 Puncture the skin 1-2 cm inferior to xiphoid process
 45/45/45 degree angle
 Advance needle to tip of left scapula
 Withdraw on needle during advance of needle
 Preferable under ultrasound guidance or EKG lead V
attachment
 Complications
– Aspiration of ventricular blood
– Laceration of coronary arteries, veins,
epicardium/myocardium
Author unknown,
http://www.trauma.org/images/image_library/ch – Cardiac arrhythmia
est0054_thumb.jpg – Pneumothorax
– Puncture of esophagus
– Puncture of peritoneum

Author unknown,
70
www.brooksidepress.org/ProductsTrauma_Surgery?M=A
 Circulation
 A word about cardiac arrest . . .
– Care of the trauma patient in
cardiac arrest
 CPR
 Bilateral Tube Thoracostomy
 Pericardiocentesis
 Volume Resuscitation
– Traumatic cardiac arrest due to
blunt injury has very low survival
rate (< 1%)
 No point for emergency thoracotomy
– Selected cases of cardiac arrest due
Author unknown,
to penetrating traumatic injury may
http://www.trauma.org/images/image_library/chest0 benefit from emergent
046.jpg
thoracotomy
 Pericardial tamponade
 Cross clamp aorta

71
 Disability
 Baseline Neurologic Exam
– Pupillary Exam
 Dilated pupil – suggests transtentorial herniation on ipsilateral side
– AVPU Scale
 Alert
 Responds to verbal stimulation
 Responds to pain
 Unresponsive
– Gross Neurological Exam – Extremity Movement
 Equal and symmetric
 Normal gross sensation
– Glasgow Coma Scale: 3-15
– Rectal Exam
 Normal Rectal Tone
 Note: If intubation prior to neuro assessment, consider quick
neuro assessment to determine degree of injury

72
 Glasgow Coma Scale
Disability GCS ≤ 8
Intubate
– Eye
 Spontaneously opens 4
 To verbal command 3
 To pain 2
 No response 1
– Best Motor Response
 Obeys verbal commands 6
 Localizes to pain 5
 Withdraws from pain 4
 Flexion to pain (Decorticate Posturing) 3
 Extension to pain (Decerebrate Posturing) 2
 No response 1
– Verbal Response
 Oriented/Conversant 5
 Disoriented/Confused 4
 Inappropriate words 3
 Incomprehensible words 2
 No response 1

73
 Disability
 Key Principles
– Precise diagnosis is not necessary at this point in
evaluation
– Prevention of further injury and identification of
neurologic injury is the goal
– Decreased level of consciousness = Head injury until
proven otherwise
– Maintenance of adequate cerebral perfusion is key
to prevention of further brain injury
 Adequate oxygenation
 Avoid hypotension
– Involve neurosurgeon early for clear intracranial
lesions

74
 Disability
 Cervical Spinal Clearance
– Patients must be alert and oriented to person,
place and time
– No neurological deficits
– Not clinically intoxicated with alcohol or drugs
– Non-tender at all spinous processes
– No distracting injuries
– Painless range of motion of neck

75
 Exposure
 Remove all clothing
– Examine for other signs of injury
– Injuries cannot be diagnosed until seen by provider
 Logroll the patient to examine patient’s back
– Maintain cervical spinal immobilization
– Palpate along thoracic and lumbar spine
– Minimum of 3 people, often more providers required
 Avoid hypothermia
– Apply warm blankets after removing clothes
– Hypothermia = Coagulopathy
Increases risk of hemorrhage

76
 Exposure

Author unknown,
http://www.trauma.org/index.php/main/image/98/C11
77
 Exposure

Author unknown,
http://www.trauma.org/images/image_library/chest0044b.jpg
78
 Secondary Survey
 Secondary Survey is completed after primary
survey is completed and patient has been
adequately resuscitated.
 No patient with abnormal vital signs should
proceed through a secondary survey
 Secondary Survey includes a brief history
and complete physical exam

79
 History
 AMPLE History
–Allergies
–Medications
–Past Medical History, Pregnancy
–Last Meal
–Events surrounding injury, Environment
 History may need to be gathered from family
members or ambulance service

80
 Physical Exam
 Head/HEENT
 Neck
 Chest
 Abdomen
 Pelvis
 Genitourinary
 Extremities
 Neurologic

81
 Adjuncts to Secondary Survey
 Radiology
– Standard emergent films
 C-spine, CXR, Pelvis
– Focused Abdominal Sonography in Trauma
(FAST)
– Additional films
 Cat scan imaging
 Angiography
 Foley Catheter
– Blood at urethral meatus = No Foley catheter
 Pain Control
 Tetanus Status
 Antibiotics for open fractures

82
 Definitive Care
 Secondary Survey followed by radiographic
evaluation
– CatScan
– Consultation
Neurosurgery
Orthopedic Surgery
Vascular Surgery
 Transfer to Definitive Care
– Operating Room
– ICU
– Higher level facility

83
 Damage control

The “lethal triad” in the pathophysiology of severely injured

patients leading to a vicious circle and adverse outcome.
This implication constitutes the underlying
rationale for the concept of “damage control” surgery
Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin
North Am 1997;77:761–77.
Damage control resuscitation
 Permissive hypotension
• Keep the blood pressure low enough to avoid exsanguination
while maintaining perfusion of end-organs.
• Injection of a fluid will increase blood pressure:
• Clot disruption
• Hemoglobin and clot factor dilution
• Hypothermia

Trauma patients without definitive hemorrhage control should

have a limited increase in blood pressure until definitive
surgical control of bleeding can be achieved
 Permissive hypotension
Safe strategy for use in the trauma population
•Results in significant reduction in blood product transfusion and overall fluid
administration
•Decreases postoperative coagulopathy and lowers the risk of early postoperative
death
•MAP 50mmHg better than 65 mmHg
Morrison CA.J Trauma-Injury Infection and Critical Care.2011

Resuscitation end points:

1.Penetrating trauma – systolic 80-90mmHg or presence of radial pulse
2.Blunt trauma – systolic 80-90 mmHg or presence of radial pulse
3.Head injury – MAP ≥ 80 mmHg or systolic >100mmHg

Spahn DR. Crit Care 2013.

Cooper. JAMA 2004
The Brain Trauma Foundation. J Neurotrauma 2010
Damage control surgery
 minimal stabilisation of fractures
Stop the bleeding

stop the contamination Angioembolisation

 Golden hour
There is a golden hour between life and death. If you are critically injured you
have less than 60 minutes to survive. You might not die right then; it may be
three days or two weeks later – but something has happened in your body
that is irreparable.
R. Adams Cowley

Who coined the term and why?

Time matters...
“the golden hour” presented by
Dr. Cowley in1963
with no scientific evidence to
support this statement at that
time!
 First 24 h management
• Primary survey with baseline diagnostics and immediate life-saving
procedures and establishing access to life-support systems according to
the A-B-C algorithm of the ATLS® protocol;

• Damage control surgery in patients who are not responsive to the

initial measures of resuscitation: surgical control for exsanguinating
hemorrhage and decompression of body cavities (“life-saving
surgery”);

• Secondary survey in hemodynamically stable patients with

elaborate diagnostics including a “head-to-toe” examination and
further radiologic work-up (CT scan, conventional X-rays,
angiography, etc.);
• “Delayed primary surgery”: decontamination, surgical exploration
and management of non-immediately life-threatening injuries,
temporary fracture fixation.
 Strategy for Treatment
trauma centers
pathophysiology based

no “I” in trauma management

Proposed algorithm
for the initial
assessment and
management of
polytrauma patients
Timing and priorities of operative interventions in polytrauma
patients depending on the physiological status

Trentz O. Polytrauma: pathophysiology, priorities, and management. In:

Rüedi T, Murphy WM, eds. AO principles of fracture management.
Stuttgart–New York: Thieme, 2000:661–73.
 Head:Cranium/Maxillofacial Injury
• 40% of multiple trauma victims have brain inju
ries.
• Brain injured patients have a death rate twice
that of non-brain injured patients.
• Head injuries account for 25% of all trauma de
aths and 50% of motor vehicle fatalities.
 Brain Injury
• Most brain injuries are not from direct injury t
o the brain.

• Most occur as a result of external forces again

st the skull or from movement of the brain insi
de the skull.
 Deceleration Injuries
• The head strikes an object causing a sudden d
eceleration of the skull. The brain continues t
o travel forward and impacts the front of the s
kull.

• The brain then rebounds and strikes the rear o

f the skull.
 Coup / Countercoup
• Coup is the original impact.

• Countercoup is the rebound impact.

COU CONTRECO
P UP
Acceleration injury Deceleration injury
（ Coup injury ） （ Countercoup injury ）
Skull Fractures
 Terminology
• Direct head injury
• Open & closed head injuries
• Coup & Contrecoup injury
• Missile injury
 Signs & Symptoms

• Mechanism of Injury  Projectile Vomiting

• Decreased level of  Seizures
Consciousness  Unequal Pupils (late)
• Bleeding or Fluid
 Hemiparesis -
weakness or
from Ears / Nose paralysis on one side
• Watch the Vital Signs of the body
-Trend over Time  Posturing
Signs & Symptoms
 basal skull fracture

Anterior
cranial fossa
injury

posterior
cranial fossa middle
injury cranial fossa
injury
 Primary brain injury
• Occurs at time of insult as a result of the conta
ct between the brain and the interior of the sk
ull or a foreigh body.
• Direct traumatic forces that injure & kill brain
cells
• Four categories: contusion, diffuse axonal inju
ry, disruptive brain injuries, skull fractures
 Secondary brain injury
• Results from cerebral hypoxia, increased intra-
pressure, and decreased cerebral blood flow,
culminating in further hypoxic neuronal dama
ge
• Cause:hematoma
– Epidural
– Subdural
– Intracerebral
 Subdural Hematoma with SAH （ su
Epidural Hematoma barachnoid hemorrhage ）
 Management
• C-Spine Immobilization  Be prepared for seizures.
• Airway management  If patient is on a backboa
– have suction available
rd with C-Spine immobiliz
• High concentration oxygen
ation you can raise the h
or ventilate 12/min
ead of the board slightly
• Manage bleeding from
scalp lacerations (4-6 inches) to possibly lo
– do not attempt to stop wer ICP.
bleeding from  Evacuation:craniotomy
ears / nose
 Thoracic trauma
Chest Cavity
Two Lungs (right and left)
Heart
Diaphragm

Pleural Space
 Terminology
 Traumatic asphyxia
• Rib fractures  Myocardial contusion
• Flail chest  Pericardial tamponade
(Becks triad:distended neck
• Open pneumothorax veins,quiet heart tones,and
• Closed pneumothorax hypotension:pericardiocente
• Tension pneumothorax sis)
 Pulmonary contusion
• Hemothorax
 Violence related penetrating
• Hemo-pneumothorax trauma
 Open Versus Closed

• Closed  Open
– Rib fractures  Sucking chest wound
– Flail chest
– Pneumothorax
– Hemothorax
– Myocardial contusion
– Pulmonary contusion
 Open Pneumothorax
• An opening in the chest wall causes air to ente
r the pleural space
• Caused by trauma
• Causes the lung to collapse
• Can be a severe life-threatening condition, tha
t can deteriorate rapidly
 Open Pneumothorax S & S
• Dyspnea
• Diminished breath sounds on the affected side
• Presence of an open wound in chest wall (suck
ing chest wound)
• Poor skin color
• Accessory muscle use, shock, and possibly sub
cutaneous emphysema
 Closed Pneumothorax S & S
• Blunt trauma to chest or back
• Dyspnea
• Possible hypotension
• Shock
• Diminished lung sounds on affected side
• Accessory muscle use
• History of previous pneumothorax
 Open Pneumothorax

Inhale Exhale
 Pneumothorax
Each time we inhale,the lung
collapses further. There is no
place for the air to escape..

mediastinum
 Flail Chest
• Segment of the chest that becomes free to move wit
h the pressure changes of respiration
• Three or more adjacent rib fracture in two or more pl
aces
• Serious chest wall injury with underlying pulmonary
injury
• Reduces volume of respiration
• Adds to increased mortality
• Paradoxical flail segment movement
• Positive pressure ventilation can restore tidal volume
Flail chest
 Tension Pneumothorax
• Buildup of air under
pressure in the thorax.
• Excessive pressure
reduces effectiveness of
respiration
• Air is unable to escape
from inside the pleural
space
• Progression of Simple or
Open Pneumothorax
 Hemothorax
 Accumulation of blood in the pleural space
 Serious hemorrhage may accumulate 1,500
mL of blood
 Mortality rate of 75%
 Each side of thorax may hold up to 3,000
mL
 Blood loss in thorax causes a decrease
in tidal volume
 Ventilation/Perfusion Mismatch & Shock
 Typically accompanies pneumothorax
 Hemopneumothorax
 Management of the Chest Injury Patient

• Flail Chest
– Place patient on side of injury
• ONLY if spinal injury is NOT suspected
– Expose injury site
– Dress with bulky bandage against
flail segment
• Stabilizes fracture site
– High flow O2
• Consider PPV or ET if decreasing respiratory st
atus
– DO NOT USE SANDBAGS TO STABILIZE FX
 Management of the Chest Injury Patient

• Open Pneumothorax
– High flow O2
– Cover site with sterile occlusive
dressing taped on three sides
– Progressive airway
management if indicated
(closed tube thoracostomy)
 Management of the Chest Injury Patient

• Tension Pneumothorax
– Confirmation
• Auscultation & Percussion
– Pleural Decompression
• 2nd intercostal space in mid-cla
vicular line
– TOP OF RIB
• Consider multiple decompressio
n sites if patient remains sympt
omatic
• Large over the needle catheter:
14ga
• Create a one-way-valve: Glove
tip or Heimlich valve
 Management of the Chest Injury Patient

• Hemothorax
– High flow O2
– 2 large bore IV’s
• Maintain SBP of 90-100
• EVALUATE BREATH SOUNDS
for fluid overload
• Pericardial Tamponade
– High flow O2
– IV therapy
– Consider pericardiocentesis; rapidly d
eteriorating patient
 Abdominal Trauma

• Common source of traumatic

injury
• Mechanism is important
– Bike accident over the handlebars
– MVC with steering wheel trauma
• High suspicion with tachycardia,
hypotension, and abdominal
tenderness
• Can be asymptomatic early on
• FAST exam can be early screening
tool
 Abdominal Trauma

• Look for distension, ten

derness, seatbelt mark
s, penetrating trauma,
retroperitoneal ecchym
osis
• Be suspicious of free fl
uid without evidence o
f solid organ injury
Abdominal Cavity
 Solid Organs

Liver -Spleen -
Pancreas
Good

Bad

Rupture of these organs causes hemorrhage and s

 Splenic Injury
• Most commonly injured organ in blunt trauma
• Often associated with other injuries
• Left lower rib pain may be indicative
• Often can be managed non-operatively

Blood from spleen

Tracking around Spleen with
liver surrounding
blood
 Liver injury

• Second most common solid organ injury

• Can be difficult to manage surgically
• Often associated with other abdominal injuries

Liver contusions
 Hollow Viscous Injury
• Injury can involve stomach, bowel, or mesentery
• Symptoms are a result from a combination of blood l
oss and peritoneal contamination
• Small bowel and colon injuries result most often fro
m penetrating trauma
• Deceleration injuries can result in bucket-handle tear
s of mesentery
• Free fluid without solid organ injury is a hollow viscus
injury until proven otherwise
bowel

mesentery

Mesenteric and bowel injury from blunt abdominal

trauma. Notice the bowel and mesenteric disruption.
 CT Scan in Trauma
• Abdominal CT scan visualizes solid organs and
vessels well
• CT does NOT see hollow viscus, duodenum, di
aphram, or omentum well
• Some recent surgery literature advocates
whole body scans on all trauma
– Keep in mind that there is an increase in mortality
related to cancer from CT scans
 FAST Exam

• Focused Abdominal Scanning in Trauma

• 4 views: Cardiac, RUQ, LUQ, suprapubic
• Goal: evaluate for free fluid

See normal
Liver and kidney
Free fluid in Morrison's
Pouch between liver and
kidney
Spinal Injury
 Mechanisms of Spinal Injury

• Motor vehicle crashes

• Auto-pedestrian collisio
ns
• Falls
• Blunt or penetrating
 Emergency Care Steps
• Body substance isolation
• Maintain in-line stabilization.
• Care for airway with in-line stabilization when
possible.
• Assess pulse, movement, and sensation in extr
emities.
• Assess the neck and spine
 Emergency Care Steps
• Apply properly sized cervical spine immobiliza
tion device.
• Apply and secure patient to appropriate immo
bilization device. 、
• If proper size collar is not available, use rolled
towel and tape.
• Pad around child as necessary to maintain sta
bilization.
Stabilize and measure
Soft Tissue Trauma
 Contusions and Hematomas
• Contusion
 characterized by blood vessel disruptio
n beneath the epidermis
 Results in swelling, pain, ecchymosis
that may occur 24 to 48 hours after the
injury
• Hematoma
 Collection of blood beneath the skin
 May occur along with a contusion
 Represents a larger amount of tissue da
mage and disruption of larger vessels
 Crush Injury

• Can occur when a crushing forc

e is applied to a body area
• Can be severe and may be asso
ciated with
 Internal organ rupture
 Major fractures
 Hemorrhagic shock
 Abrasion
• Partial-thickness injury
• Caused by the scraping or rubbing away of a
layer or layers of skin

Deep abrasion caused by a fall from a

bicycle
 Laceration
• Results from a tear, a split
, or an incision of the skin
 Sizes and depths of lacera
tions can vary greatly dep
ending on the injury sites
and wounding mechanism
 May be sources of signific
ant bleeding Large wound caused
by a broken power
saw.
 Puncture

• Commonly results fro

m contact with a shar
p, pointed object
• Entrance wound gene
rally small

Wood impaled in right chest,

piercing diaphragm and
lacerating spleen, stomach, and
 Avulsion

• A full-thickness skin loss in which the wound

edges cannot be approximated
• Frequently involves the ear lobes, nose tip, an
d fingertips

Ring avulsion injury

 Degloving Injury
• A type of avulsion in which shearing forces se
parate the skin from the underlying tissues
• Bleeding may be significant
• Amputation
 Involves a complete or partial loss of
a limb secondary to mechanical force
 Bleeding is a potentially fatal compli
cation
• Bites
 An animal or human bite is frequentl
y a combination of puncture, lacerati
on, avulsion, and crush injury
 Human bite to the hand.
 Compartment Syndrome
• A continuation in the disea
se spectrum of crush injury
• Usually results from compr
essive forces or blunt trau
ma to muscle groups confi
ned in tight fibrous sheaths
with minimal ability to stre Prolonged crushing,
tch (below the knee, above as when an
the elbow) unconscious person
lies on a body part
for several hours
Questions?

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