Occupational Trauma: Occupational Health Program Postgraduate Program University of Sumatera Utara

Postgraduate Program USU
OCCUPATIONAL TRAUMA
Occupational Health Program

Postgraduate Program
University of Sumatera Utara
SK
Mechanisms Of Injury And Related
Injury Patterns
Frontal Impact
Bent Steering Wheel

Knee Imprint, Dashboard
Bull's-eye Fracture, windshield
Cervical Spine Fracture
Anterior Flail Chest
Frontal Impact Injury Pattern
Myocardial/ Pulmonary Contusion

Pneumothorax
Traumatic Aortic Disruption.
Fractured Spleen or Liver
Posterior Fracture/disloc.of Hip,
Knee
Side Impact Injury Pattern

Contralateral neck sprain
Cervical spine fracture
Lateral flail chest
Pneumothorax
Diaphragmatic rupture
Fractured spleen/liver, kidney
Fractured pelvis / acetabulum

Rear Impact Injury Pattern
Cervical spine
Soft-tissue neck injury
Ejection

Precludes meaningful prediction of injury
patterns
Patient at greater risk for all injury
mechanisms
Mortality significantly increased
M-V vs. Pedestrian
Head injury
Traumatic aortic disruption
Abdominal visceral injuries
Fractured lower extremities/pelvis
Penetrating Trauma
Type and extent of injury related to:

Region of the body injured
Organs in proximity to the bullet, knife,
spear, arrow etc.
Injuries due to Burns
Burns may occur alone or may be

coupled with blunt and penetrating
trauma.
PRIMARY SURVEY
The ABCDEs of trauma care sequentially
identify life-threatening conditions

A. Airway maintenance with cervical spine
protection
B. Breathing and ventilation
C. Circulation with hemorrhage control
D. Disability: Neurologic status
E. Exposure: Completely undress but
prevent hypothermia
Life-threatening conditions are identified and
simultaneous management is instituted

DEFINITIVE AIRWAY
Three methods:
Orotracheal intubation
Nasotracheal intubation
Surgical airway (cricothyrotomy
or tracheostomy)
The decision to provide
a definitive airway:
Apnea
Inability to maintain a patent airway
Protection of the airway from

aspiration
Impending or potential
compromise of the airway
Inhalation injury
Facial fractures
Retropharyngeal hematoma
Sustained seizure activity
Closed head injury (GCS < 8)
Inability to maintain SaO2 by
face mask oxygen
Airway Maintenance with Cervical Spine
Protection
Assess for patency including inspection for
foreign bodies, facial, rnandibular, or
tracheal/laryngeal fractures which may result in
airway obstruction.
PROTECT the CERVICAL SPINE

NEVER hyperextend, hyperflex, or rotate the
neck establish and maintain the airway.
Neurologic examination alone does not
exclude a cervical spine injury.
If immobilizing devices must be removed ,
stabilize head and neck with manual, in-line
immobi!ization.
Equipment used to protect the patient's spinal
cord should be left in place until cervical spine
injury is excluded.
Assume a cervical spine injury in patient with

multi-system trauma with altered level of
consciousness or blunt trauma above the
clavicle
Breathing and Ventilation
Airway patency does not assure adequate
ventilation.
Ventilation requires adequate function of
lungs, chest wall, and diaphragm
Exposure, assess chest wall to detect
injuries that may compromise ventilation.
Auscultation for presence and
quality of breath sounds
Percussion may demonstrate the
presence of air (pneumothorax) or blood
(hemothorax)
Injuries that acutely impair ventilation:
Open/Tension Pneumothorax
Flail Chest/Pulmonary Contusion
Massive Hemothorax
Circulation with Hemorrhage Control
Blood Volume and Cardiac Output
Hemorrhage is the predominant cause

of post-injury deaths
Hypotension is hypovolemic in origin
until proven otherwise
Observations that provide clinical
information:
Level of consciousness
Skin color
Pulse

• Impaired cerebral perfusion = altered
level of consciousness
• A GCS 15 conscious patient may have

significant blood loss
Skala Koma Glasgow (1)
• Membuka mata
Spontan 4
Atas printah lisan 3
Atas rangsang nyeri 2
Tidak dapat membuka mata 1
• Bicara
Bicara sesuai orientasi 5
Kalimat baik tapi isi bicara- 4
Kata baik tapi kalimat tidak 3
Kata tidak dimengerti 2
Tidak keluar suara 1
Skala Koma Glasgow (2)
• Gerakan motorik
Mengikuti perintah 6
Dapat menunjuk lokasi 5
Penarikan (menarik diri) 4
Fleksi 3
Response ekstensor 2
Tidak ada gerakan 1
• Seorang yang sadar skor= 15
Skin Color
Pink skin, face and extremities,rarely
critically hypovolemic
Ashen, gray skin, an ominous sign of
hypovolemia.
Pulses

Carotid, radial, femoral pulses assessed for
quality, rate, and regularity
Full, slow, and regular pulses = relative

normovolemia
Rapid thready pulse, usually a sign of

hypovolemia
Irregular pulse may indicate potential

cardiac dysfunction.
Bleeding
External blood loss is managed by direct
pressure.
The use of hemostats in a bloody field may
cause significant injury to adjacent structures
(vessels, nerves, tendons).
SITES of BLOOD LOSS in TRAUMA
OBVIOUS
Scalp lacerations
Facial injuries
Open Fractures
HIDDEN
Intra/retroperitoneal
Hemothorax
Pelvic hematoma
Long-bone fx. sites
Aortic disruption
Elderly patients- limited ability to increase their
heart rate in response to blood loss,
obscuring one of the earliest signs of
volume depletion, tachycardia
Blood pressure has litttle correlation with cardiac

output in the older patients.
Children - abundant physiologic
reserve
Often demonstrate few signs of
hypovolemia even after severe
volume depletion
When deterioration occurs, it is
precipitous and catastrophic.
Disability
Neurologic Evaluation

AVPU method:
A - Alert,
V - Responds to Vocal stimuli
P - Responds only to Painful
stimuli
U - Unresponsive to all stimuli
Pupillary size and reaction.

The Glasgow Coma Scale (GCS)
A more precise evaluation and

predictor of patient outcome
A decreased level of
consciousness may result from:
Decrease in cerebral perfusion

and/or oxygenation
Direct cerebral injury

Exposure/Environmental Control
Completely undress to facilitate thorough

examination and assessment.
Cover with warm blankets or use an
external warming device to prevent
hypothermia
Warmed intravenous fluids
Maintain a warm environment (room
temperature)
ADJUNCTS to PRIMARY SURVEY and
RESUSCITATION
ECG
Dysrhythmias, ST changes - myocardial

contusion
PEA – cardiac tamponade, tension
pneumothorax, hypovolemia
Bradycardia – hypoxia, hypovolemia
Urinary Catheters

No transurethral catheter until
genitalia,perineum, and rectal exam
Urethral injury indicators - meatal blood,
shaft hematoma, perineal/scrotal ecchymosis,
non-palpable prostate, pelvic fracture
Suspected urethral injury requires retrograde

urethrogram (RUG) prior to transurethral
catheter insertion
Gastric Decompression
Reduces the risk, but does not always

prevent aspiration
Passage of the tube may induce vomiting
OGT (oral insertion) if facial fractures,
especially if cribriform plate fracture is
suspected
MONITORING ADJUNCTS
Carbon Dioxide Detector- confirms ETT is

located somewhere in the airway
Does not confirm proper placement of the
tube
Pulse Oximetry- indicator of O2 saturation,
not partial pressure
X-RAYS and Diagnostic Studies
X-rays should not delay patient
resuscitation
The AP chest film and an AP
pelvis may provide
information which may guide
resuscitation efforts
A lateral cervical spine x-ray that
demonstrates an injury is an important
finding
A negative or inadequate film does not

exclude cervical spine injury.
Diagnostic peritoneal lavage (DPL),
Abdominal Ultrasonography and CT may be
useful for the evaluation of intra-abdominal
and retroperitoneal bleeding
Early identification of the source of hidden
blood loss may indicate the need for
emergent operative intervention
SECONDARY SURVEY
After primary survey (ABCDEs) complete

Head-to-toe examination of the patient
Blunt Trauma
Results from vehicular collisions (MVC),

falls, and, and occupation-related injuries
Injury patterns may often be predicted by
the mechanism of injury
Penetrating Trauma

Penetrating trauma (firearms, stabbings,
and impaled objects)
Factors determining the type and extent of
injury:
Region of the body, organs in the
proximity to the path of the
penetrating object
Velocity, caliber, presumed path, and the
distance from the weapon
Physical Examination
Head

Pupillary size, conjunctival hemorrhages and fundi,
penetrating injury,dislocation of the lens,ocular
entrapment
Visual acuity can be evaluated by the reading of
printed material, e.g., words on an intravenous
container.
Extra-ocular mobility should be evaluated to exclude
entrapment of muscles due to orbital fractures
The entire scalp and skull should be examined for

lacerations, contusions, and evidence of fractures.
Head Injury Classification
Mechanism
BLUNT
High velocity (MVC)
Low velocity (fall, assault)
PENETRATING
GSW
Severity

MILD GCS 14-15
MODERATE GCS 9-13
SEVERE GCS 3-8

SKULL FRACTURES

Cranial Vault
Linear/Stellate
Depressed/Non-depressed
Open/Closed
Basilar
Raccoon eyes, Battle’s sign
Hemotypanum
+ / – CSF leak
+ / – VII n. palsy
INTRA-CRANIAL
Focal
Epidural
Subdural
Intracerebral
Diffuse
Mild Concussion
Classic Concussion
Diffuse Axonal
MANAGEMENT
Intravenous Fluids
Hypovolemia
Decrease cerebral perfusion (CBF)

Increase hypoxia
Normal saline or Ringer’s
ICP Control
Hyperventilation (controlled)
Osmotic diuresis (mannitol)
Barbiturates (if ICP reduction
refractory to standard Rx.)
Anticonvulsants (early and
short term)
Diagnostic Procedures

CT Scan
Hematomas
Epidural (supradural,convex/lenticular)
Subdural (concave)
Intra-cerebral (high density & low density halo)
MRI
Better for parenchymal and brain stem, but time
to perform 45 min. vs 2-5 min for CT. MRI, at
present, not initial management study
Ventriculography
Degree of supratentorial shift

Direct measurement and
monitoring of ICP
Maxillofacial

Maxillofacial trauma without airway
obstruction or major bleeding,
treated after stabilization
Mid-face fractures may involve a

fracture of the cribriform plate.
Orotracheal and gastric intubation

should be performed.
Cervical Spine and Neck
Patients with maxillofacial or head trauma,

assume an unstable cervical spine injury,
(fracture and/or ligamentous).
The absence of neurologic deficit does not
exclude injury to the cervical spine.
Neck - cervical spine tenderness,

subcutaneous emphysema, tracheal deviation,
and laryngeal fracture.
Carotid arteries - amplitude, equality of
pulsation, bruit
Occlusion or dissection of the carotid artery
can occur late in the injury
Blunt trauma to the neck or a traction
injury from a shoulder harness restraint can
result in intimal disruption, dissection, and
thrombosis.
CHEST
Contusions, hematomas, chest wall - possibility

of additional injury
Sternal tenderness – sternal fracture,
costochondral separation
Tension pneumothorax – hypotension,
hyperresonance, decreased breath sounds
Massive hemothorax - dullness to percussion,
absent breath sounds,hypotension
Cardiac tamponade – hypotension, narrow pulse
pressure, distant heart sounds
Chest X-Ray
Chest wall (rib, sternal fxs.)
Hemothorax
Simple pneumothorax
Mediastinal width (upright film)
Abdomen
DPL, abdominal US, contrast CT
Unexplained hypotension, impaired CNS, or

equivocal findings
Pain from pelvic, lower rib fractures may

prevent accurate diagnostic exam
Perineum/Rectum/Vagina
Contusions, hematomas, lacerations, and

urethral (meatal) blood.
Rectal exam prior to inserting a urinary catheter
High-riding prostate, sphincter tone, integrity of
rectal wall, blood within the bowel lumen
Female patient - blood in the vaginal vault and
vaginal lacerations
Musculoskeletal
Pelvic fractures - ecchymosis over the iliac wings,

symphysis pubis, labia, scrotum, pain on palpation
of the pelvic ring
Mobility of the pelvis - gentle anterior-to-posterior
presssure with the heels of the hands on both
anterior iliac spines and symphysis pubis
Joint instability- ligament disruption
Neurovascular deficit- nerve injury or ischemia
(compartment syndrome)
Neurologic

Motor and sensory evaluation of the
extremities
Reevaluation of the patient's level of
consciousness
GCS facilitates detection of early changes
and trends in the neurologic status
Protection of the spinal cord is
required until a spine injury
is excluded
ADJUNCTS TO THE SECONDARY SURVEY
These include additional x-rays of the spine

and
extremities, computed tomographic scans of
the
head, chest, abdomen, and spine, contast
urography
angiography, and other diagnostic procedures
REEVALUATION

After initial life-threatening injuries are
managed,
other equally life-threatening problems and less
severe injuries may become apparent
Relief of severe pain is an important part of the
management of the trauma patient

Effective analgesia requires intravenous opiates
and/or anxiolytics
Intramuscular injections are to be avoided.
SUMMARY
MECHANISMS of INJURY

>40 mph
Unrestrained driver, passenger
Major auto deformity (>20 in.)

Intrusion into passenger
compartment (>12 in.)
Roll-over
Extrication time >20min.
Ejection
Auto - Pedestrian injury (>5mph.
impact)
Pedestrian thrown / run over
Death of occupant in same passenger
compartment
Motorcycle crash (>20mph.), or rider
separated from bike
Falls ( >20ft.)
RAPID ASSESSMENT and MANAGEMENT
Primary Survey (ABCDEs)

Airway (noisy, sonorous, stridor =
obstructed)
Breathing (chest wall, breath sounds,
resp. rate)
Circulation (pulses, skin color, capillary
refill) External hemorrhage control (direct
pressure)
Disability (level of consciousness)
Exposure/Environment
Resuscitation

Oxygenation
Volume replacement
Monitor (ECG, O2 sat., urine
output)
Gastric (NGT/OGT)
decompression
Urethral catheters (if not
contraindicated)
Detailed Secondary Survey (after
stabilization)
Head
Scalp lacerations (skull fx? depressed?)

Battle’s, Raccoon eyes, Hemotympanum,
CSF
Maxillofacial fxs. (stability, airway
compromise, cribriform)
Neck
Trachea (midline, tender, crepitus)

Carotids (amplitude, bruit)
Venous distension
C-spine (stable / unstable, fracture,
ligamentous)
Chest
Wall ( expansion, paradoxical,

ecchymosis, tenderness, crepitus)
Sternal tenderness ( myocardial /
pulmonary contusion)
Rib Fractures
1,2 (aortic disruption)

3 - 8 (hemo/pneumothorax,
disruption diaphragm)
9 - 12 (liver, spleen, kidney)
Flail (pulmonary contusion)
Abdomen
Ecchymosis (flank / kidney?)

Tenderness
RUQ (liver) LUQ (spleen)
CVA ( kidney)
Suprapubic ( bladder, symphysis)
Pelvis (tenderness, crepitus,
instability)
Genitalia (perineal/scrotal/shaft
hematoma, meatal blood)
Rectum (tone, prostate, blood)
Extremities (tenderness, deformity,
pulses, sensation)
Neurologic (detailed exam)
Life Threatening Conditions Requiring
Emergent Intervention
Open Pneumothorax
Treatment:
Occlusive dressing, sealed on three
sides, creating a one-way valve
Chest tube
Tension Pneumothorax
NOT AN X-RAY DIAGNOSIS

Respiratory distress, tracheal deviation,
unilateral absence of breath sounds,
neck vein distension (related to volume
status, degree of mediastinal shift)
Cyanosis (late)
Treatment: Needle decompression

2nd/3rd ICS, MCL
Chest tube
Massive Hemothorax
Hypotension, dullness to percussion,

absent breath sounds
Treatment: Volume restoration, chest
tube decompression
Initial and subsequent volume of
chest tube drainage may determine the
need for operative intervention
Traumatic Cardiac Tamponade
Wound in area to suspect cardiac injury

Hypotension refractory to fluid infusion
Narrow pulse pressure
Muffled heart tones?
Neck vein distension(volume related)
Treatment: Pericardiocentesis
Surgical intervention
Traumatic Aortic Disruption
Mechanism ( rapid deceleration, fall 20 ft.

or greater)
X-Ray: 1st, 2nd rib fxs., wide mediastinum
Treatment: Aortogram
Operative intervention

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Postgraduate Program USU

Occupational Health Program

Bent Steering Wheel

Myocardial/ Pulmonary Contusion

Postgraduate Program USU

Fractured pelvis / acetabulum

Postgraduate Program USU

Type and extent of injury related to:

Burns may occur alone or may be

Postgraduate Program USU

simultaneous management is instituted

Protection of the airway from

PROTECT the CERVICAL SPINE

Assume a cervical spine injury in patient with

Hemorrhage is the predominant cause

Postgraduate Program USU

• A GCS 15 conscious patient may have

Pink skin, face and extremities,rarely

Postgraduate Program USU

Full, slow, and regular pulses = relative

Rapid thready pulse, usually a sign of

Irregular pulse may indicate potential

Blood pressure has litttle correlation with cardiac

Postgraduate Program USU

Pupillary size and reaction.

A more precise evaluation and

Decrease in cerebral perfusion

Direct cerebral injury

Completely undress to facilitate thorough

Dysrhythmias, ST changes - myocardial

Postgraduate Program USU

Suspected urethral injury requires retrograde

Reduces the risk, but does not always

Carbon Dioxide Detector- confirms ETT is

A negative or inadequate film does not

After primary survey (ABCDEs) complete

Results from vehicular collisions (MVC),

Postgraduate Program USU

Postgraduate Program USU

The entire scalp and skull should be examined for

Postgraduate Program USU

MODERATE GCS 9-13

SEVERE GCS 3-8

Postgraduate Program USU

Decrease cerebral perfusion (CBF)

Postgraduate Program USU

Degree of supratentorial shift

Postgraduate Program USU

Mid-face fractures may involve a

Orotracheal and gastric intubation

Patients with maxillofacial or head trauma,

Postgraduate Program USU

Postgraduate Program USU

Chest wall (rib, sternal fxs.)

DPL, abdominal US, contrast CT

Unexplained hypotension, impaired CNS, or

Pain from pelvic, lower rib fractures may

Contusions, hematomas, lacerations, and

Pelvic fractures - ecchymosis over the iliac wings,

Postgraduate Program USU

These include additional x-rays of the spine

Postgraduate Program USU

management of the trauma patient