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Trauma
Prehospital phase and triage Primary Survey ABCDE Resuscitation Adjuncts to primary survey and resuscitation ‡ Secondary Survey ‡ Records, Consent, Forensic evidence ‡ ‡ ‡ ‡ ‡

Primary Survey
‡ Airway and cervical spine control ‡ Breathing ‡ Circulation with control of hemorrhage ‡ Disability ‡ Exposure/environment (expose patient, but avoid hypothermia)

Resuscitation
‡ ‡ ‡ ‡ Oxygenation and Ventilation Shock management IV lines²Normal Saline lines² Management of life-threatening problems life-

Adjuncts to Primary Survey and Resuscitation
‡ Monitoring:
± ABGs and ventilatory rate ± End-tidal CO2 End± EKG ± Pulse oximetry ± Blood pressure

Adjuncts to Primary Survey and Resuscitation
‡ Urinary and gastric catheters ‡ X-rays and diagnostic studies
± Chest ± Pelvis ± C-spine ± FAST / CT SCAN / DPL

Trauma Mortality
‡ 35 per 100,000 population ‡ Most common cause of death in children

Airway and Ventilation
‡ These are first priorities!!!! ‡ Risks for obstruction:
± Coma ± Aspiration ± Maxillofacial trauma ± Neck trauma

Airway and ventilation
‡ Neck trauma: disruption of the larynx or tracheatrachea-or compression by soft tissue injury ‡ Laryngeal trauma:
± Hoarseness ± Subcutaneous emphysema ± Palpable fracture

Airway and ventilation
‡ Obstruction:
± Agitation or obtundation ± Abnormal airway sounds ± Trachea not in midline

Airway and ventilation
‡ Inadequate ventilation
± Asymmetric chest rise ± Asymmetric chest sounds ± Poor oxygenation

Airway and ventilation
‡ Airway Maintenance
± Chin lift ± Jaw thrust ± Oropharyngeal airway ± Nasopharyngeal airway

‡ Definitive Airway
± Endotracheal tube ± Cricothyroidotomy

Airway and ventilation
PaO2 Levels 90 mm Hg 60 mm Hg 30 mmHg 27 mmHg O2 Hgb Saturation 100% 90% 60% 50%

Pulse Oximetry
‡ LED absorbed differently between oxygenated and non-oxygenated Hgb non‡ Affected by:
± Poor perfusion ± Anemia ± Carboxyhemoglobin or methehemoglobin ± Circulating dye ± Patient movement, ambient light or signals

Thorax
‡ Breathing: ± Tension pneumothorax ± Open pneumothorax (³sucking wound´) ± Flail chest ± Massive hemothorax

Thorax
‡ Tension Pneumothorax ± Collapse of affected lung ± Decreased venous return ± Decreased ventilation of opposite lung

Thorax
‡ Tension pneumothorax:
± Respiratory distress ± Distended neck veins ± Unilateral decrease in breath sounds ± Hyperresonance ± Cyanosis

‡ Needs immediate decompression!

Thorax
‡ Open pneumothorax: ± Occlusive dressing ‡ Flail chest: ± Trauma principles and ventilation ‡ Massive hemothorax ± Chest decompression

Thorax
‡ Circulation: ± Massive hemothorax ‡ Flat v. distended neck veins ‡ Shock with no breath sounds ‡ Treat with decompression

Thorax
‡ Circulation: ± Cardiac tamponade ‡ Decreased arterial pressure ‡ Distended neck veins ‡ Muffled heart sounds ‡ PEA (pulseless electrical activity) ‡ Treat with decompression

Thorax
‡ Resuscitative thoracotomy:
± Penetrating trauma ± Pulseless with myocardial activity ± Evacuate blood ± Stop bleeding ± Cardiac massage ± Cross clamp of aorta ± Infusion of fluids and blood

Thorax Secondary Survey
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Simple pneumothorax Hemothorax Pulmonary contusion Tracheobronchial tree injury Blunt cardiac injury Aortic disruption Diaphragm injuries Mediastinal traversing wounds Esophageal rupture Rib, sternum, scapular fractures

Shock ‡ Hemorrhage is the most common cause of shock in the injured patient!!

Shock
‡ Hemorrhagic shock ‡ Non-hemorrhagic shock: Non± Cardiogenic ± Tension pneumothorax ± Neurogenic shock ± Septic shock

Shock
‡ Blood volume:
± 5 liters in the 70 kg adult ± 80-90 ml/kg in the child 80-

‡ Classes of Hemorrhage (% loss)
± I: <15% ± II: 15-30% 15± III: 30-40% 30± IV: >40%

Shock
‡ Initial Therapy: ± Stop the bleeding! ± Vascular Access lines ‡ 2 large bore IV lines ‡ Intraosseous lines ‡ Central lines ± Fluid bolus ‡ 2 Liters NS: adult ‡ 20ml/kg: Child

Shock
‡ Assess: ± Capillary refill (should be < 2 sec) ± Peripheral pulses ± Heart rate ± Temperature and color of skin ± Sensorium ± Pulse pressure

Shock
‡ Signs of hemodynamic recovery: ± Slowing of pulse ± Decrease in skin mottling ± Increase in extremity temperature ± Clearing of sensorium ± Urinary output > 1ml/kg/hour ± Increased systolic blood pressure

Abdomen
‡ Mechanisms:
± Blunt ± Penetrating

‡ Spaces:
± Peritoneal cavity ± Pelvis ± Retroperitoneum

Abdomen
‡ Physical exam:
± Inspection ± Auscultation ± Percussion ± Palpation ± Evaluate penetrating wounds ± Local exploration of stab wounds

Abdomen
‡ Physical exam:
± Assess pelvic stability ± Genital and rectal exam ± Gluteal exam

Abdomen
‡ Diagnostic studies:
± CT scan ± Ultrasound ± DPL ± Urethrography/cystography

Abdomen
‡ Indications for exploration:
± Blunt trauma with instability and positive US or DPL ± Blunt trauma with recurrent hypotension ± Peritonitis ± Hypotension from penetrating wound ± Bleeding from stomach/rectum/GU (penetrating) ± Gunshot wound ± Evisceration

Abdomen
‡ Special considerations:
± Diaphragm ± Duodenum ± Pancreas ± Liver/Spleen ± GU ± Small bowel

Left: Massive hemothorax Right: Chest tube decompression

Tension pneumothorax

Chest tube placed and pneumopneumothorax resolved

Circulation
Heart rate Infants Preschool School age Adolescent 100100-160 8080-140 8080-140 6060-120 Systolic BP 60 80 90 100 Urine ml/kg/hr 2 1.5 1-1.5 10.5-1 0.5-

Head Trauma
‡ 500,000 cases per year in US ‡ 10% die prior to hospital

Head Trauma
‡ Cerebral Perfusion Pressure
± CPP=MAP-ICP CPP=MAP‡ MAP =Mean arterial pressure ‡ ICP = Intracranial pressure

‡ Cerebral Blood Flow
± 50ml/ 100g of brain/minute ± <25-EEG activity disappears <25± 5 ± brain death

Head Trauma
‡ Mechanism: ± Blunt v. Penetrating ‡ Severity: ± Mild: GCS 14-15 14± Moderate: GCS 9-13 9± Severe: GCS 3-8 3‡ Morphology: ± Skull fractures ± Intracranial lesions

Head Trauma
‡ Skull fractures: ± Battle¶s Sign ± Racoon eyes ± Rhinorrhea/otorrhea ± Linear vault fractures ‡ 400 X risk hematoma in awake patients ‡ 20 X risk in comatose patients

Head Trauma
‡ Intracranial lesions ± Epidural hematomas ± Subdural hematomas ± Contusions/hematomas ± Concussion ± Diffuse axonal injuries

Head Trauma
‡ Management; ± ABCs! (GCS < 8 intubate patient) ± Hypotension is never presumed to be from head trauma ± CT scan ± Hyperventilation ± Mannitol/lasix ± Steroids ± Barbiturates

Spinal Injuries
‡ Level ‡ Severity ‡ C-spine-protect always!! spine± 10% have another vertebral fracture ± Respiratory function may be lost

‡ Spinal shock ‡ High dose methylprednisolone in first 8 hours ‡ Pediatric considerations (SCIWORA)
‡ SCIWORA ± Spinal Cord Injury WithOut Radiographic ithO Abnormality

Subluxation C-5 on C-6 C-

Musculoskeletal Injuries
‡ ‡ ‡ ‡ May have significant bleeding source Evaluate vascular and neurologic status Immobilize/traction Pelvic fracture
± Stabilize ± Embolize

Musculoskeletal Injuries
‡ Crush injuries:
± Myoglobinuria

‡ Open fractures
± Immobilize ± Antibiotics/tetanus

Musculoskeletal Injuries
‡ Compartment Syndrome:
± Pain (especially with passive stretching) ± Paresthesia ± Decreased sensation or function ± Paralysis or loss of pulse are LATE changes and loss of limb is imminent ± Tissue pressures >35-45 mm Hg threaten >35limb

Cerebral contusion with cerebral swelling and skull fracture

Tear drop fracture anterior C-4 C-

Massive left hemothorax with compressed lung

Tension pneumothorax on right with shifted mediastinum

Fractured vertebral body on CT scan view

Stomach herniated through diaphragm

Epidural hematoma

Massive facial trauma

Contusion of right lobe of liver

Fracture through body of pancreas

IntraIntra-osseous access

Technique for pericardiocentesis

Lap belt abrasion-indicates force of injury abrasionand high risk of internal injuries

View of normal vocal cords

Fractured larynx

MRI image of thoracic vertebral fracture and injured spinal cord

Subdural hematoma

Lines of escarotomy in burn injuries

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