m







Introduction
y Trauma:- one of the most serious as well as the most
preventable health care problem.
y Common causes of trauma:-
1. Road traffic accidents
2. Interpersonal violence
3. Sports injuries
4. War injuries
y Death and disability due to trauma is far more
greater than all other causes combined.
"rimodal distribution of death due
to trauma
y 

  occurs within seconds or minutes
of injury.50% of all deaths due to trauma.cause can be
laceration of heart,major blood
vessels,brain,brainstem or spinal cord.
y 3 occur within 2-3 hours of injury.30% of
all deaths due to trauma.causes can be epidural and
subdural hematoma,hemopneumothorax,pelvic
fractures,long bone fractures,abdominal injuries.
y a  deaths occur days or weeks after
trauma.20% of all deaths due to trauma.causes can be
infection,sepsis and multiorgan failure.
›hases of trauma care
y ›   
1. ABCs
2. Control of heamorrhage
3. Fracture stabilisation
4. Spine stabilisation
5. Rapid transport
y ›
 
   :-ABCDEs, and
monitoring,resuscitation.
y m     :-comprehensive physical
examination,investigations,continued monitoring and
resuscitation
y ©  
y  
›re hospital care
y 2 main objectives:-
1. Safe removal
2. Rapid transport to the nearest medical facility that
can appropriately manage the particular trauma.
y GOLDEN HOUR:-It is the time to reach the
operating room.time whereby manoeuvres can be
done to save the patient.
›rimary assesment and
resuscitation
y 5-10% of patients in emergencies are life threatening
y Rapid assesment consists of(American college of
surgeons ATLS guidelines):-
1. Airway with Cervical spine control
2. Breathing and Ventilation
3. Circulation and Hemorrhage control
4. Disability and neurological status
5. Exposure and physical examination
"riage
y 1) Those who are likely to live, regardless of what care
they receive;
y 2) Those who are likely to die, regardless of what care
they receive;
y 3) Those for whom immediate care might make a
positive difference in outcome.
 





 

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m
 easure vital signs & level of consciousness

Glasgow coma scale<13 or systolic B.P<90 or

respiratory rate <10 or >29

Yes No

Take to trauma center Assess anatomy & mechanism of injury

 





 
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Take to trauma center

y Step 3
y Age<5 or >55:-
1. Yess-take to trauma centre
2. No-reevaluate



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6espiratory status
y Signs of respiratory embarrasment:-
1. Stridor
2. Cyanosis
3. Tachypnea>25/min
4. Anxiety
5. Intercostal retraction
6. Use of accessory muscles
3stablishment of airway with
cervical spine control
y Clear the airway
y Reposition the patient:-
1. Semi prone position
2. Chin lift
3. Jaw thrust
4. Digital disimpaction of displaced maxilla
y Oral and nasopharyngeal airways:-they are designed to
displace the tongue anteriorly off the posterior
pharyngeal wall.
y Endotracheal intubation
y Cricothyroidotomy
y Tracheostomy
3ndotracheal Intubaton
y INDICATIONS:-
1. When the airway patency is threatened and non
invasive modalities are unsuccessful
2. When patient is in extremes and urgent and surest
means of establishing a patent airway is required
3. For tracheal suction or pulmonary toilet
4. For controlled positive pressure ventilation
y Contraindications:-
1. Confirmed or suspected cervical spine injury
2. Presence of cerebrospinal rhinorrhea or fracture of
anterior cranial fossa:-oroendotracheal intubation is
preferred.
3. Presence of retro pharyngeal swelling.
4. A fractured larynx
"echniques of endotracheal
intubation
y Direct laryngoscopy:-
X can be performed only if cervical spine injury has been
ruled out.
X The patient is put into Ǯsniffing positionǯ
X The laryngoscope blade is inserted into right side of
mouth,the epiglottis and vocal cords are examined and the
endotracheal tube is gently inserted into the trachea.
X The correct placement is then verified by observing lung
expansion on tube to bag ventilation and auscultation of
chest and abdomen.
X Should be accomplished within seconds.if not then
attempts should be discontinued.
y Blind endotracheal intubation:-indicated in cases of
suspected or presence of cervical spine injuries.
y Fiberoptic laryngoscopy:-alternative to blind nasal
intubation.
y Retrograde transcricoid intubation
"racheostomy
y Earliest reference found in Rig Veda,published 2000
B.C.
y Indications:-
1. Upper airway obstruction
2. Facilitation of tracheobronchial toilet
3. Anticipated prolonged mechanical ventilation
4. In cases of cervical spine inuries or oncologic
resections in head and neck
5. Laryngeal trauma
natomical and surgical
considerations of tracheostomy
y
 fibrocartilagenious tube.9-10 mm in
diameter,9.5-12 cm in length.extent from C6 till upper
border of T5.
y 3
  
:-
X The neck is extended and head supported
X The cricoid cartilage is palpated and a vertical incision
from the level of cricoid cartilage to just above the supra
sternal notch is made.
X Dissect through the superficial layer of deep fascia,until the
pretracheal fascia and thyroid isthmus is identified
X Dissect through the pretracheal fascia,retract the isthmus
and incise through the tracheal rings (2nd,3rdand 4th)
X The tracheostomy tube is inserted and closure is done.
  

 





EERGENCY
TRACHEOSTOY.
omplications of tracheostomy
y ›   

1. Hemorrhage
2. Hypoxia
3. Pneumothorax
4. Emphysema
5. Tracheo-esophageal fistula
6. Damage to the recurrent laryngeal nerve
y ›  
:-
1. Delayed hemorrhage
2. Infection
3. Hypoxia
4. Aspiration
5. Tracheal stenosis
6. Tracheal ulcers and erosions
7. Unsatisfactory esthetic result
ricothyroidotomy
y It was first described by the french surgeon and
anatomist . /0 "1&#
y  2    
-
1. It can be performed more rapidly,usually <2 mins
2. Extensive knowledge of neck anatomy is not
required.more safer.
3. Less complications
4. Does not require extension of neck
y   
:-
1. In children and adolescents
2. Laryngeal injury
3. Pre existing laryngeal pathology
natomic and surgical
consideration of cricothyroidotomy
y The cricothyroid membrane is about 2-3 cm inferior to the
thyroid notch denoted as a slight concavity between thyroid and
cricoid cartilage.
y Extends vertically around 1 cm and horizontally around 3 cm.
y
. 
X Under LA or GA,and minimal extended head and neck,a
tranverse incision of 2 cm is made just superior to the cricoid
cartilage.
X Dissection through the skin,subcutaneous tissue,superficial
layer of deep fascia,crocothyroid muscle and membrane and into
trachea with a stabbing transverse incision.
X Insertion of tracheostomy tube and securedwith tapes.
y Complications of cricothyroidotomy:-
1. Hemorrhage
2. Improper placement
3. Voice change
4. Infection
5. stenosis
ventilation
y Patient is able to breath
y Assisted ventilation:-
X Bag-valve mask ventilation
X echanical ventilation
y aintain PO2>60 mm hg and PCO2<35 mm hg
3mergency respiratory conditions
y Open pneumothorax
y Closed pneumothorax
y Tension pneumothorax
y Hemothorax
y Flial chest
anagement
y Emergency thoracsotomy and chest tube placement.
y Splint for flial chest.
"horacostomy
ervical spine
y Segmental Spinal Cord Level and Function Level
Function Cl-C6 Neck flexors Cl-Tl Neck extensors C3,
C4, C5 Supply diaphragm (mostly C4) C5, C6 Shoulder
movement, raise arm (deltoid); flexion of elbow
(biceps); 3 externally rotates the arm (supinates) C6,
C7 Extends elbow and wrist (triceps and wrist
extensors); pronates wrist C7, T1 Flexes wrist C7, T1
Supply small muscles of the hand
y Signs of cervical spine injury:-
1. Flaccid extremities
2. Diaphragmatic breathing
3. Facial grimace in response to pain above clavicle but
not below it
4. Hypotension without evidence of hemorrhage
5. priapism
ardiovascular and fluid
management
y 3 things to be considered:-
1. Is the heart beating?
2. Extent and presence of external or internal bleeding
3. Perfusion
y Absence of radial pulse implies BP<80 mm hg
y Absence of carotid pulse implies BP<60 mm hg
y Start CPR immediately
y Look for the cause:-
y ? Hypovolemia
y ? Cardiogenic
 
ssesment of Hemorrhage
y The American college of Surgeons classification of
hemorrhage(ATLS):-

" ,"#$    
 

    

lass 2 15-3 loo loss Tachycar ia,tachy nea, ecrease

ulse ressure,cool s in,slight
anxiety

lass 3 3 - loo loss A ove lus ecrease systolic ,

oliguria an mental confusion or
agitation

lass loo loss A uve lus loss of consciousness

an cool ale s in.
anagement Of Hypovolemic
Shock
,%&$    4*
 "
 
5

20-50% blood loss Crystalloids +RBCs+albumin

>50% blood loss Crystalloids+RBCs+Fresh frozen

plasma

(evidence of myocardial ischemia such

as fatigue,angina,ST-T changes on ECG
and Hct < 20% should serve as
indications for RBC replacement.)
 "echnique Of Fluid hallenge In
Shock
y Arterial systolic and Central Venous Pressure are
measured.
y 200-300 ml of crystalloid solution are infused over 5-10
minutes and the measurements are repeated.

m › a  3  

    
   
     4a

›5 2
No change Rises than falls Repeat fluid challenge
No change Rises and LVFP not low easure pulmonary capillary wedge
remains so pressure and Inotropic therapy.
Important ›arameters In "he
anagement Of Shock
y Pulse
y Blood pressure :-systolic >80 mm hg.
y Central venous pressure :- 5-10 cm HΩO
y Hematocrit:- 30-50%
y Electrolite profiles:- urine sodium >20 mmols/ltr
y Arterial Blood gases:- PaO2-95, PaCO2-40
y Acid base status:-HCO3 = 22-26 mmols/ltr
y Rate of urine output:- 1 ml/min
›erfusion
y Cool,pale,moist skin:- shock until proven otherwise
y Capillary refill >2 sec:-shock until proven otherwise
y Neck veins distended implies cardiogenic shock
y Neck veins flat implies hypovolemic shock
Hemorrhage control
y External hemorrhage:-
X Pressure
X Traction splints
X Suture
y Internal hemorrhage:-surgical intervention
ëeurological status
y It involves rapid assessment of :-
1. Level of consciousness and
2. Pupillary reflex
aevel of consciousness
y AVPU:-
1. Alert
2. Response to verbal commands
3. Response to pain
4. Unresponsive /unconscious
y Differential diagnosis of unconsciousness:-
1. Alcohol
2. Epilepsy
3. Insulin
4. Opiates
5. Trauma
6. Infection
7. Poison
8. shock
  

53m
333m› m3(435
1 NO EYE OPENING.
2 EYE OPENING TO PAIN.
3 EYE OPENING TO VERBAL COAND.
4 EYES OPEN SPONTANEOUSLY.

53m
3a3m› m3(45

1 NO VERBAL RESPONSE
2 INCOPREHENSIBLE SOUNDS.
3 INAPPROPRIATE WORDS.
4 CONFUSED
5 ORIENTATED

C)3m

3m› m3(45
1 NO OTOR RESPONSE.
2 EXTENSION TO PAIN.
3 FLEXION TO PAIN.
4 WITHDRAWAL FRO PAIN.
5 LOCALISING PAIN.
6 OBEYS COANDS.
y Individual elements as well as the sum of the score are
important. Hence, the score is expressed in the form
"GCS 9 = E2 V4 3 at 07:35".
y Generally, brain injury is classified as:
y Severe, with GCS ϐ 8
y oderate, GCS 9 - 12
y inor, GCS ϑ 13.
›upillary reflex
y If direct reflex is absent but consensual reflex is
present:-optic nerve damage.known as marcus gunn
pupil.
y If direct as well as consensual reflex is absent:-
transtentorial herniation causing compression of
occulomotor nerve
Signs of increased intracranial
pressure
y Headache,nausea and vomitting
y Pupillary dilatation
y Altered consciousness
y Cushingǯs triad:
1. Increased systolic blood pressure
2. Widened pulse pressure
3. bradycardia
History
y Allergy
y edications
y Past illness
y Last meal
y Events preceding the injury
aaboratory investigations and
radiography
y   
"(
:-
X remains unchanged for several hours following acute
haemorrhage if no intravenous replacement is given.
X In patients given fluid therapy,it falls by 3 point for every
1 unit blood loss.

%(
3.   
)(m 
   
y   
1. Blood,glucose,drugs,toxins etc
y Chest X rays:-
X Every trauma patient should have a chest x ray early in
the course of resuscitation.
X Can diagnose hemothorax,pneumothorax etc
y Lateral spine:-indicated in
X Stable patients with major craniofacial trauma
X Physical signs of cervical spine injury
y CT Scans:-indications
X Altered mental status
X Ipsilateral fixed dilated pupil
X Contralateral hemiperesis
X High velocity trauma to the skull and face
X CSF leakage
3pi dural hematoma
3xposure and examination
y What we cant see,we cant treat!
y Disrobe the patient completely and perform rapid
examination of the entire body.
y Scalp:-lacerations,swelling,any sign of skull fracture
y axillofacial region:-
X soft tissue lacerations
X Eye-subconjunctival heamorrhage,pupillary
reflex,extraocular muscles
X Nose-bleeding,CSF rhinorrhea,fracture,obstruction
X Ear-bleeding and CSF ottorrhea
X axilla-for Le Fort fractures and airway obstruction
X andible-fractures
X Oral cavity-occlusion and airway obstruction
y Neck:-distended veins,lacerations,swelling
y Chest:-chestwall movements,lacerations,rib fractures
y Abdomen:-lacerations,distensions
y Extremities:-fracture and hemorrhage
y onitor and resuscitate as required
y Once patient is stable proceed towards secondary
survey
y Finally definative treatment and rehabilitation
onclusion
y In the pre hospital set up,ǯit is better to scoop and run
than to stay and playǯ
y The ATLS guideline of ABCDE should be followed
religiously for better chance of survival of the
traumatised patient
y Trauma is preventable and everybody can contribute.
¦ibliography
y Oral and maxillofacial trauma,fonseca and walker
third edition,vol 1.
y Rowe and williamǯs maxillofacial injuries,second
edition,vol 1
y Petersonǯs principles of oral and maxillofacial
surgery,second edition,vol 1.
y Hamilton baileyǯs emergency surgery,twelfth edition
y Bailey and loveǯs short practice of surgery,twenty
second edition.
THANK YOU