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TRAUMA OVERVIEW

Mark E. Armstrong, M.D.

Overview
1. Preparation
2. Triage
3. Primary Survey
4. Resuscitation
5. Secondary Survey
6. Continued postresuscitation
monitoring and re-evaluation
7. Definitive care

Preparation
Prehospital

Notify receiving hospital


Closest appropriate facility
Report pertinent information

Inhospital

Warmed IV solutions
Ancillary departments notified
Equipment made readily available

Hospital personnel protection

Primary Survey
Airway
Breathing
Circulation
Disability: Neurologic
Evaluation
Exposure/Environmental Control

Primary Survey
Airway

Patency
Foreign bodies
Facial Fractures
Protect C-spine

Primary Survey
Breathing

Patency does not equal adequate ventilation


Expose chest
Auscultate
Conditions that may acutely impair
ventilation
Tension pneumothorax

Massive hemothorax
Flail chest
Rib fractures
Open pneumo
Pulmonary contusion

Primary Survey
Circulation
Hemorrhage control
Two Key Elements
1. Level of Consciousness
-AVPU
-Glasgow Coma Score
2. Pulse

Bleeding
Control
No hemostats
Consider occult sources

Primary Survey
Disability
AVPU

Glasgow Coma
Verbal Response
Oriented
6
Confused
Inappropriate words
Incomprehensible sounds
None
1

Eye Opening
Spontaneous
To speech
To pain
None

4
3
2
1

Motor response
5
4
3
2
1

Obeys
Localizes
Withdraws
4
Decortication
3
Decerebration
None

Primary Survey
Exposure
Remove all clothes
Cover to prevent hypothermia

Resuscitation
Airway
Oral
Nasal- do not put in someone with
facial
trauma

Endotracheal

Surgical

Breathing

Supply O2
Ventilate alveoli

Resuscitation
Circulation

Establish 2 large bore IVs


Draw blood
Vigorous IV therapy
ECG monitoring
Avoid hypothermia
Evaluate PEA
Other dysrhythmias

Hemorrhage classification
Class

% blood
loss
10 19
(750 cc)

Heart rate

Blood
pressure

II

20 29
(1250)

>100

Slightly

III

30 39
(2000)

>120

IV

>40

>140

Pulse
pressure

Resp rate

Capillary
refill
Normal

Urine
output

Other

Mortality

Oliguria

Acidosis

25%

Delayed

(>30)

Very
Delayed

Anuria

60%

Resuscitation
Catheters
Urinary

Rectal first
Check for other signs of urethral
injury

Gastric

Oral v.s. nasal placement

NGT Intracranial

Resuscitation
Monitoring

ABGs
Pulse oximetery
Blood pressure
ECG

Roentgenograms

Should not delay resuscitation


AP pelvis
AP chest
Lateral C-spine
Odontoid, AP C-spine

Other Imaging
FAST scan
Focused Assessment Sonography in Trauma

Ultrasound
1. Pericardial sac (epigastric area)
2. Hepatorenal fossa
3. Splenorenal fossa
4. Pelvis or Pouch of Douglas (bladder)

Secondary Survey
Head-to toe evaluation
Vital sign evaluation
Detailed neuro exam if not
done in primary survey

Special procedures

Tubes and fingers in every


orifice

Secondary Survey
History

A Allergies
M Medications
P Past illnesses
L Last meal
E Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment

Secondary Survey
History

A Allergies
M Medications
P Past illnesses
L Last meal
E Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment

Secondary Survey (PE)


Head

Scalp
Eyes
Nose
Mouth
Bite occlusion

Secondary Survey (PE)


Head
PITFALLS
Hyphema
Optic nerve injury
Lens dislocation
Head injury
Posterior scalp laceration

Secondary Survey (PE)


Maxillofacial

Midline facial fractures


Bite occlusion
Bleeding
Fracture repair can wait

Midface Fractures
LaFort
I: Maxilla only transversely above the
alveolar ridge
Most common isolated

II (pyramidal): Through nasal bone or


nasal bone disarticulation with frontal
bone
Most common when associated with other fractures

III (dislocated face): Through nasal bone,


across floor of orbit, through lateral
wall of orbit, zygomatic arch
Rare

Secondary Survey (PE)


Maxillofacial
PITFALLS
Pending airway obstruction
Changes in airway status
Cervical spine injury
Exsanguinating midface fracture
Lacrimal duct lacerations
Facial nerve injuries

Secondary Survey (PE)


C-spine and neck

Must be immobilized
Inspection
Palpation
Auscultation (carotids)

Secondary Survey (PE)


C-spine and neck
PITFALLS
C-spine injury
Esophageal injury
Tracheal or laryngeal injury
Carotid injury (blunt or
penetrating)

Secondary Survey (PE)


Chest

Visual evaluation (ant & post)


Palpate rib cage
Sternal pressure
Auscultation (heart & lungs)
Chest xray

Secondary Survey (PE)


Chest
PITFALLS
Tension pneumothorax
Open chest wound
Flail chest
Cardiac tamponade
Aortic rupture (widened
mediastinum)

Pneumothorax

Tension Pneumothorax

Secondary Survey (PE)


Abdomen
Frequently repeated exams
Inspection
Palpation
Normal initial exam does not
rule out injury
Peritoneal lavage v.s. CT scan
v.s. U/S (FAST)

Secondary Survey (PE)


Abdomen
PITFALLS
Liver or splenic flexure
Deceleration injuries
Hollow viscus, Lumbar spine

Pancreatic injury
Major intraabdominal vascular injury
Renal injury
Pelvic fractures

Secondary Survey (PE)


Perineum/Rectum/Vagina

Contusions,Hematomas, Lacerations
Urethral bleeding
Rectal blood
High riding prostate
Sphincter tone
Vaginal vault injuries (pelvic
fractures)

Secondary Survey (PE)


Perineum/Rectum/Vagina
PITFALLS
Urethral injury
Rectal injury
Bladder injury
Vaginal injury

Retrograde urethrogram

Secondary Survey (PE)


Musculoskeletal

Contusion
Deformity
Palpation
Pelvic pressure and compression
Vascular exam
Neurologic exam

Secondary Survey (PE)


Musculoskeletal
PITFALLS
SPINE FRACTURES
Fractures with vascular
compromise
Pelvic fractures
Digital fractures

Secondary Survey (PE)


Neurologic
Immobilization of entire patient
Reevaluate GCS
Cranial nerve exam
Motor exam
Sensory exam
Monitor frequently for changes in neuro
status
Assess O2 delivery if changes noted
Early neurosurgical consultation

Secondary Survey (PE)


Neurologic
PITFALLS
Increased intracranial pressure
Subdural hematoma
Epidural hematoma
Depressed skull fracture
Spine injury
Beware of unconscious patient

Subdural Hematoma

Epidural Hematoma

Aftercare
Continuous reevaluation
Definitive care