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TRAUMA CARE
CELSO M. FIDEL, MD, FPCS,
FPSGS
LOVE your
CALLING with
PASSION.
It is the
MEANING of
your LIFE
Vehicular Accident
Smash up Cars
Primary Survey
Initial Assessment used to identify and
treat conditions that pose as immediate
treat to patients life.
Survey the scene; make sure that its
safe
Check for responsiveness by gently
shaking the patients shoulders and
asking him ARE YOU OKEY?
Primary Survey
4 Levels of Responsiveness
Primary Survey
WHAT DO YOU INITIALLY DO TO AN
INJURED PATIENT?
A. ENSURE ADEQUATE AIRWAY
B. BREATHING
C. CIRCULATION AND HEMORRHAGE
CONTROL
D. DISABILITY( NEUROLOGIC STATUS)
E. EXPOSURE OF THE PATIENT/
ENVIRONMENTAL FACTORS(COMPLETELY
UNDRESS THE PATIENT)
Primary Survey
A. ENSURE ADEQUATE AIRWAY
Responsive patient- if patient can speak the
airway is not obstructed.
Unresponsive patient- needs aggressive
airway maintenance immediately; make
sure airway is open and patient is breathing
adequately.
Trauma patient- establish adequate airway
and cervical spine control. Apply cervical
collar if needed.
AIRWAY PATENCY
Primary Survey
A. ENSURE ADEQUATE AIRWAY
Airway Obstruction Management
Advantages of OROTRACHEAL intubation
direct visualization of the vocal cords
ability to use larger diameter
endotracheal tubes
applicability to apneic patients
Operative
Intervention>CRICOTHYROIDOTOMY
only tubes < 6mm can be inserted
Primary Survey
A. ENSURE ADEQUATE AIRWAY
Airway Obstruction Management
Snoring and gurgling sound implies partial
.
PHARYNGEAL OCCLUSION; Hoarseness implies
LARYNGEAL OBSTRUCTION.
Nasotracheal intubation- for patients breathing
spontaneously.
Orotracheal intubation- for cervical spine injuries
provided manual in-line cervical immobilization
is
maintained.
Primary Survey
HOW DO WE MAINTAIN THE AIRWAY AND
SAFEGUARD THE CERVICAL SPINE?
Crash Helmet should be left in place until a cross
table x-Ray has been done and the cervical spine
cleared of any injury.
Orotracheal or nasotracheal airway can be helpful
Needle or Surgical Cricothyroidotomy is an easy,
fast and safe access to the airway.
Endo tracheal Intubation; best airway maintenance
device.
Primary Survey
HOW DO WE MAINTAIN THE AIRWAY AND SAFEGUARD
THE CERVICAL SPINE?
Keep airway patent w/o compromising spine
injury.
The AIRWAY must be cleared of blood, loose
teeth and dentures, or foreign bodies.
Do the JAW THRUST maneuver w/o hyperextension
of the head.( grasping the angles of the
lower jaw and displacing the mandible
forward)
Strap forehead of the victim on the stretcher
or any board used to immobilize the
patient with sandbags on both sides of the
head.
Primary Survey
B. HOW DO WE ASSESS BREATHING?
Assess for adequacy of ventilation and
maximum gaseous exchange.
PATENCY of the AIRWAY does NOT mean
that VENTILATION is adequate.
Expose and examine the chest for rate &
depth.
Inspect and palpate the neck and chest for
evidence of external trauma, fractures,
tracheal deviation & disparity, subcutaneous
emphysema, lack of movement of hemithorax
Percuss for hyperresonance and dullness
Primary Survey
B. BREATHING
ADEQUATE BREATHING
full rise and fall of chest
early breathing
normal respiratory rate 12-20/min
INADEQUATE BREATHING
Primary Survey
B. BREATHING
Remember cyanosis is a late sign, and should
not be relied upon to determine inadequacy
of ventilation
Measurement of end tidal CO2 is the most
sensitive indicator of adequacy of ventilation.
Causes of inadequacy of ventilation
Tension pneumothorax
Open pneumothorax
Flail chest/ pulmonary contusion
Primary Survey
B. BREATHING
Management
Commence 100% oxygen; Patients with
inadequate ventilation may require assisted
ventilation
Suction secretions
Tension/open pneumothorax management
Open pneumothorax should be closed by
plastic wrap, sealing only 3 sides
Taping of an examining glove with one
finger cut will allow the same.
Primary Survey
Primary Survey
C. HOW DO WE ASSESS CIRCULATION ?
Not only controlling hemorrhage but, also
restoring adequate perfusion.
Skin perfusion( color, temperature, moisture,
capillary return). BLANCH TEST
Responsive PATIENT; Pulse rate, quality, and
regularity)
Appreciable pulse>> At least 80 mmHg
Systolic
Femoral pulse >>> At least 70 mmHg.
Systolic
Carotid Pulse >>>
60
.
Primary Survey
C. HOW DO WE ASSESS CIRCULATION ?
Irregular suggest ; cardiac abnormality
threading means HYPOXIA; cardiac rate
and rhythm; Check BP if possible.
Mental Status .Check consciousness level. In
the absence of head injury a fall in level
signifies>>>Diminished cerebral perfusion
Unresponsive patient- check carotid pulse;
Present if systolic pressure is 60 mm Hg.
Determine rate of external hemorrhage.
CIRCULATION
Primary Survey
WHAT ARE THE PRIORITIES OF HYPOVOLEMIC
SHOCK?
Gain access to the circulation
Rapidly transfuse fluids or volume expanders
Obtain blood samples and send for
BASELINE studies such as hematocrit,
typing and cross matching.
Replace Blood loss
Stop the Bleeding
Primary Survey
C. CIRCULATION & CONTROL OF
HEMORRHAGE
Management:
Control external hemorrhage by direct
pressure; No tourniquets/hemostats.
Primary Survey
C. CIRCULATION & CONTROL OF
HEMORRHAGE
Management:
Apply pneumatic splint
Begin cardiac monitoring
Insert an indwelling catheter and
nasogastric tube unless contraindicated
Prevent hypothermia
CARDIOPULMONARY RESUSCITATION
Primary Survey
D. DISABILITY (DO BRIEF NEUROLOGIC EXAMINATIONS)
Determine level of consciousness
A Alert
V Vocal stimuli response
Can he speak?
Does he make sense?
P Pain stimuli response
U- Unresponsive
Primary Survey
Check Pupils
size; evidence of inequality
reaction
response to light
Sensory- can feel in all parts of body?
Motor- can move all limbs?
Airway
Systolic Blood Pressure
NORMAL
+2
MAINTAINABLE +1
NOT MAINTAINABLE -1
> 90 mm Hg
50-90 mm Hg
< than 50 mm Hg
+2
+1
-1
>>TRAUMA SCORING
PEDIATRIC Trauma Scale>> In the
absence of proper size BP cuff,
Assess BP by assigning these
values:
Pulse palpable at Wrist>>>>>+2
Pulse palpable at Groin>>>>> +1
Pulse not Palpable>>>>>>>>>>> -1
>>TRAUMA SCORING
4.EYE OPENING
> 89
13-16
Spontaneous
76-89
9-12
Opens on Command or
50-75
6-8
verbal stimuli
1-49
4-5
Response to pain
Nil
2. RESPIRATORY RATE
5. MOTOR RESPONSE
6. VERBAL
10-29
Obeys Command
Conscious, Coherent
> 29
Localizes Pain
Disoriented/Incoherent
6-9
Withdraws to Pain
Inappropriate Words
1-5
Abnormal Flexion
Incomprehensible Sounds
Abnormal Extension
Nil
IF THE PATIENT HAS A SCORE < 11 CRITERION for direct transport into a TERTIARY HOSPITAL OR
A TRAUMA CENTER.
SECONDARY SURVEY
What are the Important points in the
HISTORY of TRAUMA VICTIMS?
Systematic Evaluation
S- Signs and symptoms
A- Allergies
M- Medications taken
P- Pertinent History
L- Last meal taken
E- Events preceeding the injury
SECONDARY SURVEY
Physical Examinations
Look for signs of injury
D- Deformities
O- Open injuries
T- Tenderness
S- Swelling
SECONDARY SURVEY
Physical Examinations Head to Toe
Examination of the Head
A. Scalp and Skull ;Look for signs of injury
D- Deformities
O- Open injuries
T- Tenderness
S- Swelling
SECONDARY SURVEY
A. Scalp and Skull
Brisk bleeding= rapid suture closure
Nasopharyngeal bleeding= French
20 foley catheter
Ecchymosis about the ear (battle sign); or
about the eyes (raccoon eyes)= presumptive
evidence of BASAL SKULL FRACTURE
SECONDARY SURVEY
B. Pupils
Symmetry
Reactivity
Size
C. Ears and Nose
Blood or Fluid from opening
SECONDARY SURVEY
D. Mouth
D- Deformities
O- Open Injuries
T- Tenderness
S- Swelling
F- Foreign Bodies
SECONDARY SURVEY
A. Examination of the Neck
D- Deformities
O- Open Injuries
T- Tenderness
S- Swelling
B. Cervical Vertebrae
Deformities
Palpate for step-up Deformities
SECONDARY SURVEY
Examination of the Chest; Check for
Symmetry of Expansion
Breath Sounds
Abrasions
Subcutaneous Emphysema
Open Wounds
Rib or Clavicular Fracture
SECONDARY SURVEY
Examination of the Abdomen
A. Inspection
Deformities; Abdominal Distension
Open Injuries
Protruding Organs
Swelling & Discoloration
SECONDARY SURVEY
B. Palpation
Rigidity ( Hardness)
Tenderness
Masses
C. Auscultation
Listen for bowel sounds
SECONDARY SURVEY
Diagnostic Aids for the Abdomen
Diagnostic Peritoneal Lavage for
suspected blunt injury
One shot IVP if GU injury is suspected
A Cystogram may be done by clamping
the catheter
CT scan if accessible and available can
be done on stable patients
SECONDARY SURVEY
Examination of the Pelvis and Rectum
Check for scrotal hematoma
Check for blood in the urethral meatus
Check for a high lying prostate
Blood on rectal exams may indicate injury to
the rectum or neighboring organs
Blood in the vagina vault or introitus
may indicate pelvic fracture
SECONDARY SURVEY
Examination of the Back
A. Inspection
Chest Wall deformities
Open Injuries
Foreign Objects
Dislocation
B. Palpation
Palpate for deformities along spine
Tenderness
SECONDARY SURVEY
Examine Upper & Lower Extremities
A. Inspection
>> Deformities, Open injuries, Swelling
>> Color
>> Motion, Wiggle test
>> Sensation
B. Palpation
>> Tenderness
>> Crepitation
>> Deformities
SECONDARY SURVEY
Measuring Vital Signs
1. Respiration
2. Pulse Rate
3. Blood Pressure
Increased BP
1. Cold environment
2. Stress; Pain
3. Smoking
4. Caffeine
5. Decongestant
Decreased BP
1. Heart failure
2. Trauma
3. Shock
SECONDARY SURVEY
Pupils
Normal Findings
Abnormal Findings
> constricts when >> No reaction to
exposed to sunlight
light
>> Remains constricted
>Dilate with less
>> Fixed, dilated or
light
unequal
>Should be of the same size
SECONDARY SURVEY
ESSENTIAL LAB. PROCEDURES
Baseline Hematocrit, Blood Typing, and Cross
Matching.
A cross table x-Ray of the cervical spine w/o
the victim being hyperextended. Swimmers
view if not possible; x-Ray tube positioned at
axilla directed to C-7. It will view lower
Cervical vertebra and T1.
SECONDARY SURVEY
WHERE and HOW do WE LOOK for Blood Loss?
There are three sites for exsanguinating
hemorrhage:
CHEST
ABDOMEN
THIGH (2-3 liters of blood in Hematoma)
SECONDARY SURVEY
Patients with injury to these sites; Thoracic is
1st followed by Abdomen then extremities.
Control of life threatening activities takes
precedence over limb salvage.
Chest x-Ray important especially looking for
sites of blood loss.
HEAD INJURIES
All injuries to the head are potentially
dangerous
Proper assessment of consciousness
>> If impaired
Damage to the brain
Damage to the vessel inside the skull
Skull fracture
HEAD INJURIES
I.CONCUSSION
Widespread but temporary disturbance of the
brain due to a violent blow to the head.
A. REGOGNITION
1. Dizziness or nausea on recovery
2. Loss of memory of events at the time
of or immediately preceeding the injury
3. Mild generalized headache
HEAD INJURIES
II. SKULL FRACTURE
1. Suspected in patients of trauma with a
head wound
2. There maybe brain damage & bacteria
may pass thru easily
3. Patient is unconscious after head injury
Vomiting
Blurred vision
Headache
Neck and back pain
Dizziness
Confusion
Any obvious depression or break in the skull
Any obvious sign or bleeding including
periorbital swelling and/or hematoma
Fluid dripping from the ears or nose
HEAD INJURIES
III. CEREBRAL COMPRESSION
Very serious condition requiring surgery
Occurs when a pressure is exerted on the brain
within the skull due to:
accumulation of blood
swelling of the injured brain
Associated with head injury and skull fracture
Maybe associated with stroke, infection and
brain
tumor
HEAD INJURIES
A. RECOGNITION
HEAD INJURIES
NO
YES
YES
BLEEDING STOPPED?
NO
BLEEDING STOPPED?
YES
NO
NO
7. SEEK MEDICAL
ATTENTION
HEAD INJURIES
1. CHECK ABCs & TREAT ACORDINGLY
2. CHECK FOR POSSIBLE SPINAL
INJURY
IMMOBILIZE HEAD AND NECK
HEAD BLEEDING
YES
N
O
NO
UNCONSCIOUS
YES
NO
PENETRATING WOUNDS
YES
NO
YES
IMPALED OBJECTS
NO
PROTRUDING ORGANS ?
YES
2. DO NOT REMOVE OBJECT
Stabilize subject
resuscitate if necessary
Impaled objects should not be removed
and should be stabilized by bunching
dressing around it then fixed with
adhesive tape
Protruding intestine should be covered
to prevent drying. If casualty coughs
prevent further protrusion by pressing
on the moist dressing
CHEST INJURIES
Flow Chart
CHECK ABCs and TREAT ACCORDINGLY
NO
YES
PENETRATING WOUNDS
NO
NO
SUCKING
CHEST WOUNDS
IMPALED OBJECTS
YES
YES
DO NOT REMOVE OBJECT
Stabilize subject
SEAL WOUND
TO PREVEN T
AIR TO ENTER
RIB FRACTURE
5.SEEK MEDICAL
ATTENTION
4. STABILIZE RIBS
and CHEST
AVULSIONS
Wash and clean wound
Control bleeding by direct pressure
Compression dressing
Call an ambulance or medical team.
or bring the patient to a hospital
AMPUTATIONS
Amputation is forceful partial or complete
AMPUTATIONS
AMPUTATIONS
CARE OF THE AMPUTATED PART
Wrap the severed part in a plastic bag
Wrap again in gauze or soft fabric,
place in another container filled with
crushed ice
Clearly mark the package w/ casualtys
name time of injury and give it
personally to the medical personnel.
Impalement
This is a condition wherein a foreign
object is protruding from a casualtys
body
1. Do not remove the impaled object
unless it is impaled in the cheek or
affecting the airway or CPR
2. Check the airway & breathing. Be
ready to resuscitate if necessary
Impalement
3. Check the airway & breathing. Be
ready to resuscitate if necessary
4. Control the bleeding
5. Prevent further injury by stabilizing
the object with bulky dressing, then
applying bandage
6. Call an ambulance or a medical team
Gunshot Wounds
Military gunshot wounds are often heavily
contaminated with delays in treatment.
The severity of the wound does not
depend on the velocity of the bullet but
depends on the amount of kinetic
energ transferred to the tissues. .
Gunshot Wounds
. How to Manage:
Crushing Injuries
Common among casualties who
have been crushed beneath debris
because of explosives, natural disasters,
or vehicular disasters. They are at
risk of developing Crush Syndrome
or traumatic rhabdomyolysis resulting
from skeletal muscle injury with
release of muscle cell content into
the general circulation.
Crushing Injuries
Crushing Injuries
TREATMENT for CRUSHING VICTIMS
Casualties Crushed for less than 10 minutes
Release the casualty as quickly as possible
Control external bleeding & cover wound
Secure & support suspected fracture
Examine & observe for shock; Treat
accordingly
Call for an ambulance. Insert an IV
line
Crushing Injuries
TREATMENT for CRUSHING VICTIMS
Casualties Crushed for more than 10
minutes
Call for an ambulance or medical team
Insert an IV line while waiting for an
ambulance
Comfort and reassure casualty until
help comes
Blast Injury
Injuries Sustained in Blast Explosions
1. Rupture of the Tympanic Membrane=
Ear pain;ringing in the ears; hearing
loss
2. Respiratory Effects= Inhalation injury;
airway hemorrhage
3. Skull Fractures
4. Burns
5.Fractures
Blast Injury
Injuries Sustained in Blast Explosions
6. Traumatic Brain Injury
7. Arterial Air Emboli= Confusion;
disorientation; focal neurologic signs
Blast Injury
TREATMENT of VICTIMS in Blast Explosions
1. Lay the casualty on the ground. Reassure
patient.
2. Maintain an open airway. Check breathing.
Be ready to resuscitate if necessary.
3. Control bleeding; Cover wounds with clean
and if possible sterile dressing. May apply
a cervical collar if neck injury is suspected.
4. Call an ambulance or medical team; May
start an intravenous line if trained to do so.
5. Continuously monitor patient until help arrives
Eye Wounds
The Eye can be bruised or cut by direct blows
or by sharp, chipped fragments of metal &
glass. All eye injuries are potentially
serious. Corneal injury can lead to scarring
with resultant loss of vision. There may be
rupture of the eyeball.
RECOGNITION
Visible Wound
Bloodshot appearance to the injured eye
Partial or total loss of vision
Leakage of blood or fluid from the wound
Eye Wounds
TREATMENT
1. Lay the casualty down on his back, holding
his head to keep it as still as possible.
2.Tell the casualty, keep both eyes still;
movement of the good eye will cause
movement of the injured eye; Do not
touch, attempt to remove an embedded
foreign body.
3. Ask the casualty to hold an eye pad over
injured eye. Bandage the pad in place.
4. Take or send the casualty to a hospital.
Internal Bleeding
TREATMENT
1. Help the casualty to lie down; raise and
support his legs. Loosen clothing at the
neck, chest and waist. If unconscious
place him with injury uppermost.
2. Call for an ambulance or a medical team.
3. Insulate him from the cold. Monitor and
record breathing, pulse and level of
response every 10 minutes.
4. Note the type, amount and source of blood
loss coming from bony orifices.
1.
2.
1.
2.
3.
4.
5.
Nosebleeds
Most commonly occurs when blood vessels
inside the nostrils rupture. It is usually
unpleasant, but can be dangerous if casualty
loses a lot of blood. Thin & watery nosebleeds
after head injury is serious problem= CSF leakage.
TREATMENT
1. Sit the casualty down with his head held
forward. Do Not let his head tip back; blood
may run down his throat and induce vomiting.