In itial

M an ag em e
nt
in Trau m a
Phakawat Chunthong,MD
Trimodal distribution of death
 Timing of Death Resulting from
Trauma
The first peak
50%
Death at the time of injury
Primary injury to major organs such as
brain,heart,great vessels
The injuries are irrecoverable, rapid
treatment and transfer may salvage some
patients
Primary prevention
 Timing of Death Resulting from
Trauma
The second peak
30%
From the end of the first peak to several hours
GOLDEN HOUR
Morbidity and mortality are prevented by avoidance
of a secondary injury due to
hypoxia,hemorrhage,inadequate tissue perfusion
Intracranial hematoma,major hemorrhage from
viscera,bones and vessels or hemothorax
ATLS [Advanced Trauma Life Support] 9%
Prehospital and in hospital
 Timing of Death Resulting from
Trauma
The third peak
20%
Death occurs days or weeks after the injury
Sepsis and multiple organ failure
Advances in intensive care reduce deaths
Improvements in initial management on
admission reduce morbidity and mortality
 ATLS guideline
1. preparation
2. triage
3. primary survey[ABCDE]
4. resuscitation
5. adjuncts to primary survey and
resuscitation
6. secondary survey
7. adjuncts to secondary survey
8. continued post resuscitation monitoring
and reevaluation
9. definitive care
 Preparation
1.Prehospital phase [EMS]
Notify receiving hospital
Airway maintenance, control of external
bleeding and shock, immobilization of the
patient
2.Inhospital phase
Resuscitation area
Equipment, monitor,warmed fluid
Trauma team
Protective communicable disease
 Cap
Gown
Gloves
Mask
Shoe Covers
Goggles / face
shield
 Triage
Sorting of patients according to
ABCDEs
Available resources

Multiple
Mass
 Primary survey and
resuscitation
identify immediately treatable life
threatening injury with initial
resuscitation
A airway maintenance with cervical spine
control
B breathing and ventilation
C circulation and bleeding control
D disability:neurologic status
E exposure/environmental control:complete
undress the patient but prevent hypothermia
 A airway maintenance with
cervical spine control
Talk to the patient
Check the airway patency: secretion,
blood, stridor
C-spine protection
 A airway maintenance with
cervical spine control
Basic airway management

1.remove of foreign material from mouth

and pharynx
2.Chin lift and jaw thrust
3.Oropharyngeal or nasopharyngeal
airway
 A airway maintenance with
cervical spine control
Definitive airway

1.orotracheal intubation
2.nasotracheal intubation
3.surgical airway
3.1 cricothyroidotomy
3.2 tracheostomy
 A airway maintenance with
cervical spine control
orotracheal nasotracheal
intubation intubtion

cervical
spine injury
A airway maintenance with
cervical spine control
 A airway maintenance with
cervical spine control
surgical airway
failure endotracheal intubation
maxillofacial injury,blunt or penetrating
intubate
neck injury

Cricothyroidotomy
1.Needle cricothyroidotomy
2.Surgical cricothyroidotomy
Tracheostomy
 A airway maintenance with
cervical spine control
1.Needle cricothyroidotomy
2.Surgical cricothyroidotomy
 A airway maintenance with
cervical spine control
C-spine protection

unconscious
GCS 8
Neck pain
Quadriplegia, paraplegia, hemiplegia
 B breathing and ventilation
Respiration
Chest movement
RR
Tracheal position
Breath sound
Subcutaneous emphysema
Inspection of neck vein and wound
B breathing and ventilation
Tension pneumothorax
Flail chest
Open chest wound
Massive hemothorax
Tension pneumothorax
 Tension pneumothorax
Chest pain Tracheal deviation
Air hunger Unilateral absence
Respiratory of breath sound
distress Neck vein
Tachycardia distention
hypotension Cyanosis
Tension pneumothorax
 Tension pneumothorax
Management
Immediate decompression: needle
thoracocentesis (Rapidly inserting a
large-bore needle into the 2nd intercostal
space , midclavicular line of the affected
side)
Definitive treatment: chest tube
 Flail chest


2 1
3



1
costochondral separation fracture
sternum
lung contusion,pneumothorax,hemothorax
paradoxical respiration
hypoventilation
( pain) hypoxia( pulmonary
Flail chest
Flail chest
 Open chest wound
sucking chest wound

2/3 trachea


respiratory distress
sterile
occlusive dressing plaster 3
chest tube

Open chest wound
Open chest wound
 Massive hemothorax


1,500 ml
tension pneumothorax
chest drain
fluid resuscitation
indication for thoracotomy


chest tube 1,500 ml

Massive hemothorax
 C circulation and bleeding
control
BP, PR, LOC
Skin color, capillary refill
External bleeding site
Internal bleeding site: thorax,
abdomen, pelvis, extremities
 Cl ass 1 Cl ass 2 Cl ass 3 Cl ass 4
Blood loss (ml) 750 750-1,500 1,500-2,000 > 2,000

Blood loss (% ) 15 15-30 30-40 >40

Pulse <100 >100 >120 >140

BP normal normal

Pulse pressure

Capillary refill normal Slow (>2s) Slow (>2s) undetectable

RR 14-20 20-30 30-40 >35

Urine >30 20-30 5-15 negligible

output(ml/hr)

Mental status slightly anxious mildly anxious anxious/confused confused/

lethargic

Fluid crystalloid crystalloid crystalloid Crystalloid

replacement plus blood plus blood
 C circulation and bleeding
control
Warmed Balnced salt solution
2 large bore
2 liters in 10-15 mins, child bolus
20 ml/kg
G/M
 C circulation and bleeding
control
Hemorrhagic shock
Cardiogenic shock
neurogenic shock
 Hemorrhagic shock
Initial fluid therapy

hypotension

bolus 2 10-15
bolus 20 ml/kg
1.Rapid response
2.Transient response
3.Minimal or no response
 Hemorrhagic shock
Rapid response




fluid maintenance
20%
 Hemorrhagic shock
Transient response
initial fluid bolus





fluid

fluid

20-40%
 Hemorrhagic shock
Minimal or no response
fluid





pump failure cardiac injury
 Cardiogenic shock

Myocardial dysfunction
tension pneumothorax, myocardial contusion,
cardiac tamponade, air embolism, myocardial
infarction
Cardiac tamponade penetrating
injury Becks triad
venous pressure elevation, hypotension,

distance heart sound
tension pneumothorax
myocardial contusion blunt chest
Cardiogenic shock
 neurogenic shock

spinal cord injury

mid thoracic
head injury

hypovolemic shock severe
brain injury

loss symphathetic tone
vasodilatation
 neurogenic shock

hypotension heart rate

initial treatment fluid
resuscitation adequate
resuscitation hypotension
vasopressor drug

CVP monitoring
D disability:neurologic status
GCS
Pupils size and light reaction
 GLASGOWCOMA SCALE
Vari ables Scor e
Eye openi ng Spontaneous 4
To speech 3
To pain 2
None 1
Verbal response Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best mot or response Obeys commands 6
Localizes pain 5
Normal flexion 4
Abnormal flexion 3
Extension 2
None 1
 E exposure/environmental
control
Undressed
Exam back region
All entry and exit wound
Prevent hypothermia(warming light,
warm blankets, warm resuscitation
fluid, warm inspired air)
Patients right, closed area
adjuncts to primary survey and
resuscitation
Vital signs
ECG
O2 sat,pulse oximeter
Uinary and gastric catheter
Urine out put
Trauma film:lateral c-spine,CXR,pelvis
DPL/FAST
 Primary survey and
resuscitation
Protect and secure airway
Ventilate and oxygenate
Stop the bleeding!
Vigorous shock therapy
Protect from hypothermia
secondary survey
The complete
history and
physical
examination
 Secondary survey
History
Physical exam: head to toe
tubes and fingers in every orifice
Complete neurological exam
Special diagnosis tests
reevaluation
 Secondary survey
History
AMPLE
A:Allergies
M:Medication currently being taken by the
patient
P:Past illness and operations,pregnancy
L:Last meal
E:Event/Environment related to the injury
 Secondary survey
Mechanism of injury
 Secondary survey
HEAD
Signs of skull base Contact lens
fracture Dislocation of lens
Pupillary size Hyphaema
Hemorrhages of Ocular movement
conjunctiva/fundi Posterior scalp
Visual acuity laceration
Penetrating injury
 Secondary survey
MAXILLOFACIAL
Associated with airway obstruction or
major bleeding
Fracture cribriform plate
No NG tube [performed oral route]
 Secondary survey
NECK
Cervical tenderness, subcutaneous
emphysema
Oesophageal injury
Tracheal/laryngeal injury
Carotid injury (penetrating/blunt)
 Secondary survey
CHEST
Inspect
Palpate
Percuss
Auscultate
Obtain x-rays
 Secondary survey
ABDOMEN
Inspect
Auscultate
Palpate
Percuss
Reevaluate
Special studies
 Secondary survey
Perineum:contusion,hematoma,
laceration,urethral blood

Rectum:sphincter tone,high riding

prostate,pelvic fracture,rectal wall
integrity,blood

Vagina:blood,laceration
 Secondary survey
Musculoskeletal
Contusion,
deformity
Pain
Perfusion
Peripheral
neurovascular
status
X-ray
 Secondary survey
Neurologic: brain
GCS Score

Lateralizing signs
Frequent reevaluation
Prevent secondary brain injury
 Secondary survey
Neurologic: spine and cord
Complete motor and sensory exams

Imaging as indicated
Reflexes
Adjuncts to secondary survey
Special diagnostic tests as indicate
CT
Contrast x-ray studies
Extremity x-ray
Endoscopy
Ultrasound
 Monitoring and revaluation
Minimize missed injury
High index of suspicion
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1ml/kg/hr
Pain relief -- IM should be avoid
 Definitive care
OR
ICU
Refer