Trauma (injury)

• is defined as cellular disruption caused by an exchange

with environmental energy that is beyond the body’s
resilience which is compounded by cell death due to
ischemia/reperfusion
• remains the most common cause of death for all
individuals between the ages of 1 and 44 years
• third most common cause of death regardless of age
• leading cause of years of productive life lost.
INITIAL EVALUATION AND
RESUSCITATION OF THE
INJURED PATIENT
Primary Survey

Advanced Trauma Life Support (ATLS)

– was developed in the late 1970s, based on the premise that
appropriate and timely care can significantly improve the
outcome for the injured patient
– emphasizes the “golden hour” concept that timely, prioritized
interventions are necessary to prevent death and disability
– assessment of the “ABCs” (Airway with cervical 2 spine
protection, Breathing, and Circulation)
Airway Management with Cervical Spine Protection

• Ensuring a patent airway is the first priority in the primary survey

• efforts to restore cardiovascular integrity will be futile unless the oxygen
content of the blood is adequate

Blunt trauma
o require cervical spine immobilization until injury is excluded
o accomplished by applying a hard collar or placing sandbags on both sides of
the head with the patient’s forehead taped across the bags to the backboard
Penetrating neck wounds
o cervical collars are not believed useful because they provide no benefit, but
may interfere with assessment and treatment
Comatose patients
othe tongue may fall backward and obstruct the hypopharynx;
this can be relieved by either a chin lift or jaw thrust

Altered mental status

omost common indication for intubation

Agiation or obtundation
ooften attributed to intoxication or drug use
omay actually be due to hypoxia
Nasotracheal intubation
ocan be accomplished only in patients who are breathing
spontaneously

Orotracheal intubation
ois the preferred technique used to establish a definitive
airway
Advantages:
➢direct visualization of the vocal cords
➢ability to use larger diameter endotracheal tubes
➢applicability to apneic patients
Disadvantage:
oconscious patients usually require neuromuscular
blockade, which may result in :
➢inability to intubate
➢aspiration
➢medication complications
Cricothyroidotomy
ois recommended for emergent surgical establishment of
a patent airway
ocontraindicated with patients under 11 y/o due to the risk
of subglottic stenosis, and tracheostomy should be
performed
Breathing and Ventilation

o All injured patients should receive supplemental oxygen

and be monitored by pulse oximetry

Life threatening conditions due to inadequate ventilation

1.tension pneumothorax
2.open pneumothorax
3.flail chest with underlying pulmonary contusion
4.massive air leak
Diagnosis of Pneumothorax

o patient manifesting respiratory distress and hypotension in

combination with any of the following physical signs
➢tracheal deviation away from the affected side
➢lack of or decreased breath sounds on the affected side
➢subcutaneous emphysema on the affected side
o Patients may have distended neck veins due to
impedance of venous return, but the neck veins may be
flat due to concurrent systemic hypovolemia
 Open pneumothorax or “sucking chest wound”
o occurs with full-thickness loss of the chest wall, permitting
free communication between the pleural space and the
atmosphere
o prevents lung inflation and alveolar ventilation, and results
in hypoxia and hypercarbia
Flail Chest

o occurs when three or more contiguous ribs are fractured in

at least two locations
o Pulmonary contusion often progresses during the first 12
hours
Massive Air Leak

o occurs from major tracheobronchial injuries

Type I injuries
o those occurring within 2 cm of the carina
o are often not associated with a pneumothorax due to the
envelopment in the mediastinal pleura
Type II injuries
o more distal injuries within the tracheobronchial tree and
manifest with pneumothorax
o Bronchoscopy confirms diagnosis and directs
management.
Tube thoracostomy

o is performed in the
midaxillary line at the
fourth or fifth intercostal
space (inframammary
crease) to avoid
iatrogenic injury to the
liver or spleen
Circulation with Hemorrhage Control

o With a secure airway and adequate ventilation established,

circulatory status is the next priority
o An initial approximation of the patient’s cardiovascular status
can be obtained by palpating peripheral pulses
Systolic blood pressure (SBP)
➢60 mm Hg for the carotid pulse
➢70 mm Hg for the femoral pulse
➢80 mm Hg for the radial pulse
o Blood pressure and pulse should be measured at least every
5 minutes in patients with significant blood loss until normal
vital sign values are restored
o IV access for fluid resuscitation is
obtained with two peripheral catheters,
16-gauge or larger in adults
o For patients in whom peripheral
angiocatheter access is difficult,
intraosseous (IO) needles can be
rapidly placed in the proximal tibia of
the lower extremity
o Intraosseous infusions are indicated for
children <6 years of age in whom one
or two attempts at IV access have failed
• Intraosseous (IO) route – if IV is not accessible

• Rule of thumb: (secondary access)

– Femoral venous access – for thoracic trauma
– Jugular/subclavian venous access – for abdominal trauma
• Provides more reliable measurement of central venous pressure (CVP)

• Severely injured children (<6y/o)

– Preferred venous access: peripheral intravenous catheter followed by IO needle
• External control of any visible hemorrhage should be achieved promptly while circulating
volume is restored

• Manual compression of open wounds with ongoing bleeding:

✓ Use of a single 4 × 4 gauze, a gloved hand and enough pressure
✓ Digital occlusion for bleeding of extremities
✓ Fracture reduction with stabilization via splints for open fractures
✓ Skin staples, Raney clips, or a large full-thickness continuous running nylon stitch for scalp
lacerations
✓ Do not use excessive dressings
✓ Avoid blind clamping of blood vessels
• During the primary survey for circulation, 4 life-threatening injuries
must be identified promptly:
1.Massive hemothorax
2.Cardiac tamponade
3.Massive hemoperitoneum
4.Mechanically unstable pelvic fractures with bleeding
 Massive hemothorax

• defined as:
– Adult: >1500 mL of blood in the pleural space
– Pediatric patients: >25% of the patient’s blood volume in the pleural space

• In blunt traumas - due to multiple rib fractures with severed intercostal arteries
• In penetrating trauma, due to injury to a great vessel or pulmonary hilar vessel

• Thoracostomy – only reliable means to quantify the amount of hemothorax

 Cardiac tamponade
• Acute accumulation of <100 mL of pericardial blood
• occurs most commonly after penetrating thoracic wounds
• Beck’s triad
– dilated neck veins
– muffled heart tones
– decline in arterial pressure

• Diagnosis – bedside ultrasound of the pericardium

• Interventions:
– Pericardial drain - removing as little as 15 to 20 mL of blood
– Pericardiocentesis
Access to the pericardium is
obtained through a
subxiphoid approach, with the
needle angled 45 degrees up
from the chest wall and
toward the left shoulder
Seldinger Technique
▪used to place a pigtail
catheter
▪blood can be repeatedly
aspirated with a syringe or
the tubing may be attached
to a gravity drain
▪Evacuation of unclotted
pericardial blood prevents
subendocardial ischemia
and stabilizes the patient
for transport to the
operating room for
sternotomy
Resuscitative thoracotomy (RT)

• with opening of the pericardium for rapid

decompression
• for patients with a systolic BP of <60 mm Hg
• It is performed through the 5th ICS using the
anterolateral approach
• The pericardium is opened anterior to the
phrenic nerve, and the heart is rotated out for
evaluation
• Open cardiac massage should be performed with
a hinged, clapping motion of the hands, with
sequential closing from palms to fingers
• The two-handed technique is strongly
recommended because the one-handed
technique poses risk of myocardial perforation
with the thumb
 Glasgow Coma Scale (GCS)

• should be determined for all injured patients

• quantifiable determination of neurologic function that is useful for triage, treatment, and
prognosis
• neurologic evaluation is critical before administration of neuromuscular blockade for intubation
• calculated by adding the scores of the best:
– Motor response (6)
– Verbal response (5), and
– Eye response (4)
• Scoring: range from 3 (lowest) to 15 (highest)
• 13 to 15 - mild head injury
• 9 to 12 - moderate injury
• ≤8 - severe injury
Glasgow Coma Scale (GCS)
 Shock

• Classic signs and symptoms

– Tachycardia
– Hypotension
– Tachypnea
– Altered mental status
– Diaphoresis
– Pallor
• The quantity of acute blood loss correlate with physiologic abnormalities
• Physical findings should be used as an aid in the evaluation of response to treatment
 Fluid Resuscitation

• Goal:
– Re-establish tissue perfusion

• Begins with a 2 L (adult) or 20 mL/kg (child) IV bolus of isotonic crystalloid,

typically Ringer’s lactate

• Persistent hypotension (SBP <90 mm Hg in an adult)

– Administer blood cells (RBC) and fresh-frozen plasma (FFP)
 Urine Output

• A quantitative, reliable indicator of organ perfusion

• Adequate UO:
– 0.5 mL/kg per hour in an adult,
– 1 mL/kg per hour in a child
– 2 mL/kg per hour in an infant <1 year of age
Secondary Survey

• When the conditions that constitute an

immediate threat to life have been
attended to or excluded, the patient is
examined in a systematic fashion to
identify occult injuries. Get an AMPLE hx:
Allergies
Medications
Past medical history/ Pregnancy
Last meal
Events related to injury
• The secondary survey is a complete head to toe
evaluation of the patient
• Adjuncts to the secondary survey include CT’s, plain
radiographs, blood tests
• Treatment plans, especially for multiple injuries, based on
clinical status and specific injuries
• Indications
• Evaluate trauma patients for whom no life-threatening
injuries were identified during the primary survey.

» Contraindications include the presence of life-threatening

conditions identified during the primary survey.
• Mechanism and Pattern of Injury:
- blunt trauma
-penetrating trauma
• Direct Rectal Exam:
to evaluate sphincter
tone and to look
for blood,
perforation, or a
high-riding prostate.
Foley catheter
should be
inserted to
decompress the
bladder, obtain a
urine specimen,
and monitor
urine output.
• A nasogastric tube
should be inserted
to decrease the risk
of gastric aspiration
and allow inspection
of the contents for
blood suggestive of
occult gastroduodenal
injury.
Regional Assessment and Special
Diagnostic Tests
Head and Face

• Examine the head for

scalp hematoma, skull
depression, or
laceration. The scalp
should be palpated,
since scalp lacerations
or bony step-offs may be
identified only by careful
palpation.
• No nasogastric tube
(NG) should be inserted
if there is facial trauma
or evidence of basilar
skull fracture.
• The ears should be evaluated for hemotympanum or retro-auricular
ecchymosis (Battle's sign). The presence of blood or clear drainage from
the ear canal indicates basilar skull fracture with cerebrospinal (CSF) leak.

» The pupillary size and response, as well as eye movements, should be

assessed. The ocular examination should also include ocular
mobility/entrapment, or periorbital ecchymosis (Raccoon eyes).
Neck

• The neck should be carefully inspected and palpated.

Beware that injuries under the hard collar may not be
obvious. It is assumed that every patient with blunt trauma
may have sustained an injury to the cervical spine, until
proven otherwise. C-spine can be cleared either clinically
by applying decision rules, or by obtaining imaging
studies, such as plain radiographs or a CT scan.
• Patients with high spinal cord disruption
– are at risk for shock due to physiologic disruption of sympathetic fibers.
– Significant neurologic recovery is rare.

• Central cord syndrome

– typically occurs in older persons who experience hyperextension
injuries.

• The ff. are sensations that are preserved in the lower extremities but
diminished in the upper extremities
✓Motor function
✓pain
✓temperature
• Anterior cord syndrome
– characterized by diminished motor function, pain, and
temperature sensation below the level of the injury
– position sensing, vibratory sensation, and crude touch are
maintained.
– Prognosis for recovery is poor.
• Brown-Séquard Syndrome
– usually the result of a penetrating injury in
which one-half of the spinal cord is
transected.
– This lesion is characterized by the ipsilateral
loss of motor function, proprioception and
vibratory sensation, whereas pain and
temperature sensation are lost on the
contralateral side.
• Fracture of the larynx due to blunt trauma
– a more subtle injury that may not be identified
– Signs and symptoms include
• hoarseness
• subcutaneous emphysema
• palpable fracture

• Penetrating injuries of the anterior neck that

violate the platysma
– are potentially life-threatening because of the density
of critical structures in this region.
• Indications for immediate operative
intervention for penetrating cervical injury
include
✓hemodynamic instability
✓significant external hemorrhage
✓evidence of aerodigestive injury
• Zone I - inferior to the clavicles
encompassing the thoracic outlet structures
• Zone II - between the thoracic outlet and the
angle of the mandible
• Zone III - above the angle of the mandible.
• Due to technical difficulties of injury
exposure and varying operative
approaches, a precise preoperative
diagnosis is desirable for symptomatic zone
I and III injuries.
• Therefore, these patients should ideally
undergo diagnostic imaging before
operation if they remain hemodynamically
stable
• Management of patients is further divided into those who are
symptomatic and those who are not .

• Specific symptoms or signs that should be identified include

– dysphagia, hoarseness, hematoma, venous bleeding, minor
hemoptysis, and subcutaneous emphysema

• Symptomatic patients should undergo CTA with further evaluation

or operation based upon the imaging findings; less than 15% of
penetrating cervical trauma requires neck exploration.

• Asymptomatic patients are typically observed for 6 to12 hours.

• CTA of the neck and chest determines trajectory of the
injury tract; further studies are performed based on
proximity to major structures.

• Such additional imaging includes angiography, soluble

contrast esophagram followed by barium esophagram,
esophagoscopy, or bronchoscopy

• Angiographic diagnosis, particularly of zone III injuries,

can then be managed by selective angioembolization.
• Chest Blunt trauma to the chest may involve:
– chest wall,thoracic spine, heart, lungs, thoracic aorta and great vessels, and rarely the
esophagus.

• Most of these injuries can be evaluated by

– physical examination and chest radiography, with supplemental CT scanning based on
initial findings.

• Any patient who undergoes an intervention in the ED—endotracheal intubation,

central line placement, tube thoracostomy—needs a repeat chest radiograph to
document the adequacy of the procedure.

• This is particularly true in patients undergoing tube thoracostomy for a

pneumothorax or hemothorax.
• Patients with persistent pneumothorax, large air leaks after tube thoracostomy,
or difficulty ventilating
– should undergo fiber-optic bronchoscopy to exclude a tracheobronchial injury or
presence of a foreign body.

• Patients with hemothorax

– must have a chest radiograph documenting complete evacuation of the chest;
– a persistent hemothorax that is not drained by two chest tubes is termed a caked
hemothorax and mandates immediate thoracotomy

• Occult thoracic vascular injury must be diligently sought due to the high
mortality of a missed lesion.

• Widening of the mediastinum on initial anteroposterior chest radiograph, caused

by a hematoma around an injured vessel that is contained by the mediastinal
pleura, suggests an injury of the great vessels.
• The mediastinal abnormality may suggest the location of the arterial
injury (i.e., left-sided hematomas are associated with descending torn
aortas, whereas right-sided hematomas are commonly seen with
innominate injuries)

• Posterior rib fractures, sternal fractures with laceration of small

vessels, and mediastinal venous bleeding also can produce similar
hematomas.

• Screening spiral CT scanning

– performed based on the mechanism of injury:
• High-energy deceleration motor vehicle collision with frontal
or lateral impact (> 30 mph frontal impact and >23 mph lateral
impact)
• Motor vehicle collision with ejection
• Falls of >25 ft, or direct impact (horse kick to chest,
snowmobile or ski collision with tree)
• For penetrating thoracic trauma the ff. will identify the majority of
injuries
– physical examination
– plain posteroanterior and lateral chest radiographs with metallic markings of
wounds
– pericardial ultrasound
– CVP measurement .
***Injuries of the esophagus and trachea are exceptions.

• Bronchoscopy
– should be performed to evaluate the trachea in patients with a persistent air leak
from the chest tube or mediastinal air.

• Esophagoscopy
– can miss injuries following an apparent normal endoscopy
– patients at risk should undergo soluble contrast esophagraphy followed by barium
examination to look for extravasation of contrast to identify an injury.
• As with neck injuries
– hemodynamically stable patients with transmediastinal gunshot
wounds should undergo CT scanning to determine the path of the
bullet
–this identifies the vascular or visceral structures at risk for injury and
directs angiography or endoscopy as appropriate.
–If there is a suspicion of a subclavian artery injury, brachial-brachial
indices should be measured, but >60% of patients with an injury may
not have a pulse deficit.
–Therefore, CTA should be performed based on injury proximity to
intrathoracic vasculature.
–Finally, with wounds identified on the chest, penetrating trauma
should not be presumed to be isolated to the thorax.
–Injury to contiguous body cavities (i.e., the abdomen and neck) must
be excluded;
–plain radiographs are a rapid, effective screening modality.