•Trauma.
•Intra-Abdominal
Injuries
•Crush
Injuries
•Fracture.
Dr. Huda B. Hassan
Emergency Approach to the Trauma Patient
Injury is the fourth leading cause of death in
the United States. Among patients aged 1-44
years, it is the leading cause of death.
Trauma can be classified into blunt (e.g.
vehicular, falls) or penetrating (e.g. gunshot
wounds, stab wounds
Death due to injury occurs in one of three time
periods.
abdominal trauma
A. Penetrating Abdominal Trauma
Causes:
-Gunshot wound
-Stab wound
-Embedded object from explosion
Assessment:
-Absence of bowel sound-Hypovolemic shock
-Orthostatic hypotension-Pain and tenderness
Management:
1. Maintain hemodynamic status –IVF & blood transfusion
2. Surgery-EXLAP
3. Peritoneal Lavage
Blunt Abdominal Trauma
Assessment:
-Left upper quadrant pain (Spleen)
-Right upper quadrant pain (liver)
-Signs of hypovolemic shock
Management:
1. Maintain hemodynamic status
2. Monitor VS and oxygen supplements
3. Assess signs and symptoms of shock
Trimodal Death Distribution from Trauma:
First Peak – occurs within seconds to minutes of injury
Lacerations to the brain, brainstem, high spinal cord,
heart, aorta
Second Peak – occurs within minutes to hours of injury
Subdural and epidural hematomas
Hemopneumothorax
Lacerated spleen or liver
Pelvic fracture
Other injuries associated with significant blood loss
Third Peak – occurs several days to weeks after injury
Sepsis
Multi-system organ failure
it is essential to have a method of providing
rapid patient assessment and interventions to
decrease the number of deaths encountered
in the second peak
Triage
Not all injured patients require transport to a
Level I (highest level) trauma center. Criteria
have been established to help pre-hospital
personnel decide which patients to transport
to such a center.
The composition of a trauma team is institutionBased
Trauma resuscitations are “run” by a senior
emergency medicine or senior surgical
resident. Subspecialty consultants such as
neurosurgeons and orthopedists are available
on short notice.
Referral to a trauma center is dependent on
anatomic criteria and mechanism of injury
criteria
Mechanism of Injury:
•
High-speed traffic crash (>40mph)
•
Vehicle space invaded > 20 inches
•
Pedestrian accident (age < 5 years or > 55 years)
•
Pedestrian accident (vehicle moving > 5mph)
•
Pedestrian thrown > 15 feet by car
•
Ejection from vehicle
•
Rollover
•
Death of other occupants of same vehicle
•
Prolonged extrication time (>20 minutes)
•
Falls greater than 20 feet
• Anatomic factors:
•
Penetrating trauma to the head, neck, torso
or groin to mid-thigh
•
Major burn (covering >20% partial-thickness
or full-thickness skin area)
•
Major amputation above ankle or wrist
•
Limb paralysis
•
Two or more proximal long bone fractures
• Flail chest,
• Hemo- or pneumothoraces
• Abnormality in vital signs
• Abnormal or change of mental status in route
• Significant patient comorbidities
• Initial ED Resuscitation
Assessments based on the primary and secondary
surveys. Three important underlying concepts
taught by ATLS are:
1. Treat the greatest threat to life first. Injury kills
in reproducible time frames. The mnemonic ‫ضع‬
‫في ذاكرتك‬ABCDE was developed to order our
evaluations and treatment such that most lethal
problem is treated first.
2. The lack of a definitive diagnosis should not
impede treatment.
3. A detailed history is not essential to begin the
evaluation of the acutely injured patient.
• Primary Survey
•
•
•
•
•
A – airway and C-spine stabilization
B – breathing
C – circulation
D – disability
E – exposure and environmental control
• Airway is assessed first for patency and
measures to establish a patent airway are
instituted.
• Methods for managing the airway include
simple maneuvers such as chin lift, placement
of a nasal airway (should not be used if there
are facial injuries) or oropharyngeal‫فموي بلعومي‬
airway.
• If these measures fail, bag-valve-mask
ventilation should be attempted.
Breathing is assessed by visualizing movement
of the chest and auscultating for breath
sounds which should be equal and audible
bilaterally. If there are signs of a hemo- or
pneumothorax, a tension pneumothorax,
open chest wounds or flail chest, then
attention to these matters should be paid at
this time. Tube thoracostomy should be done
for hemothorax or pneumothorax
Circulation is assessed next, by evaluating for the
presence of a pulse, heart tones, capillary refill,
and warmth of the extremities. Although the
blood pressure is not part of the ATLS algorithm,
it is an important indicator of a patient’s
hemodynamic status
Initial fluid resuscitation is with 20ml/kg, of
Lactated Ringer’s or normal saline. If vital signs
are not improved after 30ml/kg (2 liters) of
crystalloids, blood should be transfused. If cross
matched blood is not available when the decision
to transfuse is made, then type O blood should
be given to the unstable patient.
Assessment of the circulatory status of the
trauma patient includes evaluation for
evidence of external hemorrhage
There are five potential areas of blood loss that
can lead to hypotension:
• chest
• abdomen/pelvis
• Retro-peritoneum
• thigh
• on the street (external hemorrhage)
Disability, referring to the neurologic
assessment, is evaluated next. A rapid means
of evaluating neurologic status is the use of
the AVPU mnemonic. The Glasgow Coma Scale
is a more detailed method of evaluation and
can be done as part of the secondary survey.
AVPU
A – alert
V – responds to verbal stimuli,
P – responds only to painful stimuli,
U – unresponsive to all stimuli
Glasgow Coma Scale (GCS)
Best Eye Response. (E)
No eye opening
Eye opening to pain
Eye opening to verbal command
Eyes open spontaneously
Best Verbal Response. (V)
No verbal response
Incomprehensible sounds
Inappropriate words
Confused
Orientated
Best Motor Response. (M)
No motor response
Extension to pain
Flexion to pain
Withdrawal from pain
Localizing pain
Obeys Commands
1
2
3
4
1
2
3
4
5
1
2
3
4
5
6
Glasgow Coma Scale Score = (E+V+M)
Best possible score = 15
Worst possible score = 3
Coma is defined as GCS less than or equal to 8:
Severe head injury
GCS 8 or below
Moderate head injury
GCS 8-13
Minor head injury
GCS 14-15
Exposure of the trauma patient is essential for a
thorough examination
In order to obtain such exposure without
moving the patient’s c-spine and/or injured
limbs, it is often necessary to cut off the
patient’s clothing. Once assessment is
completed, the patient should be covered
with warm blankets in order to prevent
hypothermia
Other interventions are undertaken during the
primary survey. These are called adjuncts
‫ اضافي‬to the primary survey and include:
ECG monitoring, pulse oximetry, monitoring of
vital signs, placement of a gastric tube to
decompress the stomach in order to help
decrease the risk of aspiration, and the
placement of a Foley catheter for monitoring
of urinary output.
• . A nasogastric catheter is contraindicated in a
patient with facial fractures, bleeding from the
nostrils and CSF rhinorrhea, as the tube may
penetrate the brain in patients with suspected
cribriform plate injuries
A Foley catheter should not be placed if there is
suspicion of a urethral injury heralded by: 1)
blood at the penile meatus, 2) perineal
ecchymoses, 3) scrotal hematoma, 4) highriding prostate or nonpalpable prostate, or 5)
a pelvic fracture.
Remember, placement of gastric and urinary
catheters is not a life-preserving intervention
X-rays may be obtained.
Examine the chest X-ray for injury to the bony
structures such as the humerus, clavicles, ribs
or scapula; correct placement of all lines and
tubes; air in the soft tissues; free air under the
diaphragm as an indicator of abdominal viscus
perforation; pneumo- or hemothoraces;
pulmonary contusions; and signs of aortic
injury
Secondary Survey
The secondary survey comprises a head-to-toe
evaluation of the trauma patient and
reevaluation of the vital signs. A focused history is
obtained at this point using the AMPLE
mnemonic.
AMPLE
A – allergies
M – medications
P – past illnesses/pregnancy
L – last meal consumed
E – events leading up to the injury
CT scan evaluation of the abdomen in the
trauma patient has several benefits
Orthopaedic Injuries
• Goals of ED Treatment
• identify injuries accurately and address
potentially life/limb threatening problems
appropriately
• reduce immobilize fractures (cast/splint) as
appropriate
• provide adequate pain relief
• arrange proper follow-up if necessary
Physical Examination Rotation
• Look (inspection): "SEADS" Swelling, Erythema,
Atrophy, Deformity, Skin changes Translation (e.g.
bruises) Alignment/angulation
• Feel (palpation): all joints/bones -local
tenderness, swelling, warmth, crepitus, joint Type
(i.e. Salter-Harris, etc.) effusions, subtle deformity
• Move: joints affected plus above and below injury
-active ROM preferred to passive
• Neurovascular status: distal to injury (BEFORE
and AFTER reduction)
life and limb threatening injuries
• threat to life is usually due to blood loss (e.g.
up to 3 L in pelvic fractures, 1.5 L per long
bone fracture)
• threat to limb is usually due to interruption of
blood supply to distal part of limb or to
susceptible part of bone
Life and Limb Threatening Orthopedic Injuries
Major pelvic fractures
Limb Threatening Injuries
Major pelvic fractures
Fracture/dislocation of ankle
(talar AVN)
Traumatic amputations
Crush injuries
Massive long bone injuries (beware Compartment syndrome
fat emboli)
Open fractures
Vascular injury proximal to
knee/elbow
Dislocations of knee/hip
Fractures above knee/elbow
•Open Fractures
• communication between fracture site and
external surface of skin -risk of osteomyelitis
• remove gross debris, irrigate, cover with sterile
dressing -formal irrigation and
debridement often done in the OR
• control bleeding with pressure (no clamping)
• splint
• antibiotics (15' generation cephalosporin and
amino-glycoside) and tetanus prophylaxis
• must secure definitive surgical care within 6-8
hours
• Soft Tissue Injuries/ Emergency Wound
Management
• Goals of ED Treatment
• identify injuries and stop any active bleeding direct pressure
• manage pain
• wound examination and exploration (history
and physical)
• cleansing, ± antibiotic and tetanus prophylaxis
• repair and dressing
• Bruises
• tender swelling (hematoma) following blunt trauma
• is patient on anticoagulants? do they have a
coagulopathy (e.g. liver disease)?
•
•
•
•
Abrasions
partial to full thickness break in skin
• management
dean thoroughly, ±. local anesthetic, with brush to
prevent foreign body impregnation (tattooing)
• antiseptic ointment (Polysporin™ or Vaseline™) for 7
days for facial and complex abrasions
• tetanus prophylaxis -see Table 9 above
• Lacerations
• consider every structure deep to a laceration injured until proven
otherwise
• in hand injury patient, include following in history: handedness,
occupation, mechanism of injury, previous history of injury
• physical exam
• think about underlying anatomy
• examine tendon function actively against resistance and neurovascular
status distally
• clean and explore under local anesthetic; look for partial tendon
injuries
• x-ray wounds if a foreign body is suspected (e.g. shattered glass) and
not found when exploring wound (remember: not all foreign bodies
are radiopaque), or if suspect intra-articular involvement
• management
• disinfect skin/use sterile techniques
• irrigate copiously with normal saline
• analgesia ± anesthesia
• • maximum dose of lidocaine:
• 7 mglkg with epinephrine
• 5 mglkg without epinephrine
• in children, topical anesthetics such as LET (lidocaine,
epinephrine and tetracaine) and in selected cases a
short-acting benzodiazepine (midazolam or other
agents) for sedation and amnesia are useful
• secure hemostasis
• evacuate hematomas, debride non-viable tissue,
remove hair and remove foreign bodies
• • ± prophylactic antibiotics
• suture unless delayed presentation, a puncture wound,
or mammalian bite
• take into account patient and wound factors when
considering suturing
• advise patient when to have sutures removed
Thank you
for Listening
Dr.Huda