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
 A irway
 B reathing
 C irculation
 D isability: Neurologic Evaluation
 E xposure/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 Motor response
Oriented 5 Obeys 6
Confused 4 Localizes 5
Inappropriate words 3 Withdraws 4
Incomprehensible sounds 2 Decortication 3
None 1 Decerebration 2
None 1
Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1

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

III
IV
I
Class
II
Hemorrhage classification
% blood loss
10 – 19
(750 cc)
20 – 29
(1250)
Heart rate
>100
Blood pressure
Slightly
Pulse pressure
Resp rate Capillary refill
Normal
Urine output
Delayed
30 – 39
(2000)
>40
>120
>140
(>30) Very
Delayed
Oliguria
Anuria
Other
Acidosis
Mortality
25%
60%

Resuscitation
 Catheters
 Urinary
 Rectal first
 Check for other signs of urethral injury
 Gastric
 Oral v.s. nasal placement

NGT Intracranial

Resuscitation
 Monitoring
 ABG ’ s
 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