TRAUMA
Doctor Liang
Department of Emergency Surgery, the First Affiliated Hospital,
School of Medicine, Zhejiang University
outline
Trauma
background
definition
calssification
three peaks of death
trauma system
primary survey
prehospital--BTLS
ABCD
trauma center
hospital—E.D.
principle
ATLS
procedure
DCS+ICU
skills
Addition (traumatic shock/scores/abdominal
trauma)
background

Accidental trauma:
the leading cause of death in USA in
the 1-to 44-year-old age group and the
fourth leading cause overall. (National
Center for Health Statistics)

Approximately 10% of total medical
spending
Definition
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Destruction of organizational structures
caused by injury factors including physical
factors (such as mechanical force, high fever,
electric shock, etc.), chemical factors (such as
acids, alkalis and blister agents, etc.) and
biological factors (such as insects, snakes,
rabid dog, etc.)
Usually referred to the destruction and
dysfunction of organizational structures
caused by mechanical factors.
Classification-1
According to
the integrity of skin
Open traumas
penetrating
laceration
scrape
incised wound
Closed traumas
Contusion
crush injury
sprain injury
closed fracture
concussion injury
Classification-2
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According to the injury position
head, face, neck
chest
abdomen
pelvis
limbs
multiple injury
In clinic
multiple injury
One factor >two anatomic parts injury
 Compound injury
 >two factors

Three peaks of death
after trauma
First
peak
Seconds~minut
es
Brain/brainstem/
spine/heart/aorta/
great vessels
injury
Second
peak
minutes~hours
Epidural hematoma
/Subdural hematoma/
hemopneumothorax
/rupture of liver and
spleen/pelvic fracture/
massive blood loss
Third
peak
days~weeks
severe
inflammation
MODS and MOF
Gold time
Gold time =
one hours after trauma
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Life=emergency
outline
Trauma
background
definition
calssification
three peaks of death
trauma system
prehospital--BTLS
hospital—ED
DCS+ICU
primary survey
ABCD
trauma center
principle
ATLS
procedure
skills
Trauma system
transport
field first aid
Training&
database
Prophylaxis system
Trauma
system
hospital remedy
Treatment&
rehabilitative
Life chain
Prehospital
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120
Airway & CPR
antishock &
hemostasis
Simple fixation
life sign monitoring
transport
record：time , place,
mechanism, and
history
Prehospital :primary survey
first
next
Attention
airway
Ascertain the
airway opened or
obstructed
head
Past medical
history
Neck
carotid pulsation,
tracheal position,
character of neck
veins
neck
medications
taking
Chest
palpate for bony
crepitus or
subcutaneous air,
auscultate for
breath sounds
Extremities
life
signs


chest
allergies
cool, moist, pale,
-hemorrhagic
shock
abdomen
unconscious
Observe, Stabilize
Extremities
open fractures
Primary survey
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minimal trauma: require no testing
moderate trauma: complete blood count,
basic metabolic panel, blood type and
screen, urinalysis
vital sign instability without obvious
source, it is prudent to evaluate the
abdomen for hemorrhage
Prehospital skill: Airway--A
A
B
Prehospital skill: mouth to
mouth--B
facility face mask--B
Compression mask--B
CPR--C
defibrillation--D
Transport to hospital
Emergency department (ED)
ED（Emergence Department）
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Trauma center (Emergency
Department):
Ancillary staffing, experienced nurse
Up-to-date technology
Readily available consultants , have advanced
skills
Rapid operating room capability
Intensive care unit (ICU) capability
Rehabilitative care
ATLS

ATLS:
advanced trauma life
support
ATLS principle-1
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1.Patient life-threatening injured first in
group injurys, life-threatening priority
of multiple injury
2.Effective treatment not be delayed
without clear diagnosis
3.Comprehensive analysis of injuries is
in need, history in the first assessment,
diagnosis and treatment is not necessary.
ATLS principle-2
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If the injured patients and the severity
do not exceed the processing power of
the medical staff, to give priority to
those critically ill, multiple trauma
patients.
If exceed, to give priority to those timeconsuming short, less manpower and
equipment needed to care for patients.
ATLS procedure
ATLS
prepare
Triage
first survey
Resuscitation
&first aid
Auxiliary
examination of
first time
assessment
Auxiliary
examination of
second time
Life sign
monitoring
&treatment
Specialist
treatment
E.D. evaluation
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Emphasis on airway, breathing, and
circulation (ABCs)
Assessment of airway patency, adequacy of
ventilation (respiratory excursion and lung
auscultation), hemodynamic status (pulse
rate, central and peripheral pulse quality,
blood pressure), and evidence of controllable
hemorrhage should be immediately linked
with interventions.
Crash plan
C
cardiac
R
CRASH
PLAN
A
S
H
P
pelvis
L
limb
A
arteries
N
nerves
respiratory
abdomen
spine
head
interventions
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1. secure the airway while protecting the
cervical spine
2. enhance oxygenation
3. provide ventilatory assistance
4. limit further hemorrhage
5. gain intravenous access
6. initiate volume replacement
7. obtain blood for laboratory and blood
bank testing
Important process
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1. Monitoring of heart rate, respiratory rate,
blood pressure, temperature, pulse oximetry
2. Early placement of central venous pressure
lines
3. Placement of a nasogastric or orogastric
tube for decompression
4. Placement of a urinary drainage catheter
Laboratory
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Complete blood count (CBC)
Arterial blood gases (base deficit)
Electrolytes (including BUN, creatinine,
glucose)
Coagulation studies (PT, PTT, platelet count)
Type and crossmatch for 4 units of blood
Toxicologic studies (as indicated)
Serum lactate
Urinalysis
Radiographs
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X-ray of chest, cervical spine, pelvis
CT
US
Skills:Trauma airway
management
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Expert management of the airway is an
essential skill for the emergency
physician (EP).
Trauma patients benefit from early
control of the airway to ensure
adequate oxygenation and ventilation
and to protect against aspiration.
Techniques of airway management
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orotracheal intubation (OTI)
conjunction with rapid sequence
induction (RSI) is the preferred
approach to the airway management of
the majority of patients with traumatic
injuries.
blind nasotracheal intubation (NTI)
surgical cricothyrotomy
Oropharyngeal airway
orotracheal intubation (OTI)
blind orotracheal intubation
blind orotracheal intubation
ED management
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1. Oxygen should be administered to all
major trauma patients, early control of the
airway may be lifesaving and should take
priority over all other interventions.
2.Gaining intraveneous access rapidly is
essential to begin volume replacement and
support the hemodynamics.
ED management
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3. Fluid therapy, intravascular volume
replacement to compensate for blood loss and
restore tissue perfusion has been accepted
standard therapy for many years.
Optimal type of fluid:
crystalloid solutions such as normal saline
Lactated Ringer solution
Fluids may be warmed ahead of time or be
administered through a fluid warmer.
ED management
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4. Red blood cell substitutes, with the
ability to carry oxygen
Typed and cross-matched PRBC are
the best choice for blood transfusion
If there is ongoing massive
hemorrhage, fresh frozen plasma (FFP)
and platelets may be needed to restore
the coagulation system.
ED management
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5. Pneumothorax or hemothorax should
be managed by the placement of a
large chest tube (32 or 36 French) in
the lateral chest.
A
B
ED management

6. A pericardiocentesis needle is
inserted in the left subxiphoid area and
directed 45 degrees toward the left
shoulder or sternal notch in pericardial
tamponade patients.
Summary：skills in ATLS
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assessment
CPR
orotracheal intubation /blind intubation
surgical cricothyrotomy
venesection
Pneumothorax / hemothorax drainage
Fixation and hemostasis
let’s have a rest!
outline
Trauma
background
definition
calssification
three peaks of death
trauma system
primary survey
prehospital--BTLS
ABCD
trauma center
hospital—ED
principle
ATLS
procedure
DCS+ICU
skills
Addition (traumatic shock/scores/abdominal
trauma)
DCS


Triad of death in severe trauma:
hypothermia, metabolic acidosis and
coagulation disorder
1993, Rotondo. DCS (damage control
surgery)
DCS
Simplify the
initial surgery
！
Resuscitation
in ICU
?
Trauma center
repair &
reconstruction
！
Moreover in ICU
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Nutrition(EN/PN)
Anti-inflamation
rehabilitative
surgery
DCS
Trauma patient: DCS+ICU
Doctor: E +
S +
ICU
Additional-1
Trauma scoring systems

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Trauma scores are an imperfect but
commonly used tool in trauma systems. They
are used for planning purposes and as a
quality assurance screen to monitor system
performance.
Regional trauma planners use these scoring
systems to compare institutions and assess
resource needs and as a tool for performing
research on the effects of different
interventions.
Revised Trauma Score (RTS)
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Three components: GCS, systolic blood
pressure, respiratory rate
RTS<12 identified 97.2% of all fatally
injured patients.
Anatomic Scores
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Injury Severity Score (ISS) : an extension of
the Abbreviated Injury Scale(AIS)
AIS grade divide the body into six
regions( thorax, abdomen, visceral pelvis,
head and neck, face, bony pelvis and
extremities, external structures), and
utilizing the site with the worst injury from
each region when calculating the overall
score.
Anatomic Scores

ISS was devised by summing the
squares of the highest AIS grade in
each of the three most severely injured
areas. When ISS above 15, death from
trauma begins to rise significantly.
Additional-2:
occult abdominal injury
Evaluate the abdomen
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1. Diagnostic peritoneal lavage (DPL)
Advantages:
high accurate(92~98%), has reliable
significance when negative, mandate a
laparotomy prior to transfer to a trauma
center
Limitations:
invasive, insensitve for retroperitoneal
injures, when CT and US are unavailable
DPL
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A positive DPL in a hemodynamically
stable patient should not automatically
lead to laparotomy.
Up to 30% of grossly positive lavages
lead to nontherapeuric laparotomies.
Diagnostic peritoneal lavage can
improve the positive rate of peritoneal
puncture.
DPL
ultrasonography (US)
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Advantages: noninvasive, can be performed
at the bedside, able to reliably find fluid
within the abdomen and within the pericardial
sac, accurate with significant intra-abdominal
hemorrhage, has good diagnostic accuracy
for long-bone fractures and hemothorax and
is more accurate than supine chest
radiography for detection of a pneumothorax
Limitations: can’t show the source or
magnitude of the injury,
CT
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Advantages: offers both quantitative
and qualitative information, gold
standard for evaluation of the
abdomen in the hemodynamically
stable blunt trauma patient,
Limitation: decreased sensitivity for
bowel, mesenteric, pancreatic injury
Additional-3:
Traumatic shock
First
peak
Seconds~minut
es
Brain/brainstem/
spine/heart/aorta/
great vessels
injury
Second
peak
minutes~hours
Epidural hematoma
/Subdural hematoma/
hemopneumothorax
/rupture of liver and
spleen/pelvic fracture/
massive blood loss
Third
peak
days~weeks
severe
inflammation
MODS and MOF
Additional-3:
Traumatic shock

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Shock is the ultimate consequence of
inadequate tissue perfusion, which may
be manifested clinically by hemodynamic
disturbances or organ dysfunction.
Shock is a common and potentially
treatable cause of death in injured
patients.
Traumatic shock
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Caused by:
Most related to loss of circulating blood
volume caused by hemorrhage
Inadequate oxygenation
Cardiac dysfunction
Neurologic dysfunction
Mechanical vascular obstruction
Types of shock
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1. hemorrhagic or hypovolemic
loss of circulating intravascular volume
caused by blood loss internally,
externally, or both
2. cardiogenic
3. neurogenic or vasogenic
4. septic
complications
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If the acute stress of the traumatic
shock state is sufficiently severe or
prolonged, organ dysfunction may also
develop, including acute tubular
necrosis (ATN), adult respiratory
distress syndrome (ARDS), and multiple
organ failure (MOF).
Clinical presentation
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Initial findings: tachycardia, hypotension,
signs of poor peripheral perfusion, alteration
in mental status
Continued blood loss result in: BP decrease,
narrowed pulse pressure(pulse quality weak
or thready), cool, pale, clammy extremities,
alteration in mental status, decline in urine
output (caused by renal hypoperfusion and
renal fluid reabsorption)
Classes of hemorrhagic shock
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Class blood volume heart rate systolic BP respiratory mental status
lost (ml)
( bpm)
rate ( /min)
Ⅰ 750(15%)
<100
normal
14-20
slight anxious
Ⅱ 750-1500(15-30%) >100
normal
20-30
mildly anxious
Ⅲ 1500-2000(30-40%) >120
decreased
30-40 anxious, confused
Ⅳ >2000
>140 markedly decreased >35 confused, lethargic
Systemic work
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Rapid diagose
Fluid therapy
Optimal type of
fluid
Red blood cell
substitutes as
well as plt&ffp
DCS
ICU
What should you know from
our lessons
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Multiple injury
Compound injury
Classification of trauma
Three peaks of death
Gold time
Life chain
Crash plan
DCS
Classes of hemorrhagic shock