Critically injured patient
Prof Mohan de Silva
Essential words to remember
• TRIMODAL distribution of deaths
• ATLS
• Primary survey
• Secondary survey
The Critically Injured
Trauma

commonest cause of hospital admissions
in Sri Lanka since 1995

commonest cause of death below the
age of 40 in many countries
The critically injured

Majority died due to inadequate
treatment

Initial treatment determines the
outcome

Early intervention is essential
GOLDEN HOUR OF TRAUMA
TRIMODAL DISTRIBUTION OF
DEATHS
• Immediate
• 1st few hours
• Few days after
admission
Conventional approach

History

Examination

Investigations

Diagnosis

Treatment
How it all started
Another accident ………..
New approach… A T L S

Initial assessment ( History,
Examination )
Resuscitation
( Treatment )
WILL BEGIN SIMALTANEOUSLY
 Recognize and treat the most life
threatening injury first
TRAUMA KILLS ACCORDING TO A
SEQUENCE !


Acute airway obstruction
- The quickest killer
Inadequate breathing

Hypovolaemia

Expanding intra cranial
haematoma

Hypoxia and Hypovolaemia
are the main killers

Hypoxia kills before
hypovolaemia

PRIMARY SURVEY

SECONDARY SURVEY
Initial assessment and resuscitation
Primary survey






A ir way with cervical spine control
B reathing
C irculation
D isability (Neurological )
E xposure
F oleys catheter
Airway obstruction
recognition and treatment

Identify – SPEAK TO THE PATIENT

establish
OXYGEN

protect
OXYGEN

maintain
OXYGEN
10 L / minute
Immobilisation of the C spine
 sand bag
 collar
 tape
B reathing
 Inspection
-
wall movements,ext.
injuries etc

Palpation
-
cripitus

percussion

Auscultation - breath sounds
absent
-
hyperesonence
or stony dullness
RESPIRATORY RATE
Circulation
All critically injured patients are in
hypovolaemic shock
Action
PULSE RATE , B P

2 Big drips to Two big veins

2 L of N Saline fast in

Blood cross matching
D isability (Neurological )

A V P U

Glasgow coma score

Expose the patient
Where is the scissor !
Secondary survey
Pulse - BP – RR -Temperature

Systematic examination from head
to toe

LOG ROLL

Finger to all orifices

Minor injuries
History
AMPLE
 A llergies
 M edications
 P ast illnesses
 L ast meal
 E vents leading to the injury
Outcome
•?
•?
•?
TAKE HOME MESSAGE
 What is the first thing you do when you get a
critically injured ?
 What is the quickest killer of the injured?
 What is trimodal distribution of deaths?
 What is the difference between conventional and
ATLS approach
 What do you do in Primary and secondary
surveys?