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
Airway
Breathing
Circulation
Disability: Neurologic Evaluation
Exposure/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
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None

Eye Opening
Spontaneous
To speech
To pain
None

4
3
2
1

Motor response
5
4
3
2
1

Obeys
Localizes
Withdraws
Decortication
Decerebration
None

6
5
4
3
2
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

Hemorrhage classification
Class

% blood
loss
10 19
(750 cc)

Heart rate

Blood
pressure

II

20 29
(1250)

>100

Slightly

III

30 39
(2000)

>120

IV

>40

>140

Pulse
pressure

Resp rate

Capillary
refill
Normal

Urine
output

Other

Mortality

Oliguria

Acidosis

25%

Delayed

(>30)

Very
Delayed

Anuria

60%

Resuscitation
Catheters
Urinary
Rectal first
Check for other signs of urethral injury

Gastric
Oral v.s. nasal placement

NGT Intracranial

Resuscitation
Monitoring

ABGs
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.
2.
3.
4.

Pericardial sac (epigastric area)

Hepatorenal fossa
Splenorenal fossa
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
M
P
L
E

Allergies
Medications
Past illnesses
Last meal
Events related to injury

1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment

Secondary Survey
History
A
M
P
L
E

Allergies
Medications
Past illnesses
Last meal
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