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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 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
Hemorrhage classification
Class % blood Heart rate Blood Pulse Resp rate Capillary Urine Other Mortality
loss pressure pressure refill output
I 10 19 Normal
(750 cc)
II 20 29 >100 Slightly Delayed
(1250)

III 30 39 >120 (>30) Very Oliguria Acidosis 25%


(2000) Delayed

IV >40 >140 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. 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

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