Trauma

trauma

o Trauma is the most common cause of deathfor all individuals between the ages of 1 and 44years, and is the third most common cause ofdeath regardless of age.

Primary Survey

The Advanced Trauma Life Support (ATLS) courseof the American College of Surgeons Committee ATLS provides a structured approach to the

trauma patient with standard algorithms of care initial management1. primary survey/concurrent resuscitation2. secondary survey/diagnostic evaluation,

definitive care3. tertiary survey

The goal of primary survey: toidentify and treat conditions thatconstitute an immediate threat tolife.“ABCs” (Airway with cervicalspine protection, Breathing, andCirculation).although at times restoringCirculatory volume may proceedactive Airway intervention The timing of emergentintubation in the hypovolemicpatient remains controversialbecause of the risk of furthercompromising cardiac function.

Key points1. Patients with hemodynamic instability require

prompt intervention; one must consider the dominantcauses of acute shock, i.e., hemorrhagic, cardiogenic,and neurogenic shock.

2. Indications for immediate operative intervention forpenetrating cervical injury include hemodynamicinstability and significant external arterialhemorrhage

3. All patients with blunt injury should be assumed tohave unstable cervical spine injuries until provenotherwise;

4. The gold standard for blunt descending aortic injuryis ct-scan; indications are primarily based on injurymechanism.

Key points

5. The abdomen is a diagnostic black box. Physicalexamination and FAST ultrasound can identify patientsrequiring emergent laparotomy. (CT) scan is the mainstayof evaluation in the remaining patients .

6. Manifestation of the “bloody vicious cycle” (the lethalcombination of coagulopathy, hypothermia, andmetabolic acidosis) is the most common indication fordamage control surgery.

7. The abdominal compartment syndrome may beprimary (due to the injury of abdominal organs, bleeding,and packing) or secondary (due to reperfusion visceraledema, retroperitoneal edema, and ascites).

Airway Management With Cervical SpineProtection

• the first priority ‘because the oxygen contentof the blood is adequate to restorecardiovascular integrity

• all patients with blunt trauma require cervicalspine immobilization

Airway Management With Cervical SpineProtection

•applying a hard cervical collar or placingsandbags on both sides of the head with thepatient’s forehead taped across the bags.

• For penetrating neck wounds, however,cervical collars are not recommended becausethey provide no benefit and may interfere withassessment and treatment

• conscious, without tachypnea, and have a normalvoice unlikely to require early airway interventionExceptions: penetrating injuries to the neck with an

expanding hematoma; evidence of chemical or thermal injury to the

mouth, nares, or hypopharynx;extensive subcutaneous air in the neckcomplex maxillofacial trauma; or airway bleeding.

•may become compromised if soft tissueswelling, hematoma formation, or edemaprogresses.

preemptive intubation should be performed

• an abnormal voice, abnormal breathing sounds,tachypnea, or altered mental status

require further airway evaluation

Blood, vomit, the tongue, teeth, foreign objects,and soft tissue swelling can cause airwayobstruction;

suctioning

In the comatose patient, the tongue may fallbackward and obstruct the hypopharynx; this canbe relieved by either a chin lift or jaw thrust

endotracheal intubation indication:

• apnea

• inability to protect the airway due to alteredmental status(most common)

• impending airway compromise due toinhalation injury

• hematoma

endotracheal intubation indication:

• facial bleeding

• soft tissue swelling

• aspiration

• inability to maintain oxygenation

endotracheal intubation include :1. Nasotracheald

only in patients who are breathingspontaneously

frequently used by prehospital providers

in whom chemical paralysis cannot be used.

endotracheal intubation include :2 . orotracheal the preferred technique to establish a definitive airway

Because all patients have cervical spine injuriesCorrect endotracheal placement is verified with direct

laryngoscopy, capnography, audible bilateral breathsounds, and finally a chest film. Advantages : the direct visualization of the vocal cords,

ability to use larger-diameter endotracheal tubes, andapplicability to apneic patients. disadvantage : conscious patients usually require

neuromuscular blockade, which may result in theinability to intubate, aspiration, or medicationcomplications.

endotracheal intubation include :3 . operative

in whom attempts at intubation have failed

extensive facial injuries

Cricothyroidotomy

tracheostomy

In patients under the age of 11, cricothyroidotomy is

relatively contraindicated due to the risk of subglottic, and

tracheostomy stenosisshould be performed. Emergent

tracheostomy is indicated in patients with laryngotracheal

separation or laryngeal

fractures, in whom

cricothyroidotomy may

cause further damage or

result in complete loss of

the airway

Breathing and Ventilation Once a secure airway is obtained, adequate

oxygenation and ventilation must be ensured. All injured patients should receive supplemental

oxygen and be monitored by pulse oximetry. should be recognized during the primary survey: tension pneumothorax open pneumothorax flail chest with underlying pulmonary contusionmassive hemothorax major air leak due to a tracheobronchial injury

Tension pneumothorax is presumed in any patientmanifesting respiratory distress and hypotension incombination with any of the following physical signs:

•tracheal deviation away from theaffected side• lack of or decreased breathsounds on the affected side• subcutaneous emphysema on the•affected side

hypotension qualifies the pneumothorax as atension pneumothorax.

Although immediate needle thoracostomydecompression with a 14-gauge angiocathetermay be indicated in the field, tube thoracostomyin the midaxillary line should be performedimmediately in the ED before a chest radiographis obtained

finaly_ cardiovascular collapse

An open pneumothorax or “sucking chest wound” occurs with full-thickness loss of the chest wall, permitting free communication between the pleural space and the atmosphere

•Temporary management of thisinjury includes covering the woundwith an occlusive dressing that istaped on three sides. This acts as aflutter valve, permitting effectiveventilation on inspiration whileallowing accumulated air to escapefrom the pleural space on theuntapped side, so that a tensionpneumothorax is prevented.

Flail chest occurs when three or more contiguous ribs are fractured in at least two locations. Paradoxical movement of this free-floating segment of chest wall is usually evident in patients with spontaneous ventilation, due to the negative intrapleural pressure of inspiration.

Pulmonary contusions often progress duringthe first 12 hours.Resultant hypoventilation and hypoxemiamay require intubation and mechanicalventilationradiograph often underestimates the extentof the pulmonary parenchymal damage close monitoring and frequent clinicalreevaluation are warranted.

Circulation With Hemorrhage Control

peripheral pulses:o60 mmHg for the carotid pulseo 70 mmHg for the femoral pulseo80 mmHg for the radial pulsesystolic blood pressure (SBP) :oAny episode of hypotension (defined as a SBP <90 mmHg) is assumed to be

caused by hemorrhage until proven otherwise.o Patients with rapid massive blood loss may have paradoxical bradycardia.

should be measured at least every 5 minutes in patients with significant blood loss until normal

vital sign values are restored

• Intravenous (IV) access for fluid resuscitation with two peripheral catheters, 16-gauge or larger in adults.• intraosseous (IO) needles . For

patients in whom peripheral angiocatheter access is difficult in the proximal humerus or tibia .• All medications administered IV

may be administered in a similar dosage intraosseously• IO osteomyelitis

• Blood sample simultaneouslyfor a bedside hemoglobin level androutine trauma laboratory tests. seriously injured patient arriving

in shock :1. abg _cross-matching _ a

coagulation panel should beobtained.

2. secondary large bore (7 to 9 Fr)cannulae should be obtained viathe femoral or subclavian veins.

Saphenous vein cutdowns at theankle can also provide excellentaccess

During the circulation section of the primary survey, four life-threatening injuries must be identified promptly:

(a) massive hemothorax

(b) cardiac tamponade

(c) massive hemoperitoneum

(d) mechanically unstable pelvic fractures withbleeding

During the circulation section of the primary survey, four life-threatening injuries must be identified promptly:

Critical tools used to differentiate these in themultisystem trauma patient :

A. the chest and pelvis radiographs

B. extended focused abdominal sonography fortrauma (eFAST)

A massive hemothorax(life-threatening injurynumber one) is defined as>1500 mL of blood or, inthe pediatric population,>25% of the patient’sblood volume in thepleural space

tube thoracostomy is the only reliable means toquantify the amount of hemothorax.

After blunt trauma, a hemothorax is usually dueto multiple rib fractures with severed intercostalvessels, but occasionally bleeding is fromlacerated lung parenchyma, which is usuallyassociated with an air leak.

After penetrating trauma, a great vessel orpulmonary hilar vessel injury should bepresumed.