TRAUMADoctor LiangDepartment of Emergency Surgery, the First Affiliated Hospital, School of Medicine, Zhejiang University

outlineTrauma background definition calssification three peaks of death trauma system primary survey prehospital--BTLS A B C D trauma center hospitalE.D. principle ATLS procedure DCS+ICU skills Addition (traumatic shock/scores/abdominal trauma)

backgroundAccidental 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 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-1Closed traumas Contusion crush injury sprain injury closed fracture concussion injuryOpen traumas penetrating laceration scrape incised wound According to the integrity of skin

Classification-2According to the injury position head, face, neck chest abdomen pelvis limbs multiple injury

In clinicmultiple injuryOne factor >two anatomic parts injuryCompound injury>two factors

Three peaks of death after traumaFirstpeakSecondpeakThird peakSeconds~minutesBrain/brainstem/ spine/heart/aorta/ great vessels injurydays~weekssevere inflammation MODS and MOFminutes~hours Epidural hematoma /Subdural hematoma/ hemopneumothorax /rupture of liver and spleen/pelvic fracture/ massive blood loss

Gold time Gold time = one hours after trauma

Life=emergency

outlineTrauma background definition calssification three peaks of death trauma system primary survey prehospital--BTLS A B C D trauma center hospitalED principle ATLS procedure DCS+ICU skills

Trauma systemTraumasystemtransportfield first aid hospital remedyTreatment&rehabilitativeTraining&databaseProphylaxis system

Life chain

Prehospital

120Airway & CPRantishock & hemostasisSimple fixationlife sign monitoringtransport

recordtime , place, mechanism, and history

Prehospital :primary survey

Primary surveyminimal trauma: require no testing moderate trauma: complete blood count, basic metabolic panel, blood type and screen, urinalysisvital sign instability without obvious source, it is prudent to evaluate the abdomen for hemorrhage

Prehospital skill: Airway--AAB

Prehospital skill: mouth to mouth--B

facility face mask--B

Compression mask--B

CPR--C

defibrillation--D

Transport to hospital

Emergency department (ED)

EDEmergence DepartmentTrauma center (Emergency Department):Ancillary staffing, experienced nurseUp-to-date technologyReadily available consultants , have advanced skillsRapid operating room capabilityIntensive care unit (ICU) capabilityRehabilitative care

ATLSATLS: advanced trauma life support

ATLS principle-11.Patient life-threatening injured first in group injurys, life-threatening priority of multiple injury2.Effective treatment not be delayed without clear diagnosis3.Comprehensive analysis of injuries is in need, history in the first assessment, diagnosis and treatment is not necessary.

ATLS principle-2If 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 time-consuming short, less manpower and equipment needed to care for patients.

ATLS procedureassessmentAuxiliary examination of second timeLife sign monitoring &treatmentSpecialist treatmentprepareTriagefirst surveyResuscitation&first aidAuxiliary examination of first timeATLS

E.D. evaluationEmphasis 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 planCRASH PLANCRASHcardiacrespiratoryabdomenheadspinePLANpelvislimbarteriesnerves

interventions1. secure the airway while protecting the cervical spine2. enhance oxygenation3. provide ventilatory assistance4. limit further hemorrhage5. gain intravenous access6. initiate volume replacement7. obtain blood for laboratory and blood bank testing

Important process1. Monitoring of heart rate, respiratory rate, blood pressure, temperature, pulse oximetry2. Early placement of central venous pressure lines3. Placement of a nasogastric or orogastric tube for decompression4. Placement of a urinary drainage catheter

LaboratoryComplete 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 bloodToxicologic studies (as indicated)Serum lactateUrinalysis

RadiographsX-ray of chest, cervical spine, pelvisCTUS

Skills:Trauma airway managementExpert 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 managementorotracheal 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 management1. 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 management3. 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 solutionFluids may be warmed ahead of time or be administered through a fluid warmer.

ED management4. 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 management5. Pneumothorax or hemothorax should be managed by the placement of a large chest tube (32 or 36 French) in the lateral chest.

AB

ED management6. 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.

Summaryskills in ATLSassessmentCPRorotracheal intubation /blind intubationsurgical cricothyrotomyvenesectionPneumothorax / hemothorax drainageFixation and hemostasis

lets have a rest!

outlineTrauma background definition calssification three peaks of death trauma system primary survey prehospital--BTLS A B C D trauma center hospitalED principle ATLS procedure DCS+ICU skills Addition (traumatic shock/scores/abdominal trauma)

DCSTriad of death in severe trauma: hypothermia, metabolic acidosis and coagulation disorder

1993, Rotondo. DCS (damage control surgery)

Simplify the initial surgery

Resuscitation in ICU

repair &reconstructionTrauma centerDCS?

Moreover in ICU Nutrition(EN/PN)Anti-inflamationrehabilitativesurgery

DCS

Trauma patient: DCS+ICU

Doctor: E + S + ICU

Additional-1Trauma scoring systemsTrauma 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)Three components: GCS, systolic blood pressure, respiratory rate RTS

Anatomic ScoresInjury 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 ScoresISS 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 abdomen1. Diagnostic peritoneal lavage (DPL)Advantages: high accurate(92~98%), has reliable significance when negative, mandate a laparotomy prior to transfer to a trauma centerLimitations: invasive, insensitve for retroperitoneal injures, when CT and US are unavailable

DPLA 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)

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: cant show the source or magnitude of the injury,

CT

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 shockFirstpeakSecondpeakThird peakSeconds~minutesBrain/brainstem/ spine/heart/aorta/ great vessels injurydays~weekssevere inflammation MODS and MOFminutes~hours Epidural hematoma /Subdural hematoma/ hemopneumothorax /rupture of liver and spleen/pelvic fracture/ massive blood loss

Additional-3:Traumatic shockShock 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 shockCaused by: Most related to loss of circulating blood volume caused by hemorrhageInadequate oxygenationCardiac dysfunctionNeurologic dysfunctionMechanical vascular obstruction

Types of shock1. hemorrhagic or hypovolemicloss of circulating intravascular volume caused by blood loss internally, externally, or both 2. cardiogenic3. neurogenic or vasogenic4. septic

complicationsIf 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 presentationInitial findings: tachycardia, hypotension, signs of poor peripheral perfusion, alteration in mental statusContinued 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 shockClass blood volume heart rate systolic BP respiratory mental status lost (ml) ( bpm) rate ( /min) 750(15%) 100 normal 20-30 mildly anxious 1500-2000(30-40%) >120 decreased 30-40 anxious, confused >2000 >140 markedly decreased >35 confused, lethargic

Systemic workRapid diagoseFluid therapyOptimal type of fluidRed blood cell substitutes as well as plt&ffpDCSICU

What should you know from our lessonsMultiple injury Compound injury Classification of traumaThree peaks of deathGold timeLife chainCrash planDCS Classes of hemorrhagic shock

According to the integrity of skinOpen traumas: penetratinglacerationscrapeincised wound Closed traumascontusioncrush injurysprain injuryclosed fractureconcussion injury 221,,: ,,;,,,,;,,;

combined injury22 There are three peaks of death after trauma. The first peak happens within seconds to a few minutes, usually caused by Brain/brainstem/ spine/heart/aorta/ great vessels injury.minutes~hours; mainly due to epidural hematoma/subdural hematoma/hemopneumothorax/rupture of liver and spleen/pelvic fracture/massive blood loss .MODSdays~weeks,caused by severe inflammation,MODS and MOF

.The gold time refer to the one hours after trauma, which is coincident with the second peak of death. It require emergency treatment for trauma patients.

field first aid, transport, hospital remedy, Treatment&rehabilitative, Prophylaxis system, Training&databaseNext, we will talk about part 1(field first aid, transport)and part 2(hospital remedy, Treatment&rehabilitative).Trauma :traffic accidentHow to do?Like first aid, life chain for the trauma patient is necessary.120CPRBTLSbasic trauma life supportPrehospital :primary survey1.1Ascertain the airway opened or obstructed1.2Neck :carotid pulsation, tracheal position, character of neck veins1.3Chest (sucking wounds): palpate for bony crepitus or subcutaneous air, auscultate for breath sounds 1.4Extremities: cool, moist, pale, ------hemorrhagic shock1.5Observe the change of life signs and Stabilize during resuscitation.2.The next priority is a complete head-to-toe examination, including repeat maxillofacial, cardiopulmonary, abdominal, neurologic examinations. 3.1Past medical history ,medications taking and allergies.3.2 If unconscious, determining the level of brainstem function and presence of herniation syndrome3.3Attention:open fractures: gently irrigated, debridement splinted to prevent further injury and reduce pain and bleeding , covered with clean dressings , intravenous antibioticsAlift the head and chin, easy but not for the cervical vertebra injury patientBsafe for the cervical vertebra injury patient cardiac apex cardiac baseATLS: advanced trauma life supportATLS Trauma must have the three principles: patient life-threatening injured in group injurys first, life-threatening priority of multiple injury ;effective treatment not be delayed without clear diagnosis Comprehensive analysis of injuries is in need, history in the first assessment, diagnosis and treatment is not necessary.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 the injured patients and the severity exceed the processing power of medical staff, to give priority to those time-consuming short, less manpower and equipment needed to care for patients.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)

FreelandCRASH PLANC=cardiacR=respiratoryA=abdomen()S=spinaH=head P=pelvisL=limbA=arteriesN=nerves

Oropharyngeal airway :ApneumothoraxBhemothorax:1993Rotondo,.damage control surgery, DCS

DCSSimplify the initial surgery ICUResuscitation in ICUrepair and reconstruction surgeryHow to diagnosis the occult abdominal injury? There are three peaks of death after trauma. The first peak happens within seconds to a few minutes, usually caused by Brain/brainstem/ spine/heart/aorta/ great vessels injury.minutes~hours; mainly due to epidural hematoma/subdural hematoma/hemopneumothorax/rupture of liver and spleen/pelvic fracture/massive blood loss .MODSdays~weeks,caused by severe inflammation,MODS and MOF

2. cardiogenicprevents the normal pumping of the heart, caused by pericardial tamponade that prevents normal ventricular filling, tension pneumothorax with vena caval compression and reduction in venous return to the heart, or direct cardiac damage with loss of contractile force(myocardial contusion).3. neurogenic or vasogenic result from spinal cord injury with loss of peripheral vascular resistance. Major spinal cord injury results in acute vasodilatation but generally does not cause impaired tissue perfusion unless other injuries are present. Spinal cord injuries result in a loss of sympathetic tone and are therefore accompanied by bradycardia (spinal shock).4. septica hyperdynamic response (elevated cardiac output and low systemic vascular resistance), followed by decreased cardiac output and increased systemic vascular resistance, eventually resulting in organ function deterioration associated with the inflammatory mediators accompanying infection.