Published on March 12, 2014
Trauma 1 Leading cause of death ages 1-40 Third leading cause in all age groups Co-Morbid Factors Extremes ofAge Underlying Disease & Poor General Health Pregnancy Environmental Extremes Protective Devices
When Trauma Deaths Occur <1 hour 1-3 hours 4 to 6 weeks Temple College EMSP 2 “The Trimodal Distribution”
Immediate Deaths (seconds to minutes) unpreventable Temple College EMSP3 Loss of Airway Brain Stem Laceration High Cx-Spine Lesion Aortic/Heart Rupture
Early Deaths (few minutes to hours ) Temple College EMSP4 Epidural Hematoma Subdural Hematoma Hemo/Pneumothorax Intra-abdominal Bleeding Pelvic Fractures Femur Fractures Multiple Long Bone Fractures
Late (days to week ) Temple College EMSP5 Sepsis Multiple Organ System Failure(MODS- MOSF-MOFS). Complications due to surgery or initial injury .
Initial Assessment and Management of Trauma
Sorting of patients in mass casualty. Their ranking according to both their clinical need and the available resources to provide treatment. Based on the ABCDE priority Three categories of patient
Initial Assessment (Primary Survey) Find life threats If life threat present, CORRECT IT! If life threat can’t be corrected Support ABCs TRANSPORT!!
PRIMARY SURVEY Identify and treat what can kill the patient . Airway( patent and protected ) with Cervical spine protection Breathing (adequate bilateral air entry +no life threatening chest conditions) and ventilation Circulation with hemorrhage control Disability:(AVPU assessment ) Neurologic status Exposure/ Environmental control(keep the patient warm )
Airway with Cervical spine
Management: Ascertain patency Rapidly assess for airway obstruction Chin lift / jaw thrust maneuver (the mandible is gripped and lifted forward whilst the neck is extended) Clear the airway of FB Insert an oro- / naso-pharyngeal airway. Establish a definitive airway Orotracheal / nasotracheal intubation Surgical cricothyroidotomy( failed intubation due to edema of the glottis +laryngeal fractures +severe oral Hge) Jet insufflations.
Cervical spine Maintain the cervical spine in a neutral position with manual immobilization as necessary when establishing an airway Immobilization of the cx-spine with appropriate devices after establishing an airway (neck collar)
Breathing and Ventilation Injuries that should be identified in the Primary survey : 1.Tension pneumothorax 2. Massive hemothorax 3. Open pneumothorax 4. Flail chest
Circulation with Hemorrhage Control Assessment: Pulse / skin color, capillary refill / Blood pressure Identify source of external hemorrhage Identify potential source(s) of internal hemorrhage Management: Apply direct pressure to external bleeding site. Internal hemorrhage ? Need for surgical intervention ? Establish IV access / central line Fluid resuscitation / blood replacement Cardiac tamponade
Disability Assessment of Level of consciousness AVPU scale Alert Voice = response Pain = response Unresponsive GCS Pupils size, equality and reaction Management Intubation and allow mild hyperventilation Administer IV mannitol ( 1.5-2.0g/kg ) Arrange for brain CT
GCS - BEST!!! (3 – 15) Eye Verbal Motor 6 Obeys 5 Normal Localizes 4 Spontaneous Confused Withdraws 3 Voice Inappropriate abN flexion 2 Pain Incomprehensible Extension 1 Nil Nil Nil
Mild H.I. GCS 13 – 15 Moderate GCS 8 – 12 Severe GCS < 8
CT is contraindicated when the patient is hemodynamically unstable A decrease in the level of consciousness may due to: Decreased cerebral oxygenation (A,B) Decreased cerebral perfusion (C) Direct cerebral injury (D) Drugs orAlcohol Always rule out hypoxemia and hypovolemia first. Reevaluation
Exposure / Environment Control Completely undress the patient. Prevent hypothermia Pain relieve
Jaw thrust/chin lift Suction Intubations Cricothyroidotomy Airway ( with protection of C-spine ) Oxygenation Needle decompression Tube thoracostomy Supplemental oxygen Seal open pneumothorax Breathing/Ventilation Hemorrhage control IV line/ central line Venous cut down Fluid resuscitation/Blood transfusion Pericardiocentesis for cardiac tamponade Circulation IV mannitol Hypervntilation Surgery Disability
Radiological and laboratory Assessment ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION CXR pelvis C-spine Abdominal ultrasonography (FAST)
Medical history (AMPLE) A =allergies M=medications P=past medical history L=last meal E=events leading to injury
Secondary SURVEY The secondary survey does not begin until: The primary survey is completed, Resuscitation efforts are well established, The patient is demonstrating normalization of vital functions. Complete history and Examination Head-to-toe evaluation Reassessment of all vital signs. Complete Neurological Examination . Indicated x-rays ,CTS, US are obtained.
Fingers and tubes in every orifice: PR PV CHECK ENT NG tube if no skull fracture . URINARY CATHETER if no evidence of genitourinary trauma
Factor influencing wound healing Local factors Tissue trauma Hematoma - associated with higher infection rate Blood supply Temperature Infection Technique and suture materials General factors Systemic effect of steroids Nutrition Uncontrolled DM Chemotherapy Chronic illness
Type of wounds and their treatment Cut wound Abrasion Contusion Laceration Avulsion Puncture wound
Management of the clean wound Goal - close wound as soon as possible to prevent infection, fibrosis and secondary deformity. General principles: 1 -Immunization 2- Pre-anesthetic medication if needs 3- Local anesthesia – use epinephrine adjuvant unless contraindicated, eg., digit , tip of penis 4-Tourniquet 5- Cleaning of surrounding skin – do NOT use strong antiseptic in the wound itself 6- Debridement: Remove clot and debris, necrotic tissue ;Copious irrigation good adjunct to sharp debridement 7- Closure - atraumatic technique to approx. dermis Consider undermining of wound edges to relieve tension. 8- Dressing – must provide absorption,protection,immobilization, even compression, and be aesthetically acceptable.
Types of sutures
Wound dressings 1- Protect the wound from trauma 2 -Provide environment for healing 3 -Antibacterial medication provide moisture and control microorganism. 4- Splinting – casting : For immobilization to promote healing Do not splint too long – may promote joint stiffness 5- Pressure dressings May be useful to prevent dead space, seroma,hematoma Do NOT compress flaps tightly 6- Do NOT leave dressing too long before changing
Polytrauma: the wounds of war. on ResearchGate, the professional network for scientists.
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1. Adv Skin Wound Care. 2007 Sep;20(9 Pt 1):471-3. Polytrauma: the wounds of war. Salcido R. PMID: 17762209 [PubMed - indexed for MEDLINE] Publication Types: