atls short cut melati.ppt
TRANSCRIPT
ATLS
Advance Trauma Life Support
Melati Yalti KaustarS(406102025)
Conselor drSjaiful SpB
Definition
bull Advanced Trauma Life Support (ATLS) is a training program for medical doctors in the management of acute trauma cases developed by the American College of Surgeons
bull Originally designed for emergency situations where only one doctor and one nurse are present ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers
Initial assessment and management 1 Preparation amp Triage2 Primary survey3 Resuscitation4 Adjuncts to primary survey and
resuscitation5 Secondary survey6 Adjuncts to secondary survey7 Post resuscitation monitoring and
reevaluation8 Definitive care
Preparation amp Triage
bull Pre-hospital phase
bull Hospital phase
Pre-hospital phase
bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest
hospitalndash Collect also a description of the incident
causes and history of the patient
Hospital phase
bull The preparation of equipment and medical personel that are needed in the Hospital
Triage
bull The way the selection of patients based on treatment needs and available resources
bull Therapy is based on the needs of ABC
bull Used START method (Simple Treatment and Rapid Treatment)
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Definition
bull Advanced Trauma Life Support (ATLS) is a training program for medical doctors in the management of acute trauma cases developed by the American College of Surgeons
bull Originally designed for emergency situations where only one doctor and one nurse are present ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers
Initial assessment and management 1 Preparation amp Triage2 Primary survey3 Resuscitation4 Adjuncts to primary survey and
resuscitation5 Secondary survey6 Adjuncts to secondary survey7 Post resuscitation monitoring and
reevaluation8 Definitive care
Preparation amp Triage
bull Pre-hospital phase
bull Hospital phase
Pre-hospital phase
bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest
hospitalndash Collect also a description of the incident
causes and history of the patient
Hospital phase
bull The preparation of equipment and medical personel that are needed in the Hospital
Triage
bull The way the selection of patients based on treatment needs and available resources
bull Therapy is based on the needs of ABC
bull Used START method (Simple Treatment and Rapid Treatment)
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Initial assessment and management 1 Preparation amp Triage2 Primary survey3 Resuscitation4 Adjuncts to primary survey and
resuscitation5 Secondary survey6 Adjuncts to secondary survey7 Post resuscitation monitoring and
reevaluation8 Definitive care
Preparation amp Triage
bull Pre-hospital phase
bull Hospital phase
Pre-hospital phase
bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest
hospitalndash Collect also a description of the incident
causes and history of the patient
Hospital phase
bull The preparation of equipment and medical personel that are needed in the Hospital
Triage
bull The way the selection of patients based on treatment needs and available resources
bull Therapy is based on the needs of ABC
bull Used START method (Simple Treatment and Rapid Treatment)
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Preparation amp Triage
bull Pre-hospital phase
bull Hospital phase
Pre-hospital phase
bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest
hospitalndash Collect also a description of the incident
causes and history of the patient
Hospital phase
bull The preparation of equipment and medical personel that are needed in the Hospital
Triage
bull The way the selection of patients based on treatment needs and available resources
bull Therapy is based on the needs of ABC
bull Used START method (Simple Treatment and Rapid Treatment)
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Pre-hospital phase
bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest
hospitalndash Collect also a description of the incident
causes and history of the patient
Hospital phase
bull The preparation of equipment and medical personel that are needed in the Hospital
Triage
bull The way the selection of patients based on treatment needs and available resources
bull Therapy is based on the needs of ABC
bull Used START method (Simple Treatment and Rapid Treatment)
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Hospital phase
bull The preparation of equipment and medical personel that are needed in the Hospital
Triage
bull The way the selection of patients based on treatment needs and available resources
bull Therapy is based on the needs of ABC
bull Used START method (Simple Treatment and Rapid Treatment)
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Triage
bull The way the selection of patients based on treatment needs and available resources
bull Therapy is based on the needs of ABC
bull Used START method (Simple Treatment and Rapid Treatment)
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)
bull Airway Try to talk to the patient
bull Breath calculate the repiration rate
bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Primary survey
bull A = Airway maintenance with cervical spine protection
bull B = Breathing and ventilationbull C = Circulation with hemorrhage
controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control
completelyndash undress the patientbut prevent
hypothermia
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
A = Airway maintenance with cervical spine protection
The first stage of the primary survey is to assess the airway
LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness
LISTENBreath of air movement with
FEELBreath of air motion to cheek
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Airway Maintenance
Is the Victim is conscious or not
Conscious
Unconscious
Try to talk to the victims
Can the victim breath(look-listen-feel)
able to talk airway is clear (no obsrtruction)
YesNo
-Give artificial respiration-Give O2
Is there snoringgarglingcrowing
YESSnoring put GuedelGargling do suctionCrowing Intubated
NO
Airway is clear
Put Collar neck until we are sure that there is no servical fracture
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Sign of Obstruction
bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway
bull Gargling sounds liquid inside the mouth
bull Crowing(stridor) spasm edema of the vocal cords
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Collar Neck Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Guedel (Oropharyngeal airway)
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Intubation
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
When are we doing CricothyroidotomyCricothyroidotomy
bull Failed intubation because the airway is blocked
bull Patients can not be given artificial respiration from above (nose mouth)
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
CricothyroidotomyCricothyroidotomy
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Complication CricothyroidotomyCricothyroidotomy
1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach
ea 1048708 Vocal cord paralysis
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
B = Breathing and ventilation
bull The chest must be examined by ndash Inspection
bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)
ndash Palpation ndash Percussion
bull Sonor Normalif dull (+)fluid
ndash Ausculationbull VBS (Vesicular Breath Sound) are the
right and left same
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax
ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with
Pulmonary Contusion ndash Cardiac Tamponade
Flail chest penetrating injuries and bruising can be recognized by inspection
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Tension Pneumothorax
bull SpontaneousndashPrimaryndashSecondary
bull COPDbull Infectionbull Neoplasm
bull TraumaticndashBluntndashPenetrating
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Tension Pneumothorax
bull One way valve (fenomena ventil)
bull Intrapleura pressure increase
bull The lungs collapsbull The Mediastinum is
displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Tension Pneumothorax
bull Respiratory distressbull Distended neck veinsbull Unilateral depression in
breath soundsbull Hyperresonancebull Cyanosis (late)
bull Management ndash Immediate
Decompression with wide bore cannula in 2nd space MCL
ndash Put Chestube 5th ICS the tube connect to bottle that contains water
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Massive Hemothoraxbull Sistematic pulmonary
vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck
veinsbull Shock with no breath
sounds and or percussion dullnes
Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion
defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy
Management - 3 side cover ndash over defect
bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]
- Chest tube- Definitive operation
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Open Pneumothorax
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Flail chest Pulmonary contusion
bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures
bull Pain and restricted movement
bull Paradoxical movement of chest wall with respiration
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Flail chest Pulmonary contusion
bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Cardiac Tamponade
bull Injuries caused by penetrating blunt injury
bull Pericardium filled with blood
bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling
bull TRIAS BECKndash Venous pressure
increasendash Arterial pressure
decreasendash Muffled heart sound
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Cardiac Tamponade
Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
C = Circulation with hemorrhage control
bull Hemorrhage is the predominant cause of preventable post-injury deaths
bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
The main set are bull Change the volumebull Stop the bleeding
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
ASSESSMENT OF CIRCULATION
bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
CLINICAL SIGNS OF SHOCK
bull Rapid breathing nervous consciousness until coma
bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Slightly Slightly anxiousanxious
Respirations Respirations 14-20min14-20min
Heart rate Heart rate lt100minlt100min
Urine Urine
30 mLhr 30 mLhr harr harr BPBP
crystalloidcrystalloid
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Mildly Mildly anxiousanxious
Respirations Respirations 20 ndash30min20 ndash30min
UrineUrine
20-30 mLhr20-30 mLhr
Heart rate Heart rate gt100mingt100min harrharr BPBP
darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid
blood blood
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Confused Confused anxiousanxious Respirations Respirations
30-40min30-40min
Urine Urine 5-15 mlhr5-15 mlhr
Heart rate Heart rate gt 120mingt 120min BPBP
Pulse Pulse pressurepressure
Crystalloid Crystalloid blood operationblood operation
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Confused Confused lethargiclethargic
Respirations Respirations gt35mingt35min
Heart rate Heart rate gt140mingt140min
Urine Urine negligiblenegligible
BPBP
Pulse Pulse pressurepressure
Rapid fluids Rapid fluids blood operationblood operation
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Assessment of Stages of Shock
Blood Volume loss
lt 15 15 ndash 30 30 ndash 40 gt40
HR lt100 gt100 gt120 gt140
SBP N N
Pulse Pressure
N or
Cap Refill lt 3 sec gt 3 sec gt3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 gt35
CNS anxious v anxious confused lethargic
Treatment 1 ndash 2 L crystalloid + maintenance
2 L crystalloid re-evaluate
2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Fluid Resuscitation of Shock
bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte
bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC
plasma)
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Crystalloid Solutions
bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume
lossbull eg estimate 1 L blood loss
require 3 L of crystalloid to replace volume
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Colloid Solutions
bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11
ratio
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
D = Disability Neurological status
bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey
bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome
bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Glasgow Coma Scale
bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point
bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point
bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
E = ExposureEnvironmental control completely
The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
bull 1 Cloths cut all the cloths using sharp scissors
bull 2 Warmth cover with blankets
bull 3 Intravenous fluids should be warmed and a warm environment maintained
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Secondary survey
bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained
bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration
pneumonia)ndash Event of injury (to predict site amp
extent of injury
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Adittional ExaminationAdittional Examination
bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or
pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity
bull DPL (replaced by FAST)bull Diagnostic laparoscopy
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Post resuscitation monitoring andreevaluation
bull Repeat ABCDEbull Repeated resuscitation if
necessary
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Definitive care
bull Consult a specialistbull Treatment measures according to
the problembull Operation
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Abdomen Trauma
Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]
ndash Present with picture of internal hemorrhage
bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-
72 hours)
bull Management ndash I All penetrating trauma immediate exploration
(laparotomy)ndash II Blunt trauma
bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
bull - Investigations ndash I Plain X-ray fracture ribs ndash air under
diaphragm ndash fluid level in ileus ndash II FAST
bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)
bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard
[DONrsquoT send unstable patient to CT] IV DPL
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Burn Injury
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)
Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity
9 9 anterior trunk 18
18 posterior trunk
18 18 each lower extremity
18 14 perineum 1 1 100 100
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn
ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief
contact with hot objectndash b Involves the epidermis and part of the
dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very
painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts
of scarring
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity
flash electricity chemicals or prolonged contact with hot liquids or hot objects
ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black
may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so
wound becomes leathery and feels firm to the touch
ndash f Marked edema and decreased elasticity may necessitate escharotomies
ndash g Generally painless to touch
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Fluid Management Burn Injurybull Parkland formula
bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or
higher
This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated
plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Fluid Management
bull Maintance for Adultndash M= 40 cc weight (kg)24 hour
bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24
hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24
hourbull X = the overmeasure weight
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Fluid Management for Dehydration
bull Grade of Dehydrationndash Mild 4 (adult) 6
(children)ndash Moderate 6 8ndash Severe 8 10
ndash D = Grade of dehydration x (weight)Kg x 1000
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
Fluid Management for 24 Hours
bull First 6 hour ndash frac12 D + frac14 M = (X) cc
bull Next 18 hourndash frac12 D + frac34 M = (Y) cc
THANK YOU
THANK YOU