trauma -in detail
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Principles of TraumaPrinciples of Trauma
ManagementManagementhttp://apexiondental.com/http://apexiondental.com/
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TraumaTrauma
Prehospital phase and triagePrehospital phase and triage
Primary SurveyPrimary Survey
ABCDEABCDE ResuscitationResuscitation
Adjuncts to primary survey andAdjuncts to primary survey and
resuscitationresuscitation Secondary SurveySecondary Survey
Records, Consent, Forensic evidenceRecords, Consent, Forensic evidence
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Primary SurveyPrimary Survey
AAirway and cervical spine controlirway and cervical spine control
BBreathingreathing
CCirculation with control ofirculation with control of
hemorrhagehemorrhage
DDisabilityisability
EExposure/environment (exposexposure/environment (expose
patient, but avoid hypothermia)patient, but avoid hypothermia)
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ResuscitationResuscitation
Oxygenation and VentilationOxygenation and Ventilation
Shock managementShock management
IV linesIV linesNormal SalineNormal Saline
Management of lifeManagement of life--threatening problemsthreatening problems
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Adjuncts to Primary SurveyAdjuncts to Primary Survey
and Resuscitationand Resuscitation Monitoring:Monitoring:
ABGs and ventilatory rateABGs and ventilatory rate
EndEnd--tidal CO2tidal CO2
EKGEKG
Pulse oximetryPulse oximetry
Blood pressureBlood pressure
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Adjuncts to Primary SurveyAdjuncts to Primary Survey
and Resuscitationand Resuscitation Urinary and gastric cathetersUrinary and gastric catheters
XX--rays and diagnostic studiesrays and diagnostic studies
ChestChest
PelvisPelvis
CC--spinespine
FAST / CT SCAN / DPLFAST / CT SCAN / DPL
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Trauma MortalityTrauma Mortality 35 per 100,000 population35 per 100,000 population
Most common cause of death in childrenMost common cause of death in children
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Airway and VentilationAirway and Ventilation These are first priorities!!!!These are first priorities!!!!
Risks for obstruction:Risks for obstruction:
ComaComa
AspirationAspiration
Maxillofacial traumaMaxillofacial trauma
Neck traumaNeck trauma
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Airway and ventilationAirway and ventilation Neck trauma: disruption of the larynx orNeck trauma: disruption of the larynx or
tracheatrachea--or compression by soft tissueor compression by soft tissue
injuryinjury
Laryngeal trauma:Laryngeal trauma:
HoarsenessHoarseness
Subcutaneous emphysemaSubcutaneous emphysema
Palpable fracturePalpable fracture
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Airway and ventilationAirway and ventilation Obstruction:Obstruction:
Agitation or obtundationAgitation or obtundation
Abnormal airway soundsAbnormal airway sounds
Trachea not in midlineTrachea not in midline
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Airway and ventilationAirway and ventilation Inadequate ventilationInadequate ventilation
Asymmetric chest riseAsymmetric chest rise
Asymmetric chest soundsAsymmetric chest sounds
Poor oxygenationPoor oxygenation
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Airway and ventilationAirway and ventilation Airway MaintenanceAirway Maintenance
Chin liftChin lift
Jaw thrustJaw thrust
Oropharyngeal airwayOropharyngeal airway
Nasopharyngeal airwayNasopharyngeal airway
Definitive AirwayDefinitive Airway
Endotracheal tubeEndotracheal tube
CricothyroidotomyCricothyroidotomy
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Airway and ventilationAirway and ventilationPaOPaO22 LevelsLevels
90 mm Hg90 mm Hg
60 mm Hg60 mm Hg
30 mmHg30 mmHg27 mmHg27 mmHg
OO22 Hgb SaturationHgb Saturation
100%100%
90%90%
60%60%50%50%
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Pulse OximetryPulse Oximetry LED absorbed differently betweenLED absorbed differently between
oxygenated and nonoxygenated and non--oxygenated Hgboxygenated Hgb
Affected by:Affected by:
Poor perfusionPoor perfusion
AnemiaAnemia
Carboxyhemoglobin or methehemoglobinCarboxyhemoglobin or methehemoglobin
Circulating dyeCirculating dye
Patient movement, ambient light or signalsPatient movement, ambient light or signals
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ThoraxThorax Breathing:Breathing:
Tension pneumothoraxTension pneumothorax
Open pneumothorax (sucking wound)Open pneumothorax (sucking wound)
Flail chestFlail chest
Massive hemothoraxMassive hemothorax
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ThoraxThorax Tension PneumothoraxTension Pneumothorax
Collapse of affected lungCollapse of affected lung
Decreased venous returnDecreased venous return
Decreased ventilation of opposite lungDecreased ventilation of opposite lung
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ThoraxThorax Tension pneumothorax:Tension pneumothorax:
Respiratory distressRespiratory distress
Distended neck veinsDistended neck veins
Unilateral decrease in breath soundsUnilateral decrease in breath sounds
HyperresonanceHyperresonance
CyanosisCyanosis
Needs immediate decompression!Needs immediate decompression!
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ThoraxThorax Open pneumothorax:Open pneumothorax:
Occlusive dressingOcclusive dressing
Flail chest:Flail chest:
Trauma principles andTrauma principles and
ventilationventilation
Massive hemothoraxMassive hemothorax
Chest decompressionChest decompression
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ThoraxThorax Circulation:Circulation:
Massive hemothoraxMassive hemothorax
Flat v. distended neck veinsFlat v. distended neck veins
Shock with no breath soundsShock with no breath sounds
Treat with decompressionTreat with decompression
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ThoraxThorax Circulation:Circulation:
Cardiac tamponadeCardiac tamponade
Decreased arterial pressureDecreased arterial pressure
Distended neck veinsDistended neck veins
Muffled heart soundsMuffled heart sounds PEA (pulseless electrical activity)PEA (pulseless electrical activity)
Treat with decompressionTreat with decompression
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ThoraxThorax Resuscitative thoracotomy:Resuscitative thoracotomy:
Penetrating traumaPenetrating trauma
Pulseless with myocardial activityPulseless with myocardial activity
Evacuate bloodEvacuate blood
Stop bleedingStop bleeding
Cardiac massageCardiac massage
Cross clamp of aortaCross clamp of aorta
Infusion of fluids and bloodInfusion of fluids and blood
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ThoraxThorax
Secondary SurveySecondary Survey Simple pneumothoraxSimple pneumothorax
HemothoraxHemothorax
Pulmonary contusionPulmonary contusion Tracheobronchial tree injuryTracheobronchial tree injury
Blunt cardiac injuryBlunt cardiac injury
Aortic disruptionAortic disruption
Diaphragm injuriesDiaphragm injuries
Mediastinal traversing woundsMediastinal traversing wounds
Esophageal ruptureEsophageal rupture
Rib, sternum, scapular fracturesRib, sternum, scapular fractures
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ShockShock
Hemorrhage is the mostHemorrhage is the most
common cause of shock in thecommon cause of shock in theinjured patient!!injured patient!!
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ShockShock Hemorrhagic shockHemorrhagic shock
NonNon--hemorrhagic shock:hemorrhagic shock:
CardiogenicCardiogenic
Tension pneumothoraxTension pneumothorax
Neurogenic shockNeurogenic shock Septic shockSeptic shock
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ShockShock Blood volume:Blood volume:
5 liters in the 70 kg adult5 liters in the 70 kg adult
8080--90 ml/kg in the child90 ml/kg in the child
Classes of Hemorrhage (% loss)Classes of Hemorrhage (% loss)
I: 40%
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ShockShock
Initial Therapy:Initial Therapy:
Stop the bleeding!Stop the bleeding!
Vascular Access linesVascular Access lines
2 large bore IV lines2 large bore IV lines
Intraosseous linesIntraosseous lines
Central linesCentral lines
Fluid bolusFluid bolus 2 Liters NS: adult2 Liters NS: adult
20ml/kg: Child20ml/kg: Child
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ShockShock Assess:Assess:
Capillary refill (should be < 2 sec)Capillary refill (should be < 2 sec)
Peripheral pulsesPeripheral pulses
Heart rateHeart rate
Temperature and color of skinTemperature and color of skin SensoriumSensorium
Pulse pressurePulse pressure
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ShockShock Signs of hemodynamic recovery:Signs of hemodynamic recovery:
Slowing of pulseSlowing of pulse
Decrease in skin mottlingDecrease in skin mottling
Increase in extremity temperatureIncrease in extremity temperature
Clearing of sensoriumClearing of sensorium Urinary output > 1ml/kg/hourUrinary output > 1ml/kg/hour
Increased systolic blood pressureIncreased systolic blood pressure
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AbdomenAbdomen
Mechanisms:Mechanisms:
BluntBlunt PenetratingPenetrating
Spaces:Spaces:
Peritoneal cavityPeritoneal cavity
PelvisPelvis
RetroperitoneumRetroperitoneum
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AbdomenAbdomen Physical exam:Physical exam:
InspectionInspection
AuscultationAuscultation
PercussionPercussion
PalpationPalpation
Evaluate penetrating woundsEvaluate penetrating wounds
Local exploration of stab woundsLocal exploration of stab wounds
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AbdomenAbdomen Physical exam:Physical exam:
Assess pelvic stabilityAssess pelvic stability
Genital and rectal examGenital and rectal exam
Gluteal examGluteal exam
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AbdomenAbdomen Diagnostic studies:Diagnostic studies:
CT scanCT scan
UltrasoundUltrasound
DPLDPL
Urethrography/cystographyUrethrography/cystography
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AbdomenAbdomen
Indications for exploration:Indications for exploration:
Blunt trauma with instability and positive US orBlunt trauma with instability and positive US or
DPLDPL
Blunt trauma with recurrent hypotensionBlunt trauma with recurrent hypotension
PeritonitisPeritonitis
Hypotension from penetrating woundHypotension from penetrating wound
Bleeding from stomach/rectum/GU (penetrating)Bleeding from stomach/rectum/GU (penetrating)
Gunshot woundGunshot wound
EviscerationEvisceration
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AbdomenAbdomen
SpecialSpecial
considerations:considerations:
DiaphragmDiaphragm
DuodenumDuodenum
PancreasPancreas
Liver/SpleenLiver/Spleen
GUGU
Small bowelSmall bowel
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Left: Massive hemothoraxLeft: Massive hemothorax
Right: Chest tube decompressionRight: Chest tube decompression
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Tension pneumothoraxTension pneumothorax
Chest tube placed and pneumoChest tube placed and pneumo--
thorax resolvedthorax resolved
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CirculationCirculationHeart rate Systolic BP UrineHeart rate Systolic BP Urine
ml/kg/hrml/kg/hr
Infants 100Infants 100--160 60 2160 60 2
Preschool 80Preschool 80--140 80 1.5140 80 1.5
School age 80School age 80--140 90 1140 90 1--1.51.5
Adolescent 60Adolescent 60--120 100 0.5120 100 0.5--11
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Head TraumaHead Trauma
500,000 cases per year in US500,000 cases per year in US
10% die prior to hospital10% die prior to hospital
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Head TraumaHead Trauma Cerebral Perfusion PressureCerebral Perfusion Pressure
CPP=MAPCPP=MAP--ICPICP MAP =Mean arterial pressureMAP =Mean arterial pressure
ICP = Intracranial pressureICP = Intracranial pressure
Cerebral Blood FlowCerebral Blood Flow
50ml/ 100g of brain/minute50ml/ 100g of brain/minute
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Head TraumaHead Trauma Mechanism:Mechanism:
Blunt v. PenetratingBlunt v. Penetrating
Severity:Severity:
Mild: GCS 14Mild: GCS 14--1515
Moderate: GCS 9Moderate: GCS 9--1313
Severe: GCS 3Severe: GCS 3--88
Morphology:Morphology: Skull fracturesSkull fractures
Intracranial lesionsIntracranial lesions
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Head TraumaHead Trauma Skull fractures:Skull fractures:
Battles SignBattles Sign
Racoon eyesRacoon eyes
Rhinorrhea/otorrheaRhinorrhea/otorrhea
Linear vault fracturesLinear vault fractures
400 X risk hematoma in awake patients400 X risk hematoma in awake patients
20 X risk in comatose patients20 X risk in comatose patients
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Head TraumaHead Trauma
Intracranial lesionsIntracranial lesions
Epidural hematomasEpidural hematomasSubdural hematomasSubdural hematomas
Contusions/hematomasContusions/hematomas
ConcussionConcussion
Diffuse axonal injuriesDiffuse axonal injuries
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Head TraumaHead Trauma Management;Management;
ABCs! (GCSABCs! (GCS
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Spinal InjuriesSpinal Injuries LevelLevel
SeveritySeverity
CC--spinespine--protect always!!protect always!!
10% have another vertebral fracture10% have another vertebral fracture Respiratory function may be lostRespiratory function may be lost
Spinal shockSpinal shock
High dose methylprednisolone in first 8 hoursHigh dose methylprednisolone in first 8 hours
Pediatric considerations (SCIWORA)Pediatric considerations (SCIWORA) SCIWORASCIWORA SSpinalpinal CCordord IInjurynjury WWithithOOutut RRadiographicadiographic
AAbnormalitybnormality
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SubluxationSubluxationCC--5 on C5 on C--66
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Musculoskeletal InjuriesMusculoskeletal Injuries May have significant bleeding sourceMay have significant bleeding source
Evaluate vascular and neurologic statusEvaluate vascular and neurologic status
Immobilize/tractionImmobilize/traction
Pelvic fracturePelvic fracture
StabilizeStabilize
EmbolizeEmbolize
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Musculoskeletal InjuriesMusculoskeletal Injuries Crush injuries:Crush injuries:
MyoglobinuriaMyoglobinuria
Open fracturesOpen fractures
ImmobilizeImmobilize
Antibiotics/tetanusAntibiotics/tetanus
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Musculoskeletal InjuriesMusculoskeletal Injuries
Compartment Syndrome:Compartment Syndrome:
Pain (especially with passive stretching)Pain (especially with passive stretching)
ParesthesiaParesthesia
Decreased sensation or functionDecreased sensation or function
Paralysis or loss of pulse are LATE changesParalysis or loss of pulse are LATE changes
and loss of limb is imminentand loss of limb is imminent Tissue pressures >35Tissue pressures >35--45 mm Hg threaten45 mm Hg threaten
limblimb
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Tear drop fractureTear drop fracture
anterior Canterior C--44
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Massive left hemothorax with compressed lungMassive left hemothorax with compressed lung
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Tension pneumothorax on right with shifted mediastinumTension pneumothorax on right with shifted mediastinum
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Fractured vertebral body on CT scan viewFractured vertebral body on CT scan view
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Stomach herniated through diaphragmStomach herniated through diaphragm
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Epidural hematomaEpidural hematoma
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Massive facial traumaMassive facial trauma
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Contusion of right lobe of liverContusion of right lobe of liver
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Fracture through body of pancreasFracture through body of pancreas
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IntraIntra--osseous accessosseous access
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Technique for pericardiocentesisTechnique for pericardiocentesis
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Lap belt abrasionLap belt abrasion--indicates force of injuryindicates force of injury
and high risk of internal injuriesand high risk of internal injuries
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View of normal vocal cordsView of normal vocal cords
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Fractured larynxFractured larynx
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MRI image of thoracicMRI image of thoracic
vertebral fracture andvertebral fracture and
injured spinal cordinjured spinal cord
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Subdural hematomaSubdural hematoma
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Lines of escarotomy inLines of escarotomy in
burn injuriesburn injuries