trauma -in detail

8/6/2019 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


Chest decompressionChest decompression


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ThoraxThorax Circulation:Circulation:


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


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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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

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