1

Initial management in Trauma

.

" Emergency life threatening condition

" Advanced trauma Life Support (ATLS)

Preparation
Triage
Primary survey (ABCDE)
Resuscitation
Adjuncts to Primary survey and Resuscitation
Consider need for transfer patient
Secondary survey ( Head to toe evaluation and patient history)
Adjuncts to Secondary
Continued postresuscitation monitoring and reevaluation
Definite care
Preparation

Prehospital phase
airway maintenance,control of
external bleeding and shock,immobilization .
,
,
Hospital phase
airway

2
equipment ( Laryngoscope and tube), warmed
intravenous crystalloid solution,
Monitoring Laboratory test ,

Triage

airway cervical spine
breathing circulation triage

Multiple casulties

Life threatening condition Multiple system injuries

Mass casulties


Primary Survey
Life threatening condition

ABCDE
A : Airway maintenance and Cervical spine protection
airway Neck
injury maxillofacial injury airway compromise change
in voice / sore throat,stridor(airway obstruction),tachypnea,agitation,abnormal breathing
pattern,decrease level of consciousness,decrease oxygen saturation
cervical spine injury altered level of
consciousness blunt injury above the clavicle
airway hyperextension
excessive movement cervical spine spinal cord injury
2 " Manual in line
stabliztion "

1 Manual in line stabilization Protection of cervical spine Hard cervical collar

airway compromise
airway compromise Oxygen supplement
High flow oxygen (oxygen mask with bag 10L/min)
Airway maintenance technique open airway ,
Chin-Lift Maneuver JawThrust Maneuver 2

2 Chin -lift maneuver Jaw thrust Maneuver

Oropharyngeal airway
gag reflex
Definite airway manangement airway

4
compromise
Surgical Cricothyroidotomy

Endotracheal tube

Definite airway management

1.Presence of apnea
2.Inaility to maintain a patent airway
3.Need for protect airway from aspiration of bloodor vomitus
4. Impending or potential compromise airway (Inhalation injury,Retropharyngeal
hematoma,Sustained seizure)
5. Severe Head injury (Glasgow coma scale <8)
6. Inability to maintain oxygenation by facemask oxygen supplementation
Endotracheal intubation
Cricoid
Esophageal occlusion aspiration Endotracheal tube
tube 2 ,
Monitor oxygen saturation End-tidal CO2 Chest X-ray
Surgical cricothyroidotomy Endotracheal tube
2 Surgical cricothyroidotomy
Sever maxillofacial injury,Fracture of larynx,Edema of glottis,Severe oropharyngeal
hemorrhage airway management 3

3 airway compromise

B : Breathing and Ventilation

adequate ventilation airway patency
adequate gas exchange Oxygen carbon dioxide adequate function Lung,Cheat
wall Diaphragm ventilation

Emergency life threatening codition Inadequate ventilation
Tension Pneumothorax
One -way valve collapse mediastinum
chest pain ,tachypnea,air hunger,tracheal deviation,unilateral absence of
breath sound,hypotension,neck vein distension needle Thoracocentesis
NO.16-18 second intercostal space mid-claicular line
simple pneumothorax Intercostal chest tube

4 Needle thoracocentesis tension pneumothorax

Open Pneumothorax (Sucking chest wound) 2/3

trachea lung
collapse Hypoxia,Hypercarbia
sterile occlusive 3 side dressing
( Flutter -type valve effect)

Intercostal chest tube
Failed chest Pulmonary contusion
2 3 rib " Paradoxical movement
failed segment Lung parenchyma Pulmonary
contusion Hypoxia adequate
ventilation,oxygen supplementation,
Epidural anesthesia Systemic nacrotic
Massive Pneuthorax

adequate ventilation Decrease breath sound Dullness

on percusion Hypotension Definiton Massive pneumothorax
1500 cc Intercostal chest tube Intercostal chest tube
200-300 cc 2-4

C : Circulation and Hemorrhagic control

level of
consciousness,skin color,pulse Hemorhagic shock
shock
30-40% blood volume

5 Estimated blood loss on patient's initial resuscitation

Warm intravenous fluid resuscitation Ringer's

lactate Ringer 's acetate NO.16-18 2 20 cc/Kg () 15
intravenous fluid resuscitatio venesection Great
saphenous vein Fluid Intraosseous tibia 6

6 Venesection of Greater saphenous vein

Initial fluidresuscitation vital sign

, adequate end organ perfusion and ventilation (urine output,level of consciousness,peripheral
perfusion) 3
Rapid response 20% blood volume
vital sign initial fluid resuscitation
Shock
Transient response 20-40% blood volume
initial fluid resuscitation Unstable vital
sign Inadequate resuscitation Ongoing blood loss
surgical intervention

8
Minimal or No response
Initial fluid
resusucitation Blood tranfusion group O, Rh-negative
adequate circulation

initial fluid resuscitation

massive
bleeding Hemorhagic shock Intraperitoneal
cavity,Intrathoracic cavity , Pelvic bleeding, Long bone fracture, External wound Bleeding
control external bleeding direct manual pressure
Pelvic fracture pelvic stabilization pelvic bone (pelvic wrap)
immobilization Long bone fracture

7 Pelvic stabilization pelvic sheet

shock
Cardiogenic shock : cardiac tampoande blunt penetrating
chest injury great vessel pericardial sac cardiac
output Classic symptom
Muffle heart sound,engorged neck vein,Hypotension ( Beck's triad),Kussmaul 's sign (increase venous
pressure during spontaneous inspiration) Focus assess sonographic in trauma
patient (FAST) fluid pericardial sac pericacardiocentesis

9
cardiac tmponade Great vessel
Neurogenic shock : spinal cord injury loss of sympathetic tone
Hypotension tachycardia ,cutaneous vasoconstriction narrowed pulse
pressure Hemorrhagic shock monitor CVP 2
Intravenous fiuid resuscitation vasopressive drug
D : Disability ( Neurologic evaluation)
Glasgow Coma Scale (GCS)
of consciousness
pupillary size
Celebral oxygenation/Celebral perfusion

Level

Direct celebral injury

8 Glasgow Coma Scale (GCS)

E : Exposure / Environmental control

Log roll maneuver
Per rectal examination
hypothermia
warming device

warm blankets

external

10

9 Log roll maneuver

Adjuncts to Primary Survey and Resuscitation

primary survey

monitoring ,

monitor ECG
atrial fibrillation,premature ventricular
contraction, ST-segment abnormalities
Cardiac injury
Blunt chest injury
tension pneumothorax,cardiac tamponade,profound hypovolemia
ECG
Pulselesss electrical activity (PEA)
Urinary catheters
urinary catheter
urine output
urine output 0.5-1 cc/kg/hr
fluid resuscitation
renal perfusion
urinary catheter
urethral injury
blood at urethral
meatus,perineal echymosis,blood in scrotal,high riding prostate,pelvic fracture
Retrograde urethrogram
urine catheter
Gastric catheter
Gastric tube
gastric distension
aspiration
gastict tube
gastric
content
oropharynx
, injury
gastric tube
injury upper digestive tract
fracture base of skull
orogastric route
Other monitoring
resuscitation
monitoring physiologic parameter pulse rate,blood pressure,ventilatory rate,arterial bloos gas,
Electrocardiographic monitoring (ECG)

11
body temperature

urine output
resuscitation
vital sign
, urine output 0.5-1 cc/kg/hr
acid base
X-ray examination and diagnostic studies
film chest x-ray AP veiw,
film pelvis AP view
film c-spine lateral veiw
immediated life threatening
condition
resuscitation
abdominal injury
Focused assessment
sonography in trauma (FAST)
Diagnosis peritoneal lavage (DPL)
Secondary survey
secondary survey
secondary survey
examination)
History

(Head to toe

mechanism of injury,

A : Allergies
M : Medication currently used
P : Past ilnesses / Pregnancy
L : Last meal
E : Events / Environment related to injury
mechanism of injury
Blunt trauma
,
,
Penetrating trauma
,
,
Thermal injury
trauma
closed space
Hazardous Environment

,
,
blunt
penetrating
inhalation injury

expose

,toxin,radiation

12
,
Physical examination
head,neck,abdomen,pelvis,perineum,musculoskeletal
specific organ injury
study,Angiogram (Adjuncts to secondary survey)
Reevaluation

(head to toe examination)

neurologic system
CT scan, Contrasted

" Emergency life threatening

condition

resuscitation
,urine output
0.5-1 cc/kg/hr
oxymetry,end-tidal carbondioxide
aterial blood gas
,
problem

primary survey

opioid
intramuscular injection
Definite care
Intervention radiology

Angiogram with embolization

,

monitor EKG,pulse
underlying medical