General Principles of Trauma Dr.

Tayag
Trauma or injury - cellular disruption caused by an exchange with environmental energy that is beyond the body’s
resilience.
Mechanisms and Patterns of Injury
The mechanism of injury is important to give an idea of what pattern of injury to expect.
Blunt trauma results to multiple widely distributed injuries. Solid organs are the most likely injured in these type of
injury. It is further divided into:
• high energy transfer (auto-pedestrian accidents, motor vehicle collisions exceeding 40kph or in which the patient
has been ejected, motorcycle collisions, and falls from > 20 ft.
• Low energy trauma include being struck with a club or failing from a bicycle.
• Penetrating injuries usually injure the organs with the largest surface area. It is further classified to Stab wound and
Gunshot wounds.
• Gunshot wounds are further subdivided as to the velocity of the bullet and the distance to which the gun is fired.
Trimodal Pattern of Death
Trauma remains the most common cause of death for all individuals between the ages of 1 and 44 years.
Third most common cause of death regardless of age. Also the number one cause of years of productive life lost.
U.S. government classifies injury-related death into the following categories:
● accidents ( unintentional injuries)
● intentional self-harm (suicide)
● assault ( homicide)
● legal intervention or war
● undetermined causes
Initial Evaluation and Resuscitation of the Injured Patient
Advanced Trauma Life Support (ATLS)
- Provides a structured approach to the trauma patient with standard algorithms of care; emphasizes the “golden
hour” concept that timely prioritized interventions are necessary to prevent death - Refers to the primary survey
(ABC’s)
• Primary Survey
• Concurrent Resuscitation
• Secondary Survey
• Diagnostic Evaluation
• Definitive Care
Goal: To identify and treat the conditions that constitute an immediate threat to life.

Blunt Trauma
AIRWAY WITH CERVICAL SPINE PROTECTION BREATHING CIRCULATION DISABILITY EXPOSURE High
energy transfer
Immediate Life-threatening Injuries To Be Identified during the Primary Survey
Low energy transfer
 Penetrating injuries
Stab wound
Gunshot wound
• High velocity injury
• Low velocity injury

20% 30% 50%

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Hemorrhagic shock Massive hemothorax Massive hemoperitoneum

Disability
Intracranial hemorrhage /mass lesion

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Flail chest with underlying pulmonary contusion
Airway obstruction
Tension pneumothorax
Open pneumothorax
Airway injury
Mechanically unstable pelvis fracture Extremity losses Cardiogenic shock

Circulation
Cardiac tamponade Neurogenic shock Cervical spine injury
Airway Management with Cervical Spine Protection
*Ensuring a patent airway is the first priority in the primary survey.
• Penetrating injuries to the neck and expanding hematoma
• Evidence of chemical or thermal injury to the mouth, nares, or hypopharynx
• Extensive subcutaneous air in the neck
• Complex maxillofacial trauma
• Airway bleeding
Further airway evaluation:
• Abnormal voice
• Abnormal breathing sounds
• Tachypnea
• Altered mental status
Indications of establishing definitive airway: ( i.e. endotracheal intubation)
• Patients with apnea
• * Inability to protect the airway due to altered mental status
• Impending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling or aspiration
• Inability to maintain oxygenation
Endotracheal intubation:
a. Nasotracheal b. * Orotracheal c. Surgical routes- cricothyroidotomy, tracheostomy
Airway Management with Cervical Spine Protection (Cricothyroidotomy)
Breathing and Ventilation
Breathing and Ventilation (Tension pneumothorax- tube thoracostomy)
Breathing and Ventilation (Flail Chest with Underlying Pulmonary Contusion)
• Occurs when 3 or more contiguous ribs are fractured in at least 2 locations.
• decreased compliance and increased shunt fraction caused by the associated pulmonary contusion – typically the
source of postinjury pulmonary dysfunction
Circulation with Hemorrhage Control
Palpating peripheral pulses: initial approximation of patient’s cardiovascular status
• IV access for fluid resuscitation is obtained with two peripheral catheters
• Blood should be drawn simultaneously – sent for measurement of Hematocrit level, typing and cross- matching
• Poiseuille’s law= flow of liquid through the tube is proportional to the diamter and inversely proportional to the length
* Venous lines- short with a large diameter
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Secure airway is obtained
Adequate oxygenation and ventilation must be assured
Supplemental oxygen monitored by pulse oximetry

Secure airway is obtained

Systolic Blood pressure
Carotid pulse: 60 mmHg
Femoral pulse: 70 mmHg

Adequate ventilation established

Circulatory status
Radial pulse: 80 mmHg
• Initial access in trauma patients: best secured in the groin or ankle
• Patients requiring vigorous fluid resuscitation in whom peripheral angiocatheter access is difficult: saphenous vein
cutdowns the ankle provide excellent access
*Femoral access- thoracic trauma *Jugular or subclavian access- abdominal trauma
• Under 6 years of age- intraosseous needle (proximal tibia> distal femur
• External control of hemorrhage should be achieved promptly while circulating volume is restored.
• Manual compression of open wounds with ongoing bleeding
• Bleeding vessels- apply enough pressure directly , patient to the OR for open definitive treatment
3 Critical tools used to differentiate these multisystem trauma patient
• Chest radiograph
• Pelvis radiograph
• Focused abdominal sonography for trauma (FAST)
Massive hemothorax
life-threatening injury number one
• -defined as >1500 mL of blood, 1/3 of the patient’s blood volume in pleural space (pediatric population)
• May be suspected on CXR
• Tube thoracostomy- * quantify amount of hemothorax.
Cardiac tamponade life-threatening injury number two
• Beck’s triad- dilated neck veins, muffled heart tones, decline in arterial pressure
• Occurs most commonly, after penetrating thoracic injuries, occ. Blunt rupture of the heart (atrial appendage)
• Dx: bedside UTZ of pericardium
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Disability and Exposure
Glasgow Coma Scale
Hemorrhagic Shock
“After a traumatic injury, hemorrhage is responsible for over 35% of pre-hospital deaths and over 40% of deaths
within the first 24 hours.”
According to the Study by Kauvar, et. al. in 2006, hemorrhage is responsible for over 35% of pre-hospital deaths and
over 40% of deaths within the first 24 hours. Circulatory integrity and hemorrhage control, the C in the ABC of trauma
is very important in the management of such cases so that hemorrhagic shock would be prevented. Since what is
complicating most trauma cases is the fact that acute blood loss, wherein the body could not compensate is almost
always inevitable.
Signs and Symptoms of Advancing Stages of Hemorrhagic Shock
This table presents the important parameters in categorizing the extent of hemorrhage a patient has such as pulse
rate, blood pressure, pulse pressure, respiratory rate, urine output, and mental status. The classic signs and
symptoms of shock are tachycardia, hypotension, tachypnea, altered mental status, diaphoresis, and pallor.
Tachycardia is the initial manifestation of ongoing blood loss.
• Class I hemorrhage represents up to 750ml or <15% of blood loss. Minimal physiological changes occur since the
body is resilient enough to maintain homeostasis despite this amount of blood loss. This situation is mimicked by
blood donation.
• Class II hemorrhage is blood loss from 750 ml to 1500 or 15-30% of blood volume. Sympathetic nerve stimulation
occurs which triggers release of catecholamines that would increase the heart rate, and increase the peripheral
vascular resistance leading to increased diastolic pressure and subsequently narrowed pulse pressure. There is
increased RR as a response to decreased oxygen saturation and ongoing acidosis. There would also be preferential
blood flow to vital organs such as the brain, heart and adrenals hence there would be decreased urine output
(decreased blood flow to kidneys

→
decreased GFR

→
decreased urine formation), and the patient would present with cool
extremities.
• Class III hemorrhage is blood loss from 1500-2000 ml or 30-40% of blood volume. In this stage, hemorrhagic shock
is established and compensatory mechanisms in Class II start to fail. There would be hypotension because of
deteriorating cardiac output.
• Class IV hemorrhage happens when there is >2000 ml or >40% of blood loss. There is severe organ hypoperfusion
and the vital organ perfusion such as in the brain is failing leading to a confused and lethargic patient.
Fluid Resuscitation
Fluid resuscitation is the primary management in an ongoing blood loss to re-establish tissue perfusion. In an adult,
2L fast drip of isotonic crystalloid, usually lactated ringers. In children, the rate used is 20ml/kg. This is repeated once
in adults and twice in children before blood transfusion is initiated. As to the initial fluid resuscitation, the patients are
categorized into:
• responders: those who would have normal vital signs, mental status, and urine output;
• transient responders: those who respond initially to volume loading by an increase in blood pressure then again
hemodynamically deteriorate
non-responders: those who have persistent hypotension despite aggressive resuscitation.
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Persistent Hypotension
If the patient still has persistent hypotension, we should consider shock as the underlying cause namely:
hemorrhagic, cardiogenic, neurogenic, and septic.
• Septic shock is rarely considered except for patients who consulted >12 hours after the injury.
• Neurogenic shock occurs after a spinal cord injury and hemodynamic instability ensues due to depression of the
cardiorespiratory centers.
• Cardiogenic shock would have distended neck veins and CVP of >15 cm H2O.
• Hypovolemic shock has flat neck veins and CVP of <5cm H2O because of the ongoing hemorrhage. The
management for uncontrolled hemorrhage is rapid search for the source/s of hemorrhage and the patient is taken to
the OR immediately.
In patients without clear operative indication but has persistent hypotension, it is also important to evaluate the
potential sources of blood loss: scalp, chest, abdomen, pelvis and extremities.
Chest x-ray, focused abdominal sonography for trauma, and pelvic radiograph are used.
If still with negative results, extremity examination and radiographs are used to search for fractures. Fractures could
cause hemodynamic instability because each rib would have 100-200ml of blood loss, 300-500ml for tibia,
800-1000ml for femur, and >1000ml for pelvic fractures.
Secondary Survey
Secondary survey is done once the immediate threats to life have been addressed.
History of the patient focusing on allergies (especially to any drug), medications (that might affect the management),
past medical history and pregnancy, last meal, events related to the trauma.
Head to toe physical examination with special attention to patient’s back, axilla and perineum is also done. It is also
important to reassess the VS, do CVP and ECG monitoring, foley catheter placement to monitor urine output.
Adjuncts such as repeat FAST (to determine present of fluid in the abdomen), Radiogragraphs of the cervical spine,
chest and pelvis are done for blunt trauma patients. Routine trauma panel for critically injured patients include blood
type, crossmatching, CBC, coagulation studies, lactate level and ABG.
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