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15-Principles of Trauma Care Trans
15-Principles of Trauma Care Trans
TRAUMA
A cornerstone of trauma care is the TIMELY IDENTIFICATION and
TRANSPORT to a trauma center of those patients most likely to
benefit, that is, the principle of TRIAGE.
TRIAGE
System of sorting out the patient in terms of priority of treatment
a.) Post injury- 50% of trauma deaths Polytrauma patients should receive top priority
spinal cord ,intra abdominal, aortic injuries Done pre-hospital and In-hospital
b.) brain injury or uncontrolled hemorrhage
c.) refractory increase ICP, pulmonary complications TRAUMA
TRIAGE SCHEME: assess the potential for life or limb threatening
“Multiple trauma patients are more likely to die from their intraoperative injury.
Prolonged prehospital time
Pedestrian struck at speed >20mph
Systolic < 90 mmHg
RR > 29 bpm
GCS < 14
TRAUMA
A basic principle of trauma resuscitation is the need for continual
reevaluation and reassessment.
Tertiary Trauma survey- missed injury 56%
Transfer to a higher level of care – trauma center, physician to
physician communication.
Management of polytrauma
Preparation
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Focused Assessment Sonography for Trauma ( FAST)
Hypotension
Abdominal trauma
Impaired consciousness
Pulseless electrical activity
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TRAUMA
Definitive hemorrhage control.
Hypovolemic hypotension >15-30% blood loss, is a late sign for
young adult.
Failure to correct tachycardia/hypotension after 2-3L crystalloid =
deficit >15%.
Blood transfusion using type “O” considered if blood loss >1 liter
or >3 crystalloid needed to maintain SBP.
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Antibiotics
Tetanus immunization- >6h, crush injuries, burns, electrical
injuries, high velocity injuries, devitalized tissues, direct Definitive care
contamination with feces Definitive surgery vs DCS
End points of resuscitation Definitive surgery should be short as possible
Control the cause- best end point If patients condition not optimal might opt for DCS
Volume resuscitation - colloids vs crystalloid
Blood pressure – aim MAP >70mmHg Standard Surgical Teaching
Temperature – keep it normothermic,< 32c (>60% mortality)
Lactate – tissue ischemia
Circulation
Categories of shock
Persistent hypovolemia
1. Hemorrhagic
- Flat neck veins TRAUMA
- CVP < 5 cm h20 The triad of doom:
- Base deficit > 8 mmol/ l Coagulopathy
2. Cardiogenic Acidosis
- Distended neck veins Hypothermia
- CVP > 15 cmh20
3. Neurogenic Metabolic failure
4. Septic Hypothermia – exacerbates coagulopathy and interferes with the
blood homeostatic mechanism
Acidosis – uncorrected shock leads to inadequate cellular
perfusion , anaerobic metabolism and lactic production
Coagulopathy – hypothermia, acidosis and massive blood
transfusion
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Principles of DCS:
Control of hemorrhage
Prevention of contamination
Avoid further injury
Organ-Specific Techniques
LIVER- peri-hepatic packing will arrest most hemorrhage except
for major arterial bleed
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- Pringle’s maneuver
Finger fracture technique
Selective angiographic embolization
SPLEEN – direct suture ,splenectomy
GIT – suture closure, resection, exteriorize
Pancreas- drainage, debridement, resection
Abdominal Trauma
Anterior abdomen - Anterior costal margins to inguinal creases,
between the anterior axillary lines
Intrathoracic abdomen or thoracoabdominal area - Fourth
intercostal space anteriorly (nipple) and seventh intercostal space
posteriorly (scapular tip) to inferior costal margins
Flank - Scapular tip to iliac crest, between anterior and posterior
axillary lines
Back - Scapular tip to iliac crest, between posterior and axillary
line
4. FAST– sensitive for pericardial fluid, high false negative for intra-
abdominal injury.
+ FAST= peritoneal penetration
- FAST= doesn’t exclude significant abdominal injury
Benefits:
Decreases the time to diagnosis for acute abdominal injury
in BAT
Helps accurately diagnose hemoperitoneum
Helps assess the degree of hemoperitoneum in BAT
Noninvasive
Can be integrated into the primary or secondary survey and
Adjuncts that can provide clues for intra-peritoneal injury can be performed quickly, without removing patients from
Chest X-ray – sub-diaphragmatic air the clinical arena
NGT – blood drained from stomach, bowels
Urinary catheter- macroscopic hematuria 5. CT scan- multi slice scanner with triple contrast
Rectal examination – blood indicates rectal or sigmoid Retroperitoneal injuries
penetration. Proctoscopy or sigmoidoscopy should be performed Signs of peritoneal violation: free intra- peritoneal air, free intra-
peritoneal fluid, wound track extending through peritoneum
Diagnostics Abdominal Trauma Signs of bowel injury: bowel wall defect, bowel wall thickening,
1. Serial physical examination (SPE) contrast leak intraluminally, diaphragmatic tear
Best sensitivity and negative predictive value for the evaluation of
penetrating abdominal trauma. 6. Laparoscopy- diaphragmatic injury
Sequence 1,4,12, & 24 hrs. after initial assessment. Some every 4 Therapeutic for diaphragmatic injury
hrs. Reevaluation after observation with persistence s/sx
Same examiner False negative missed bowel injuries ,retroperitoneal injury
Adjunct CT scan, laparoscopy, laparotomy if still with fever, pain, A prospective study of 99 patients showed that diagnostic
tachycardia >24 hrs. laparoscopy was negative in 62% of the patients with penetrating
abdominal trauma, reducing the rate of unnecessary laparotomy
2. Local wound exploration (LWE) from 78.9% to 16.9%.
Under local anesthesia at OR
Penetration of the posterior fascia + 7. Laparotomy – explor lap , celiotomy
+ = laparotomy or DPL or laparoscopy Resource –limited environment
Even if the peritoneum is penetrated ,many of these patients will High non therapeutic rate
have no intra peritoneal injury or any injury that does not require Incidence of complication with negative laparotomy rate 12%-41%
surgery
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Blunt Abdominal Trauma
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Penetrating Abdominal Trauma
Explore !
Hypotension (with or without abdominal distention)
Narrow pulse pressure Back wound
Tachycardia Retroperitoneal injury
High or low respiratory rate Colon, kidney, lumbar vessels, pancreas, aorta, IVC
Signs of inadequate end organ perfusion Colon most often missed.
Peritoneal signs (eg, pain, guarding, rebound tenderness) and/or Triple contrast CT scan
peritonitis
Diffuse and poorly localized pain that fails to resolve
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Retroperitoneal injury
Associated injuries ,high index of suspicion
Hallmark is retroperitoneal hematoma
Ct scan
Management depends on the zone involved
CT scan
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Chest Trauma
Physical examination
Look – determine Respiratory rate & depth,
asymmetry,paradoxical chest wall motion,bruising,penetrating
wounds
Feel – tracheal deviation, tenderness, subcutaneous
emphysema,rib crunching
Listen – Breath sounds
Percuss – dullness or resonance
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Tension Pneumothorax
Progressive build up of air in the pleural space
Lung laceration
+ pressure ventilation exacerbate this one way valve effect
Tracheal deviation, mediastinal shift
Depression of diaphragm- XRAY
Needle thoracostomy, CTT
Hemothorax
Collection of blood in the pleural space
CXRAY, FAST, CT scan
CTT- initial step, 32-36F
Thoracotomy – 1-1.5l initial , bright red, 200-250cc/hr, unstable
VS
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Flail chest
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Indication for ICP monitoring
GCS of 3-8
Abnormal cranial ct scan
Any two of the ff
Age older than 40yrs
Posturing response to pain
Systolic bp < 90
TBI
Ct scan should be evaluated for
Mass effect or effacement of the lateral ventricle
Midline shift
Presence or absence of CSF in basal cisterns
Head injury
Indications for operative intervention
Clot volume
Amount of midline shift
GCS
Location of clot
Depressed skull fracture
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Penetrating head injury
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