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Atls Important Notes Triage: Ali M. Ahmad Consultant Pediatric Surgery
Atls Important Notes Triage: Ali M. Ahmad Consultant Pediatric Surgery
TRIAGE
The process of prioritizing patient treatment during mass-casualty events.
Do the most good for the most patients using available resources
Sorting of patients based on their needs for treatment ABC
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Ali M. Ahmad; Consultant Pediatric Surgery
A = Airway & cervical spine control
Airway management
1. Clearing the airway & Suctioning
2. Administering oxygen
3. Securing the airway
B = Breathing
Injuries that severely impair ventilation include
o Tension pneumothorax
o Open pneumothorax
o Massive hemothorax
o Flail chest with pulmonary contusion,
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Ali M. Ahmad; Consultant Pediatric Surgery
o Surgical intervention
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Ali M. Ahmad; Consultant Pediatric Surgery
Which patients do I transfer to a higher level of care?
When should the transfer occur?
Transfer should be considered whenever the patient’s treatment needs exceed the
capability of the receiving institution; including equipment, resources, and
personnel.
These criteria take into account the patient’s physiologic status, obvious anatomic
injury, mechanisms of injury, concurrent diseases, and other factors that can alter
the patient’s prognosis.
On arrival of the patient, the team leader supervises the hand-over by EMS
personnel, making certain that no team member begins working on the patient
unless immediate life-threatening conditions are obvious (“hands-off hand-over”).
A useful format is the MIST acronym:
o Mechanism (and time) of injury
o Injuries found and suspected
o Symptoms and Signs
o Treatment initiated
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Ali M. Ahmad; Consultant Pediatric Surgery
AIRWAY AND VENTILATORY MANAGEMENT
Supplemental oxygen must be administered to all trauma patients.
Tachypnea can be a subtle but early sign of airway or ventilatory compromise.
Obtundation suggests hypercarbia.
Agitation suggests hypoxia
Cyanosis indicates late sign of hypoxemia due to inadequate oxygenation
Laryngeal injury, can present with acute airway obstruction. It is indicated by the
following triad of clinical signs:
1. Hoarseness
2. Subcutaneous emphysema
3. Palpable fracture
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Ali M. Ahmad; Consultant Pediatric Surgery
# DEFINITIVE AIRWAY
Tube placed in the trachea
With the cuff inflated below the vocal cords
The tube connected to some form of oxygen-enriched assisted ventilation
The airway secured in place with tape.
Select the proper-size tube {same size as the infant’s nostril or little finger}
Insert the endotracheal tube not more than 2 cm past the cords
There are three types of definitive airways:
1. Orotracheal tubes
2. Nasotracheal tubes
3. Surgical airways (Cricothyroidotomy or tracheostomy).
1. Airway problems
Inability to maintain a patent airway by other means
Potential compromise of the airway (e.g., following inhalation injury, facial
fractures, or retropharyngeal hematoma)
2. Breathing problem
Inability to maintain oxygenation by face-mask
Presence of apnea
3. Disability problems
Head injury + GCS score of 8 or less
Protect airway from aspiration of blood or vomitus
Sustained seizure activity
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Ali M. Ahmad; Consultant Pediatric Surgery
RAPID SEQUENCE INTUBATION {RSI}
Use of drugs for endotracheal intubation in trauma patients
Anesthetic, sedative, and neuromuscular blocking
Is potentially dangerous; so you must have a plan in the event of failure that includes
the possibility of performing a surgical airway.
If RSE failed, the patient must be ventilated with a bag-mask device until the
paralysis resolves; long acting drugs are not routinely used for RSI for this reason
Particular attention must be paid in cases of preexisting chronic renal failure, chronic
paralysis, and chronic neuromuscular disease
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Ali M. Ahmad; Consultant Pediatric Surgery
Surgical Airway {Cricothyroidotomy or Tracheostomy} Indications
Edema of the glottis
Fracture of the larynx
Severe oropharyngeal hemorrhage obstructs the airway
Endotracheal tube cannot be placed through the vocal cords
Note: surgical Cricothyroidotomy is preferable to a tracheostomy for most patients
Needle Cricothyroidotomy
Insertion of a needle through the cricothyroid membrane or into the trachea
It provides oxygen on a short-term basis until a definitive airway can be placed
Cannula 12- to 14-gauge for adults, and 16- to 18-gauge in children
Connected to oxygen at 15 L/min
Used for 30 to 45 min Because of the inadequate exhalation,
CO2 slowly accumulates, especially in patients with head injuries
Complications of Needle Cricothyroidotomy
Inadequate ventilation, leading to hypoxia and death
Aspiration (blood)
Esophageal laceration
Hematoma
Perforation of the posterior tracheal wall
Subcutaneous and/or mediastinal emphysema
Pneumothorax
Surgical Cricothyroidotomy
a skin incision that extends through the cricothyroid membrane.
A curved hemostat may be inserted to dilate the opening
Small ETT or tracheostomy tube (preferably 5 to 7 mm OD) can be inserted.
Care must be taken, especially with children, to avoid damage to the cricoid
cartilage, which is the only circumferential support for the upper trachea.
It’s not recommended below 12 year
Complications of Surgical Cricothyroidotomy
Aspiration (blood)
Creation of a false passage into the tissues
Subglottic stenosis/edema
Laryngeal stenosis
Hemorrhage or hematoma formation
Laceration of the esophagus
Laceration of the trachea
Mediastinal emphysema
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Ali M. Ahmad; Consultant Pediatric Surgery
Vocal cord paralysis, hoarseness
Note: percutaneous tracheostomy is not a safe procedure in the acute trauma
Pt.
# MANAGEMENT OF OXYGENATION { PULSE OXIMETRY & ABG}
1- Pulse oximetry
Noninvasive method
Measure oxygen saturation and pulse rate of
arterial blood
It does not measure the partial pressure of
oxygen (PaO2)
But if 95% or greater = adequate peripheral
arterial oxygenation
(PaO2 >70 mm Hg, or 9.3 kPa)
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Ali M. Ahmad; Consultant Pediatric Surgery
In a noisy ED or when the patient is transported several times, this device
is extremely reliable in differentiating between tracheal and esophageal
intubation.
SHOCK
Diagnosis of shock is based on clinical recognition of the presence of inadequate tissue
perfusion and oxygenation
Treatment of shock
1. Providing adequate oxygenation& Ventilation
2. Appropriate fluid resuscitation
3. Stopping the bleeding.
RECOGNITION OF SHOCK
1. Cool skin {Cutaneous vasoconstriction}
2. Tachycardia if {> 160 infant, > 140 preschool age, > 120 prepuberty, > 110 adult}
3. Narrowed pulse pressure suggests significant blood loss
Hematocrit unreliable and should not be used to exclude the presence of shock
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Ali M. Ahmad; Consultant Pediatric Surgery
The failure of fluid resuscitation to restore organ perfusion suggests
either continuing hemorrhage or neurogenic shock
Patient with injuries above diaphragm may have evidence of inadequate
organ perfusion due to poor cardiac performance {inadequate venous return
(preload).
o Blunt myocardial injury, Cardiac tamponade,
o Tension pneumothorax
o Spinal cord injury {Neurogenic Shock}
o Septic shock
NEUROGENIC SHOCK
Cervical or upper thoracic spinal cord injury can produce hypotension due to loss of
sympathetic tone but
1. No tachycardia
2. No cutaneous vasoconstriction.
3. No narrowed pulse pressure
SEPTIC SHOCK
Early septic shock can have a normal circulating volume + modest tachycardia
Warm skin, systolic pressure near normal, and a wide pulse pressure.
HEMORRHAGIC SHOCK
Normal blood volume is:
o Adult, 7% of body weight {70-kg male has approximately 5 L}.
o Child, 8% to 9% of body weight (80–90 mL/kg)
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Ali M. Ahmad; Consultant Pediatric Surgery
Nonresponse to fluid administration almost always indicates persistent
blood loss with the need for operative or angiographic control.
The usual dose is 1 to 2 L for adults and 20 mL/kg for pediatric patients.
Absolute volumes of resuscitation fluids should be based on patient response.
initial fluid amount includes any fluid given in the Prehospital setting
Excessive fluid administration can exacerbate the lethal triad of coagulopathy,
acidosis, and hypothermia with activation of the inflammatory cascade.
o Balancing the goal of organ perfusion with the risks of rebleeding by
accepting a lower-than-normal blood pressure has been termed “controlled
resuscitation,” “balanced resuscitation,” “hypotensive resuscitation
o The goal is the balance, not the hypotension.
o Such a resuscitation strategy may be a bridge to, but is not a substitute for,
definitive surgical control of bleeding
Adequate resuscitation should produce a urinary output of approximately 0.5
mL/kg/hr. in adults, whereas 1 mL/kg/hr. in pediatric patients
Persistent acidosis is usually caused by inadequate resuscitation or ongoing blood
loss and, it should be treated with fluids, blood, and consideration of operative
intervention to control hemorrhage. Serial measurement of these parameters can be
used to monitor the response to therapy. Sodium bicarbonate should not be used to
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Ali M. Ahmad; Consultant Pediatric Surgery
(I) cardiac output
(R) (afterload). systemic vascular resistance
o Increase in blood pressure should not be equated with a
concomitant increase in cardiac output or the recovery from shock.
o An increase in peripheral resistance—for example, with vasopressor therapy
—with no change in cardiac output results in increased blood pressure, but
no improvement in tissue perfusion or oxygenation.
HYPOTHERMIA
Most efficient way to prevent hypothermia in any patient receiving massive volumes
of crystalloid is to heat the fluid to 39°C before infusing it.
Blood products cannot be warmed in a microwave oven
Massive transfusion, defined as >10 units of pRBCs within the first 24 hours.
Early administration of pRBCs, plasma, and platelets, and minimizing aggressive
crystalloid administration is termed balanced, hemostatic or damage control
resuscitation
Prothrombin time, partial thromboplastin time, and platelet count are valuable
baseline studies to obtain in the first hour
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Ali M. Ahmad; Consultant Pediatric Surgery
# THORACIC TRAUMA
Identify and initiate treatment of the following potentially life-threatening injuries during
THE SECONDARY SURVEY:
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheobronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Blunt esophageal rupture
Tension Pneumothorax
Most common cause is mechanical ventilation with positive-pressure ventilation
Must be Clinical diagnosis
Rx should not be delayed to wait for radiologic confirmation
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Ali M. Ahmad; Consultant Pediatric Surgery
Open Pneumothorax
Promptly closing the defect with a sterile occlusive dressing {large enough
to overlap the wound’s edges and then taped securely on three sides in order to
provide a flutter-type valve effect}
Then chest tube remote from the wound should be placed as soon as possible
Massive Hemothorax
Rapid accumulation of more than 1500 mL of blood or one-third of the patient’s
blood volume in the chest cavity
Is suggested when shock is associated with the absence of breath sounds or dullness
to percussion on one side of the chest
Initially managed by the simultaneous restoration of blood volume and
decompression of the chest cavity
If 1500 mL is immediately evacuated, early thoracotomy is almost always required.
Penetrating anterior chest wounds medial to the nipple line and posterior wounds
medial to the scapula should alert the practitioner to the possible need for
thoracotomy because of potential damage to the great vessels, hilar structures, and
the heart, with the associated potential for cardiac tamponade.
Cardiac Tamponade
Most commonly results from penetrating injuries.
Human pericardial sac is a fixed fibrous structure; a relatively small amount of blood
can restrict cardiac activity and interfere with cardiac filling.
Classic diagnostic Beck’s triad:
1. Elevated Venous pressure
2. Decline in arterial pressure
3. Muffled heart tones
Additional diagnostic includes; Echocardiogram & FAST, or pericardial window.
Preparation to transfer such a patient for definitive care is always necessary
Thoracotomy is indicated only when a qualified surgeon is available.
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Ali M. Ahmad; Consultant Pediatric Surgery
If surgical intervention is not possible, Pericardiocentesis can be
diagnostic as well as therapeutic, but it is not definitive treatment for
cardiac tamponade
1. Penetrating thoracic injuries + pulseless + with myocardial electrical activity, may
be candidates for immediate resuscitative thoracotomy
2. Penetrating thoracic injuries + CPR in the Prehospital setting + no any signs of life
and no cardiac electrical activity no further resuscitative effort should be made.
3. Blunt thoracic injuries + pulseless + with myocardial electrical activity (PEA) are
not candidates for emergency department resuscitative thoracotomy.
4. Blunt thoracic injuries + cardiac arrest; Thoracotomy is rarely effective.
Signs of life include
Reactive pupils, Spontaneous movement, or organized ECG activity.
PERICARDIOCENTESIS
Using a 16 to 18 gauge
6 in. (15-cm) or longer over-the-needle catheter
Attach a 35-mL empty syringe with a three-way stopcock
Puncture the skin 1 to 2 cm inferior to the left of the xiphochondral junction, at a 45-
degree angle to the skin.
After aspiration is completed, remove the syringe and attach a three-way stopcock,
leaving the stopcock closed. Secure the catheter in place.
COMPLICATIONS OF PERICARDIOCENTESIS
Aspiration of ventricular blood instead of pericardial blood
Laceration of ventricular epicardium/ myocardium
Laceration of coronary artery or vein
New hemopericardium, secondary to lacerations of the coronary artery or vein,
and/or ventricular epicardium/ myocardium
Ventricular fibrillation
Pneumothorax, secondary to lung puncture
Puncture of great vessels with worsening of pericardial tamponade
Puncture of esophagus with subsequent mediastinitis
Puncture of peritoneum with subsequent peritonitis or false positive aspirate
Simple Pneumothorax
An upright, expiratory x-ray of the chest aids in the diagnosis.
Any pneumothorax is best treated with a chest tube placed in the fifth ICS
You must inset ICT before any GA or using PPV and air ambulance
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Ali M. Ahmad; Consultant Pediatric Surgery
Pulmonary Contusion
Patients with significant hypoxia (PaO2 <65 mm Hg or SaO2 <90%) on
room air may require intubation and ventilation within the first hour after injury.
Associated medical conditions, such as chronic obstructive pulmonary disease and
renal failure, increase the likelihood of needing early intubation and mechanical
ventilation
A properly performed and interpreted helical CT that is normal may obviate the need
for transfer to a higher level of care to exclude thoracic aortic injury.
All patients with a mechanism of injury and simple chest x-ray findings suggestive of
aortic disruption should be transferred to a facility capable of rapid definitive
diagnosis and treatment of this injury.
# DIAPHRAGM INJURIES
may be missed during the initial trauma evaluation.
An undiagnosed diaphragm injury can result in pulmonary compromise or
entrapment and strangulation of peritoneal contents
CHEST X-RAY
Guidelines for examining a series of chest x-rays:
• Trachea and bronchi
• Pleural spaces and lung parenchyma
• Mediastinum- Diaphragm- Bony thorax
• Soft tissues
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Ali M. Ahmad; Consultant Pediatric Surgery
• Tubes and lines
Any patient who has sustained significant blunt torso injury from a direct blow,
deceleration, or a penetrating injury must be considered to have an abdominal visceral,
vascular, or pelvic injury until proven otherwise
Airbag deployment does not preclude abdominal injury
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Ali M. Ahmad; Consultant Pediatric Surgery
o >100,000 red blood cells (RBC)/mm3,
o > 500 white blood cells (WBC)/mm3,
o or a Gram stain with bacteria present
FAST
Is performed with a low frequency (3.5 MHz) transducer
Higher frequency transducers may be appropriate for children or extremely thin adults
CT scan
Can miss some gastrointestinal, diaphragmatic, and pancreatic injuries.
In the absence of hepatic or splenic injuries, the presence of free fluid in the abdominal
cavity suggests an injury to the GI tract and/or its mesentery, and many trauma
surgeons find this to be an indication for early operative intervention.
If there is early or obvious evidence that the patient will be transferred to another
facility, time-consuming tests, including abdominal CT, should not be performed.
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Ali M. Ahmad; Consultant Pediatric Surgery
An early normal serum amylase level does not exclude major pancreatic
trauma. Conversely, the amylase level can be elevated from
nonpancreatic sources.
# HEAD TRAUMA
Obtaining a CT scan should not delay patient transfer to a trauma center that is capable
of immediate and definitive neurosurgical intervention.
Early endotracheal intubation should be performed in comatose patients
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Ali M. Ahmad; Consultant Pediatric Surgery
o Tentorium cerebelli divides the intracranial cavity into the
supratentorial and infratentorial compartments & midbrain passes
through an opening called the tentorial hiatus or notch.
o Medial part of the temporal lobe, known as the uncus
o Oculomotor nerve runs along the edge of the tentorium and may become
compressed against it during temporal lobe herniation.
o Parasympathetic fibers that constrict the pupil lie on the surface of the third
cranial nerve. Compression of these superficial fibers during herniation
causes pupillary dilation due to unopposed sympathetic activity, often
referred to as a “blown” pupil
o Uncal herniation also causes compression of the corticospinal (pyramidal)
tract in the midbrain. The motor tract crosses to the opposite side at the
foramen magnum, so compression at the level of the midbrain results in
weakness of the opposite side of the body (contralateral hemiparesis).
Ipsilateral pupillary dilation associated with contralateral hemiparesis is the classic
sign of uncal herniation.
Normal ICP in the resting state is approximately 10 mmHg. If ICP greater than 20
mmHg, particularly if sustained, are associated with poor outcomes.
Monro-Kellie doctrine theory explained why ICP not initially rise {due to decrease in
CSF and venous volume} However, once the limit is reached, ICP rapidly increases.
Every effort should be made to enhance cerebral perfusion and blood flow by
o Reducing elevated ICP,
o Maintaining normal intravascular volume,
o Maintaining a normal mean arterial blood pressure (MAP),
o Restoring normal oxygenation and normocapnia.
Hematomas that increase intracranial volume should be evacuated early.
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Ali M. Ahmad; Consultant Pediatric Surgery
CLASSIFICATIONS OF HEAD INJURIES
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Ali M. Ahmad; Consultant Pediatric Surgery
Medical therapies for brain injury include
1. Intravenous fluids {Ringer’s lactate or NS}
2. Temporary hyperventilation {for limited a period as possible}
Normocarbia (35 mm Hg to 45 mm Hg) is the preferred range
3. Mannitol {20% solution = 20 g per 100 ml) is used to reduce elevated ICP in a
euvolemic patient with dose of bolus of (1 g/kg) over 5 minutes)
4. Hypertonic saline {3% to 23.4%} is also used to reduce elevated ICP; this may be the
preferable agent with hypotension, as it does not act as a diuretic
5. Barbiturates {Effective in reducing ICP refractory to other measures}. They should not
be used in the presence of hypotension or hypovolemia.
6. Anticonvulsants.
o Prolonged seizures (30 to 60 minutes) may cause secondary brain injury Vs.
Anticonvulsants inhibit brain recovery, so they should be used only when
absolutely necessary {IV 1 g of phenytoin no faster than 50 mg/min followed by
maintenance 100 mg/8 hours, with the dose titrated to achieve therapeutic
serum levels}
o Note: it is important to remember that seizures are not controlled with muscle
relaxants.
ANCILLARY STUDIES that may be used to confirm the diagnosis of brain death include:
a. Electroencephalography: No activity at high gain
b. CBF studies: No CBF (isotope studies, Doppler studies, xenon CBF studies)
c. Cerebral angiography
Note: Local organ-procurement agencies should be notified about all patients with the
diagnosis or impending diagnosis of brain death prior to discontinuing artificial life support
measures.
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Ali M. Ahmad; Consultant Pediatric Surgery
# SPINAL CORD TRAUMA
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Ali M. Ahmad; Consultant Pediatric Surgery
C5 Area over the deltoid
C6 Thumb
C7 Middle finger
C8 Little finger
T4 Nipple
T8 Xiphisternum
T10 Umbilicus
T12 Symphysis pubis
L4 Medial aspect of the calf
L5 Web space between the first and second toes
S1 Lateral border of the foot
S3 Ischial tuberosity area
S4 and S5 Perianal region
# NEUROGENIC SHOCK
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Ali M. Ahmad; Consultant Pediatric Surgery
Impairment of the descending sympathetic pathways in the cervical or
upper thoracic spinal cord.
Results in the loss of vasomotor tone and in sympathetic innervation to
the heart.
Is rare in spinal cord injury below the level of T6; if shock is present in these patients,
an alternative source should be strongly suspected.
Atropine may be used to counteract hemodynamically significant bradycardia.
# SPINAL SHOCK
Refers to the flaccidity and loss of reflexes seen after spinal cord injury.
“shock” to the injured cord may make it appear completely nonfunctional, although
the cord may not necessarily be destroyed.
The duration of this state is variable.
Injuries of the first eight cervical segments of the spinal cord result in quadriplegia,
and lesions below the T1 level result in paraplegia
# MUSCULOSKELETAL TRAUMA
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Ali M. Ahmad; Consultant Pediatric Surgery
Three goals for the assessment of trauma patients’ extremities:
1. Identification of life-threatening injuries (primary survey)
2. Identification of limb-threatening injuries (secondary survey)
3. Systematic review to avoid missing any other musculoskeletal injury
Doppler ankle/brachial index of less than 0.9 is indicative of an abnormal arterial flow
secondary to injury or peripheral vascular disease. The ankle/brachial index is determined
by taking the systolic blood pressure value as measured by Doppler at the ankle of the
injured leg and dividing it by the Doppler-determined systolic blood pressure of the
uninjured arm.
@Limb-Threatening Injuries
1. Open fractures & Joint injuries,
2. Vascular injuries,
3. Compartment syndrome,
4. Neurologic injury secondary to fracture dislocation.
Muscle does not tolerate a lack of arterial blood flow for longer than 6 hours before
necrosis begins
A patient with multiple injuries who requires intensive resuscitation and emergency
surgery is not a candidate for replantation.
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Ali M. Ahmad; Consultant Pediatric Surgery
Traction splint of a femur fracture should be avoided if there is a concomitant
ipsilateral lower leg fracture.
Despite a thorough examination, occult associated injuries may not be identified
during the initial evaluation. it is imperative to repeatedly reevaluate the patient to
assess for these injuries.
Normal capillary refill (<2 seconds) of the pulp space or nail bed
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Ali M. Ahmad; Consultant Pediatric Surgery
THERMAL INJURIES
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Ali M. Ahmad; Consultant Pediatric Surgery
The initial fluid rate for burn patients
2 to 4 x kg x BSA per 1st 24h
o ½ in the 1st 8h
o then ½ to the remaining 16 h
example 100 kg with 80% burn {2 to 4 x 100 x 80} = 16000 or 32000 ml/24h
o Give 8000 ml in 1st 8 h {to 16000}
o Ten 8000 in the following 16 h {to 16000}
Amount of fluids provided should be adjusted based on the urine output target of
0.5 mL/ kg/ hr for adults and 1 mL/kg/hr for children <30 kg.
In very small children (i.e., <10 kg), it may be necessary to add glucose to their IV
fluids to avoid hypoglycemia
Pressure >30 mm Hg within the compartment may lead to muscle necrosis need
{Escharotomy} but usually are not needed within the first 6 hours after a burn injury
Do not apply cold water to a patient with extensive burns (>10% total BSA).
NO indication for prophylactic antibiotics in the early post-burn period. Antibiotics
should be reserved for the treatment of infection.
Alkali burns are generally more serious than acid burns, because the alkalies
penetrate more deeply. Alkali burns to the eye require continuous irrigation during
the first 8 hours after the burn
Patients with electrical injuries frequently need fasciotomy and should be
transferred to burn centers early in their course of treatment.
Hypothermia
Core temperature below 36°C
Severe hypothermia is any core temperature below 32°C
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Ali M. Ahmad; Consultant Pediatric Surgery
PEDIATRIC TRAUMA
Pediatric Trauma Score
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Ali M. Ahmad; Consultant Pediatric Surgery
LMA sizes
1 (appropriate for infants <6.5 kg)
1.5 (for 5 to 10 kg)
2 (for 10 to 20 kg)
2.5 (for 20 to 30 kg)
3 (for between 30 and 70 kg)
over 70 kg, adult sizing is appropriate
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Ali M. Ahmad; Consultant Pediatric Surgery
CPR done in the field + return of spontaneous circulation = 50% chance of
neurologically intact survival.
CPR done in the field + still arrest = dismal prognosis.
CPR >15 minutes + Fixed pupils = predict nonsurvival.
Operative management is indicated not by the amount of intraperitoneal blood, but by
hemodynamic abnormality and its response to treatment.
Blood found on a DPL would not mandate operative exploration in a child who is
otherwise stable
An infant who is not in a coma but who has bulging fontanelles or suture diastases
should be treated as having a more severe injury. Early neurosurgical consultation is
essential.
GCS is useful when applied to the pediatric age group. However, the verbal score
component must be modified for children younger than 4 years
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Ali M. Ahmad; Consultant Pediatric Surgery
# GERIATRIC TRAUMA
Mortality rate was three times greater in older patients with preexisting
disease (9.2% vs 3.2%).
However, more than 80% of injured older adults can return to their preexisting level of
independent living after aggressive resuscitation and follow-up care
Consequently, whereas broken dentures should be removed, intact well-fitted dentures
are often best left in place until after airway control is achieved
Undue manipulation of the osteoarthritic cervical spine, leading to spinal cord injury.
With aging, total blood volume decreases and circulation time increases
A common pitfall in the evaluation of geriatric trauma patients is the mistaken
impression that “normal” blood pressure and heart rate indicate normovolemia
Hypothermia not attributable to shock or exposure should alert the physician to the
possibility of occult disease—in particular, sepsis, endocrine disease, or pharmacologic
causes.
The most common locations of fractures in elderly patients are the ribs, proximal
femur, hip, humerus, and wrist
2. Elder maltreatment
Is any willful infliction of injury, unreasonable confinement, intimidation, or cruel
punishment that results in physical harm, pain, mental anguish, or other willful
deprivation by a caretaker of goods or services that are necessary to avoid physical
harm, mental anguish, or mental illness.
3. End-of-life decisions
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Ali M. Ahmad; Consultant Pediatric Surgery
# TRAUMA IN PREGNANCY AND INTIMATE PARTNER VIOLENCE
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Ali M. Ahmad; Consultant Pediatric Surgery
# APP A- OCULAR TRAUMA
Heat Injuries
Heat exhaustion
Core temperature usually less than 39°C
Caused by excessive loss of body water, electrolyte depletion, or both
Intact mental function
Heat stroke
Core temperature ≥ 40°C
Life-threatening disease {mortality is up to 80%}
CNS dysfunction {delirium, convulsions, and coma} & may progress to DIC
Prompt correction of hyperthermia by immediate cooling and support of organ-
system function are the two main therapeutic objectives in patients with HS
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Ali M. Ahmad; Consultant Pediatric Surgery
Incident command is a system management tool that transforms existing
organizations across planning, operations, logistics, and
finance/administration functions for integrated and coordinated response
Triage is a system decision tool used to sort casualties for treatment priority, given
casualty needs, resources, and the situation “the best for most,”
Scene triage system that uses motor response to command as a quick “sift” is helpful
in finding these critically injured
The five triage categories are:
1. Immediate (Red): immediately life-threatening injuries
2. Delayed (Yellow): injuries requiring treatment within 6 hours
3. Minimal (Green): walking wounded and psychiatric
4. Expectant (Blue): injuries greater than life or resources
5. Dead (GREY)
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Ali M. Ahmad; Consultant Pediatric Surgery
Multiple casualty incidents (MCIs)
Patient care resources are overextended but are not overwhelmed
Can stress local resources such that triage focuses on identifying the patients with
the most life-threatening injuries.
Preparation
Identify risks, build capacity, and identify resources
These activities include a risk assessment of the area, the development of a simple, yet
flexible, disaster plan that is regularly reviewed and revised as necessary, and provision
of training that is necessary to allow these plans to be implemented when indicated.
Mitigation
involves the activities a hospital undertakes in attempting to lessen the severity and
impact of a potential disaster.
These include adoption of an incident command system for managing internal and
external disasters, and the exercises and drills necessary to successfully implement,
test, and refine the hospital disaster plan.
There is no substitute for adequate training and drilling.
Response
involves activities a hospital undertakes in treating victims of an actual disaster
These include activation of the hospital disaster plan, including the ICS, and
management of the disaster as it unfolds, implementing schemes for patient
decontamination, triage, surge capacity and surge capability.
Recovery
involves activities designed to help facilities resume operations after an emergency.
The local public health system plays a major role in this phase of disaster management,
although health professionals will provide routine health care to the affected
community consistent with available resources, in terms of operable facilities, usable
equipment, and credentialed personnel.
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Ali M. Ahmad; Consultant Pediatric Surgery
# BLUNT TRAUMA
Vehicular impact when the patient is inside the vehicle
Pedestrian injury
Injury to cyclists
Assaults (intentional injury)
Falls
Blast injury
Passenger restraints
Reduce fatalities by up to 70%
10-fold reduction in serious injury.
Frontal air bags provide no protection in rollovers, second crashes, or lateral
When worn correctly, safety belts can reduce injuries. When worn incorrectly—for
example, above the anterior/superior iliac spines—the forward motion of the
posterior abdominal wall and vertebral column traps the pancreas, liver, spleen,
small bowel, duodenum, and kidney against the belt in front.
# BLAST INJURIES
Primary: result from the direct effects of the pressure wave and are most injurious
to gas-containing organs. The tympanic membrane is the most vulnerable to the
effects of primary blast
Secondary: result from flying objects striking an individual.
Tertiary: thrown against a solid object or the ground.
Quaternary: burn injury, crush injury, respiratory problems from inhaling dust,
smoke, or toxic fumes, and exacerbations or complications of existing conditions
such as angina, hypertension, and hyperglycemia.
# PENETRATING TRAUMA
1. Low energy—knife or hand-energized missiles {little cavitation}
2. Medium energy—handguns {5-time cavitation}
3. High energy—military or hunting rifles {up to 30-time cavitation}
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# TETANUS IMMUNIZATION
Passive immunization
250 units of human TIG intramuscularly must be considered for each patient.
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# PERITONEAL DRAINAGE
Drainage systems can be classified as ‘open’ or ‘closed’, ‘suction’ or ‘nonsuction’.
Peritoneal cavity suction drains risk drawing bowel or other viscera into the tip, with
the attendant risk of perforation or bleeding
Remember to send ascitic fluid for microscopy, culture and sensitivity,
protein/albumin, amylase and electrolytes.
# TRAUMA LAPAROTOMY
Two approach: Transverse supra-umbilical and Midline.
If massive intraperitoneal haemorrhage encountered, manual compression of the
infra-diaphragmatic aorta while all four quadrants of the abdomen are packed may
assist.
Liver bleeding may be controlled using ‘Pringle’s manoeuvre’. The dual blood supply of
the liver (hepatic artery and portal vein) is compressed between the surgeon’s index
finger (placed through the foramen of Winslow) and thumb, as they run through the
hepatoduodenal ligament anterior to the foramen of Winslow
A stepwise and systematic exploration of each quadrant, starting from the liver and
moving in a clockwise manner around the abdomen should be performed
A retroperitoneal haematoma should be left undisturbed unless it is expanding or it
overlies the duodenum or pancreas.
Suspect bladder rupture if:
1. Large volume of clear fluid in the abdomen
2. High preoperative creatinine
3. Low serum sodium
Open bowel perforations should be occluded temporarily with light, non-crushing
clamps to prevent further contamination.
If a site of injury is not obvious after a general search of the abdomen, the lesser sac
(which is opened by dividing the gastrocolic omentum), subdiaphragmatic spaces and
posterior abdominal wall should all be inspected.
Care must be taken to avoid the phrenic nerve, which divides into anterior and
posterior branches in a medial to lateral orientation. The phrenic nerve is easier to
visualise using a thoracic approach
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TRAUMA
Trauma is the commonest cause of death in the pediatric over 1 year of age (less than 1
year, congenital abnormalities, prematurity and SIDS)
B- Nasotracheal intubation:
Is preferred for patients with suspected cervical spine injury.
C- Circulation
Assess-heart rate/blood pressure/capillary refill/mental status
Establish two large bore intravenous cannulae rapidly
If circulation inadequate – 20 mL/kg normal saline bolus
Ongoing circulatory support – if third bolus is required, use O-negative blood
Ensure cross-matched sample sent early.
Ensure platelets and FFP and cryoprecipitate available if on-going support required
All fluids should be warmed.
Arrange early surgical consult.
Consider hidden sources of bleeding: head, chest, abdominal, pelvis and femur.
Establish haemorrhage control.
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D- Disability:
Assess mental state using the AVPU or the paediatric Glasgow coma score
AVPU
A: Alert child
V: Responds to voice
P: Response to pain (equivalent to GCS < 8)
U: Unconscious
TRAUMA RADIOLOGY
1. CXR
2. C-Spine lateral
3. Pelvis – if the child is awake, orientated with no other distracting injuries and there
is no clinical suspicion of a pelvic fracture then this x-ray may be omitted.
SECONDARY SURVEY
Comprehensive examination top-to-toe and front-to-back (including log roll)
examining all orifices, with full documentation of all injuries with instigation of first
aid management
In paediatrics a rectal and vaginal examination are not routine and should only be
performed once if deemed necessary by the appropriate specialist.
TYPES & MECHANISM OF INJURY
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Ali M. Ahmad; Consultant Pediatric Surgery
Mechanisms Common pattern of injury
Type
Pedestrian 1. Low speed: lower extremity fractures
struck 2. High speed: Head/ Neck injuries & multiple trauma
1 MVA
Automobile 1- Unrestrained: Head/ Neck injuries & multiple trauma
occupant 2- Restrained: Chest, Abdomen, spine & lower limb
1. Low: upper extremity fractures
From high 2. Medium: Head/ Neck & extremity fractures
2 Fall 3. High: Head/ Neck injuries & multiple trauma
1. Without helmet: Head/ Neck injuries & multiple trauma
From a bicycle
2. With helmet: upper extremity fractures
3 Blunt Striking handlebar: internal abdominal injuries
Types Shock
1. Pump Defects (Cardiogenic)
2. Vascular beds Defects (Distributive) @septic @spinal @anaphylactic
3. Blood volume Defects (Hypovolemic)
4. Blood Flow Restriction Defects (obstructive)
a. Cardiac Tamponade
b. Constrictive Pericarditis
c. Aortic stenosis
d. Tension Pneumothorax
e. Massive pulmonary embolism
5. Oxygen-Releasing Defects (dissociative)
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TRAUMATIC BRAIN INJURY {TBI}
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INDICATIONS FOR CT SCAN AFTER HEAD INJURY
GCS < 13 at any point since injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haem tympanum, panda eyes, Battle’s sign, CSF
otorrhea)
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting
Amnesia for greater than 30 min of events before impact {Assessment of amnesia not
possible in children <5 years old}
CSF leak
CSF rhinorrhoea may result from a fracture of the base of the skull involving the
frontal, ethmoid or sphenoid sinuses
Fracture of the temporal bone may cause CSF otorrhoea and/or rhinorrhoea.
Both types are initially treated conservatively; In about 70% cases of CSF rhinorrhoea
and almost all case of CSF otorrhoea the leak stops spontaneously.
The treatment of a CSF leak persisting for more than 10 days after a head injury is an
operative repair.
Prophylactic antibiotics are not recommended because resistant organisms may
develop and meningitis may still occur.
If the CSF leak persists the communication with the exterior through a mucosal space
is a potential source of meningitis and this may occur months or years later.
A skull defect should be suspected when meningitis occurs after a head injury.
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Ali M. Ahmad; Consultant Pediatric Surgery
When the Patient is stable; the CT with contrast is the gold standard
But If hemodynamic stability cannot be achieved with resuscitation, it may
be more appropriate for the patient to have an urgent laparotomy.
Diagnostic Peritoneal Lavage {DPL} is not indicated in children because free blood in the
peritoneal cavity per se is not an indication for surgical interventions.
Non-operative management
Is appropriate for most solid visceral injuries in children
Provided they are kept under close supervision
Best managed in ICU
Nearly always, the bleeding stops and surgery is not needed
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Ali M. Ahmad; Consultant Pediatric Surgery
US: Four-view FAST examination includes Morrison’s
pouch/right upper quadrant, the left flank to include
the perisplenic anatomy/left upper quadrant, and a subxiphoid
view to visualize the pericardium and the pouch of
Douglas/pelvis. This bedside examination may be useful as a
rapid screening study
Even the most severe solid organ injuries can be treated without surgery if there is
prompt response to resuscitation. In contrast, emergency
laparotomy and/or embolization are indicated in patients who
are hemodynamically unstable despite fluid and red blood cell
transfusion. Most spleen and liver injuries requiring operation
are amenable to simple methods of hemostasis using a
combination of manual compression, direct suture, topical
hemostatic agents, and woven polyglycolic mesh wrapping
Hypothermia, coagulopathy, and acidosis, triad creates a vicious cycle in which each
derangement exacerbates the others
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Surgical options in duodenal trauma
Repair of the duodenum
Diversion of GIT (pyloric exclusion or a duodenal diverticulization).
Gastric decompression (gastric tube insertion or gastrojejunostomy).
GIT access for feeding (jejunostomy tube or gastrojejunal anastomosis).
Decompression of the duodenum (duodenostomy tube).
Biliary tube drainage.
Wide drainage of the repaired area (lateral duodenal drains)
(Whipple procedure) should rarely be required. This pancreaticoduodenectomy
should be reserved for the most severe injuries to the duodenum and pancreas
when the common blood supply is destroyed and any possibility of
reconstruction is impossible.
Renal Injury
Renal injuries such as ureteropelvic junction (UPJ) disruption or segmental
arterial thrombosis may occur without the presence of hematuria or
hypotension. Therefore, a high index of suspicion is necessary to diagnose these
injuries.
Non-visualization of the injured kidney on intravenous pyelogram and failure to
uptake contrast with a large associated perirenal hematoma on CT are hallmark
findings for renal artery thrombosis.
Ureteropelvic junction disruption is classically seen as perihilar extravasation of
contrast with non-visualization of the distal ureter
Intravenous infusion of indigo-carmine (a vital dye excreted in the urine) at
operation may help identify sites of extravasation
Proximal control of the renal vessels prior to opening Gerota’s fascia may
facilitate retroperitoneal exploration.
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o The crush and shearing mechanisms may lead to progressive
ischemia with delayed perforation or stricture.
Children with the ‘seatbelt sign’ across their lower abdomen should be
admitted for serial examinations even if the initial examination and diagnostic tests
are normal
Burn
Palmar surface of open hand of patient is 1 % TBSA {Can used for measurement}
ABC & Remove hot clothing immediate
Hydrotherapy: small burns (<25 percent TBSA) are immersed in cold water
Copious irrigation of the wound with water is indicated for chemical burn
For suspected inhalation injury, 100 % oxygen is given by facemask
Escharotomy should always be considered
Tetanus toxoid should be administered
Parkland IVF formula: 4 mL/kg per BSA burn
UROGENITAL TRAUMA
1-Renal Injury
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High grades: 1Pseudocysts, 2caliceal diverticulum and 3renal hypertension
are possible
Work-up
Lab: blood and urine analysis
Radiology:
o Doppler US (RA thrombosis)
o IVU for the evaluation of the pelvis and ureters.
o CT with contrast which allows to discover combined intraabdominal injuries; In one
quarter of the injuries of the spleen the ipsilateral kidney is involved, too
Indications for surgical intervention are relative rather than absolute and include:
1. Haemodynamic Instability @ any Grade
2. Grade V even if haemodynamic stable
3. Major Urinary extravasation {Most of Localised collections can be aspirated or
drained}
4. Vascular injuries: except only case of a solitary kidney or bilateral injury
Aim of Rx: Establishing bladder drainage and evaluating the severity injury
Give Analgesic and observe
o if passed urine spontaneously is Ok
o if Not passed urine: PC Suprapubic Catheter under GA rather than
transurethral procedures {cystoscope or transurethral catheter} @ risk of
more trauma
After several days do descending cystography or, ideally, ascending urethrogram
o If no extravasation or disruption, the Suprapubic catheter can be clamped
and normal urethral voiding re-established
o If extravasation or disruption @urethroplasty
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Ali M. Ahmad; Consultant Pediatric Surgery
Aim of Rx: Prolonged Suprapubic drainage followed by elective
urethroplasty or open exploration, debridement and attempted re-
alignment approximation of the urethra over a catheter once the
initial effects of the injury have subsided, e.g. after 7–14 days.
MISCELLANEOUS INJURES
# BURNS:
Indication for hospital Admission
Any type with Total BSA burn >10%
Full thickness burn >5%
Specific: Inhalation burn; face, hand or buttock burns; non-accidental burn.
Hair clips pass easily as far as the duodenojejunal flexure, but may be too long and
rigid to negotiate this flexure in children less than 7 years of age, and require
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Ali M. Ahmad; Consultant Pediatric Surgery
endoscopy or laparotomy for their removal. In children more than 6 or 7
years of age, observation for up to 1 week is justified, although impaction
at the duodenojejunal flexure should not be allowed to continue for more
than 10–12 days.
In general, where a blunt foreign body has been impacted without progress for 6
weeks, removal at laparotomy may be considered, even in the absence of symptoms.
failure to progress through the bowel may raise concerns of impending impaction,
ulceration and perforation
# TETANUS
Active immunization
Tetanus immunization should be part of routine childhood immunization
Three doses of triple antigen (Diphtheria, Tetanus, Pertussis)
Booster doses at 4 and 15 years.
Passive immunization
Tetanus immunoglobulin indicated in case of Tetanus-prone wound, and those
who have received less than three doses of tetanus vaccination.
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Ali M. Ahmad; Consultant Pediatric Surgery