Trauma

T HA R A NGA WI JE THI LAK E

CON S ULTA NT E ME RGENCY P HYS I CI AN
L EC T UR ER - DE PA RTM ENT OF A N A ESTHESIOLOGY A N D CR I T I CA L CA R E
Global burden of Trauma
 Trimodal Distribution
• Apnoea of Deaths
due to severe brain injury
PREVENTION

• High spinal cord injury

1st Peak
Seconds - Minutes • Rupture of heart, aorta or other large blood vessel

GOLDEN HOUR OF
• SDH/ EDH CARE Haemo-pneumothorax
• Ruptured spleen/Liver Laceration Pelvic fracture
2nd Peak
Minutes - Hours • Multi-trauma with significant blood loss

• Sepsis
3rd Peak • Multiple organ system dysfunction
Days – Weeks
GOLDEN HOUR and PLATINUM TEN
MINUTES
The first hour after injury will largely determine a critically injured person’s chances for survival

•Rapid transit to hospital remains the standard of care

TRAUMA TEAM
ESSENTIAL
Team Leader
Airway Manager (Doctor A)
Airway Assistant
Second Provider (Doctor B)
2 Nurses (Assistant A and B)
ADDITIONAL
Scribe/ Coordinator
Transporters/ nursing assistants/ technicians
Radiology support
Specialist (orthopaedic/ neurosurgery/
vascular )
Trauma Team Pearls
Leadership
Clinical Expertise
Communication
Mutual respect
Feedback and debriefing

MIST handover (Mechanism/ Injury/ Signs/ Treatment & travel)

Primary Survey
Managing the airway
Inspect for foreign bodies
Identify facial, mandibular, and/or tracheal/laryngeal fractures and other injuries that can result
in airway obstruction
Suctioning to clear accumulated blood or secretions

If GCS <8/15
◦ Definitive airway (cuffed, secured tube)
Assessing Breathing
Jugular venous distension
Position of trachea
Chest wall excursion
Inspect neck & chest
Auscultation
Injuries that significantly impair
ventilation
Tension pneumothorax
Massive hemothorax
Open pneumothorax
Tracheal or bronchial injuries
Chest injuries identified during the
secondary survey
Simple pneumothorax
Simple hemothorax
Fractured ribs
Flail chest
Pulmonary contusion
Managing breathing
Oxygen for all injured patients
Manage the airway
Decompressing the chest
◦ Finger thoracostomy
◦ IC tube

Ventilation
Circulation
Haemorrhage is the leading cause of preventable death after injury
Exclude tension pneumothorax as cause of shock
Clinical observations
Level of Consciousness
◦ Impaired cerebral perfusion

Skin Perfusion
◦ Pink skin rarely has critical hypovolemia after injury
◦ Ashen, gray facial skin and pale extremities suggest critical hypovolaemia

Pulse
◦ A rapid, thready pulse is typically a sign of hypovolemia
◦ Assess central pulse (e.g., femoral or carotid artery) bilaterally for quality, rate, and regularity
◦ Absent central pulses that cannot be attributed to local factors signify the need for immediate
resuscitative action
Bleeding
External bleeding
◦ Identify during primary survey and control
➢ direct manual pressure
➢ tourniquet (only when direct manual pressure not successful)

Internal bleeding
◦ Chest, abdomen, retroperitoneum, pelvis and long bones
◦ Identify by :
➢ physical examination
➢ imaging (chest and pelvis X rays/ FAST)
➢ diagnostic peritoneal lavage (DPL)
Actions required to manage shock
Chest decompression
Pelvic stabilization device
Extremity splints

Surgical interventions
Interventional radiology intervention
Orthopaedic interventions
Managing Bleeding
2 wide bore cannulae
➢IO line
➢Central venous line
➢Venous cut down

Basic bloods (FBC, SE, BU/S. Creatinine)

◦ LFT/ CK-Mb/ Coagulation profile/ TEM

Blood grouping and cross match

Pregnancy test for all females of child-bearing age
VBG
Fluids in trauma
All fluids to be warmed
Initial crystalloid resuscitation (limited volume)
◦ 0.9% saline 1 L
◦ >1.5L of crystalloid fluids are associated with increased mortality

Haemostatic resuscitation (1:1:1 ratio of RBC:FFP:Platelets)

◦ To prevent trauma induced coagulopathy
◦ Massive transfusion protocol

Permissive hypotension
IV Tranexamic acid 1 g within 3 hours of injury followed by 1g over 8 hours infusion
Non haemorrhagic shock in trauma
Cardiogenic shock
◦ Blunt cardiac injury
◦ Cardiac tamponade
◦ Air embolus
◦ Myocardial infarction

Tension pneumothorax- Obstructive shock

Neurogenic shock
➢Spinal shock

Septic shock
◦ Uncommon in trauma
Managing Disability
Level of consciousness
◦ GCS
◦ Consider hypoglycaemia, alcohol, narcotic and other drugs

Pupillary size and reaction

Lateralizing signs
Spinal cord injury level
Exposure
Completely undress and examine during primary survey
Immediately cover to prevent hypothermia
◦ Warm blankets
◦ External warming devices
◦ Warm fluids
Secondary survey
Head to toe examination
Identify injuries missed during primary survey
Head and Neck trauma
Done as a separate lecture
The Cervical Spine
THORACIC TRAUMA
MAJOR THORACIC INJURIES

Tension Penumothorax Simple pneumothorax

Open Pneumothorax Hemothorax
Massive Haemothorax Flail chest
◦ >1500ml blood in one side of chest
Pulmonary contusion
Blunt cardiac injury
Traumatic aortic disruption
Traumatic diaphragmatic injury
Blunt esophageal rupture
Finger
Thoracostomy
Dressing the open pneumothorax
ABDOMINAL TRAUMA
common injuries
Blunt trauma
◦ spleen (40% to 55%)
◦ liver (35% to 45%)
◦ small bowel (5% to 10%)
Stab wounds
◦ liver (40%)
◦ small bowel (30%)
◦ diaphragm (20%)
◦ colon (15%)
Gunshot wounds
◦ small bowel (50%)
◦ colon (40%)
◦ liver (30%)
◦ abdominal vascular structures (25%)
PELVIC TRAUMA
Unexplained hypotension may be the only initial indication of major pelvic disruption
pelvic fractures with hypotension and no other source of blood loss
◦ Suspect mechanical instability of the pelvic ring

Pelvic binder is a priority and may be lifesaving

ruptured urethra
◦ scrotal hematoma or blood at the urethral meatus
◦ discrepancy in limb length
◦ rotational deformity of a leg without obvious fracture
Indications for laparotomy
➢Blunt abdominal trauma with hypotension, positive FAST or clinical evidence of intraperitoneal
bleeding, or without another source of bleeding
➢Hypotension with an abdominal wound that penetrates the anterior fascia
➢Gunshot wounds that traverse the peritoneal cavity
➢Evisceration
➢Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma
➢Peritonitis
➢Free air, retroperitoneal air, or rupture of the hemidiaphragm
➢Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder
injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma
EXTREMITY TRAUMA
Potentially life-threatening extremity injuries
Include major arterial hemorrhage
Bilateral femoral fractures
Crush syndrome
Acute compartment syndrome
Replantation of amputated parts
Thoroughly wash the amputated part in isotonic solution (e.g., Ringer’s lactate)
Wrap it in moist sterile gauze
Then wrap the part in a similarly moistened sterile towel
Place in a plastic bag
Transport with the patient in an insulated cooling chest with crushed ice
Be careful not to freeze the amputated part
THE POLYTRAUMA VICTIM
Team approach/ Call for help
Golden hour
Primary survey
◦ A with C spine

Damage control resuscitation

◦ Haemostatic resuscitation
◦ Permissive hypotension
◦ Damage control surgery

Massive transfusion protocol

Stabilize before imaging
Preserve forensic evidence
Manage the pain
Remember the family
Treating the trauma patient
Retrieval Services
ETHICAL ASPECTS
Consent
Privacy
Disclosure
Advanced care directives
Survivors and family members
QUIZ