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BASIC PRINCIPLES OF
TRAUMA MANAGEMENT

DR. GEORGE MUGENYA

MBCHB, M.MED, FCS (ECSA)

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Introduction
Trauma is leading cause of death in the first four decades
of life.
More than 5 million trauma-related deaths occur each
year worldwide.
Motor vehicle crashes cause over 1 million deaths per
year.
Injury accounts for 12% of the world’s burden of disease.
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Definition:
• Trauma is tissue damage which occur due to transfer of different forms of
energy on a patient.
• Types:
I. Cause:
 Homicides
 Road traffic accidents and falls
 Industrial accidents and Burns
II. Mechanisms:
A. Blunt injury:
 Caused by acceleration, deceleration, rotational or shearing force.
B. Penetrating injury:
 Caused by direct breach by penetrating object, eg. bullet injury,
stab injury.
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Introduction
Trauma is leading cause of death in the first four decades
of life.
More than 5 million trauma-related deaths occur each
year worldwide.
Motor vehicle crashes cause over 1 million deaths per
year.
Injury accounts for 12% of the world’s burden of disease.
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Trauma Death Distribution

Deaths from trauma follow a trimodal distribution:
1. Immediate deaths in the first minutes at the scene due to:
 Massive haemorrhage
 Crush injuries.
 Massive CNS trauma.
 Airway obstruction.
2. Early deaths during ‘Golden hour’ are often due to:
 The effects of haemorrhage.
 The effects of hypoxia.
3. Late deaths are chiefly due to:
 Sepsis.
 Organ failure.
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TRIMODAL PEAKS OF DEATH

• 1-First peak:
Seconds to minutes – (50%).
• 2-Second peak:
Minutes to hours – (30%).
• 3-Third peak:
Several days to weeks from initial trauma – (20%)
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'Golden Hour'
• The Golden Hour is the time period of one hour in
which the lives of a majority of critically injured
trauma patients can be saved if definitive surgical
intervention is provided.
During this period all efforts should be made to save a
life before irreversible pathological changes occur in
order to reduce or prevent death in the 2nd and 3rd phases.
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…..'Golden Hour'
'Golden Hour' concept was derived from French World War-I data
in 1918.
Time between injury and adequate shock treatment determined
mortality/outcome:
Time from injury Mortality
1 hr. 10 %
2 hrs. 11 %
3 hrs. 12 %
4 hrs. 33 %
5 hrs. 36 %
6 hrs. 41 %
8 hrs. 75 %
10 hrs. 75 %
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‘Platinum 10 Minutes’
The platinum 10 minutes are the very important first ten minutes of
the golden hour.
 It is the period during which emergency crews, upon their arrival at the
scene, assess the situation and initiate treatment and transport of
casualties.
It should be distributed as follows:
Assessment of the victim and primary survey—1 min.
Resuscitation and stabilization—5 min.
Immobilization and transport to nearby hospital—4 min.

NB: Trauma management concepts:

“Scoop and run”—vs—”Stay and play”
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Principles Of Early Trauma

Management
• Treat the greatest threat to life first.
• Lack of definitive diagnosis should never impede the
application of an indicated treatment.
• A detailed history is not a prerequisite to begin the
evaluation of an acutely injured patient.
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ATLS Concept
• ABCDE approach to evaluation and treatment of trauma
patients:
Treat greatest threat to life first
Definitive diagnosis not immediately important
Time is of the essence
Do no further harm
• It involves:
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation: stop the bleeding!
Disability / neurological status
Expose /Environment / body temperature
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Triage
• The word triage comes from the French word trier that
literally means to sort.
• Dominique Larrey a Surgeon General during the reign
of Napoleon Bonaparte used this concept for
determining treatment priorities among casualties.
• Right patient gets the right treatment at right time.
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Primary Objectives Of Triage

1. Identification of immediate life threatening situations.
2. Reduce severity of the condition by ensuring immediate
intervention.
3. Reduce delay in the treatment.
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Primary Assessment (Survey)

• A- Airway with in-line cervical spine immobilization.

• B- Breathing with oxygen supplementation.
• C- Circulation with haemorrhage control
• D- Disability => neurological status (AVPU-vs- GCS).
• E- Exposure of the entire body ,looking for occult
injuries.
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Airway
1. Clear speech is a good indicator of clear airway.
2. Noisy breathing is a indicator of airway obstruction.
3. Always assume that the patient has a cervical spine
injury.
4. Chin lift and jaw thrust manoeuvres along with
suctioning prevents airway obstruction.
5. Manual in-line stabilization of spine is essential.
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Breathing
• Hypoxia is most serious problem:
Early interventions aimed at reversing it.
• Once the airway is established, oxygen is administered
using high flows of reservoir mask to insure high fraction
of inspired oxygen concentration.
• Inspection, palpation and auscultation of chest
(LOOK,LISTEN, FEEL)
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Circulation With Haemorrhage

Control
 PULSE
 NEUROLOGICAL STATUS
 BLOOD PRESSURE
 The assessment of circulation begins with the insertion of 2 wide bore
canullae.
 Initial fluid bolus of 1 - 2 L of Ringer’s lactate (20 mL/kg in children).
 Haemorrhage control.
 End point of volume resuscitation is unclear.
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Disability
Make a rapid neurological assessment (is the patient awake,
vocally responsive, responsive to pain or unconscious?)
There is no time to do the Glasgow Coma Scale (Score).
Use the following clear, quick system at this stage:
A—Awake
V—Verbal response
P—Painful response
U—Unresponsive
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Disability Glasgow Coma Scale

CLINICAL ASSESSMENT SCORE
Eye Opening
Spontaneously 4
Opens eye to call 3
Opens eye to painful stimuli 2
No response 1
VERBAL RESPONSE
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensive sounds 2
No response 1
MOTOR RESPONSE
Obeys commands 6
Localizes painful stimuli 5
Withdraws from painful stimuli 4
Abnormal flexion to pain 3
Abnormal extension to pain 2
No response to pain 1
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GCS
• Severe - 8 or less
• Moderate - 9 – 12
• Mild – 13 – 15
• E(c) when patient cannot open eyes
• V(t) when patient cannot speak
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Resuscitation

Circulation Airway

Breathing
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Secondary Assessment (Survey)

• Detailed head-to-toe examination of the patient.
• Neurological examination and determination of GCS.
• ‘Tubes and fingers in every orifice’.
• Further investigation as warranted by findings.
• Information regarding the injury.
• Past medical history.
• Continued monitoring of patient.
• Revert to primary survey if patient becomes unstable.
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Adjuncts To Secondary Survey

• Special diagnostic tests as indicated:
Trauma series x-rays +/- specific x-rays
Ultrasound /FAST
CT-Scan/ MRI

• Pitfalls:
Patient deterioration
Delay of transfer
Deterioration during transfer
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Signs Of Airway Obstruction

• Hoarse voice.
• Decreased air entry and exit.
• Stridor.
• Retraction of suprasternal, supraclavicular and intercostal space.
• Tracheal tug.
• Restlessness.
• Cyanosis.
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Primary Management
NON EQUIPMENTAL
• Chin lift
• Jaw thrust

EQUIPMENTAL
• Oropharyngeal airway
• Nasopharyngeal airway
• LMA and Combitube
• Surgical airway
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…Airway
Head tilt, chin lift, jaw thrust
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Basic Airway Management

• Head tilt and chin lift
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…Basic Airway Management

• Jaw thrust
• Suspected cervical spine injury
• Finger sweep and manual removal of foreign
bodies
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Guedel Airway
(Oropharyngeal Airway)
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Endotraction Tube—ETT
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Laryngeal Mask Airway

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Definitive Airway
INDICATIONS
• Apnoea
• Inability to maintain a patent airway by other means.
• Closed head injury requiring hyperventilation.
• Anticipated need.
Definitive airway are of 3 varieties
• 1-Orotracheal intubation.
• 2-Nasotracheal intubation.
• 3-Surgical airway  Cricothyroidotomy.
NB: Tracheostomy not emergency procedure.
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Cricothyroidotomy/
Laryngotomy
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Cricothyroidotomy/
Laryngotomy
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Adjuncts To Basic Airway

Techniques
• Oxygen inhalation
▫ Oxygen masks with reservoir bag
▫ Oxygen flow / litre per minute
▫ SpO2 and ABGs

• Suction
▫ Blood, saliva and gastric contents
▫ Intact gag reflex (vomiting)
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Ventilation
• Mouth to mouth breathing:
Instant availability /no equipment required
Oxygen content 16-17%
Aesthetically unpleasant
Risk of acquiring infection (TB,SARS,HBV,HCV)
• Pocket resuscitation masks
Transparent just like anesthesia masks
Uni-directional valve
Connection for addition of O2
Large tidal volume or excessive inspiratory flow  gastric
distention and regurgitation
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Self Inflating Bag

• Can be connected to face mask /ETT /LMA / combitube
• Oxygen delivery:
> Room air 21%
> O2 attachment 45%
> Reservoir bag 85% (10 L/min flow)
• Difficult for one person to ventilate
• Two person technique more effective
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Evaluation In Casualty
Stabilize cervical spine
Airway
Breathing
Circulation
History
Demographic
Mode of trauma and Time of trauma
H/o consciousness / seizures/vomiting
H/o blood loss
Prior medical problem
Head to toe examination
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Examination
A B C => Do not proceed until satisfactory
GCS (time consuming)
Pupils
Hemiparesis /Lateralizing signs
Scalp, skull, spine
Chest & Abdomen
Trauma series x-rays
Lateral cervical spine
Chest x-ray
Pelvic x-ray
Other specific x-rays
Others as necessary: eg. FAST / CT-SCAN, MRI etc.
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Pain Management

• Relief of pain / anxiety as appropriate.

• Administer intravenously.
• Careful monitoring is essential.
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Definitive Care

• A clear plan should be formulated regarding

patient’s further care:
Further investigation
Transfer to operating theatre
Transfer to ICU/HDU
Interhospital transfer (e.g. to neurosurgical centre,
burns unit)
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Chest Injuries For Urgent

Attention
Open Closed

• Tension pneumothorax • Tension pneumothorax

• Sucking chest wound • Haemothorax
• Haemothorax • Flail chest
• Impaled object • Rib fractures
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Indications for Laparotomy

Blunt Trauma Penetrating Trauma

• Hemodynamically
abnormal with suspected •Hemodynamically
abdominal injury (DPL / abnormal
FAST) •Peritonitis
• Free air •Evisceration
• Diaphragmatic rupture •Positive DPL, FAST, or
• Peritonitis CT-Scan
• Positive CT-Scan
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To Refer or Not To Refer

•Which patients to transfer to a higher level of care?
Those whose injuries exceed institutional capabilities:
• Multisystem or complex injuries
• Patients with comorbidity or age extremes
•When should the transfer occur?
As soon as possible after stabilization:
• Airway and ventilatory control
• Hemorrhage control
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Referral
• When transferring to another unit:
 Ensure that appropriate transport and equipment to
transfer the patient safely is available.
 Send all the documentation, X-rays and cross-matched blood
with the patient.
 Communicate with the receiving unit.
 Remember the patient is the responsibility of the transferring
unit until he or she physically reaches the receiving unit
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Summary
• Early management of trauma is a definite established
protocol, which needs to be methodically followed.
• The primary assessment provides basic data essential for the
patient’s survival when life or limb is threatened.
• Airway is of primary importance.
No other therapeutic assessment or intervention should
take place before airway is secured.
• Resuscitation goes hand in hand with the Primary
Assessment.
It is performed when the component of Primary
Assessment appears unstable.
• Secondary Assessment is to be provided after the completion
of Primary Assessment and Resuscitation.
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THE END