Management of Trauma

Dr. Abdul Hai

MS Phase-A Resident(General Surgery)
FCPS P-II in Surgery
 Introduction
• WHO- 5 million injury fatalities worldwide
• 4th leading cause of death in UK(1st- IHD, 2nd-Resp. disease, 3rd-Cancer)
• 9% of global death
• 1.7 times higher than death caused by Malaria, TB, AIDS
• RTA, Falls, Intentional violence- Most common
• Above 3 combined rate of 64%
• Trauma increasing due to Industrialization, Increasing motorized transport
• 15% major trauma(ISS score more than 15)
• Annual medical cost- 3.5-4 billion.
 What is trauma
• Trauma is defined as a tissue injury that occurs more or less suddenly due
to violence or accident and is accountable for initiating hypothalamic–
pituitary–adrenal axis, immunologic and metabolic responses that
are responsible for restoring homeostasis.
 Trimodal distribution of death
• 1st peak- Shortly after inury- Major neurological or vascular injuries-
Unsalvageable
• 2nd peak- Several hours after injury- Airway, Breathing or Circulatory
problems- Potentially treatable.
• Final peak- Days or weeks following inury- MSOF, Sepsis syndrome-
Preventable
 Biomechanics of injury
• Blunt trauma- 90%
• Shearing force- Two force acting in opposite direction
• Irregular skin abrasion, laceration
• More damage to surrounding structure
• Higher risk of infection
• More excessive scarring
• Maximal effect on abd. Viscera where organ are tethered
 Biomechanics of injury
• Tension force: Act on a tissue surface at an angle of less than 90°
• Avulsion & Flap formation
• More tissue damage & necrosis
• Compression force: Act on tissue surface at 90°
• Contusion, Hematoma
• May rise internal pressure then rupture
• Significant damage & necrosis
 Biomechanics of injury
• Penetrating trauma- Consequence depends on
• Energy transfer
• Anatomical factors
• Burns- Thermal & Electric burn
• Blast injuries
• Primary effects- Band of pressure strikes- Affecting air containing organs(Lung, Bowel, Ear)
• Secondary effects- Direct impact of fragments- Multiple extensive wound in varying depth
• Tertiary effects- Dynamic force of the wind itself- Deceleration injuries, Amputation
• Miscellaneous effects- Falling, masonry, fire, toxic chemicals, flash burn, psychological trauma.
 Importance
• Allows you to predict possible life threatening secondary injuries that may
not be immediately apparent.
• Gives a clue as to the degree of energy transfer & consequently the level
of tissue damage.
 Physiological response to trauma
• Patient response:
• Homeostasis mechanism
• Acute phase response
• Ongoing blood loss
• Low blood pressure
• Decreased perfusion
• Decreased oxygenation
• Low body temperature
• Development of coagulopathy
• Traumatized lung can’t tolerate surplus fluid
 Medical response to injury
• Preparation
• Activation of trauma team
• Triage
• ATLS protocol
• Local protocol & guidelines
• NICE guideline
• DCS & ETC
• Prompt Individualized Safe Management(PRISM) concept
 Timeline concept
• There is an optimal time window during which an intervention can have a radically
positive effect on treatment outcome.
• 3 categories:
• Emergent(Life-saving)
• Acute(Restoring & maintaining physiological & physical activity)
• Delayed or semi-elective(Focus on post fracture fixation & complications)
• What kills first should be managed first.
• Time point 0- Seconds prior to the event, when the patient is at their normal baseline.
 Golden Hour
• The time(first hour) following injury when it is critical to resuscitate &
stabilize patient.
• In this time appropriate management can reduce mortality rate of 2 nd peak.
• Objective: To reach the end point of resuscitation & completion of
diagnostic procedures identifying the injuries sustained.
 Trauma Team
• Doctors from
• Emergency dept.
• Anesthesia
• Critical care
• Orthopedics
• General surgery
• Radiology
• Hematology
 Role of trauma team
• Apply the principles of ATLS
• Activity can occur concurrently instead of sequentially
• Anticipate the next key decisions
• Activation of massive transfusion protocols
Triage
 ATLS protocol
• Primary Survey & resuscitation
• Secondary survey
• Definitive care
 Primary Survey
Aims to identify and manage the most immediately life-threatening pathologies first.
The cABCDE of trauma care
c – Control of massive external haemorrhage
A – Airway with cervical spine protection
B – Breathing and ventilation
C – Circulation and haemorrhage control: apply a pelvic binder and do not remove until a pelvic
fracture is excluded
D – Disability (neurological status)
E – Exposure (assess for other injuries)
c: Exsanguinating external haemorrhage

• Pressure
• Pack
• Position-Elevation
• Haemostatic dressing
• Tourniquet
• Surgical control
 A: Airway with cervical spine control

• Cervical spine immobilization

• Assessment of the patient’s airway
• Clearing the airway
• Simple airway manoeuvres
• Jaw thrust, chin lift and insertion of an oropharyngeal or nasopharyngeal airway
• Advanced airway manoeuvres
• Insertion of a cuffed endotracheal tube, Cricothyroidotomy, Tracheostomy
 B: Breathing and ventilation
• High-flow oxygen
• Tension pneumothorax, massive haemothorax and fail segment should be
diagnosed and managed immediately.
 C: Circulation and haemorrhage control
• Adequate intravenous (IV) access with at least two large-bore IV cannulae.
• Blood should be taken for cross-match and laboratory assessment-Haemoglobin and
venous lactate
• Assessment of the haemodynamic status
• A pelvic binder should be applied to all haemodynamically unstable patients
• Hypotensive trauma patients are treated as hypovolaemic until proven otherwise
• Simultaneous fuid resuscitation and identifcation of the source of the haemorrhage
• Target systolic blood pressure of 70–90 mmHg, although a higher pressure of >90 mmHg
in Head injury
• Small boluses of IV fuids (e.g. 250 mL of O negative blood, or normal saline if blood
is not immediately available) should be administered to achieve this target
• Excessive IV crystalloid or colloid solutions should be avoided
• Colloid has no extra benefit, Hypotonic fluid not suitable for shock mx.
• Severely injured hypovolaemic patients should be resuscitated with blood and blood
products, not crystalloid/colloid fuids.
• All hospitals managing severe trauma should have a massive transfusion protocol that
aims to provide blood and blood products in a ratio of 1 packed red cells : 1 fresh-
frozen plasma : 1 platelets.
 Tranexamic acid
• One gram is given intravenously over 10 minutes, followed by a further 1-
g dose over 8 hours. Tranexamic acid should be given to all trauma
patients suspected to have significant hemorrhage, including those with a
systolic blood pressure of <110 mmHg or a pulse of over 110 per minute
• It needs to be administered as early as possible and ideally within the frst
hour from injury; the frst dose should not be administered more than 3
hours from injury.
 Identifcation and management of
haemorrhage
• The sites of major haemorrhage in trauma patients are the chest, abdomen,
pelvis and long bones, and external haemorrhage
• Clinical examination and investigations
• X-ray: Chest, Pelvis
• FAST/eFAST
• WBCT-Gold standard- Signs or symptoms of multiple injury or deranged
physiology.
• If hemodynamically unstable: DCS
 D: Disability
• GCS
• Pupil size & reaction to light
• Moving 4 limbs or not
• Measure core temperature
• Log roll maneuver
GCS
 E: Exposure
• The patient must be adequately exposed to allow a thorough and
systematic clinical examination during the secondary survey but they must
be kept warm.
• Maintain normal temperature by minimising unnecessary exposure of the
patient and by using warmed blankets and trolleys and warmed fuids
during resuscitation.
 Response to resuscitation
A number of physiological indices are used to evaluate the response to
resuscitation, including
• Pulse rate less than 100 per minute
• Normal blood pressure and respiratory rate
• Urine output >30 mL/h.
• The patient should not have hypothermia (temperature <35°C)
• No evidence of acidosis on arterial blood gases and
• Should have a normal coagulation screen.
 Secondary survey
• AMPLE history
• Top-to-toe examination
• Tertiary Survey
 Identification of Hidden injuries
• Look everywhere approach- Secondary survey of ATLS, WBCT
• Focused exclusion approach- Remarkably missed injuries- Metatarsal,
metacarpal, scaphoid fractures, Peri-lunate & post. Shoulder dislocation.
So focused assessment to exclude this.
 Definitive care

ETC versus DCS

ETC describes the defnitive management of a patient’s injuries within 36 hours
of injury after a period of initial resuscitation
● DCS describes simultaneous resuscitation with early rapid life-and limb-
saving surgery. Time-consuming defnitive surgery is deferred until the patient’s
physiological status allows
● An ETC approach can be changed to a damage control approach if the
patient’s physiology deteriorates during defnitive surgery
 Venous lactate

Venous lactate is a useful marker of resuscitation and physiological state.

A normal lactate (<2 mmol/L) is a sign that the patient is probably
resuscitated and suitable for ETC.
An elevated lactate (>3 mmol/L) suggests the patient is under-resuscitated
and should either have a period of further resuscitation or DCS if surgery is
urgent.
Traumatic Brain Inury
EDH ICH
Acute SDH Chronic SDH
Chest Injury
Tension Pneumothorax
 Tension Pneumothorax
• Treatment consists of immediate decompression.
• Rapid insertion of a large-bore cannula into the second intercostal space in
the mid-clavicular line followed by insertion of a chest tube through the
ffth intercostal space in the anterior axillary line.
• Safe triangle – defined posteriorly by latissimus dorsi, anteriorly by the
lateral border of pectoralis major and inferiorly by a line perpendicular to
the nipple going to the back, just anterior to the mid-axillary line.
Torso Trauma
Acute wound Mx
Tetanus Prophylaxis
THANK YOU