TRAUMA

BROKENSHIRE COLLEGE SCHOOL OF

MEDICINE
SURGERY ROTATION
Clerk- Adona, Anne Katherine
G.

DEPARTMENT OF SURGERY
BROKENSHIRE HOSPITAL
 OBJECTIVES

1 Explain the importance of Trauma care

2
Identify the correct sequence of Primary & Secondary assessments of trauma pat

3To understand the structure approach tp the patient with head and spinal trauma
4To be able to identify serious and life threatening head and spinal injuries
5 Discuss how to establish management priorities
 STANDARD PRECAUTIONS
InMULTIPLE PRIMARY SURVEY

MOST
PRIMARY SURVEY
FIEL CASUALTIES
COMMO
Number patients & severity of injury
Identify
N:
1-44yrs
and treat immediate life
threatening injuries and initiate D
DOES NOT exceed the capability of the
Cellular
INITIAL disruption
resuscitation.caused
EVALUATION
appropriate
medical facility
ANDby environmental
RESUSCITATION TRIAGE energy
Advanced
PREPARATION Trauma
thatTHE
OF isIdentify
beyond
SECONDARY the body’s
SURVEY
INJURED
Life whichSupport
all injuries TRAUMA & Multiple-
(Tx 1st: Life-threatening
resilience, is
PATIENT
compounded(ATLS): by cell deaAth
In System
TERTIARY injuries)
MASS
SURVEY
due
TERTIARY SURVEY
“GOLDEN
to ischemia/reperfusion HOSPIT
Number ofCASUALTIES
Re-assess to identify any undetected
3 :RD

HOUR”
. patients & severity of injuries
DOES AL
injuries Regardless
of age
exceed the capability of SECONDARY
the facility
SURVEY
and staff

(Tx 1st: Greatest chance of survival)

 Can
Basic Airway
RAPID
patient
PRIMARY
Techniques
talk?
“ANY DOUBT”
Immobilized
EXPOSURE
ASSESSMENT:
SURVEY
Cervical Spine
Signs of Airway Obstruction:
DISABILIT
Oropharyngeal Tube
OBSERVE: No
MAINTAIN
CIRCULAT
BREATHINION •
Y
Yes
• AIRWAY
• Mental Status: Agitated or Obtunded
Color:
Airway patent
Airway
Establish
Cyanosis compromised
patent airway
E spine
and protect c-

INTEGRITY D Ventilation status: Chest retraction & use of

Airway Mgt
C
AIRWAYG High-flow O2 •
accessory muscles
Pulse oximetry
High-Flow O2
B
 Asking patient
then >B LISTEN:

A
• Noisy Breathing then >B name
!!!BEWARE!!!
Jaw-thrust Maneuver
• Snoring, gurgling & stridor Chin-lift 
Maneuver
Asking what
Suction
• Hoarseness
happened
Airway
Nasopharyngeal Tube Devices
High-flow Oxygen
EVALUATE BEHAVIOR:
• Bag-valve Mask
Abusive & belligerent obstruction
10-SECONDS
ASSESSMENT
Airway injury
 DEFINITIVE AIRWAYS
The criteria for establishing a definitive airway are based on clinical findings
CRICOTHYROIDECTOMY
Drug-Assisted Intubation
DOUBT”
and includes:
• A —Inability
recommended to maintain Orotracheal
for emergent a patent surgical
airway tube
establishment
by other means, of a with
patentimpending
airway or
It indicated
potential in patientsPalpate
airway compromise who
(e.g.,
the thyroid notch, cricothyroid interval, and sternal notch
need airway
following control,plastic
inhalation butinjury,
have intact
facial MASK
• Fever Nasotracheal
for orientation.
Place
tube
large-caliber LARYNGEAL
cannula:

N AIRWAY
fractures, or retropharyngeal hematoma) who
gag reflexes, especially in •
patients 12- have sustained
to 14-gauge for adults head
Surgical
• B —Inability airway Make (cricothyroidotomy
a
• 16- to 18-gauge in children
injuries.
to maintain adequate oxygenationvertical incision atby facemask
skin with sharpandoxygen
division of the
subcutaneous tissues then transversely incising the cricothyroid
supplementation,
• Neck
The technique
SURGICAL vein
After the
or
for the
distention
patient tracheostomy)
presence
drug-assisted
membrane
relaxes:
of
intubationapneais as
Connectedfollows:
Contraindicated:
to oxygen at 15 L/min (50 to 60 psi) with

GRITY
1. Have a plan in the event of failure that includes the possibility of performing ina the
•CRICOTHYROIDOTOMY
C —Obtundation
1. Intubate
surgical
or combativeness
the patient
airway. Know Under
where orotracheally.
resulting
a the
Y-connector
age from
of orcerebral
12 adue
side
your rescue airway equipment is located. tohole hypoperfusion
thecutrisk of tubing between
subglottic
the oxygen source and the plastic cannula.
• D —Obtundation
2. Inflate
2. Ensure indicating
the cuff
that suction and
and the the
Insert: presence
small
confirm
ability tube
to deliver of a head
endotracheal
placement
positive bystenosis.
tubeinjury and are
(preferably
auscultating
pressure ventilation requiring
5 to 7 ID)
the
• Lymphadenopathies
assisted ready. patient’s chest and
ventilation (Glasgow Tracheostomy
determining
Coma Scaletubepresence
the (preferably
[GCS]
Intermittent score5 toofin
of CO2
insufflation,
78 mm
1 orOD)
less),
second on sustained
and 4 seconds
3. Preoxygenate
TRACHEOSTOMY exhaledthe
NEEDLE patient
air.
TUBE with 100% oxygen. SURGICAL
seizure
4. activity,
Apply andover
pressure
CRICOTHYROIDOTOMY
3. Release
thetheneed
cricoid cricoid
It is
topreferable
pressure.
protect
cartilage.offthe lowerCRICOTHYROIDOTOMY
to a
airway
tracheostomy for
from
most
aspiration
patients who
of
require an
ESCHMANN TRACHEAL
ENDOTRACHEAL TUBE TUBE
blood
INTRODUCER5. or vomitus
Administer
(ETTI)
4. an induction drug (e.g., etomidate, 0.3 mg/kg) or sedative, according
Ventilate emergency surgical airway:
the patient.
• Atrophic testis
to local protocol. The patient may be adequately oxygenated for 30 to
• easier to perform
6. Administer 1 to 2 mg/kg succinylcholine45
intravenously (usual dose is 100 mg).
• less bleedingminutes using this technique
• less time
SURGICAL AIRWAYS
 VENTILATION REQUIRES
ADEQUATE FUNCTION OF THE
ADEQUATE OXYGENATION AND
LUNGS, CHEST WALL, &
VENTILATION MUST BE ENSURED
DIAPHRAGM:
symmetrical chest rise
Airway patency alone does not ensure adequate
ventilation.tracheal position
Adequate gas exchange is required to maximize
jugular venous distention
oxygenation and carbon dioxide elimination.
audible breath sounds
every injured patients should receive
Respiratory Rate & O2 Saturation
supplemental oxygen and if the patient is not
intubated, oxygen should be delivered by a
mask-reservoir device to achieve optimal
oxygenation. And can be monitored by pulse
oximetry to monitor adequacy of hemoglobin
oxygen saturation.
 BEWARE

TENSION LIFE THREATENING

OPEN THORACIC
MASSIVE AIR FLAIL CHEST
PNEUMOTHAORA
X CONDITIONS:
PNEUMOTHORAX LEAKS

 Unequal chest  Similar with  Small  Paradoxical

movement Tension (Asymptomatic) movement of flail
 Hyperresonance on pneumothorax  Moderate to Large segment
percussiom similar to  Restricted chest wall
 Decresead air entry
+ PNEUMOTHORA movement
 Open chest injury
 Tachypneic X associated with pain
 Sucking air sound
 Deviated Trachea  Palpable crepitus
 Congested neck vein during inspiration
of ribs
 Decreased air
 LIFE THREATENING THORACIC
CONDITIONS:

TENSION
PNEUMOTHAORA
X
IMMEDIATE
NEEDLE
VENTILATION,
DECOMPRESSIO
FLUID
N & CHEST
RESUSCITATION &
PAIN
Needle
Tube
A simple pneumothorax Decompression
Thoracotomy
THORACOTOMY
MANAGEMENT
can be converted to a TENSION PNEUMOTHORAX when a
•• 14-gauge
28F chest angiocatheter
tube
patient is intubated and positive pressure ventilation
TENSION
is provided beforePNEUMOTHORAX
decompressing
•• 24ndth or 5th the
intercostalpneumothorax
spacespace
intercostal
with a chest tube.
•• Midclavicular
Midaxillary line line CLOSURE OF
THORACOSTOM CHEST WALL
Y THEN DEFECT & TUBE
BRONCHOSCOPY THORACOSTOM
Y
 LIFE THREATENING THORACIC
CONDITIONS:

TENSION OPEN
PNEUMOTHAORA PNEUMOTHORA
X X
IMMEDIATE NEEDLE
VENTILATION, CLOSURE OF DECOMPRESSIO
CHEST WALL
FLUID • INJURY
Promptly close the defect with aN & CHEST
sterile
RESUSCITATION & occlusive dressing that is large enough to
THORACOTOMY
PAIN overlap the wound’s edges.
MANAGEMENT • Tape it securely on three sides to provide a
flutter-valve effect.
OPEN
PNEUMOTHORAX
• Place a chest tube remotely from the wound as
soon as possible
CLOSURE OF
• Subsequent definitive surgicalCHEST WALL
closure of the
THORACOSTOM wound is DEFECT & TUBE
Y THEN • requently required. THORACOSTOM
BRONCHOSCOP Y
 LIFE THREATENING THORACIC
CONDITIONS:

TENSION OPEN MASSIVE AIR

PNEUMOTHAORA PNEUMOTHORA LEAKS
X X
IMMEDIATE
VENTILATION, NEEDLE
FLUID DECOMPRESSIO
2 TYPESN & CHEST
RESUSCITATION
THORACOTOMY
& PAIN BRONCHOSCOPY
• TYPE-1: within 2cm of the
MANAGEMENT
Carina; no association
• Confirms diagnosis to
MASSIVE AIR LEAKS
Pneumothorax
• Direct Management
• TYPE-2: distant to
CLOSURE OF
THORACOSTOMY CHEST
tracheobronchial tree WALL
& manifest
THEN DEFECT & TUBE
BRONCHOSCOPY with Pneumothorax
THORACOSTOM
Y
LIFE THREATENING THORACIC
CONDITIONS:

FLAIL CHEST
IMMEDIATE NEEDLE
VENTILATION, DECOMPRESSIO
FLUID N & CHEST
INSPIRATION
RESUSCITATION & THORACOTOMY
PAIN • Injured chest wall collapses IN
MANAGEMENT
DEFINITIVE
• Uninjured chest wall moves OUT
FLAIL CHEST TREATMENT
• Adequate oxygenation,
• Administering fluids judiciously
EXPIRATION
• Providing analgesia
CLOSURE OF
THORACOSTOM CHEST
• Injured chest wall moves OUTWALL
Y THEN DEFECT & TUBE
BRONCHOSCOP • Uninjured chest wall moves IN
THORACOSTOM
Y Y
 CIRCULATION WITH
HEMORRHAGE
CONTROL

MAJOR CIRCULATORY ISSUES

TO CONSIDER:
BLOOD VOLUME
CARDIAC OUTPUT
BLEEDING
 BLOOD VOLUME
BLEEDING
AND CARDIAC OUTPUT
Predominant cause of preventable deaths
after injury LEVEL OF
• A rapid, thready pulse is typically a sign of
CONSCIOUSNESS

TheSITES
source
• Assess & of
hypovolemia.
Patient with
When bleeding is usually identified by:
APPROXIMATE
pink circulating
a reduced,
central
extremities,
skin, especially
rarelypulse
has
in the
blood
(e.g., perfusion
critical femoral
hypovolemia
face and
volume
ormay
is
carotid
after
cerebral be
MAJOR
• Physical AREAS OF Quickly controlling and initiating
artery) examination
BLOOD LOSS:
injury. bilaterally
criticallyforaimpaired,
Conversely, quality,
patientrate,
withand regularity.
hypovolemia
resulting in an SKIN PERFUSSION
resuscitation are therefore crucial
• Absent
may havecentral pulses
ashen, that
gray cannot skin
facial be attributed
and pale to
INTERNAL
• Imaging
local
altered level of 3 litres IDENTIFY THE SOURCE OF BLEEDING AS
consciousness
(e.g., chest x-ray, pelvic x-ray, focused assessment
Pelvic #
factors signify the need for immediate
extremities.
Closed Femoral # 1.5-2 litres PULSES
HEMORRHAGE:
resuscitative action. EXTERNAL OR INTERNAL.
with sonography for trauma [FAST], or diagnostic peritoneal
Closed Tibial # 500
ml CHEST Hemodynamic status is
lavage [DPL]).
IS THE PATIENT IN SHOCK?
Haemothorax 2
litres
ABDOMEN essential
RETROPERITONEUM
Hand sized wound 500 ml
Fist sizedPELVIS
clot 500
ml LONG BONES
Rib # (each)
150ml
INTER EXTER
HEMORRHAGE
 INITIAL
SHOCK PATIENT
Even without blood
ASSESSMENT loss, most non-
CARDIOGENIC SHOCK
NON- HEMORRHAGIC

circulatory pump failure leading to diminished forward flow and subsequent tissue
hypoxia, in the setting of adequate intravascular volume. The signs of circulatory shock

an abnormality of the circulatory

hemorrhagic shock
include hypotension, cool and mottled skin, depressed mental status, tachycardia, and
diminished pulses

states transiently
NEUROGENIC SHOCK
diminished tissue perfusion as a result of loss of vasomotor tone to peripheral arterial beds.

system that results

RECOGN in inadequate
SHOCK

Loss of vasoconstrictor impulses results in increased vascular capacitance, decreased venous

improve with
return, and decreased cardiac output. The classic s/s decreased blood pressure associated
with bradycardia, warm extremities, motor and sensory deficits indicative of a spinal cord
ITION
injury.
“ VOLUME
NON-HEMORRHAGIC
organ perfusion
HEMORRHAGIC
and tissue
SEPTIC SHOCK
OF
dysfunction of the endothelium and vasculature secondary to circulating inflammatory

SHOCK RESUSCITATIO
mediators and cells or as a response to prolonged and severe hypoperfusion. It is is
characterized by peripheral vasodilation with resultant hypotension and resistance to
treatment with vasopressors.
N”.
oxygenation
OBSTRUCTIVE SHOCK
Is most commonly due to the presence Tension pneumothorax. Cardiac tamponade can also caused
obstructive shock when sufficient fluid has accumulated in the pericardial sac to obstruct blood flow
to the ventricles. Tachycardia, muffled heart sounds, and dilated, engorged neck veins with
hypotension and insufficient response to fluid therapy suggest cardiac tamponade
 INITIAL
HEMORRHAGIC PATIENT
CONFOUNDING
SHOCK FACTORS: 7%
NORMAL
ASSESSMENT
ADULT BLOOD
VOLUME

“Most common
BASIC MANAGEMENT PRINCIPLE
cause of shock in
trauma••patients.”
Patient age STOPRECOGN
BLEEDING
•• Severity of injury,OBESE
particularly Ideal Body
the type and anatomic
ADULTS BLOOD
REPLACE
location of injury
It is define as an THE
VOLUME VOLUME
ITION LOSS Weight
HEMORRHAGIC OF NON-HEMORRHAGIC
acute loss of
•• Time lapse between injury and initiation of treatment
circulating blood SHOCK
volume•• Prehospital fluid therapy
•• Medications used forBLOOD
CHILD chronic conditions
VOLUME 8-9%
 For severely injured
TWO LARGE CALIBER peripheral children younger
than 6 yearscatheters
intravenous of age orforforfluid
patients in
whom one or two
resuscitation andattempts
medication at IV access
European and American URINE military studies
have failed
OUTPUT: demonstrate
consider
administration. placement improved
of an
survival when TRANEXAMIC INTRAOSSEOUS
ACID is NEEDLE for within
administered
ADULT 0.5ml/kg/hr
temporary access
CRYSTALLOID
GOAL
3 hours of injury. WhenOFbolused
CHILD RESUSCITATION
in SOLUTION
the field
1ml/kg/hr follow : up infusion
Most desirable2ml/kg/hr
INFANT <1yr sites for peripheral
Restoreisorgan 1percutaneous
overliter
given perfusion forand
8 hours adults
in tissue oxygenation
the hospital.
intravenous lines in adults:
For seriously injured patient arriving in
20 mL/kg for pediatric
shock a secondary large bore (7-9Fr)
FOREARMS <40kgs
ANTECUBITAL VEINS
BLOOD
cannula should be obtainedPRODUCTS
via
FEMORAL or SUBCLAVIAN VEINS
or SAPHENOUS VEIN CUTDOWN.
 isability

GCS is a quick,
BASELINE NEUROLOGIC
simple, and EXAM:
objective method
Prevention of of determining
further the identification of neurologic
injury and
level of Pupillary Exam:
consciousness, and includes
injury is our GOAL.
the assessments of EYE OPENING,
VERBAL
DecreasedRESPONSE and MOTOR = Head injury until proven
level of consciousness
MOVEMENT. otherwise
Bilateral fixed,
Unilateral fixed,dilated,
dilated,
IN traumatic brain injurypupils
unresponsive
unresponsive 3it has
pupils
category based on Patients score of:
• 13-15 are considered mild
• 9-12 are considered
moderate
• 3-8 are described as severe
 xposure & Environmental control

Cover the patient with

warm blankets or an
external warming
PREVENT
device to prevent him
Caution
HYPOTHERMIA
TRAUMA
or her from developing
LOGROLL
hypothermia in the
trauma receiving area.
 Adjuncts
What to Primarysurvey?
is the secondary Survey
useful tools for quick
Is an important monitoring for all
detection of intraabdominal
blood,pneumothorax, and
AMPLE
eFAST
HISTORY:
ECG
trauma patients

hemothorax /DPL
 Allergies
provide information to guide
X-RAY The COMPLETE
resuscitation efforts of patients with
PULSE
OXIMETRY
a valuable adjunct for
monitoring oxygenation in

 Medications history and

blunt trauma & can show potentially
life-threatening injuries that require
injured patients.

 Past Medical History,

treatment or further investigation
is a sensitive indicator of physical
Pregnancy
volume status and reflects renal URINARY CO2
examination
 Last Meal
perfusion. GI cath decompress
distention and assess for
& GI
CATH
evidence of blood.
 Events surrounding injury,
ABG VENT
RATE Environment
used to monitor the adequacy of the
patient’s respirations & provides
insight into the patient’s
ventilation, circulation, and
 THERMAL INJURY:
Hazardous Environment
This is an injury caused by exposure to
PENETRATING TRAUMA:
excess heat and excess
BLUNT coldTRAUMA:
sufficient to
A history of exposure causetodamage
chemicals,
to the skin, and possibly
This happens when a foreign
toxins,object
and radiation is important Thisto
deeper tissue.
kind of trauma happens
penetrates the body, tearing a hole in one
obtain for two main reasons:
or more blood vessels. Factors that
when a body part collides with
Burns are a significant
somethingtypeelse,ofusually
traumaatthat
high
determine the type and extent of injury
can occur alone orBlood
speed. in conjunction with the
vessels inside
1. Produce
and subsequent management include the a variety of pulmonary, cardiac,
blunt and/or
bodypenetrating
are torn or trauma.
crushed either
and internal
body region that was injured, organs inorgan
the dysfunctions in injured
by shear forces or a blunt
patients
path of the penetrating object, and velocity
Information regarding the circumstances
object.
of the missile.
of the burn injury can increase the index
2.Hazard to healthcare providers.
of suspicion for inhalation injury or toxic
exposure from combustion of plastics and
chemicals.
 PHYSICAL EXAM
PELVIS Pelvic fracture can be suspected be the
Head
NECK The (SOFT
NEUROLOGIC: ABDOMEN
The
MAXILLOFACIAL
finding of
MUSKULOSKETETAL
PERINEUM
NEUROLOGIC:
● Pain
POTENTIAL
TISSUES)
active
on palpation
SPINAL life
arterial
BRAIN
threatening
ASSESSMENT
bleeding, injuries
expanding
identification of hematoma,
ecchymosis over the
arterial
Mechanism: bruit
● Whole Bluntor
spine
● ●
Contusions,
●
airway
Pulmonary
vsInspect
penetrating
/compromise
Auscultate
hematomas, usually
complications
ILIAC
lacerations, requires
WINGS,
urethralPUBIS, OPERATIVE
blood LABIA or
●Head ● Leg
(Laceration,
Bony
length
●Airway
GCS
● INSPECTION:
contusion
crepitus
unequal &wounds,
fracture based skull)
Symptoms: ● Tenderness ● ● obstruction,
Myocardial
and
Palpateswelling
/
EVALUATION
hoarseness
contusion
Percuss SROTUM.
● swelling,
●Pupil contusion,
Deformity
●Eye (Ocular
Instability
●
RECTUM
entrapment) size and reaction CONTUSION & HEMATOMAS
CHEST
Findings:● Complete
deformity,
● X-rays
Unexplained
●Ear (Haemotypmanum,●● ●●
as source
motor
Aortic
Malocclusion
Sphincter
bleeding
Inspection: or
and
Reevaluate
needed
Lateralizingisolated
of
tear
signs
tone, sign)
Battle’s
Abrasion-cut
sensory exams
PAIN
paralysis
high-riding
wounds ofonan
palpation
prostate, of the
upper
pelvicof the pelvic
chest
extremity
fracture, ringwill
wall
should is analert
● Reflexes
● important finding in alert patients.
raise the
●Nose (Rhinorrhea)
Palpation:
Frequent
rectal ●
mass,
● Diaphragmatic
suspicion
wall reevaluation
Special studies
oremphysema,
CERVICAL
integrity,
surgical tear
blood carotidNERVEthe ROOT INJURY
clinical to the &
possibility
● ● Palpation:
Inspect
● Imaging studiesperipheral
● Prevent
should secondary
be brain
ACCURATELY DOCUMENTED
pulse- cervical
●Mandible & Maxillaspine ● Esophageal
fracture
pulsation, perfusion
(instability
injury of tear
midface->fracture) of occult injury.
● ● VAGINA
Spinal
Palpate
Auscultation:Injury
fracture, detected
compartmental
Carotid bruit Excessive pelvic manipulation
●Mouth (Open fracture,
syndrome Tracheobronchial
●hematoma,
Hollow viscous teeth)tear
looseinjury Delayed symptoms
Blood, lacerations Underestimating pelvic blood loss and signs
● Percuss Retroperitoneal injury Early
Early Progressive airway obstruction
● X-rays as needed Neurosurgical/
neurosurgical
Orthopedic
Occult injuries
● Auscultate air entry & heart consult
consult
 ADJUNCT TO
SECONDARY X-ray examination of the spine
01
SURVEY and extremities

CT scans of the head, chest,

02 abdomen & spine

Contrast urography and

03 angiography

04 Transesophageal ultrasound

SPECIAL DIAGNOSTIC TESTS

Bronchoscopy, esophagoscopy
AS INDICATED 05 & other diagnostic procedures
 DEFINITIVE
REEVALUATION CARE FORENSIC
RECORDS: CONSENT FOR EVIDENCES:
TREATMENT
Which patients do I transfer Whenever
to a higher the patient’s
level of care? treatment needs
When should the transfer occur?
Meticulous record keeping is crucial IfAdult:
criminal
exceed activity
the is suspected
capability of the in
Continuous urinary Periodic ABG
during patient assessment and
monitoring of vital receiving
output at 0.5 institution,
conjunction with atransfer
analyses patient’s
and is
end-
Consent isoxygen
sought beforemL/kg/h treatment, considered.
As soon
management, as possible
including signs, after stabilization: injury. All items,
tidal CO2
saturation, andif possible.For pediatric monitoring
Those whose●the
documenting injuries
times exceed
of all
urinary institutional
output is such
patientsas
>1clothing
capabilities:
yr, an and
are bullets,
useful in must
some
Airway and ventilatory control This ofdecision
1 mL/kg/hrequires a detailed .
events. Medicolegal problems essential. be
output preserved law enforcement
patients.
● Multisystem In life-threatening
or complex
● Hemorrhage injuries
control emergencies,
assessmentTRAUMA
is typically of the TEAM:injuries
patient’s
arise frequently, and precise Laboratory determinations of
adequate.
●records
Patients with
provide
comorbidity or age
treatment andfirst,
extremes
and of the capabilities of
knowledge
are helpful for all blood alcohol concentrations &
obtain formal consent later.
the institution,Team leaderequipment,
including
individuals concerned. other drugsmust
resources,
“Trauma patients
may
and
bereevaluated
particularly
personnel.
be
Airway manager
constantlypertinent
to ensure and have substantial
Trauma nursefindings are
that new
not overlooked legal implications.
and to discover any
Trauma technician
deterioration in previously noted findings. “
 Most important ways to limit
Secondary Brain Damage:
The PRIMARY GOAL of treatment for patients
with suspected 1.TBI is to PREVENT
Ensure adequate oxygenation
SECONDARY
BRAIN
2. Maintain INJURY
blood pressure at a level
sufficient to perfuse the brain

HEAD TRAUMA
 CLASSIFICATION OF HEAD
INTRACRANIAL
SEVERITY
MORPHOLOGY
SKULL OF INJURY
LESIONS:
FRACTURES:
INJURY
DIFFUSE BRAIN
Linear
<8
INJURIES
Depressed
BASILAR
Subdural Hematoma Epidural Hematoma
“COMA” or SEVERE
Classic cerebralFRACTURE:
concussion:
• Subdural
•
• involves the hematoma:
EPIDURAL
1. Transient tearing HEMATOMA:
of nerve
& reversible loss offibers caused byreturns
consciousness, the shifting and rotating by
to full consciousness of
the •brain
(diagnosed6more inside
common
• relatively
hrs. by theuncommon
CT bone skull.
than epidural
window) hematomas,
, occurring in aboutoccurring in
0.5% of patients with brain
2. No
• often • sequelae other than
approximately
causes injury
Contusions
• most often to
and30%
located
amnesia
of
multiple
in
for the
patients
areas
Intracerebral
the of
temporal
events
with
the severe
brain
Hematomas:
or and Stellate
brain
coma.injuries
temporoparietal regions
3. Post-concussion syndrome: memory difficulties, dizziness, nausea, anosmia
Skull
Clinical •&signs:
fractures
• primarytearing of
depression
fairly
most acommon;
• •responsible
due bridging
to for
tearing
9-12
vein
thethey
initial
of the loss
occur MODERATE
meningeal Intracranial
of consciousness
in
middle approximately artery20% to 30% lesions
SEVERITY INJURY &
•
• VAULT:• brain
Raccoon
• ofdamage
eyes patients
prognosis is with severe
much
usually
Battle’s signs (retroauricular
more brain
severe
excellent injuries
& prognosis
(underlying is much
brain injury worse
is limited)
What than
• EDH
•CT:
Happens
most to
occur
biconvexthein
orBrain
the When
frontal
lenticular Diffuse
&shape
in temporal AxonalMORPHOLOGY
lobes Injury Occurs?
Intracerebral
ecchymosis),
Mild concussion:
CSF leakage
•Temporary (Otorrhea & Rhinorrhea)
neurologic
•
Hematomas
dysfunction,
• Dysfunction
Pitfalls:
confusion
of CN& 7classical
& 8.
lucid interval and ‘talk and die’
MILD
disorientation without or
with amnesia

FOCAL LESIONS
13-15
 Head injury Management
MANAGEME GCS 13-15
NT GOALS:
MILD
GCS SCORE 9-12 GCS <8

 Establish diagnosis MODERATE SEVERE

----------------------------------
--------------------------- --
---- ASYMPTOMATIC & NORMAL CT- ---------------------------
 Assure brain ❑ ALL need brain CT SCAN -----
❑ Brought back to ER if need ❑ Prompt Diagnosis &
metabolism & ❑ ALL need to be (Head-Injury Warning Treatment is of
Discharge Instruction)
prevent secondary admitted for close
observation for 1st 12-
utmost important
(“wait & see”=
❑ No companion- ADMIT!
brain injury 24hrs, even if CT scan is
normal Observed at ER DISASTROUS)
❑ Do NOT DELAY
❑ Follow-up CT within SYMPTOMATIC & ABNORMAL CT-
transfer
SCAN
 Consult neurosurgeon 24hrs if initial CT is
abnormal ------------------------------
❑ ADMIT!
early or early transfer ------------------------------ --------------------------------------
----
----- -
NEUROLOGIC EXAMS SECONDARY
AIRWAYS SURVEY
& BREATHING ANESTHETIC/
ANALGESIC
This consists primarily of •• Early
Perform GCSintubation
endotracheal score,
in • Cautiously in patients
determining the patient’s : lateralizing
comatose signs, and pupillary
patients. who have suspected or
• GCS score PRIMARY SURVEY
reaction to detect neurological AND confirmed brain injury
deterioration
• Ventilate as with
the patient early100% as
• Pupillary light response
• Focal neurological deficit.
RESUSCITATION
possible& oxygen saturations of
oxygen • Overuse cause a delay in
> 98% recognizing the
Recognize confounding progression of a serious
DIAGNOSTICS
issues in the evaluation of Hypoxia
• Maintain + ofHypotension
pco2 approximately brain injury, impair
TBI: 35 mmHg respiration, or result in
• Drugs • Must obtain head CT scan as unnecessary treatment
CIRCULATION
• Alcohol soon as possible after
• Other Intoxicants hemodynamic normalization • Use short-acting, easily
• Other Injuries. Increase
and should in be
whenevereuvolemia
the relative
repeated
there is aaschange
reversible agents at the
• Establish soon asin lowest dose needed to
risk ofusing
mortality
the patient’s
possible clinical
blood status of 75% effect pain relief and mild
products,
or isotonic fluids as needed sedation
• A shift of 5 mm or greater
often indicates the need for • Eg. Midazolam (Versed),
 MEDICAL THERAPIES FOR
BRAIN INJURY
INTRAVENOUS FLUIDS
01 02
HYPERVENTILATION 03
MANNITOL & BARBITURATES04 05
• Keep euvolemic • Keep PaCO2 at 25~30 HYPERTONIC SOL ANTICONVULSANT
status, dehydration is mmHg when the • Reducing ICP refractory to
more harmful presence of raised ICP • Indication: Patient with other measures, should not High incidence of Late
bilaterally dilated and be used in the presence of epilepsy:
nonreactive pupils who hypotension or
• PaCO2 < 25 mmHg is hypovolemia.
• Not to use hypotonic are not hypotensive, 1. Early seizure
avoided has hemiparesis or loss occurring within the
or glucose-containing ( vasoconstriction ==> consciousness • Hemodynamic stability is first week
essential before and during 2. An intracranial
fluids CBF ) barbiturate therapy hematoma
• Dose ( bolus ) : 1 g/Kg
3. Depressed skull
fracture
 CRITERIA:
SURGICAL MANAGEMENT
• Glasgow Coma Scale
score = 3

• Nonreactive pupils
SCALP WOUND
PROGNOSIS DEPRESSED FRACTURE
INTRACRANIAL MASS PENETRATING INJURY
• Absent brainstem reflexes
All
BRAIN
01andpatients should
02 be treated AGGRESSIVELY. This is
(e.g., oculocephalic,
corneal, doll’s eyes,
DEAD 03 04
particularly true of children, who have a remarkable ability to
and no gag reflex)
• CT/conventional
•
• No spontaneous
recover from seemingly devastating injuries.
Clean and inspect the
wound thoroughly
ventilatory effort on
•
ANCILLARY:
CT scan is valuable in
identifying the degree of
• Intracranial mass lesions
should be managed by a
angiography
recommended when a
are

• Applying direct pressure depression. neurosurgeon. • Electroencephalography:

trajectory passes through
formal apnea testing or
and cauterizing or near the skull base or a
ligating large vessels. • Require operative • Emergency craniotomy No activity
major dural venousatsinus.
high gain
• Then apply appropriate elevation when the in a rapidly deteriorating • Burr hole
• Absence of confounding craniostomy/craniotomy
sutures, clips, or staples. degree of depression is patient should be • CBF studies: No CBF
factors
• such as alcohol
Carefully or
inspect the greater than the considered • craniotomy, 10- to 15-mm
(e.g.,
drill holeisotope studies,
in the skull, has
drug intoxication
wound, using ordirect thickness of the adjacent
vision, for signs of a skull Doppler
been studies,
advocated as xenon
a
hypothermia method of emergently
skull fracture or foreign CBF studies)
diagnosing accessible
material.
hematomas in patients with
• rapid neurologic
Cerebral angiography
deterioration.
How to protect the CERVICAL REGION 55%
spine during
evaluation,
Protection
management, and is PRIORITY; Detection is
transport?
SPINAL TRAUMA:
SECONDARY 15
THORACIC REGION

 Immobilize entire %
patient on long spine
board with proper
padding THOCACOLUMBAR
& LUMBOSCARAL
15%
 Apply cervical collar
 MECHANISM OF INJURY
SPINAL CORD
Sensory level is used when referring to
the most caudal segment of the spinal
cord with normal sensory function.

Motor level is defined similarly with

respect to motor function as the lowest
INJURY
CLASSIFICATION
key muscle that has a muscle-strength
grade of at least 3 on a 6-point scale.

LEVEL
Central cord syndrome: Incomplete or complete
• Brown-Sequard
Anterior
Motor> Sensory Loss cord syndrome:
syndrome: paraplegia (thoracic injury)
• •• .Loss
Upper> Loss
Lowerod
of Extremities
Ipsilateral
motor function,
proprioception,
pain & SEVERITY OF
•
••
temperature
light touch &
Bowel/Bladder
Preservation
Lost of
sensation
motor function.
dysfunction
contralateral
of light
is variable or
pain
touch,
and
NEUROLOGICAL Incomplete or complete
preserved quadriplegia/ tetraplegia
• vibratory
temperature
Classically occurssensation
sensation
with &
HYPERENTENSION DEFICIT (cervical injury)
proprioception
injuries of the cervical spine
• •
Prognosis: Good Poorest
Prognosis:

SPINAL CORD Spinal injuries can be described as fractures,

SYNDROMES fracture dislocations, spinal cord injury
MORPHOLOGY without radiographic abnormalities
(SCIWORA), and penetrating injuries. Each
of these categories can be further described as
stable or unstable
 PRINCIPLE OF INITIAL
NEUROGENIC
MANAGEMENT
AIRWAYS • PREVENT FURTHER DAMAGE
• ASSUME SPINE INJURY UNTIL PROVEN OTHERWISE
SHOCK
AIRWAYS
Evaluate the Need for
• Caused by high spinal cord injury
C1-C7 (Accessory
Muscles)
•Airway AIRWAYS
Characterizedmanagement
by hypotension & OCCIPUT-C3 INJURIES
 BREATHING
since
Identifyit is usually
bradycardiarisk  Require immediate intubation & ventilation due to loss of innervation
of diagpharm
• 1st r/o hemorrhage & other causes of Manual
Related to
associated Respiratory
with Level Stabilization of C-spine
•  Airway
hypotension
Ensure Intervention:
adequate C4-C6 INJURIES
•Compromise:
of injury
Fluid resuscitation & giving 2 person
A serious
C3-C5 (Diaphragm)
technique:
consideration for prophylactic intubation & ventilation if:
ventilation
 Loss of and • injury
vasopressors
oxygenation
 Ascending 1st person SPINAL SHOCK
(requirestoserial
provide manual in-line
M/S assessment)
innervation of the  Fatigue of unassisted diaphragm
stabilization •(not traction)
Occurs of after
immediately C-spine
injury
diaphragm  Inability to clear secretions • Temporary complete cessation of spinal
• 2nd person
CO-MORBIDITY intubates
 Fatigue of cordTO CONSIDER:
function
 (Intercostals)
T1-T11 Advanced age • Complete loss of all reflexes including
innervated resp  Premorbid conditions the bulbocavernosus
muscles  Chest trauma • Flaccidity of all muscles
 Hypoventilation  (Abdominal
T6-L1 History of aspiration
muscle)
Head injury or substance abuse
 AMERICAN SPINAL INJURY
ASSOCIATION (ASIA)
NEUROLOGICAL LOWER
A: Complete:UPPER EXTREMITIES
EXTREMITIES
no sensory or motor function below the level
ASSESSMENT OF of the lesion including the sacral segments
ASIA IMPAIRMENT
NEUROLOGICAL
MOTOR
SCALE ASIA
LEVEL:
(AIS)OF C5: Deltoid/Biceps
ASSESSMENT
EXAMINATION B: Sensory incomplete: sensory function is preserved
L3: Knee but
extensors
L2: Hip flexors
SENSORY motor function is lost
C6:below
Wristthe zone of injury
extensors
RECTAL:
GRADE SCALE: 0-5
• LEVEL:
SENSORY
0: total paralysis C. Motor incomplete (first grade): motor L4:function is reduced
Ankle dorsiflexors
PRESENT
1: palpable or visibleorcontraction
ASSESSMENT ABSENT in more than half of key muscle below the level
C7: Elbow of lesion;
extensors
2: active movement;
GRADE gravity eliminated
SCALE: 0-2
(Sensory Level) renders the patient unable to walk (reduced motor function is
3: active movement: against gravity
• 0: absent
4: active movement: against moderate
defined as active movement in a full ROM only if gravity is
eliminated) S1: Ankle plantar
• MOTOR
resistance1: impaired
flexors
• ASSESSMENT
5: active 2: normal against full
movement:
• NT:
resistance not tested D. Motor incomplete (second graded): motor function is
(Motor Level)
reduced
L5: Longin a fewer than half of key muscle below level of the
5*: active movement: against full C8:toe
Finextensors
ger flexors T1: Finger abductors
resistance; if identified inhibiting factors lesion; this usually allows standing and walking
were not present
NT: not testable E: Normal: reflexes may be abnormal
THORACOLUMBAR JUNCTION
THORACIC
CERVICAL
LUMBAR SPINE
SPINE INJURY
INJURY
FRACTURE
FRACTURE (T11-L1)
•• Atlas
Axis (C1)
(C2)•Fracture
Fractures
Anterior wedge compression injuries
-most common C1 fracture is a burst fracture (Jefferson
-caused by axial loading with flexion
fracture)
• •Odontoid Fractures
• Atlanto-Occipital Most-amount
Dislocation: often of wedging
result quite minor of acute
from a combination
-occurs when
- a large load falls vertically on the head or a
• Fractures
-uncommon patient
and result and
Type Dislocations
-most
hyperflexion
from I:top
severeofthethese
and tip of (C3
the
fractures
rotation
traumatic and
flexion through
odontoid
are stable and
unstable
and C7) neutral
lands on the
- In adults: -treated• with of his or her
Radiographic head in a relatively
signs associated are similar to
distraction. position a rigid brace
uncommonthoracic and thoracolumbar fractures
- •most•Results
common
Burstin level of cervical
injury:
bladder and bowel vertebral fracture isasC5
dysfunction, well as
-most patients with
-best- seen-
this injury
onType
an die
II of
:the
open-mouth brainstem
base
view of destruction
of the
the dens
C1 toand
and
C2 the
regionmost
and
most - is caused
common
decreased level ofby
sensation subluxation is C5incompression
vertical-axial
and strength onthe
C6.lower extremities
apnea or have profound
axial computed neurological impairments
- tomography
common •
extremely
(CT) scans
Probability
unstable of
anda complete
nearly neurological
always require deficit is
-common cause of death in cases of shaken baby syndrome
- Type
• Particularly III
internal : much
at the lower
fixation
vulnerable base with
of the
to rotationalthese injuries
dens and
movement
• C1 Rotary Subluxation
• extend obliquely into the body of the axis
Chance fractures:
-most often seen in children
• Posterior -caused by flexion
Element about an axis anterior to the
Fractures
-presents with a persistent rotation of the head (torticollis
vertebral column
-Hangman’safter
-occur spontaneously, fracture—the
major or minor pars
trauma, with an
most frequently seen following motor vehicle crashes
upper respiratory infection, or with rheumatoid arthritis
interarticularis
- extremely unstable and nearly always require internal
- usually
fixation caused by an extension-type injury
-associated with retroperitoneal and abdominal visceral
Evaluation
EvaluationofofSpine-
Spine- BLUNT
Injured
InjuredPatient
MANAGEMENTPatient
OF PATIENTS REQUIRING TRANSFER
CAROTID &
VERTEBRAL
REMEMBER,
CANADIAN
cervical spine injuries ARTERY
PENETRATI
NEXUS INJURIES:
WHO
above
C-SPINE
NG GROUP
RULE C6NEEDS
INJURY
• Provide
ANinIMAGING?
can result partial or total
respiratory
----------------------------
----------------------------
support as needed
• Early recognition and
treatment of these injuries
may reduce the patient’s

loss of respiratory function!

• Exclude other life-threatening injury
• A complete neurological risk of stroke
• Properly immobilize entire patient • Indications in screening for
deficit due to the path of
• the
Avoid hypothermia
missile involved (most these injuries :
DANGEROUS
often a bullet or knife) NEXUS
MECHANISMS • C1–C3 fractures
Fall from a >1m/5stairs • Cervical spine
An Axial load to the head
A motor• vehicle
Stable unless the missile
collision
GROUP fracture with
----------------------------
• High speed
destroys a significant
(>100km/hr) subluxation
•
•
Rollerover
portion of the vertebra. • Fractures involving
Ejection
Motorized recreational the foramen
vehicle collision
Bicycle collision transversarium.
THANK YOU