INTRODUCTION TO TRAUMA

MANAGEMENT
TRAUMA SERIES
 Injuries are a global health
problem
 Leading cause of death
worldwide
STATISTICS

 According to the World Health Organisation; 5.8

million people die each year as a result of
injuries. This accounts for 10% of the world’s
deaths, 32% more than the number of fatalities
that result from malaria, tuberculosis, and
HIV/AIDS combined
Definition

 Trauma means physical injury which may result in wounds, broken bones or
internal organ damage. Often people that experience a physical trauma may
also experience psychological difficulty due to the shock of the unexpected
injury.
 Traumatic injury is caused by various forces from outside of the body, which
can either be blunt or penetrating (sharp). Blunt trauma includes falls, road
traffic crashes; crush injuries, assaults (punches, kicks) and burns.
Penetrating trauma involves shooting, stabbing or falling onto a sharp object
(known as impalement).
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Aim of
management
 The main aim of trauma
management is to prevent death
 Death from Trauma has a
trimodal distribution
 Golden hour is the first hour
after injury. 80% of death occur
in this hour
Basics of trauma management

 Preparation – This involves assembly of team, sharing of roles and equipment

check
 Triage – Patients are sorted by level of acuity (Deceased, Immediate,
Delayed, Minor)
 Primary Survey (ABCDE) with immediate resuscitation of patients with life
threatening injuries. (TREAT AS YOU GO)
 Secondary Survey; Full history and clinical examination (Head to toe
examination)
 Adjuncts to secondary survey
 Definitive treatment; ICU, Theatre
Principles of primary survey

 Fixany problem you find immediately. Do not

wait (Remember slide 5)
 Ifpatients condition worsens during primary
survey, restart the primary survey from the
beginning
 Back to the top point
Primary Survey

A – Airway maintenance with protection of

cervical spine
B – Breathing and ventilation
C – Circulation with hemorrhage control
D – Disability (assessment of neurologic status)
E – Exposure and environmental control
Airway maintenance and protection of
cervical spine
 Ask the patient for name, ask what happened if able
 If you get an appropriate response, it means;
1. Breathing not severely impaired (able to generate speech)
2. Patient is alert enough to describe events
3. If speaks clearly, there is no major airway compromise

WATCH OUT FOR SIGNS OF AIRWAY OBSTRUCTION!!!

AIRWAY COULD BE OBSTRUCTED IF..

 Patient is agitated
 In coma or severe head injuries
 Ongoing secretions
 Traumatic injury above clavicle; facial, mandibular, tracheal/laryngeal injury
 Wheezy, use of accessory muscles, retraction
 Foreign bodies
Airway Interventions & Airway Support

 Suction
 Chin lift/Jaw Thrust
 Oropharyngeal or Nasopharyngeal airway
 Definitive airway (Endotracheal intubation,
crichothyroidotomy)
 C- collar
 Oxygen via Non-rebreathing mask, Bag valve mask
C-spine Imobilisation

 Prevent excessive movement of cervical spine

 Return head to neutral position
 Apply the correct size of collar
 Blocks/tapes
 Remember to always protect the entire spinal cord until a spinal cord injury
has been ruled out by clinical examination or imaging in patients with
suspicion of spinal cord injury
Breathing and
Distress / air Distended neck
Any obvious injuries?
hunger veins

Ventilation Observation
Respiratory rate & depth Breathing pattern – shallow, deep

Chest wall movement – asymmetrical, flail segment

 LOOK
Cyanosis – late sign
 LISTEN
 FEEL Palpation Trachea – central or deviated
Subcutaneous emphysema

Expansion – equal or reduced on

Remember to assess and resuscitate one side
Tenderness or obvious bony
disruption
at the same time. The key is to
identify lethal injuries Percussion Dull, resonant or hyper-resonant

Listen Breath sounds - Listen in axillae, apices and posteriorly – normal or

reduced, 1 or both sides
Heart sounds – normal or muffled

Note: it can be very difficult to hear anything in a busy resuscitation

room!
Lethal Thoracic Injuries Identified in
Primary Survey
 Airway obstruction
 Tension pneumothorax
 Massive Haemothorax
 Flail chest with pulmonary contusion
 Sucking Chest wound
 Cardiac tamponade
Breathing Resuscitation

 Complete the airway resuscitation

 Give high flow oxygen
 Chest drain if clinically indicated
 Analgesia
 We would look at the 6 lethal injuries in our thoracic trauma session
 Examine for signs of shock (Tachycardia, diminished
pulse, pallor, decreased CRT)
Assume all shock is haemorrhagic until proven
Circulation

otherwise
 Types of shock in trauma (Haemorrhagic, obstructive,
neurogenic)
with
 Focused Assessment with Sonography in Trauma (FAST haemorrhage
scan) to look for blood in the abdomen & cardiac
tamponade (pericardial fluid) control
 Sources of bleeding; Chest, abdomen, pelvis, bilateral
femur fractures.
 Remember Remember “C” ABC i.e. stop the exsanguinating
haemorrhage BEFORE assessing the airway. 

Haemorrhage Be
External haemorrhage can be managed by applying
your finger on a bleeding femoral artery, stapling a

control severe scalp laceration, applying a tourniquet 

The aim is to prevent the lethal triad from massive

Prevent blood loss (acidosis, coagulopathy and hypothermia)
 Management of a massive haemorrhage has three stages:

Limiting blood loss

Correction of tissue hypoxia

Correction of coagulation abnormalities

Resuscitation This requires a multidisciplinary approach:

Control of pain, ventilation and temperature

Rapid control of bleeding, and blood components

Pharmacologic treatment of coagulation

Resuscitation

 Vascular access: Two large bore cannula

 Cardiac Monitor, blood pressure monitoring
 Blood samples for baseline haematological studies; blood type and cross matching.
Pregnancy test should be performed in all women of childbearing age.
 Give warmed crystalloids or O – ve blood. Don’t use gelofusin or other starches
 Trauma centres use “hypotensive resuscitation” which aims for a systolic blood
pressure that is lower than normotension but still high enough for end-organ
perfusion
 It reduces haemodilutional coagulopathy from bleeding and subsequent fluid
resuscitation
 As a guide, aim for systolic BP around 90 mmHg and urine output of 10 ml/hour
  This when blood or fluids fill the space
between the sac that encases
the heart and the heart muscle. This
places extreme pressure on the heart
an in turn prevents
Cardiac the heart's ventricles from expanding
fully.
tamponade  Becks Triad; Distended jugular veins,
hypotension, muffled heart sounds
 Treatment is pericardiocentesis
(temporary), or open thoracotomy
Disability

 Decreased level of consciousness is head injury until proven otherwise

 Early identification of neurological injury and prevention of further injury is
key
 Alert neurosurgeons on time
 Precise diagnosis is not necessary at this point
 Perform gross neurological exam
 Pupils
 Glasgow coma scale
 PR exam
Disability
 Completely undress patient to look for any injuries
Undress (maintain dignity always)

Logroll patient to examine the back; maintain cervical

Exposure Logroll immobilization, palpate across thoracic and lumbar spine,
ensure minimum number of staff available to do this (3)

Avoid hypothermia by covering with warm blanket,

Avoid external warming device (bear hugger), warm environment
Secondary Survey

 Head to toe examination completed after primary survey

 This done after the patient is completely resuscitated and stable
 It involves history from the family, ambulance and ?patient
 It involves a full clinical examination

HISTORY TAKING using acronym AMPLE

A – Allergies M – Medication P – Past medical History L – Last meal E – Events
surrounding injury, or Environment
 Pain control
 Tetanus status Adjuncts to
 Antibiotics for open fratures
 Urinary catheter (do not insert if bleeding from
Secondary
urethral meatus) Survey
 Radiology (CXR, CT scans, AXR, C-spine, FAST scans)
Any questions ?