Trauma overview
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TRAUMA OVERVIEW. Mark E. Armstrong, M.D. Overview. 1. Preparation 2. Triage 3. Primary Survey 4. Resuscitation 5. Secondary Survey 6. Continued postresuscitation monitoring and re-evaluation 7. Definitive care. Preparation. Prehospital Notify receiving hospital

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TRAUMA OVERVIEW

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Trauma overview

TRAUMA OVERVIEW

Mark E. Armstrong, M.D.


Overview

Overview

1. Preparation

2. Triage

3. Primary Survey

4. Resuscitation

5. Secondary Survey

6. Continued postresuscitation monitoring and re-evaluation

7. Definitive care


Preparation

Preparation

  • Prehospital

    • Notify receiving hospital

    • Closest appropriate facility

    • Report pertinent information

  • Inhospital

    • Warmed IV solutions

    • Ancillary departments notified

    • Equipment made readily available

    • Hospital personnel protection


Primary survey

Primary Survey

  • Airway

  • Breathing

  • Circulation

  • Disability: Neurologic Evaluation

  • Exposure/Environmental Control


Primary survey airway

Primary SurveyAirway

  • Patency

  • Foreign bodies

  • Facial Fractures

  • Protect C-spine


Primary survey breathing

Primary SurveyBreathing

  • Patency does not equal adequate ventilation

  • Expose chest

  • Auscultate

  • Conditions that may acutely impair ventilation

    • Tension pneumothorax

    • Massive hemothorax

    • Flail chest

    • Rib fractures

    • Open pneumo

    • Pulmonary contusion


Primary survey circulation

Primary SurveyCirculation

  • Hemorrhage control

  • Two Key Elements

    1. Level of Consciousness

    -AVPU

    -Glasgow Coma Score

    2. Pulse


Bleeding

Bleeding

  • Control

  • No hemostats

  • Consider occult sources


Primary survey disability

Primary SurveyDisability

  • AVPU


Glasgow coma

Glasgow Coma

Verbal Response Motor response

Oriented 5 Obeys 6

Confused 4 Localizes 5

Inappropriate words 3 Withdraws 4

Incomprehensible sounds 2 Decortication 3

None 1 Decerebration 2

None 1

Eye Opening

Spontaneous 4

To speech 3

To pain 2

None 1


Primary survey exposure

Primary SurveyExposure

  • Remove all clothes

  • Cover to prevent hypothermia


Resuscitation

Resuscitation

  • Airway

    • Oral

    • Nasal- do not put in someone with facial trauma

    • Endotracheal

    • Surgical

  • Breathing

    • Supply O2

    • Ventilate alveoli


Resuscitation1

Resuscitation

  • Circulation

    • Establish 2 large bore IVs

    • Draw blood

    • Vigorous IV therapy

    • ECG monitoring

    • Avoid hypothermia

    • Evaluate PEA

    • Other dysrhythmias


Trauma overview

Hemorrhage classification


Resuscitation2

Resuscitation

  • Catheters

    • Urinary

      • Rectal first

      • Check for other signs of urethral injury

    • Gastric

      • Oral v.s. nasal placement


Ngt intracranial

NGT Intracranial


Resuscitation3

Resuscitation

  • Monitoring

    • ABG’s

    • Pulse oximetery

    • Blood pressure

    • ECG


Roentgenograms

Roentgenograms

  • Should not delay resuscitation

  • AP pelvis

  • AP chest

  • Lateral C-spine

  • Odontoid, AP C-spine


Other imaging

Other Imaging

  • FAST scan

    Focused Assessment Sonography in Trauma

    • Ultrasound

      • Pericardial sac (epigastric area)

      • Hepatorenal fossa

      • Splenorenal fossa

      • Pelvis or Pouch of Douglas (bladder)


Secondary survey

Secondary Survey

  • Head-to toe evaluation

    • Vital sign evaluation

    • Detailed neuro exam if not done in primary survey

    • Special procedures

  • “Tubes and fingers in every orifice”


Secondary survey history

Secondary SurveyHistory

  • A Allergies

  • M Medications

  • P Past illnesses

  • L Last meal

  • E Events related to injury

    1.Blunt

    2.Penetrating

    3.Burns

    4.Hazardous Environment


Secondary survey history1

Secondary SurveyHistory

  • A Allergies

  • M Medications

  • P Past illnesses

  • L Last meal

  • E Events related to injury

    1.Blunt

    2.Penetrating

    3.Burns

    4.Hazardous Environment


Secondary survey pe head

Secondary Survey (PE)Head

  • Scalp

  • Eyes

  • Nose

  • Mouth

  • Bite occlusion


Secondary survey pe head1

Secondary Survey (PE)Head

PITFALLS

  • Hyphema

  • Optic nerve injury

  • Lens dislocation

  • Head injury

  • Posterior scalp laceration


Secondary survey pe maxillofacial

Secondary Survey (PE)Maxillofacial

  • Midline facial fractures

  • Bite occlusion

  • Bleeding

  • Fracture repair can wait


Midface fractures lafort

Midface FracturesLaFort

  • I: Maxilla only transversely above the alveolar ridge

    Most common isolated

  • II (pyramidal): Through nasal bone or nasal bone disarticulation with frontal bone

    Most common when associated with other fractures

  • III (dislocated face): Through nasal bone, across floor of orbit, through lateral wall of orbit, zygomatic arch Rare


Secondary survey pe maxillofacial1

Secondary Survey (PE)Maxillofacial

PITFALLS

  • Pending airway obstruction

  • Changes in airway status

  • Cervical spine injury

  • Exsanguinating midface fracture

  • Lacrimal duct lacerations

  • Facial nerve injuries


Secondary survey pe c spine and neck

Secondary Survey (PE)C-spine and neck

  • Must be immobilized

  • Inspection

  • Palpation

  • Auscultation (carotids)


Secondary survey pe c spine and neck1

Secondary Survey (PE)C-spine and neck

PITFALLS

  • C-spine injury

  • Esophageal injury

  • Tracheal or laryngeal injury

  • Carotid injury (blunt or penetrating)


Secondary survey pe chest

Secondary Survey (PE)Chest

  • Visual evaluation (ant & post)

  • Palpate rib cage

  • Sternal pressure

  • Auscultation (heart & lungs)

  • Chest xray


Secondary survey pe chest1

Secondary Survey (PE)Chest

PITFALLS

  • Tension pneumothorax

  • Open chest wound

  • Flail chest

  • Cardiac tamponade

  • Aortic rupture (widened mediastinum)


Pneumothorax

Pneumothorax


Tension pneumothorax

Tension Pneumothorax


Secondary survey pe abdomen

Secondary Survey (PE)Abdomen

  • Frequently repeated exams

  • Inspection

  • Palpation

  • Normal initial exam does not rule out injury

  • Peritoneal lavage v.s. CT scan v.s. U/S (FAST)


Secondary survey pe abdomen1

Secondary Survey (PE)Abdomen

PITFALLS

  • Liver or splenic flexure

  • Deceleration injuries

    Hollow viscus, Lumbar spine

  • Pancreatic injury

  • Major intraabdominal vascular injury

  • Renal injury

  • Pelvic fractures


Secondary survey pe perineum rectum vagina

Secondary Survey (PE)Perineum/Rectum/Vagina

  • Contusions,Hematomas, Lacerations

  • Urethral bleeding

  • Rectal blood

  • High riding prostate

  • Sphincter tone

  • Vaginal vault injuries (pelvic fractures)


Secondary survey pe perineum rectum vagina1

Secondary Survey (PE)Perineum/Rectum/Vagina

PITFALLS

  • Urethral injury

  • Rectal injury

  • Bladder injury

  • Vaginal injury


Retrograde urethrogram

Retrograde urethrogram


Secondary survey pe musculoskeletal

Secondary Survey (PE)Musculoskeletal

  • Contusion

  • Deformity

  • Palpation

  • Pelvic pressure and compression

  • Vascular exam

  • Neurologic exam


Secondary survey pe musculoskeletal1

Secondary Survey (PE)Musculoskeletal

PITFALLS

  • SPINE FRACTURES

  • Fractures with vascular compromise

  • Pelvic fractures

  • Digital fractures


Secondary survey pe neurologic

Secondary Survey (PE)Neurologic

  • Immobilization of entire patient

  • Reevaluate GCS

  • Cranial nerve exam

  • Motor exam

  • Sensory exam

  • Monitor frequently for changes in neuro status

  • Assess O2 delivery if changes noted

  • Early neurosurgical consultation


Secondary survey pe neurologic1

Secondary Survey (PE)Neurologic

PITFALLS

  • Increased intracranial pressure

  • Subdural hematoma

  • Epidural hematoma

  • Depressed skull fracture

  • Spine injury

  • Beware of unconscious patient


Subdural hematoma

Subdural Hematoma


Epidural hematoma

Epidural Hematoma


Aftercare

Aftercare

  • Continuous reevaluation

  • Definitive care


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