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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

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
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
resuscitation2
Resuscitation
  • Catheters
    • Urinary
      • Rectal first
      • Check for other signs of urethral injury
    • Gastric
      • Oral v.s. nasal placement
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)
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
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
aftercare
Aftercare
  • Continuous reevaluation
  • Definitive care
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