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TRAUMA OVERVIEW

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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  1. TRAUMA OVERVIEW Mark E. Armstrong, M.D.

  2. Overview 1. Preparation 2. Triage 3. Primary Survey 4. Resuscitation 5. Secondary Survey 6. Continued postresuscitation monitoring and re-evaluation 7. Definitive care

  3. 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

  4. Primary Survey • Airway • Breathing • Circulation • Disability: Neurologic Evaluation • Exposure/Environmental Control

  5. Primary SurveyAirway • Patency • Foreign bodies • Facial Fractures • Protect C-spine

  6. 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

  7. Primary SurveyCirculation • Hemorrhage control • Two Key Elements 1. Level of Consciousness -AVPU -Glasgow Coma Score 2. Pulse

  8. Bleeding • Control • No hemostats • Consider occult sources

  9. Primary SurveyDisability • AVPU

  10. 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

  11. Primary SurveyExposure • Remove all clothes • Cover to prevent hypothermia

  12. Resuscitation • Airway • Oral • Nasal- do not put in someone with facial trauma • Endotracheal • Surgical • Breathing • Supply O2 • Ventilate alveoli

  13. Resuscitation • Circulation • Establish 2 large bore IVs • Draw blood • Vigorous IV therapy • ECG monitoring • Avoid hypothermia • Evaluate PEA • Other dysrhythmias

  14. Hemorrhage classification

  15. Resuscitation • Catheters • Urinary • Rectal first • Check for other signs of urethral injury • Gastric • Oral v.s. nasal placement

  16. NGT Intracranial

  17. Resuscitation • Monitoring • ABG’s • Pulse oximetery • Blood pressure • ECG

  18. Roentgenograms • Should not delay resuscitation • AP pelvis • AP chest • Lateral C-spine • Odontoid, AP C-spine

  19. Other Imaging • FAST scan Focused Assessment Sonography in Trauma • Ultrasound • Pericardial sac (epigastric area) • Hepatorenal fossa • Splenorenal fossa • Pelvis or Pouch of Douglas (bladder)

  20. 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”

  21. 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

  22. 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

  23. Secondary Survey (PE)Head • Scalp • Eyes • Nose • Mouth • Bite occlusion

  24. Secondary Survey (PE)Head PITFALLS • Hyphema • Optic nerve injury • Lens dislocation • Head injury • Posterior scalp laceration

  25. Secondary Survey (PE)Maxillofacial • Midline facial fractures • Bite occlusion • Bleeding • Fracture repair can wait

  26. 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

  27. Secondary Survey (PE)Maxillofacial PITFALLS • Pending airway obstruction • Changes in airway status • Cervical spine injury • Exsanguinating midface fracture • Lacrimal duct lacerations • Facial nerve injuries

  28. Secondary Survey (PE)C-spine and neck • Must be immobilized • Inspection • Palpation • Auscultation (carotids)

  29. Secondary Survey (PE)C-spine and neck PITFALLS • C-spine injury • Esophageal injury • Tracheal or laryngeal injury • Carotid injury (blunt or penetrating)

  30. Secondary Survey (PE)Chest • Visual evaluation (ant & post) • Palpate rib cage • Sternal pressure • Auscultation (heart & lungs) • Chest xray

  31. Secondary Survey (PE)Chest PITFALLS • Tension pneumothorax • Open chest wound • Flail chest • Cardiac tamponade • Aortic rupture (widened mediastinum)

  32. Pneumothorax

  33. Tension Pneumothorax

  34. 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)

  35. 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

  36. Secondary Survey (PE)Perineum/Rectum/Vagina • Contusions,Hematomas, Lacerations • Urethral bleeding • Rectal blood • High riding prostate • Sphincter tone • Vaginal vault injuries (pelvic fractures)

  37. Secondary Survey (PE)Perineum/Rectum/Vagina PITFALLS • Urethral injury • Rectal injury • Bladder injury • Vaginal injury

  38. Retrograde urethrogram

  39. Secondary Survey (PE)Musculoskeletal • Contusion • Deformity • Palpation • Pelvic pressure and compression • Vascular exam • Neurologic exam

  40. Secondary Survey (PE)Musculoskeletal PITFALLS • SPINE FRACTURES • Fractures with vascular compromise • Pelvic fractures • Digital fractures

  41. 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

  42. Secondary Survey (PE)Neurologic PITFALLS • Increased intracranial pressure • Subdural hematoma • Epidural hematoma • Depressed skull fracture • Spine injury • Beware of unconscious patient

  43. Subdural Hematoma

  44. Epidural Hematoma

  45. Aftercare • Continuous reevaluation • Definitive care

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