PRIMARY MANAGEMENT IN TRAUMA PATIENTS

1. GOOD MORNING
PRIMARY MANAGEMENT OF
TRAUMA PATIENT
Dr. Rahul Tiwari
3rd
Yr. Post Graduate,
Dept. of Oral & Maxillofacial Surgery,
SIBAR Institute of Dental Sciences.
09/19/16 09:30 AM RT/7/PRIM. MANAG. IN TRAUMA PT./50 1

2. CONTENTS
 Introduction
 Patient transport
 Initial Assessment
 Primary survey
 Multisystem-Injuries
 Secondary Assessment
 Intensive Care units
 Monitor in ICU Setting
 References
 Conclusion
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3. INTRODUCTION
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Trauma is the leading cause of death in children's &
young adult.
Its effects are protean, affecting not only the victim
but also their relatives & society as a whole.
“God gave you ears, eyes & hands; Use them
on the patient in that order.”
Sir William KelseyFry.

4. Introduction
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An accurate knowledge of how the injury occurred
may be of great value in indicating the severity &
extend of damage.
&
An accurate account of changes in the patients
condition may give timely warning of impending
complications & other dangers.

5. Principles of management
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When a patient with severe traumatic injury is first seen, an
immediate general evaluation must be made to determine if
emergency treatment is necessary.
Treatment Priorities
I. Immediate Intervention
- Respiratory obstruction
- Cardiac arrest
- Massive bleeding
II. Treatment required urgently
- Intra – abdominal bleeding
- Head injuries
- Chest injuries
III. Treatment that can wait
Maxillofacial trauma

6. Sequence of management
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Trauma (RTA, MVA, fall etc.)
↓
Primary Survey -> ABCDE defines the specific prioritized evaluations and
intervention that should be followed in all injured patients
↓
Secondary Survey
After initial survey has been accomplished and the patient has been stabilized
Involves more time – consuming tests and observations
Does not begin until primary survey is completed

7. Procedure
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 Scene safety
 Approach to patient
 Ambulance
 ABC
 Primary management
 Shift
 Secondary management
 Care

8. PATIENT TRANSPORT
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 Ground Ambulance.
 Advanced life support Ambulance.
 Air Ambulance.
 Helicopter
 Fixed-Wing Air Ambulance

9. Basic ambulance
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The main mode of transport of trauma patient & these vehicle appropriate
to transport patient only in supine position only.
Currently the ALS ambulance is standard care for ground transport of
trauma patient.
This vehicle in addition have basic life support equipment equipped with
defibrillators, endotracheal intubation equipment, various emergency drugs
& other specialty equipment.
The ALS Ambulance is also staffed by emergency medical technicians,
who posses skills that include advanced air way management, Intravenous
fluid & medication administration,& defibrillation.

10. Air ambulance
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Primary or Secondary Response.
Primary/Scene response, is when the air
ambulance is the sole mode of patient transport
from the scene to the receiving facility.
Secondary response involves aircraft transport
from an outlying hospital or emergency
department to higher level care facility.

11. Helicopter
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Offers several advantages.
They travel at speed of 120 to 180miles/hr. allowing for transport
time to be 75% shorter compared to ground transport.
They are able to avoid traffic delay & ground obstacles & can fly
into locations inaccessible by other mode of patient transport.
FIXED WING AIR AMBULANCE
Fly at speed of 200-300miles/hr.
Used for distance more than 150miles.
Ideal for long distance transport of donors, organs,& patient to
specialized institutions.

12. INITIAL ASSESSMENT
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The accurate & systemic assessment of injury is essential to establish the extent of
injury to vital structures.
Categories: Severe, Urgent & Non-urgent
Severe: Pt. can make up approx. 5% of all injuries. Immediate threat to life because
they interfere with vital physiological functions.
Urgent: constitute 10-15%.Not immediate threat to life. Patients requires surgical
intervention, but have stable vital signs.
Nonurgent: constitute 80% .No threat to life, patients require either medical or
surgical intervention after significant evaluation or observation.

13. Golden hour
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14. Assessment of severity
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The Glasgow Coma Scale.
Trauma score/Revised Trauma score.
Injury Severity Score.
Other Scoring Systems.

15. Glasgow coma scale
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EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
4-Spontaneous 5-Normal 6-Normal
3-To voice 4-Disoriented 5-Localizes to p
2-To pain 3-Words not coherent 4-Withdraws top
1-None 2-No words only sound 3-Decorticated posture
1-None 2-Decerebrated
1-None
Total=E+V+M
13 - 15: mild traumatic brain injury
9 -12: moderate traumatic brain injury
3 – 8: severe traumatic brain injury

16. Injury severity score
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 Deals with multiple traumatic injuries.
 Compares death rates from blunt trauma using data that
the rate of severity of the injury in each of the most
severely injured organ system.
1. Minor.
2. Moderate
3. Severe non life threatening.
4. Life threatening , survival probable.
5. Survival not probable.
6. Fatal C V S, C N S or burn injuries.
Highest injury severity score possible is 108.

17. Injury Severity Score Baker et al. in 1974
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ISS correlates with hospital stay, morbidity, mortality,
and other measures of trauma severity and is the most
widely accepted severity of injury index in use today .
Each injury is assigned an AIS code and classified in one of
six body regions, as follows:
(i) head/neck,
(ii) Face,
(iii) Thorax,
(iv) Abdomen,
(v) Extremities (including pelvis),
(vi) External

18. Organ injury scale
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The Organ Injury Scale (OIS) was developed by the American Association for the
Surgery of Trauma (AAST) in1987 as a tool to devise injury severity scores (ISSs) for
individual organs.
The classification scheme provides detailed anatomic descriptions, scaled from one to six
[one representing the least, and five the most severe that is salvageable; the value of six
denotes the organ is no salvageable.
The first OIS version covered liver, spleen, and kidney injuries. Since 1987, several
revisions have occurred and other organs were added. There now exist OIS
characterizations for lung, heart, chest wall, diaphragm, abdominal, vascular, ureter,
bladder, and urethra.

19. Primary Survey
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A---Airway maintenance with cervical spine control.
B---Breathing & adequate ventilation.
C--Circulation with control of hemorrhage
D—Disability: Neurologic examination
E--- Exposure / Environmental control

20. A- Airway obstruction
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 Blood Clots
 Teeth
 Soft Tissue & Bones
 Swelling
 Position of Head
 Head Injury
 Tongue position
 Aspiration of foreign bodies.
 Regurgitation of Stomach Contents.
 Facial, Mandibular & or Tracheal & or laryngeal fracture

21. Airway management
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Assess for Airway Obstruction!
Difficulty breathing
Patient conduct (anxious, combative)
Abnormal sounds
Improve/Establish Airway Through Maneuvers
Chin lift
Jaw thrust
Remove Debris/Suction
Airway Adjuncts:
Cervical spine collar
Nasopharyngeal airway & Oropharyngeal airway(cuffed )
Nasotracheal intubation

22. Complications
Oropharyngeal Airway
1.Air way obstruction ,it may press the epiglottis against the
laryngeal inlet pushing the tongue posteriorly.
2.Injury to lip & tongue.
3.Vomiting.
4.Laryngospasm
Nasopharyngeal Airway.
1.Long tube can enter the esophagus causing gastric distension.
2.Laryngospasm.
3.Vomiting.
4.Injury to nasal mucosa especially the turbinates.
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23. Equipment's for nasotracheal intubation
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Laryngoscope with relevant size blades.
Magill forceps.
Flexible introducer.
10-20 ml syringe.
Oropharangeal airways – all sizes.
Tape or adhesive plaster.
E.T tubes – relevant sizes.
Bag-valve-mask with oxygen connected.
Suction unit with Yankauer nozzle and endotracheal suction
catheter.

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25. Technique
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26. Tube sizes
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Newborn – to 4 kg - 2.5 mm (uncuffed).
 1-6 months 4-6 kg – 3.5 mm (uncuffed).
 7-12 months 6-9 kg – 4.0 mm (uncuffed).
 1 year 9-10 kg – 4.5 mm (uncuffed).
 2 years 11-14 kg – 5.0 mm (uncuffed).
 3-4 years 14–16 kg - 5.5 mm (uncuffed).
 5-6 years 18–21 kg – 6.0 mm (uncuffed).
 7-8 years 22-27 kg – 6.5 mm ( uncuffed).
 9-11 years 28-36 kg – 7.0 mm(cuffed).
 14 to adults 46+ kg – 7.0 – 8.0 mm (cuffed).
 Adult female 7.0 – 8.0mm (cuffed).
 Adult male 7.5 – 8.5 mm (cuffed).
 The size of the tube may also be determined by the size of the patients little
finger.

27. Other methods
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 Laryngeal mask airway
 Lighted stylet or wand
 Flexible fibreoptic laryngoscope
 Flexible fibreoptic bronchoscope
 Trans tracheal catheter
 Needle cricothyrotomy
 Cricothyrotomy
 Tracheostomy

28. B-BREATHING
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 The pulmonary function should be assessed
 The chest should be fully exposed & inspected for any sign of obvious injury. It should
be palpated for signs of rib or sternal fractures
 Neck should be evaluated for any sign of tracheal deviation& jugular venous distension
 Chest expansion should be equal bilaterally without intercostal or supraclavicular
muscle retraction during respiration
 Tachypnea with shallow respirations is suggestive of chest injury & impending hypoxia

29. Pneumothorax
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-the defect in chest wall that allows air to move in and out of the pleural cavity with each
respiration
- involved lung collapses on inspiration& slightly expands on expiration
Closed or non communicating pneumothorax
- results from rib fracture causing parenchymal laceration
- percussion of chest shows hyper resonance and breath sounds are distant or absent
- pulmonary collapse seals the air leak

30. Tension pneumothorax
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 tissues surrounding the opening into the pleural cavity acts as a valve allowing air to
enter the pleural cavity & not to escape
 this results in a shift of mediastinum with compression of the opposite lung & result in
hypoxia
 the positive intra pleural pressure produces compression of vena cava interfering with
diastolic filling of heart & resulting in low cardiac output.
 patients are restless, agitated, dyspneic, cyanotic, hypotensive, tachycardia, tachypneic
 the cervical trachea is displaced to the side opposite the pneumothorax with distended
neck veins- if untreated results in death
 positive intrapleural pressure is released with insertion of large angiocatheter in the mid
clavicular line in the 2nd
intercostal space

31. Simple pneumothorax
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 symptoms- chest pain, shortness of breath, breath sounds are distant,
subcutaneous emphysema
 thoracostomy drainage- chest tube is placed anteriorly in the 2nd
intercostal
space, mid clavicular line or in 4th
or 5th
intercostal space, mid axillary line
 skin incision 3cm is made on intercostal space below the placement of tube.
 Tube is placed superiorly & posteriorly into the pleural cavity. It is connected to
an underwater sealed drainage to remove air or fluid

32. Open pneumothorax
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 during respiration a sucking sound is heard
 the involved lung collapses on inspiration & slightly expands on expiration.
This is sucking chest wound
 collapse of involved lung- loss of negative pleural pressure- expired air from
normal lung passes to involved lung- and expired air returns to normal lung on
inspiration
 large functional dead space in normal lung
 coverage of defect with a sterile occlusive dressing secured at 3 of the 4 sides
 chest tube placed at distant site to prevent tension pneumothorax
 patient is placed on ventilator with PEEP to expand the lung

33. Hemothorax
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 source of bleeding- lungs, intercostal artery or vein, medistinal vessels and
chest wall
 collection of blood within pleural cavity
 decreased vital capacity, dyspnea, tightness of chest
 respiratory acidosis, decreased cardiac output, hypoxia
 drainage of blood in pleural cavity
 indication for thoracotomy- drainage of 1500ml of blood on placement of
chest tube, more than 300ml/ hr for 3 hrs, lack of lung re expansion,
respiratory compromise

34. Flail chest
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 result of multiple rib fractures
 the fracture is usually seen in multiple sites along the rib creating an unstable fragment of
chest wall which moves inward with inspiration & outward with expiration, movement of
thorax can br asymmetrical & unco-ordinated
 paradoxical motion can be accentuated by having the patient take deep breath or cough,
low pO2
Treatment 3 steps
 stabilization of loose segment with external splint
 sand bag, rolled sheet, iv fluid bag can be taped over the area-adequate for 30 min
 2nd
– prolonged relief of pain – intercostal nerve blocks
 3rd
- PEEP- indications for intubation- pO2 < 60mm Hg, pCO2 > 55mm Hg, RR > 35
b/min

35. Pulmonary contusion
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 damage to lung parenchyma that results in hemorrhage
& edema without accompanying pulmonary laceration
 high pressure compresses the lungs due to increased
intra thoracic pressure
 maintenance of oxygen
 intense crystalloid solution
 pain relief

36. C- CIRCULATION
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Cardiovascular stability must be evaluated and restored.
A large artery must be located and carefully palpated. The 2 large
central arteries are :
- Femoral artery in the groin
OR
- Carotid artery in the neck.

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 Reliable indicator of poor tissue perfusion
• - skin perfusion
• - cutaneous capillary bed are first to shut down in response to hypovolemia
• - the released catecholamine's result in sweating and skin feels cold and damp upon
palpation
• - Blanch test to assess capillary fill time- a time of less than 2 sec is usually seen in the
normovolemic patient
• - Pulse rate- tachycardia above 120b/min indicates hypovolemia

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• - palpable radial pulse indicates systolic is > 80 mmHg
• - carotid pulse- systolic > 60mm Hg
• - decreased urinary output- a urine output of 0.5ml/kg/hr. is minimally adequate
• - mental status changes include agitation, confusion, uncooperativeness, anxiety,
irrationality
• - veins of neck become flat
• - systolic BP < 100 mm Hg -1 l of blood volume has been lost

40. Control of bleeding
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 an acute loss of blood- hemorrhage
 firm pressure can be applied proximal to major arteries
 pressure bandages, air pillow splint, medical antishock trousers
 scalp wound cause large amount of blood loss by ooze from loose connective tissue layers
 hemorrhages from the facial fractures can be controlled with direct pressure or packing
 Ligation of external carotid in rare cases
 internal site of hemorrhage-thoracic cavity, abdomen, retro peritoneum and extremities
 Controlling internal hemorrhage X performed in 1* survey unless it has detrimental effects

41. Control of bleeding
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 Nasal hemorrhage- packing and Foleys catheter
 Fluid resuscitation
 - fluid of choice RL or 0.9% NS
 - with prolonged shock isotonic solution is lost from intravascular & interstitial
spaces into extracellular space
 - hypovolemic adult patient should initially be given 2l of fluid over 10-15min;
systolic should rise to 80-100 mm Hg
 - colloids control elevated ICP

42. CPR
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43. Ratio of Chest Compression to Artificial Ventilation
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Victim Definition Respiratory Ratio
Rate / Min (Compression/ventilation)
Infant < 1 year 29 5 : 1
Child 1 – 8 years 15 5 : 1
Adult > 8 years 12 15 : 2
One
Two 5 : 1
Victim Rate/Min Depth Hand Site
(inches)
Infant 100 ½ - 1 2-3fingers Midsternum
Child 80 1 – 1 ½ 1 heel Midsternum
Adult 60 1 ½ - 2 2 hands Lower half of sternum

44. “D” Disability assessment of neurological Deficit
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A rapid assessment of neurological disability is made noting patients
response on a 4 point scale
A - Responds appropriately, is aware
V - Responds to verbal stimuli
P - Responds to painful stimuli
U - Does not respond, unconscious
In the absence of direct damage to the eye, pupil response must be
recorded.
GCS

45. E- EXPOSURE AND ENVIRONMENTAL CONTROL
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All trauma patients must fully be exposed, if
necessary by cutting away clothing, and the
environment accordingly must be warm and
protected to ensure the patient suffer no further
harm.
At some point, unless indicated earlier, the
patient must be turned in order that the back and
other hidden areas can be properly examined.

46. Summary
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Traumatized Patient
Criteria No response to stimulation
Position victim supine, elevate feet
AIRWAY MAINTENANCE
Head tilt, check airway, breathing
Recovery Unconsciousness persists
Assistance Carotid pulse present Maintain airway, breathing
Check circulation
CPR Carotid pulse absent

47. Conclusion
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 Training in basic life support procedures is essential if they are to
be effectively applied in life – threatening situations.

 Traumatized patients must be managed appropriately and
prioritized evaluation and interventions are essential
 Thus, it is recommended that all individuals receive a training on
the primary care for a trauma patients.

48. REFERENCES
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1. Assessment and management of trauma –
by D. Demetriades - 5th
edition
2. Emergency care of trauma –
by Fion CW Davis – 2nd
edition

49. THANK YOU
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