2. Epidemiology
Golden Hour = 80% of trauma deaths
in first hour after injury
Rapid trauma care has greatest level
of impact in these patients
2
Immediately Hours Days/Weeks
50%
30%
20%
Trimodal Distribution of Trauma Deaths
3.
4. THE GOLDEN HOUR
• originated by R Adams Cowley.
• first sixty minutes after the occurrence of multisystem trauma.
• victim's chances of survival are greatest if they receive definitive care
in the OR within the first hour after a severe injury.
2nd and 3rd peak in tri-modal distribution of death can be reduced if
definitive care is received with in 1 hr.
5. SYSTEMATIC APPROACH
1] Preparation
2] Primary survey (ABCDE) and Management
3] Secondary survey and Management
4] Tertiary survey
DETERMINING THE NEED FOR PATIENT TRANSFER
6. RAPID PRIMARY SURVEY
• IDENTIFY LIFE THREATENING INJURIES in orderly manner based on
effect of injury on patients physiology and life
• INITIATE LIFE PRESERVING THERAPIES
• In settings with limited resources, the primary survey simplifies
priorities and any problems identified should be managed
immediately, in the order they are detected, before moving on to the
next step of the survey.
• However, at major trauma centers, many capable clinicians may be
present, allowing the team to address multiple problems
simultaneously.
7. The primary survey consists of the following steps:
●Airway assessment and protection (maintain cervical spine
stabilization when appropriate)
●Breathing and ventilation assessment (maintain adequate
oxygenation)
●Circulation assessment (control hemorrhage and maintain adequate
end-organ perfusion)
●Disability assessment (perform basic neurologic evaluation)
●Exposure, with environmental control (undress patient and search
everywhere for possible injury, while preventing hypothermia)
9. RECOGNITION OF AIRWAY COMPROMISE
• Maxillofacial Trauma
• Neck Trauma
• Laryngeal Trauma
Agitation,obtundation
Cyanosis indicates hypoxemia. However, cyanosis is a late finding of
hypoxia. Pulse oximetry is used early in the airway assessment to
detect inadequate oxygenation prior to the development of cyanosis.
LOOK FOR retractions, use of accessory muscles
LISTEN FOR abnormal sounds. Noisy breathing,Snoring, gurgling, and
stridor
FEEL FOR the location of the trachea.
11. AIRWAY EQUIPMENTS AT BED SIDE
Suction
Bag-valve mask attached to high flow oxygen
Oral and nasal airways
Rescue airways (eg, Combitube™, Laryngeal mask airway)
Endotracheal tubes in a range of sizes
Stylets
Endotracheal tube introducer (ie gum elastic bougie)
Laryngoscopes
Lighted and optical stylets, Video laryngoscope, flexible endoscopes if
available
Surgical airway devices
12. AIRWAY MAINTENANCE TECHNIQUES
1] CLEAR AIRWAYS FROM SECRETIONS, VOMITUS, BLOOD etc BY
THOROUGH SUCTIONING OF AIRWAYS.
2] Chin lift
3] Jaw thrust
4] Insertion of Airway
13. Indications for Definitive Airway
NEED FOR AIRWAY PROTECTION NEED FOR VENTILATION OR OXYGENATION
Severe maxillofacial fractures Inadequate respiratory efforts
• Tachypnea
• Hypoxia
• Hypercarbia
• Cyanosis
Risk for obstruction
• Neck hematoma
• Laryngeal or tracheal
injury
• Stridor
Massive blood loss and need for
volume resuscitation
Risk for aspiration
• Bleeding
• Vomiting
Severe closed head injury with
need for brief hyperventilation
if acute neurologic deterioration
occurs
Unconscious Apnea
• Neuromuscular paralysis
• Unconscious
16. B: Breathing and Ventilation
• Tension pneumothorax
• Open pneumothorax
• Massive hemothorax
• Flail chest
NEEDS TO BE IDENTIFIED AT THIS
STAGE OF PRIMARY SURVEY
• Ventilation requires functioning
lungs, chest wall, diaphragm.
• Tachypnea can indicate
respiratory distress
• Patients chest to be exposed to
assess chest wall excursion.
• Palpate to detect chest wall
injuries that compromise
ventilation.
• Percuss to demonstrate air or
blood.
17. RECOGNITION OF BREATHING COMPROMISE
1] Ventilation can be compromised by airway obstruction, altered
ventilatory mechanics, and/or central nervous system (CNS)
depression. If a patient’s breathing is not improved by clearing the
airway, other causes of the problem must be found and managed.
2] Direct trauma to the chest, especially with rib fractures,
3] Intracranial injury
4] Cervical spinal cord injury
18. OXYGENATION IS IT ADEQUATE?
Pulse oximetry is useful, as the continuous monitoring of oxygen
saturation provides an immediate assessment of therapeutic
interventions.
• Oxygenated inspired air is best provided via a tightfitting oxygen
reservoir face mask with a flow rate of at least 11 L/min. Other
methods (e.g., nasal catheter, nasal cannula, and nonrebreather
mask) can improve inspired oxygen concentration
19. Circulation with hemorrhage control
• First step is to identify the presence of shock.
• The second step in the initial management of shock is to identify the
probable cause of the shock state
20.
21. ESTIMATED BLOOD LOSS BASED ON INITIAL
PRESENTATION
Blood loss (mL) Up to 750 750–1500 1500–2000 >2000
Blood loss (% blood
volume)
Up to 15% 15%–30% 30%–40% >40%
Pulse rate (BPM) <100 100-120 120-140 >140
Systolic b pressure Normal Normal decreased decreased
Pulse pressure (mm
Hg)
normal narrow narrow narrow
Respiratory rate 14–20 20–30 30–40 >35
Urine output
(mL/hr)
>30 20–30 5–15 Negligible
CNS/mental status Slightly anxious Mild anxious confused confused
Initial fluid
replacement
crystalloid crystalloid Blood and
crystalloid
Blood and
crystalloid
22. Obvious and immediately detectable manifestations of the shock state
include:
• Tachycardia
• Hypotension
• Cool extremities
• Weak peripheral pulses
• Prolonged capillary refill (>2 seconds)
• Narrowing of the pulse pressure (<25 mmHg)
• Altered mental status not due to head injury
• DIAGNOSTIC STUDIES HELP IN IDENTIFYING SOURCE OF
HAEMORRAGE AT EARLY STAGE
23. LETHAL TRIAD
COAGULOPATHY, ACIDOSIS, HYPOTHERMIA
Due to activation of protein C as a result of tissue hypo-perfusion. Protein
C inactivates Factor V, V111…
Haemorrhage result in the consumption of coagulation factors and early
coagulopathy.
Tissue hypoperfusion leads to inadequate oxygen delivery, switch over to anaerobic
metabolism lactate production and ACIDOSIS.
Anaerobic metabolism limits endogenous heat production exacerbating
hypothermia caused by injudicious cold fluid and blood administration.
25. PERMISSIVE HYPOTENSION
• Target SBP of 70-90 mm hg [ palpable radial pulse]
• BY RESTRICTED OR DELAYED APPROACH TO FLUID ADMINISTRATION.
• Aggressive fluid administration as ineffective and potentially harmful.
• Controlled hypotension may be beneficial in patients with
hemorrhagic shock. However, it may be detrimental to blunt trauma
patients with brain injury, as hypotension reduces cerebral perfusion
and increases mortality.
• The rationale for improved outcomes with delayed fluid resuscitation
is that aggressive fluid administration might, via augmentation of
blood pressure, dilution of clotting factors, and production of
hypothermia, disrupt thrombus formation and enhance bleeding.
26. INITIAL MANAGEMENT OF HEMORRHAGIC SHOCK
The initial treatment of shock is directed toward restoring cellular and
organ perfusion with adequately oxygenated blood.
• Definitive control of hemorrhage and restoration of adequate
circulating volume are the goals of treatment of hemorrhagic shock.
• External haemorrhage is identified and controlled in primary survey
(MANUAL COMPRESSION, SPLINTS, ELASTIC BANDAGE, TORNIQUET)
• Vasopressors are contraindicated for the treatment of hemorrhagic
shock because they worsen tissue perfusion.
27. • Short, large-caliber peripheral intravenous lines are preferred
• The most desirable sites for peripheral, percutaneous intravenous
lines in adults are the forearms and antecubital vein
• If circumstances prevent the use of peripheral veins, large-caliber,
central venous (i.e., femoral, jugular, or subclavian vein.
• In children younger than 6 years, the placement of an intraosseous
needle should be attempted before inserting a central line.
28. INITIAL FLUID THERAPY
• An initial, warmed fluid bolus is given. The usual dose is 1 to 2 L for
adults and 20 mL/kg for pediatric patients.
• ISOTONIC CRYSTALLOIDS(NS,RL,plasmalyte-A ), Hypertonic saline,
COLLOIDS
• RESTRICTIVE VS LIBERAL FLUID ADMINISTRATION
Excessive fluid administration can exacerbate the LETHAL TRIAD of
coagulopathy, acidosis, and hypothermia with activation of the
inflammatory cascade.
29. ISOTONIC CRYSTALLOIDS
ADVANTAGES
• INEXPENSIVE
• READILY AVAILABLE
• NON-ALLERGENIC
• NON-INFECTIOUS
• RESTORES TOTAL BODY FLUID
• EASY TO STORE AND ADMINISTER
• CAN BE RAPIDLY WARMED TO
BODY TEMP
DISADVANTAGES
LACK OF O2 CARRING CAPACITY
LACK OF COAGULATION
LIMITED INTRAVASCULAR LIFE
RECENT DATA SHOWS IT AS A
TRIGGER OF CELLULAR APOPTOSIS
30. HYPERTONIC SALINE
• Enhanced ability to restore intravascular volume in contrast to
equivalent isotonic crystalloids
• Studies involving polytrauma patients with both hemorrhage and TBI
showed improved neurological status and recovery from shock.
so, most commonly used as an osmotic agent in TBI and increased ICP
31. • ADVANTAGES
• RAPID INTRAVASCULAR VOLUME
RESTORATION AT A LWER
VOLUME
• READILY AVAILABLE
• EASILY STORED AND
ADMINISTERED
• RELATIVELY INEXPENSIVE
• DISADVANTAGES
LACK OF O2 CARRING CAPACITY
LACK OF COAGULATION
SYSTEMATIC REVIEWS CONTINUE TO
SHOW NO BENEFIT OF COLLOIDS OVER
CRYSTALLOIDS
COLLOIDS
32. RESTRICTIVE VS LIBERAL FLUID ADMINISTRATION
• Aggressive fluid administration via augmentation of blood pressure,
dilution of clotting factors, and production of hypothermia, disrupt
thrombus formation and enhance bleeding.
• Patient’s mental status and likelihood of intracranial injury, type of
injury, severity of injury (eg, ongoing hemorrhage), and proximity
to a trauma center to be considered.
• Aggressive fluid administration as ineffective and potentially harmful.
and limited volume replacement that maintains minimally adequate
organ perfusion improve outcomes. This strategy is often referred to as
delayed fluid resuscitation or controlled hypotension, an approach
which targets early fluid resuscitation only to a systolic blood pressure of
70 – 90 mmHg.[ palpable radial pulse]
33. HEMOSTATIC RESUSCITATION
1] Early use of blood and blood products as primary resuscitation fluids
to treat ATC and prevent development of dilutional coagulopathy.
2] Aggressive hemostatic resuscitation to be equally combined with
aggressive control of bleeding.
3] Transexamic acid 1g over 10 min f/b 1g over 8hours when given
within 1 hr for uncontrollable bleeding who required blood transfusion
were benefited.
As per CRASH2 trial in 2010 transexaemic acid significantly reduced
mortality due to haemorrhage without any increase of
Thrombo-embolic complications.
4] factor7,prothrombin complex, fibrinogen concentrates also play a
role in hemostatic resuscitation.
34. BLOOD TRANSFUSION
• The decision to initiate blood transfusion is based on the patient’s response, as
described in the previous section.
• Patients who are transient responders or nonresponders—those with Class III or
Class IV hemorrhage—will need pRBCs and blood products as an early part of
their resuscitation.
• CROSSMATCHED, TYPE-SPECIFIC, AND TYPE O BLOOD
• Fully crossmatched blood is preferable. However,the complete crossmatching
process requires approximately 1 hour in most blood banks.
• Type-specific blood can be provided by most blood banks within 10 minutes. Such
blood is compatible with ABO and Rh blood types, but incompatibilities of other
antibodies may exist.
• If type-specific blood is unavailable, type O negative packed cells are indicated
for patients with exsanguinating hemorrhage.
35. RBC:PLATELET:FFP------1:1:1 or 2:1:1 ?
• PROPPR trial and PROMMTT study showed that early use of higher
amounts of plasma and platelets was associated with improved
survival during first 6 hours after admission.
• Early availability of blood products administerd within minutes of
arrival using transfusion ratio of 1:1:1 was associated with better
hemostasis ad decreased hemorrhage related death.
36. DAMAGE CONTROL SURGERY
• Concept in which initial surgery becomes a part of resuscitation
process rather than curative process.
• Aimed at restoring normal physiology rather than anatomical integrity
• 3parts initial abbreviated laparotomy, ICU resuscitation, and
subsequent reoperation for definitive resuscitation.
• Only when patient is physiologically stable final therapeutic surgery is
carried out.
37. Disability and neurologic evaluation
Glasgow Coma Scale (GCS) score
Assessments of pupillary size and reactivity
Gross motor function, and sensation
38. Exposure and environmental control
Completely undressed and entire body is examined for signs of injury
during the primary survey
Missed injuries pose a grave threat
Regions often neglected include the scalp, axillary folds, perineum,
gluteal folds and in obese patients, abdominal folds.
• While maintaining cervical spine precautions, examine the patient's
back.
• Hypothermia should be prevented if possible and treated
immediately once identified.
• department (ED) and operating room (OR) temperatures of at least
29.4°C (85°F) during the treatment of these patients
• Make liberal use of warm blankets and active external warming
devices. Warm IV fluids and blood
39. DIAGNOSTIC STUDIES
• Portable x-rays
• Ultrasound (FAST exam) & Extended FAST (E-FAST)
• Diagnostic peritoneal tap or lavage
• Electrocardiogram
• Laboratory tests
40. X-rays
• Screening x-rays should be obtained, either in the emergency
department (ED) or the operating room (OR), even in
hemodynamically compromised patients who are sent directly to the
OR during or after their primary survey.
• Prompt imaging of the lateral cervical spine, chest, and pelvis can
detect life threatening injuries that might otherwise be missed.
• A plain radiograph of the chest should be obtained in patients with
penetrating injuries of the chest, back, or abdomen regardless of the
need for CT. Plain films may reveal sub-diaphragmatic free air, a
foreign body, or a pneumothorax or haemothorax
41. FAST
• Primarily to detect pericardial and intra-peritoneal bleed.
• Reliably identifies 200-250ml of intra-peritoneal fluid
Sensitivity/specificity: 75%/98%
Performed using a curvilinear 2.5 or 3.5 MHz probe
• Cardiac: parasternal or sub-xiphoid, hepato-cardiac interface, pericardial space.
RUQ: hepato-renal interface (Morrison’s Pouch), diaphragm, inferior pole of kidney.
LUQ: spleno-renal interface, diaphragm, inferior pole of kidney, inferior tip of spleen.
Suprapubic: outline of bladder, silhouette of uterus (females).
Cannot reliably evaluate retro-peritoneal structure/hollow viscous injury/
pelvic bleeding[cannot differentiate urine or blood]
• Unstable patient: FAST >>>>>>>> OR.
Stable : abdominal CT is gold standard
42. Diagnostic Peritoneal Lavage (DPL)
• Open or closed (Seldinger) approach
• It can be performed to detect intra-peritoneal blood when FAST
is unavailable, to determine the type of intra-peritoneal fluid
when it is important to do so (eg, blood vs urine in the setting of
a pelvic fracture)
• Highly accurate for hemo-peritoneum (Sn = 95%, Sp = 99%)
• Laparotomy when:
• 10 cc gross blood
• Enteric contents
• 1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3
• High Sn for hollow viscous injuries [More so than CT]
• Retro-peritoneum can’t be assessed
• High false positive DPL with pelvic fracture
• A negative aspirate in an unstable patient with a pelvic fracture
suggests retroperitoneal hemorrhage, and angiography with
possible embolization should ensue
43. Computerized Tomography
• It is a time-consuming procedure that should be used only in hemodynamically
normal patients.
• Sn = 92-97%, Sp = 99% for bleeding
• Only modality to directly detect retroperitoneal injury
• CT scanning's benefits include:
Detects not only the presence but the source and amount of hemo-peritoneum
Active bleeding often detectable
Retro-peritoneum and vertebral column can be assessed
• CT scanning's disadvantages include:
Suboptimal sensitivity for pancreatic, diaphragmatic, bowel, and mesentery
injury.
Can be unobtainable or harmful to obtain in unstable patients
44. SECONDARY SURVEY
• A secondary survey is performed in all trauma patients determined to
be stable upon completion of the primary survey. The secondary
survey includes a
Detailed history[ AMPLE],Detailed Head to Toe examination,
Targeted diagnostic studies
plays a crucial role in avoiding missed injuries
TERTIARY SURVEY < 24 hours & prior to discharge.
• Identifies and catalogues all injuries after the initial resuscitation and
operative intervention . The timing of this survey typically occurs
within twenty four hours after admission and is repeated when the
patient is awake, responsive, and able to communicate any
complaints & prior to discharge.
45. DRUG HISTORY
1] Ask for co-morbid illness
2] Beta blockers- can maintain normal heart rate in hypovolemia.
3] Psychiatric medications-injuries can be self inflicting
4] ANTI-PLATELET AND ANTI-COAGULANTS esp in TBI
Warfarin
– Suggestive reversals
Vitamin K (10mg IV);FFP; rFVIIa; Transexamic Acid.
Unfractionated Heparin (UHF)
Reversal agent = Protamine
Low Molecular Weight Heparin
No proven antidote, Protamine is suggested but it may only
neutralize 60% of the anti-factor Xa activity in LMWH
46. Antiplatelet Agents
Platelet transfusion may be useful; DDAVP can be considered
Fondaparinux, • Apixaban and Rivaroxaban
No specific antidote
Direct Thrombin Inhibitors
Argatroban and Bivalirudin
No specific antidote
Rapidly eliminated upon cessation of the therapy
Dabigatran
NO REVERSAL
Hemodialysis, – PCC’s or activated PCCs?, FFP?, rFVIIa?
47. HEAD INJURY
• The primary goal of treatment for patients with suspected traumatic
brain injury (TBI) is to prevent secondary brain injury.
• Secondary injury may occur due to hypotension, hypoxia, hypercapnia,
and iatrogenic hypocapnia.
49. MANAGEMENT OF HEAD INJURIES
1] Adequate oxygenation (PaO2 >60 mmHg) and blood pressure
support (systolic BP >90 mmHg) Isotonic fluids (normal saline) should
be used to maintain euvolemia.
A subgroup analysis in the large SAFE study found that for patients with TBI, fluid resuscitation with
albumin was associated with a higher mortality as compared with normal saline (33 versus 20
percent); this risk was even more pronounced in those with severe TBI (42 versus 22 percent)
2] Early endotracheal intubation is generally recommended for patients
with a Glasgow coma scale score of 8 or less
3] Management of raised ICP
ventriculostomy placement with ICP monitoring in patients with
severe TBI and an abnormal CT scan showing evidence of mass effect
from lesions such as hematomas, contusions or swelling
50. 4] CPP target is 60 mmHg, avoiding CPP >70 mmHg and <50 mmHg,
which should be achieved by optimizing ICP first and then MAP (with
volume expansion, vasopressors) second
5] Short-term (one week) use of antiepileptic drugs ( phenytoin ,
valproate ) for the prevention of early seizures
6] fever and hyperglycemia be avoided for their potential to exacerbate
secondary neurologic injury. Coagulopathy should be corrected to
maintain an INR < 1.4 and a platelet count > 75,000/mm 3 .
7] SURGICAL TREATMENT OF INTRA CRANIAL HAEMORRAGES
PENETRATING INJURIES, SKULL FRACTURES, DECOMPRESSIVE
CRANIECTOMY
51. THREE TIERED APPROACH FOR INCREASED ICP
TIER 1 TIER 2
1] Head elevation to 30 degree 1] Hyperosmolar therapy
2] Neck in neutral position 2] PaCO2 of 30-35mmhg
3] Sedation, analgesia if intubated 3] Neuromuscular paralysis
4] Ventricular drainage intermittently if persistent increased ICP
5] Rpt CT, neurological examination 4] Repeat CT, neurological exam
To R/O mass lesion
IF ICP REMAINS 20-25mmhg TIER 2 IF ICP REMAINS 20-25mmhg TIER3
52. TIER 3
1] Decompressive craniectomy
2] Neuromuscular paralysis via continuous infusion to maintain alteast 2
twitches in TOF
3] Barbiturate Coma
4] Hypothermia as a rescue or salvage therapy
53. Mannitol
Use with signs of tentorial herniation
Dose: 0.25-1.0 g / kg IV bolus
• Consult with neurosurgeon first
• Mannitol should not be given to patients with hypotension, because
mannitol does not lower ICP in hypovolemia and is a potent osmotic
diuretic. This can further exacerbate hypotension and cerebral ischemia.
Hypertonic saline
2-6ml/kg bolus is also used to reduce elevated ICP.
Concentrations of 3% to 23.4% are used,
and this may be the preferable agent to use in patients with
hypotension, as it does not act as a diuretic. However, there
is no difference between mannitol and hypertonic saline
in lowering ICP
54. •Hyperventilation should be used only in
moderation and for as limited a period as
possible
• hypercarbia (PCO2 > 45mm Hg) will promote vasodilation and
increase intracranial pressure, and thus it should be avoided.
• Hyperventilation will lower ICP in a deteriorating patient with
expanding intracranial hematoma until emergent craniotomy
• Aggressive and prolonged hyperventilation may promote cerebral
ischemia in the already injured brain by causing severe cerebral
vasoconstriction and thus impaired cerebral perfusion. This is
particularly true if the PaCO2 is allowed to fall below 30 mm Hg
55. Indications for CT Scan?
1] ALL PATIENTS WITH MODERATE AND SEVERE BRAIN INJURY
NEW ORLEANS CRITERIA
Headache
Vomiting
Age over 60 years,
Drug or alcohol intoxication,
Deficits in short-term memory,
Physical evidence of trauma above the clavicles, and seizure.
CANADIAN CT HEAD RULE in MTBI
• GCS score less than 15 at 2 hours after injury
• Suspected open or depressed skull fracture
• Any sign of basilar skull fracture (e.g., hemotympanum,
raccoon eyes, CSF otorrhea or rhinorrhea, Battle’s sign)
• Vomiting (more than two episodes)
• Age more than 65 years
2]Indications for CT Scanning in MTBI
MODERATE RISK FOR BRAIN INJURY ON CT
• Loss of consciousness (more than 5 minutes)
• Amnesia before impact (more than 30 minutes)
• Dangerous mechanism (e.g., pedestrian struck by
motor vehicle, occupant ejected from motor vehicle,
fall from height more than 3 feet or five stairs
56. SPINAL SHOCK
• Spinal shock refers to the flaccidity (loss of muscle tone) and loss of
reflexes seen after spinal cord injury.
• The “shock” to the injured cord may make it appear completely
nonfunctional, although the cord may not necessarily be destroyed.
• The duration of this state is variable.
60. RADIOGRAPHIC IMAGING
NEXUS -The National Emergency X- Radiograph Utilization
Study
• Prospective study to validate a rule for the decision to obtain
cervical spine x- ray in trauma patients
• Hoffman, N Engl J Med 2000; 343:94-99
Canadian C-Spine rules
• Prospective study whereby patients were evaluated for 20
standardized clinical findings as a basis for formulating a decision
as to the need for subsequent cervical spine radiography
• Stiell I. JAMA. 2001; 286:1841-1846
61. NEXUS Criteria
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain
• Patient who fulfilled all 5 of the criteria were considered low
risk for C-spine injury
No need C-spine X-ray
• For patients who had any of the 5 criteria
radiographic imaging was indicated
( AP, lateral and open mouth views
62.
63. Canadian Cervical Spine Rule for stable and alert
patients where cervical spine injury is a concern
1. High risk factors that
require imaging
• Age ≥65 yo
• Dangerous mechanism of
injury
• Fall from 1m (5 stairs)
• Axial load to the head
(eg. Diving)
• MVA- high speed
(>100kph, rollover,
ejection)
• Motorised recreational
vehicles
• Bicycle collision
• Paraesthesia in
extremities
2. Low risk factors that allow
safe assesment of range of
motion
• Sitting position in the
emergency department or
• Simple rear end MVA or
• Ambulatory at any one time
or
• Delayed onset of neck pain
or
• Absence of midline C-spine
tenderness
64. Immobilization Cervical spine injury requires continuous immobilization of
the entire patient with a semi-rigid cervical collar, head immobilization,
backboard, tape, and straps before and after transfer to
a definitive-care facility
65. Four-Person Logroll. Logrolling a patient to remove a spine board and/or examine
the back
(A) One person stands at the patient’s head to control the head and c-spine, and two are along the patient’s
sides to control the body and extremities.
(B) As the patient is rolled, three people maintain alignment of the spine, while
(C) the fourth person removes the board and examines the back. (D) Once the board is removed,
the patient is returned to the supine position, while maintaining alignment of the spine
66. INTRAVENOUS FLUIDS in spinal trauma
1] Intravenous fluids are administered as they would usually be for
resuscitation of trauma patients.
2] If active hemorrhage is not detected or suspected, persistent
hypotension should raise the suspicion of neurogenic
shock.
3] Patients with hypovolemic shock usually have tachycardia, whereas
those with neurogenic shock classically have bradycardia.
If the blood pressure does not improve after a fluid challenge, use
of DOPAMINE is usually the vasopressor of choice.
68. B-Identify and initiate treatment of the following
potentially life-threatening injuries assessed during the
secondary survey:
1.Pulmonary contusion
2.Aortic disruption
3.Tracheobronchial disruption
4.Esophageal disruption
5.Traumatic diaphragmatic hernia
6.Myocardial contusion
69. CARDIAC TAMPONADE
DIAGNOSED BY : Beck’s triad, FAST scan, suspected if not responding to
resuscitation of haemorrhagic shock
TREATED BY : Surgical evacuation of pericardial blood.
MASSIVE HAEMOTHORAX
DIAGNOSED BY : Clinically, radiologically, suspected if not responding to
resuscitation of haemorrhagic shock.
TREATED BY : Simultaneous restoration of blood volume.
Decompression by chest tube insertion
Thoracotomy[ if >1500ml bleed or persistent bleed]
70. Chest pain
■ Respiratory distress
■ Tachycardia
■ Hypotension
■ Tracheal deviation away
from the side of
injury
■ Unilateral absence of
breath sounds
■ Neck vein distention
■ Cyanosis (late
manifestation)
Definitive treatment: insertion of a chest
tube into the 5th ICS.
. Immediate
covering of
defect
. Chest tube
. Definitive
operation
Open Pneumothorax--->
Tension Pneumothorax--^
71. FLAIL CHEST
Paradoxical motion of the chest wall during inspiration and
expiration.
If the injury to the underlying lung is significant, serious
hypoxia can result
Ensure adequate oxygenation
Provide analgesia to improve ventilation
[NSAIDS,OPIOIDS,EPIDURAL, INTERCOSTAL BLOCK]
Intubation and mechanical ventilation is rarely indicated for chest wall
injury alone. Where ventilation is necessary it is usually for hypoxia due
to underlying pulmonary contusions.
72. Resuscitative Thoracotomy
The therapeutic maneuvers that can be effectively accomplished
with a resuscitative thoracotomy are:
1] Evacuation of pericardial blood causing tamponade
2] Direct control of exsanguinating intrathoracic hemorrhage
3] Open cardiac massage
4] Cross-clamping of the descending aorta to slow blood loss below the
diaphragm and increase perfusion to the brain and heart.
73. Abdominal and Pelvic Trauma
ASSESMENT AND MANAGEMENT
1] Inspect the abdomen and flanks for lacerations, contusions and
ecchymosis; palpate for tenderness and rigidity.
The presence of a seat belt sign, rebound tenderness, abdominal
distension, or guarding all suggest intra-abdominal injury.
2] Rectum and genitourinary — Inspect the perineum of all patients for
signs of injury
3] DRE is warranted in cases where urethral injury or penetrating rectal
injury is suspected. If the examination is performed, check for the
presence of gross blood (sign of bowel injury), a high-riding prostate (sign
of urethral injury), abnormal sphincter tone (sign of spinal cord injury),
and bone fragments (sign of pelvic fracture).
74. Indications for Laparotomy
1] Blunt abdominal trauma with hypotension
with a positive FAST or clinical evidence of
Intra-peritoneal bleeding
2] Blunt or penetrating abdominal trauma
with a positive DPL
3] Hypotension with a penetrating abdominal
wound
4] Gunshot wounds traversing the peritoneal
cavity or visceral/vascular retro-peritoneum
5] Evisceration
6] Bleeding from the stomach, rectum, or
genitourinary tract from penetrating
trauma
7] Peritonitis
8] Free air, retroperitoneal air, or rupture
of the hemi-diaphragm
9] Contrast-enhanced CT that
demonstrates ruptured gastrointestinal
tract, intra-peritoneal bladder injury, renal
pedicle injury, or severe visceral
parenchymal injury after blunt or
penetrating trauma
75. Musculoskeletal Trauma
ASSESS AND MANAGE
Major arterial hemorrhage
Vascular compromise
Open fractures, Pelvic fractures
Crush syndrome
Compartment syndrome
76. MEASURES IN MUSCULOSKELETAL TRAUMA
• Reduce fracture, Stabilize pelvis
• Splint fracture
• Application of direct pressure [if bleeding]
• Use of a tourniquet may be helpful and lifesaving [ severe bleed]
• Appropriate fluid resuscitation [ prevents crush syndrome]
• All constrictive dressings, casts, and splints applied over the affected
extremity must be released[ in compartment syndrome]
If no significant changes occur, fasciotomy is required
78. Determining the Need for Patient Transfer
It is essential that clinicians assess their own capabilities and
limitations, as well as those of their institution, to allow for early
differentiation between patients who may be safely cared for in the
local hospital and those who require transfer for definitive care.
TIMELINESS OF TRANSFER
When should I transport the patient?
Patient outcome is directly related to the time elapsed between
injury and properly delivered definitive care. In institutions in which
there is no full-time, in-house emergency department (ED) coverage,
the timeliness of transfer is partly dependent on the how quickly the
doctor on call can reach the ED.
In addition, the attending doctor must be committed to respond to
the ED prior to the arrival of critically injured patients.
79. WHOM DO I TRANSFER?
CATEGORY SPECIFIC INJURY &OTHER FACTORS
CNS – Penetrating injury or depressed skull fracture
– Open injury with or without cerebrospinal fluid (CSF) leak
– GCS score <15 or neurologically abnormal
– Lateralizing signs
• Spinal cord injury or major vertebral injury
CHEST • Widened mediastinum or signs suggesting great vessel injury
• Major chest wall injury or pulmonary contusion
• Cardiac injury
• Patients who may require prolonged ventilation
PELVIS/ABDOMEN • Unstable pelvic-ring disruption
• Pelvic-ring disruption with shock and evidence of continuing
hemorrhage
• Open pelvic injury
• Solid organ injury
EXTREMITIES • Severe open fractures
• Traumatic amputation with potential for replantation
• Complex articular fractures
• Major crush injury
• Ischemia
MULTI SYSTEM INJURIES • Head injury with face, chest, abdominal, or pelvic injury
• Injury to more than two body regions
• Major burns or burns with associated injuries
• Multiple, proximal long-bone fractures
80. SECONDARY DETERIORATION Mechanical ventilation required
• Sepsis
• Single or multiple organ system
failure (deterioration in central
nervous, cardiac, pulmonary, hepatic,
renal, or coagulation systems)
• Major tissue necrosis
CO MORBID FACTORS ELDERLY, CHILD<5, DM, CARDIC
DISEASE, RESPIRATORY DISEASE,
PREGNANCY, MORBID OBESITY,
IMMUNOSUPPRESSION
Patients with evidence of shock, Significant physiologic
deterioration, or progressive
Deterioration in neurologic status require the highest
Level of care and will likely benefit from timely
transfer
81. The inter-hospital transfer of a critically injured patient is
potentially hazardous unless the patient’s condition is optimally
stabilized before transport, transfer personnel are properly
trained, and provision has been made for managing unexpected
crises during transport.
82. TREATMENT PRIOR TO TRANSFER
• Patients should be resuscitated and attempts made to stabilize their conditions as completely as
possible based on the following suggested outline:
• 1. Airway
a. Insert an airway or endotracheal tube, if needed.
b. Provide suction.
c. Insert a gastric tube to reduce the risk of aspiration.
• 2. Breathing
a. Determine rate and administer supplementary oxygen.
b. Provide mechanical ventilation when needed.
c. Insert a chest tube if needed.
• 3. Circulation
a. Control external bleeding.
b. Establish two large-caliber intravenous lines and begin crystalloid solution infusion.
c. Restore blood volume losses with crystalloid fluids or blood and continue replacement during
transfer.
d. Insert an indwelling catheter to monitor urinary output.
e. Monitor the patient’s cardiac rhythm and rate.
83. 4. Central nervous system a. Assist respiration in unconscious patients.
b. Administer mannitol, if needed.
c. Immobilize any head, neck, thoracic, and lumbar spine injuries.
5.Diagnostic studies When indicated; obtaining these studies should not delay transfer
6. Wounds Performing these procedures should not delay transfer.
7. Fractures Apply appropriate splinting and traction.
84. TREATMENT DURING TRANSPORT
• The appropriate personnel should transfer the patient, based on the patient’s
condition and potential problems.
• Treatment during transport typically includes:
1.Monitoring vital signs and pulse-oximetry
2.Continued support of cardio-vascular system
3.Continued blood-volume replacement
4.Use of appropriate medications as ordered by a
doctor or as allowed by written protocol
5.Maintenance of communication with a doctor
or institution during transfer
6.Maintenance of accurate records during transfer
PITFALL: ET tubes, IV cannulas may
get dislodged during transport.
Necessary equipments to be ready
for the procedure.
85. Establishment of transfer agreements provide
for the consistent and efficient movement of
patients between institutions, and enhance the
efficiency and quality of the patient’s
treatment during transfer.
86. Transfer responsibilities are held by both referring and receiving
doctor
• REFERRING DOCTOR
The referring doctor is responsible for initiating transfer of the patient to the
receiving institution and selecting the appropriate mode of transportation and level
of care required for optimal treatment of the patient
• Stabilizing the patient’s condition before transfer to another facility is the
responsibility of the referring doctor, within the capabilities of his or her
institution.
• Initiation of the transfer process should begin while resuscitative efforts are in
progress.
• Transfer agreements must be established to provide for the consistent and efficient
movement of patients between institutions.
• PITFALL
Inappropriate communication b/w Referring and accepting care providers resulting in loss of
information critical to the patient’s care.
87. RECEIVINGDOCTOR
1.The receiving doctor must be consulted with regard to the transfer of a
trauma patient.
2.The receiving doctor should assist the referring doctor in making
arrangements for the appropriate mode and level of care during transport.
3. If the proposed receiving doctor and facility are unable to accept the
patient, they should assist in finding an alternative placement for the patient.
4. Only by direct communication between the referring and receiving doctors
can the details of patient transfer be clearly delineated.
5.If adequately trained emergency medical personnel are not available, a nurse
or doctor should accompany the patient.
6.All monitoring and management rendered en route should be documented.
88. MODES OF TRANSPORTATION
• Do no further harm is the most important principle when choosing
the mode of patient transportation.
• Ground, water, and air transportation can be safe and effective in
fulfilling this principle, and no one form is intrinsically superior to the
others.
• Local factors such as availability , geography, cost, and weather are
the main determining factors as to which to use in a given
circumstance.
• PITFALL
failure to anticipate deterioration in the patient’s neurologic
condition or hemodynamic status during transport
89. REFERENCES
• ADVANCED TRAUMA LIFE SUPPORT 9TH EDITION
• MILLERS ANAESTHESIA 8TH EDITION
• WASHINGTON MANUAL OF CRITICAL CARE 2ND EDITION
• JOURNAL OF ANAESTHESIOLOGY CLINICAL PHARMACOLOGY: Fluid
management in trauma patients Restrictive vs Liberal approach
• INDIAN JOURNAL OF ANAESTHESIA: Transfusion practice in Trauma.
• JAMA CARDIOLOGY: Transfusion of plasma platelet RBC in 1:1:1 vs
1:1:2
• BRITISH JOURNAL OF ANAESTHESIA: Damage control surgery in the
era of damage control resuscitation
