Approach to Trauma

MOHD AZRISHAH BIN ADNAN

Asst. MEDICAL OFFICER U29
25th PPW ETD QEH II
 Sub topic.
Initial assesment and
managment: Primary
and Secondary Survey.

Life threathening injuries.

Potentially Life
Threatening Injuries.
 What is Trauma?

• Trauma refers to a physical injuries of sudden onset and severity which

require immediate medical attention.

• injuries may be minor, serious, life-threatening or potentially life-

threatening.

• usually categorised as a blunt or penetrating.

• any bodily injury or disruption of the bodily function by a physical agent.

 Trauma death.

• 1st peak- within seconds to

minutes.
• 2nd peak - within minutes to
several hours after injury.
• 3rd peak - several days or
weeks after initial injury.
First peak.
• within seconds to minutes.

• Causes:

-Leceration of the brain

-Brain stem injury

-high spinal cord injury

-heart, Aorta, Large vessels

lacerations.
 Second peak.
• Within minutes to several hours after injury.
• “GOLDEN HOUR”= Rapid transportations,
rapid assessment and stabilizations, rapid
definitive care.
• Preventable and managable.
• Causes:
-Subdural/Extra-dural hematoma
-Haemo-Pneumothorax
-Liver lacerations
-Pelvic Fractures
Multiple Injuries assoc. w. significant blood loss.
 Third peak.

• Several days or weeks after initial injury.

• Causes:

-Sepsis

-Organ Failure

-Missed Injuries
 Initial Assessment

Include several elements:

• Primary Survey

• Secondary Survey
 Primary Survey.
• Preliminary assesment in a systemic manner.
• Assess and address life threatening injuries in order and manage them as soon as they
are found.
• 10 seconds assessment.
• Primary survey and resuscitation of vital funtions are done simultaneously.
• Primary survey covers the ABCDE to identifies life-threatening conditions by
adhering to this sequence.
• Primary survey In Pre-hospital Phase (DR)ABCDE.
 Airway & Cervical Spine Protection.
• Ascertain patency (look,listen and feel).

• Identify any cause that can result to airway obstruction.

• If patient is able to communicate well, the airway is not likely to be immediate jeopardy.

• Establish a definitive airway if there is any doubt about the patient’s ability to maintain
airway integrity.

• Prevent excessive movement of the cervical spine.

 Breathing & Ventilations.
• Assessby exposing the neck and chest

• Determine rate and depth of respiration.

• Perform full examination using the IPPA sequance.

• INSPECTION: to see if there any chest rise, jvp distended ??

• PALPATION: to assess for tracheal deviation, chest wall, s/c emphysema, signs of deformity.

• PERCUSSION: if theres any dull or hyper-resonance ?

• AUSCULTATION: listen if there is any abnormal sound or equal air entry.

 CIRCULATION with HEMORRHAGE
CONTROL.
• Hemorrhagic shock should be assumed in every hypotensive trauma patient.
• Perform rapid assessment of hemodynamic status, CCTVR can be use to perform a circulation investigation.
• C=Colour,Crt, T=temperature, V= pulse volume, R= pulse rate.
• Rapid assessment of pt’s hemodynamic status:
-Level of consciousness: Reduced cerebral perfusion -> reduced GCS
-Skin colour: ashen and grey skin of face/ white skin of extremeties indicate hypovolemia – blood vol loss >30%
-Pulse: the earliest sign of shock
-Presence of rapid, weak, thready, absent pulse + Assess volume and rate
-Blood Pressure: Low only after a significant amount of circulating blood volume is lost (usually at least 2L), corresponding
to class III/IV shock
 Disability

• Level of consciousness, ams ?

• Assess GCS: E?,V?,M?=??/15(3-8 SEVERE TBI;9-12

MODERATE;13-15 MILD)

• Pupil size and reactivity

• Motor function.
 Exposure
• Exposure facilitates thorough examination and assessment

• Completely undress the patient (cut off clothing as appropriate)

• Identify all external injuries and bleeding

• Always examine the back, pelvis, genitalia, groin

• Prevention of hypothermia

• Use warm blanket/ warmer

• Warm fluids before administering.

• Ensure a warm environment

ALWAYS INSPECT
THE BACK !
 Adjuct to Primary Survey
• 2+2+2+2+4

• 2 TUBES – RYLE'S TUBE , CBD

• 2 IMAGING : CHEST XRAY PELVIS

XRAY

• 2 IX : ECG, FAST SCAN

• 2 DRUGS : ATT, ANALGESIA

• 4 V/S : RR, ABG, BP, SP02

 Secondary Survey.

• Performed after Primary survey and the patient is resusitated and stable.

• To take a complete history

• Detailed Examinations from head to toe.

• Aims to detect other significant but not immidiate life threatening injury, to reduce
missing of failling investigation to patient’s injury.
 History
AMPLE accronym are use for history taking.

• Allergies

• Medications

• Past medical hx

• Last meal

• Event leading to injuries.

 HEAD to TOE examinations.

• Any injuries should be documented

• Any woud should be dress and cover.

• Any fracture should be splint.

 Head and Maxilofacial
• Assessment:

- Inspect for lacerations/ contusions/ thermal injuries

- Palpate for fractures

- Test cranial nerve functions

- Inspect the eyes for hemorrhage, corneal haziness, penetrating injury,

visual acuity, presence of contact lens

- Inspect ears and nose for CSF leakage and hemotympanum

- Examine oral cavity for FB and bleeding

Management:

• Ensure continual airway patency

• Control hemorrhage by compression • Prevent secondary brain injury

• Remove contact lenses

 Cervical spine and Neck examination.
• Carefully inspect and palpate the neck and carefully immobilize.

• assume cervical spine injury in head trauma or maxilofacial injusires and cervical motion
must be restricted.

• perform IPPA ix, look for subcutaneous emphysema, tracheal deviation and jvp
distention.
 Chest examinations.

• Visual evaluation of the anterior and posterior to identify conditions such as open
pneumothorax and large flail segments.

• Palpations over the entire chest cage including the clavilcles, ribs,and sternum.

• Note any dullness or hyperresonance.

• Auscultation the lung to find any abnormal lungs sound.

 Abdominal and Pelvic examination.
• Inspect if there is any distended and if ecchymosis present thats indicate internal abnominal bleed. Pay
close attention to the illiac wings, pubic, labia, or scrotum for ecchymosis also.

• Palpate for tenderness, distension, gurding or rebound tenderness.

• Auscultate for bowel sound.

• Perform pelvic spring manoeuvre(Upper, Inner & Outter)

• Ensure pelvic binder apply once pelvic spring positive.

• To perform eFAST or CTa

 Upper & Lower LIMBS
• Palpate short and long bone anterior and posterior for any tenderness and unseen bleeding over
posterior side.

• Check for joints toned and muscular power.

• Assess extremities using CCTVR. Ensure DPA, PTA, Radial & Bracheal pulse are palpable.

• Body tenderness and deformity along the entire length of the spine and sacroiliac joint of pelvic.
( perform logroll prior examination)
 Posterior, Perineal and Rectal.
• Perform logroll

• Note any deformity bruising and laceration wound.

• Palpate the spine for any tenderness.

• see if any blunt or penetrating trauma.

• Perinial=see if any blood at the urethal meatus, scrotal bruising and hematoma, Perineal bruising,
wounds and tears.

• ensure anal spincter tone, perinial sensation, bowel wall integrity, bony fragments from pelvic,prostate
position and rectal bleeding.
LIFE THREARTENING
INJURIES
 ATOM TC
• Airway obstruction

• Tension Pneumothorax

• Open Pneumothorax

• Massive Haemothorax

• Tracheobronchial Injury

• Cardiac Temponade.
 Airway Obstruction.
• Control of airway is the foremost in trauma

• Protect the cervical spine as the airway is being managed (in line
immobilization)

• Causes of airway obstruction:

- The tongue is the most common cause

- Dentures, avulsed teeth, tissue, secretions, and blood

- Bilateral mandibular fracture

- Posterior dislocation of the clavicular head

- Expanding neck hematomas

- Laryngeal trauma

- Tracheal tear or transection

 Airway Obstruction
Sign and Symptoms Management
• Stridor • Intubate using a controlled rapid
• Hoarseness
sequence when in doubt of obstruction

• • Provide inline cervical spine

Subcutaneous emphysema
immobilization during intubation.
• Altered mental status
• Early intubate in cases of neck
• Accessory muscle working hematoma or possible airway edema
• Apnea and Cyanosis (sign of pre-terminal • Emergency cricothyroidotomy should
hypoxemia).
perform if endotracheal intubation
If any suspicion of airway obstruction or inability to
exchange air adequately mandates early intubation.
 Tension Pneumothorax

• Air enters pleural space and becomes trapped

leads to pressure increase.

• Increased pressure which collapses lung and

shifts mediastinum to unaffected side.

• Increased dyspnoea and compressed heart and

great vessels leads to decreased cardiac output.
Leads to Cardiogenic Shock
 Signs & Symptoms
Anxiety
Dyspnoea / Tachypnoea
Tracheal Deviation
Diminished breath sounds
Reduced chest expansion
Hyperresonance
Hypotension and Tachycardia, distended neck
veins Narrowing pulse pressure -Late Sign
of Shock

Management:
1. Immediate Needle
Thoracocentensis (temporary measure) – 2nd
ICS in the midclavicular line of affected
hemithorax.

2. Chest tube placement (definitive)

 Open Pneumothorax

• Occurs when there is a pneumothorax associated with a chest

wall defect -> pneumothorax communicates with the exterior.

• • During inspiration(anegativeintra-thoracicpressureis
generated) air enters into the chest cavity not through the
trachea but through the hole in the chest wall.

• This results in inadequate oxygenation and ventilation,anda

progressive build-up of air in the pleural space.
 Open Pneumothorax

Management:
Signs & Symptoms:
• Seal the wound with a
• • Bubbling at wound site sterile occlusive dressing,
large enough to overlap
• • Dyspnoea and Tachypnoea the wounds edges

• • Reduced breath sounds • And tape securely on 3-

sides to create a flutter-
• • Reduced chest expansion valve effect

• • Hyperresonance • Then insert a chest tube

away from the wound site
 Massive Haemothorax
• Rapid accumulation of more than 1500 mL of blood or 1/3 or more
of the patient’s blood volume in the chest cavity

Possible Sources:

• Intercostalvessels

• Internalmammary artery

• Pulmonaryvessels

• Lungparenchyma

Can lead to tension pneumothorax

 Massive Hemothorax
Signs and Symptoms
Management
• External bruising or lacerations over chest wall • Tube thoracostomy- use the largest
available and direct it posteriorly
• Evidence of a penetrating injury over the affected
hemithorax.
downwards towards spine and
diaphragm.
• Decreased chest expansion • Blood transfusion.

• Dullness to percussion

• Reduced breath sounds

• Mediastinal or tracheal deviation

Usually subtle in supine patients and are usually

diagnosed via imaging (in small to moderate
hemothoraces. Massive hemothorax is diagnosed
clinically
 Massive Hemothorax.
• In erect film- a fluid level
with a meniscus is seen.
• The chest X-ray shows a
diffuse opacification of the
hemithorax, through
which lung markings can
be seen.
 TracheoBronchial injury.
• Injury to the trachea and major bronchus.

• sometimes injuries occur within 1 inch of the carina.

• result from blunt or penetrating trauma to the neck or chest.

• Inhalation of harmful Fume/Smoke or aspiration of liquid or

object.

• Typically present with hemoptysis, cervical emphysema,

tension pneumothorax, and/or cyanosis.
 TracheoBronchial injury.

Managment:

• Intubation, may be difficult because of anatomic distortion from paratracheal hematoma.

• May use Advance airway skills such as fiber-optically assisted.

• Immediate operative intervention.

• If patient is stable operative treatment may be delayed until the acute inflammation and
edema resolve.
 Cardiac Temponade

• Compression of the heart by an accumulation of fluid in

the pericardial sac.

• Source of blood can be coronary arteries or

myocardium.

• Pericardium may hold up to 200-300ml of blood before

S&S develop.

• Beck’s Triad= Hypotension, JVP Distention, Muffled

heart sound.
 Cardiac Temponade
Managment:
• Administration of intravenous fluid.
Signs & Symptoms: • Pericardiocentensis Ultrasound guided vs blind
- Using large bore needle- eg angio-catheter, 2cm below the
• Tachycardia xiphisternum, aiming
towards the left shoulder, at a 45 degree angle.
• Paradoxical pulse
- Apply negative pressure from your syringe until fluid is
• withdrawn/ cardiac
Increased JVP
pulsations felt/ ECG waveform change noted.
• Narrowing pulse pressure - If ECG waveform shows an injury pattern (ST segment
elevation), then slowly
• Muffled heart sounds withdraw the needle until the pattern returns to normal, as this
change in waveform suggests that the spinal needle is in
• S&S of shock (squeezing direct contact with the myocardium.
pain,sob,pain radiation, increasing epi
of chest pain. • Emergency thoracotomy or sternotomy
 Potentially life treathening injury.
Beware of the “HIDDEN EIGHT”.
• Potentially life- threatening injuries assessed during secondary survey

1. Pulmonary Contusion

2. Myocardial Contusion

3. Aortic Disruption

4. Traumatic Diaphragmatic Hernia

5. Tracheobronchial Disruption

6. Esophageal Disruption

7. Simple Pneumothorax

8. Non-Massive haemothorax
 REFERANCE
• ADVANCE TRAUMA LIFE SUPPORT Student course manual

• Oxford handbook of Acute Medicine, Third Edition, edited by Punit S. Ramrakha, Kevin P. Moore, Amir Sam.

• Lecturio Medical Emergency CME (youtube)

• My Emergency teacher (youtube)

• Participants Handouts PHCLS level 1, Updated 2020/2, Pre-Hospital Malaysia Training Unit.

• Guide to the essentials in Emergency Medicine 2nd Edition, Edited by Shirley Ooi and Peter Manning.

• Discussion with Dr.Selva EP ETD QEH II

• Discussion with Mentor AMO Syaripuddin Daring & AMO Stefano Spencer T.

• Discussion with Senior AMO ETD QEH II: AMO Cheng Ming Ho & AMO JIhad Faruqiy

• Discussion with MO ETD Tuanku Ja’afar Hospital, Seremban: Dr. Annusha D/O Chandrasikran
THANK YOU !!