1. Principles of Trauma Symphony of Surgery
Dr. Hassan Bukhari
Depart of Surgery
4-1435

2. Objectives
By the end of this discussion, the doctors will be able to*:
Recognize the impaction of trauma
Understand the trimodal death distribution
understand the general principles of Primary and Secondary Survey and management
Establish the ability to recognize the critical scenarios in trauma patients
*ATLS-Student Course

3. Contents MCQ / Scenarios – based lecture Why trauma is important?
What is the Trimodal death distribution and the golden hours?
Mechanisms of Injury
Primary Survey
Secondary Survey
References

4. Why Trauma is Important?
Around 5 million deaths worldwide
Motor vehicle crash (MVC)
1 million deaths annually
The leading cause of death between the age of 1 and 44 in developing country
Almost 5000 deaths in KSA in one year (1429)*
1 death every one and half hour!!! *

5. Trimodal death phases Immediate death ( --- ) Early death ( --- )
Brain, spine, CV
Early death ( --- )
Brain bleed, rupture organ
Late death ( --- )
Infection, organ failure

6. Mechanisms of Injury Blunt Trauma Penetrating Trauma MVC Fall PHBC
Stabbing
Gunshot

8. MCQ #1
20 year old male pt, involved in MVC, came to ER unconscious and low blood pressure with bleeding wound in the leg. What is the most important initial step?
1. Control airway
2. Control blood pressure
3. Control bleeding wound
4. Order chest x-ray ✓

9. Initial assessment and management
Prehospital Phase
Paramedics
Hospital Phase
Triage
Primary Survey + Resuscitation
Adjuncts to primary survey
Secondary Survey
Adjuncts to secondary survey
Definitive treatment

10. Primary Survey

11. A Primary Survey Airway control with cervical spine Alignment
Quickest way to assess airway?
Types of airways? A

12. Primary Survey
Breathing
Look, feel and listen
Pulse oximetry B

13. C Primary Survey Circulation + Control the bleeding wound
Pulse, BP, bleeding wound
Hemorrhagic shock C

14. D Primary Survey Disability Glascow coma scale (GCS): 15 GCS Pupils
Lateralization
Glascow coma scale (GCS): 15
Eye: 4
Verbal: 5
Motor: 6
Most important predictor of outcome D

15. Primary Survey
Exposure
Avoid hypothermia E

16. MCQ #2
38 YO Female was hit by a car when crossing the street. She is screaming of pain in her leg. Her HR 98, BP 90/50, good breath sound bilateral, deformed left leg. What is the most appropriate intervention:
1 – Intubate
2 – Insert chest tube
3 – Establish intravenous access and give fluid
4 – Send her home because she is not nice with you ✓

17. Resuscitation
For each step in Primary survey, you should fix it before you move to the next step
Airway – intubate or not
Breathing – give O2 , insert chest tube
Circulation – give fluid, stop the bleeding

18. Adjunct to Primary Survey
ECG
Foley catheter + NGT
Blood tests
X-rays
FAST (focused assessment with sonography for trauma)

19. MCQ # 3
48 YO Male, fell down a 5 meter ladder. He is talking to you, C/O difficulty in breathing. HR 88, BP 110/90, O2 Sat 92 and he has no breath sound in the right chest. What would be the appropriate initial assessment and management?
1- Breathing, airway, circulation
2-Airway, circulation, breathing
3-Circulation, breathing, airway
4-Insert chest tube immediately after checking the airway ✓

20. Secondary Survey History (AMPLE) Physical examination A – Allergies
M – Medications
P – Past Medical / Pregnancy
L – Last meal
E – Event / Environment
Physical examination
Head – to - Toe

21. MCQ # 4
79 YO female. She slipped then fell down the stairs. She is talking to you, comfortable, HR 60, BP 110/70, O2 sat 95. the rest of primary survey is within normal. She told you that she has HTN. What part of AMPLE is very important in this particular patient:
1- Allergy
2- Medication
3- Past Surgical history
4-Pregnancy ✓

22. Adjuncts to Secondary Survey
Additional X-ray
CT scan
Definitive U/S
Diagnostic peritoneal lavage (DPL)

23. Transfer to Trauma center when needed
Definitive Treatment
Transfer to Trauma center when needed

24. MCQ # 5
33 YO male was stabbed to left abdomen. Is very drowsy and pale. C/O sever, generalized abdominal pain. You are the only family doctor in a small rural hospital in Al-Hafof. What would be the appropriate management?
1- Rapid assessment followed by admission
2- Rapid assessment then take him to the OR
3- Refuse to see him and transfer him immediately
4- Rapid assessment and initiate the transfer simultaneously ✓

25. Any Questions

26. MCQ # 6
A 23 YO man has a stab wound just below the left nipple. He is alert and breathing normally. HR 94, BP 111/73. His Chest x-ray is normal. All of the following is correct EXCEPT
1- Repeat CXR in 4-6 hrs
2- FAST (Focused assessment with sonography for trauma)
3- Chest CT scan
4- DPL (diagnostic peritoneal lavage) ✓

27. In Summary Importance of trauma Trimodal death distribution
Mechanisms of trauma
ABCDE of Trauma + Resuscitation
Adjuncts
Components of secondary survey
When to transfer

28. References
American College of Surgeons. Advance Trauma Life Support for Doctors (ATLS), Student Course Manual, 8th edition 2008.
American College of Surgeons. Surgical Education and Self-Assessment Program (SESAP) 13