1. Trauma management

2. Trauma Management Zohair Alaseri, MD FRCPc, Emergency Medicine
FRCPc, Critical Care Medicine
Intensivest and Emergency Medicine Consultant
King Saud University Medical City
Chairman National Emergency Medicine Development Committee

3. 1-What is the leading cause of preventable death from trauma?
A. multi-organ failure
B. sepsis
C. hemorrhage
D. respiratory arrest

4. 2-Which injuries are particularly prone to develop coagulopathy?
A. brain injury and long bone fractures
B. hepatic and splenic injuries
C. intestinal and renal injuries
D. pulmonary and cardiac injuries

5. 3..36 years old male, involved in MVC brought to Emergency Department (ED), unconscious with BP-70/40mmhg, HR- 52, O2Sat is 90% and RR-10. What is the most appropriate immediate intervention you should do?
Take Further quick history from paramedic
Give atropine 1mg to increase the heart rate which will increase blood pressure.
Insert central line and start aggressive fluid resuscitation.
Insert peripheral line and start 1L normal saline.

6. 4. A 20-years-old man was involved in a MVC and is found to be in respiratory distress. In the ER he is intubated and is on bag valve mask. The anaesthetist tells you that he has to use a lot of force to ventilate the patient. On auscultation there is reduced air entry on the left side of the chest, trachea is deviated to the right. What is the most appropriate management option for this patient?
An urgent Chest XR.
Take him to do immediate CT thorax.
Decompression using large bored cannula on the left 2nd intercostal space.
Decompression using large bored cannula on the right 2nd inter costal space

7. 5. The EMS brought unconscious patient to you in ED
5..The EMS brought unconscious patient to you in ED. He is middle aged patient involved in MVA, he has two (2) IV line started by paramedics. When two (2) liters of crystalloid finished his vital sign as follow; HR – 130, BP – 80/53, RR – 10, O2Sat. is 75% with 100% non rebreathing mask. What is your next step?
Change IV Crystalloid to albumin.
Insert new IV line.
Intubate this patient.
Circulation is still a priority, you should continue fluid resuscitation and delay intubation.

8. Trauma Management
Introduction
These patients benefit from skillful resuscitation; they are healthy, young individuals who, if salvaged, have a normal life expectancy.

9. Trauma Introduction a disease of the youth
leading cause of death in those 1 to 37 years old.
majority of trauma deaths occur either
before reaching the hospital or within four
hours of arrival.

10. Diagnostic and Therapeutic
Trauma Management
Introduction
Blunt trauma patient +
Hypotension
Altered mental status =
Diagnostic and Therapeutic
Dilemma

11. Management Requirements broad knowledge sound judgment technical skill
Trauma
Management Requirements
broad knowledge
sound judgment
technical skill
leadership capabilities.
NO MORE ONE MAN SHOW
Often what happens in the initial phase of resuscitation period often determines the outcome of care

12. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Primary Survey
Assessment and resuscitation should be performed simultaneously.
Initial evaluation to diagnose and address life- threatening.

13. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Primary Survey
Includes 5 components
A. Airway Maintenance with Cervical Spine Protection
B. Breathing and Ventilation
C. Circulation and Hemorrhage Control including FAST
D. Disability/Neurological Status
E. Exposure/Environmental Control

14. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
After the 5 main, continue with F,G,H if needed:
F. Foley Catheter
G. Gastric Tube
H. Hertz - Imaging

15. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
A. Airway
1. Clear the oropharynx of blood, mucus and foreign bodies.
2. Jaw thrust. (Don't overextend the neck; the patient might have a spinal injury!).

16. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
No oropharyngeal tubes in patients with gag reflexes.
Why? Induce vomiting
Oropharyngeal tubes have limited use!
Size…
Distance between the angle of the mouth and the earlobe.

17. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
If the patient is unconscious (GCS=<8)
What to do now?
Endotracheal intubation.
(Size 8 for adult males, size 7 for females, or the size of the patient's small finger irrespective of age).

18. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Make sure ETT in correct place by
checking for EtCO2
listening for bilateral breath sounds
obtaining a chest x-ray

19. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
If intubation is impossible
In emergencies there is no place for tracheostomy.
LMA
impossible
cricothyroidotomy

20. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Cervical Spine Protection
High index of suspicion depending on the history of the accident: (MVC, falls, certain sports).
Avoid rough manipulation of the head and neck.
Use hard collars to immobilize the neck.
Immobilize the whole body on a long spinal board.

21. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Cervical Spine Protection
Obtain appropriate radiological evaluation.
Radiological evaluation should be done only after the patient has been stabilized.
Clearance of the cervical spine is NOT an emergency!

22. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Breathing and Ventilation
Inspect for symmetrical chest movements.
Auscultate for breath sounds bilaterally.
Palpate the trachea for deviation
Palpate chest wall for fractures or emphysema.

23. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Life-threatening problems to be identified during primary survey:
1-Flail chest:
Monitor pulse oximetry
Intubate if there is hypoxia or respiratory distress
Consider early intubation in elderly or severe multitrauma patients.

24. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Life-threatening problems to be identified during primary survey:
2. Open, sucking/blowing wound in the chest wall:
Do not suture or pack before thoracostomy tube insertion.
Danger of tension pneumothorax!
A Square gauze taped on only 3 sides can be applied while preparing for chest tube insertion.

25. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
3. Tension pneumothorax:
Initial decompression with needle insertion through the
2nd or 3rd intercostal space anteriorly, mid-clavicular line Thoracostomy tube.

26. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
C. CIRCULATION AND HEMORRHAGE CONTROL
1. Assess BP, heart rate and evidence of bleeding.
2. Control any external bleeding by direct pressure.
3. In penetrating injuries of the neck, put the patient in the Trendelenberg position, (head down) to prevent air embolism.
4. If there is shock, insert one or two large intravenous lines and start fluid resuscitation.
FAST

27. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
1--Hypovolemic Shock
The most common cause of post-traumatic Hypotension.
due to external or internal blood loss.
FAST

28. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
Hypovolemic Shock
Vascular access with two or more large bore IV.
In patients with neck or arm injuries, line should be inserted on the opposite side to avoid extravasation.
FAST

29. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
Hypovolemic Shock
Consider intra-osseous infusion, if a peripheral vein is not available.
The infusion rate depends on the length and diameter of the catheter and NOT on the size of the vein.
FAST

30. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
Hypovolemic Shock
Give a fluid challenge of 2 liters of Ringer's Lactate (or 20 ml/kg for children).
If more fluids are needed, consider blood transfusion.
For clear indication for surgery no time should be wasted for fluid resuscitation!
FAST

31. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
Hypovolemic Shock
There is evidence that in penetrating trauma with active bleeding some degree of mild hypotension until the bleeding is surgically controlled may be beneficial!

32. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Blood
Rh negative: No need for typing or cross matching. For life threatening blood loss only.
Should be Available in refrigerator in the Emergency & OR.
Typing but no cross matching. ("Type specific blood") Ready in about 10 minutes.
Fully typed and cross-matched. Ready in about 30 minutes.

33. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
Blood
Always use blood warmers.
Hypothermia may aggravate acidosis, induce arrhythmias, shift the oxyhemoglobin dissociation curve to the left, and impair platelet function.
In severe hypovolemia use Level I rapid infusion blood warmers.

34. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
2--Cardiogenic Shock
Suspected in trauma pts with shock in the absence of blood loss.
Low BP and distended neck and veins. (although not always)

35. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
2--Cardiogenic Shock
Possible associated conditions with cardiogenic shock:
cardiac tamponade
myocardial contusion
tension pneumothorax
air embolism
myocardial infarction..

36. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
Cardiogenic Shock
Air Embolism may follow injuries to major veins, lungs, or the low-pressure cardiac chambers.
Occasionally it may be iatrogenic, during insertion of a central venous line.

37. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
Cardiogenic Shock
Myocardial infarction should be suspected in elderly patients presenting in cardiogenic shock.
ECG and Troponin level should be performed routinely
Cardiac Arrest: There is no place for external massage (except in head injuries).

38. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In trauma there are 3 conditions,
can cause shock:
3--Neurogenic Shock
This is the result of loss of vascular tone following cervical cord or upper thoracic spinal cord injury.
TTT with fluid and vasopressor

39. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
D. DISABILITY (NEURO EVALUATION AND MANAGEMENT)
1. Assess level of consciousness (Glasgow Coma Scale).
2. Assess pupils (size, reactivity).

40. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
E. EXPOSURE/ENVIRONMENT CONTROL
1. Undress the patient completely for thorough examination.
2. Avoid hypothermia by using warm blankets and IV fluids if needed.

41. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
E. EXPOSURE/ENVIRONMENT CONTROL
Trauma patients become hypothermic very quickly.
Risk for hypothermia:
Severe blood loss
Elderly patients
Pediatric

42. SECONDARY SURVEY
The secondary survey is done only after the primary survey is completed and resuscitation is initiated.
Sometimes the secondary survey is performed after operation for life-threatening injuries.
Complete examination from head to toe (head and neck, chest, abdomen, back,, and musculoskeletal).

43. TERTIARY SURVEY
A tertiary survey should always be performed semi-electively.
The purpose of this survey is to diagnose any occult or minor injuries!

44. EXPERT COMMENTS 1. Examination of the trauma patient:
Undress the patient completely
Always examine the back.
Serious injuries may otherwise be missed.
Cover the patient with warm blankets to prevent hypothermia.
The presence of an obvious wound should not distract from another less obvious but more dangerous injury.

45. EXPERT COMMENTS 2. Head Injury:
Correct any condition, which aggravates an existing brain injury (e.g. shock or hypoxia).
Cervical spine injury is a commonly associated problem.
Apply a semi-rigid collar, keep the head and neck in a neutral position, and apply precautions during transportation, until a cervical injury has been excluded.
The cervical spine clearance is not an emergency as long as protection is maintained.

46. EXPERT COMMENTS 2. Head Injury:
Closed head injuries alone rarely produce hypotension, except in the terminal stages or in neonates.
If the patient is in shock, look for a source of bleeding, cardiogenic shock or associated cervical spine injury.
Scalp lacerations can bleed profusely and may cause hypotension.

47. EXPERT COMMENTS 3. Fractures:
Immobilize all severe fractures at an early stage, before moving the patient to CT scan or other investigations.
minimize neurovascular damage
decrease bleeding
reduce fat embolism
reduce pain

48. EXPERT COMMENTS 3. Fractures:
Fractures of the pelvis or the femur may be associated with significant blood loss.
Early operative fixation of major fractures decreases morbidity, mortality, and hospitalization.
In the presence of severe associated head or chest trauma, prior stabilization of the patient is advisable.

49. EXPERT COMMENTS 4. Common mistakes:
Insertion of an oropharyngeal airway in the presence of brisk gag reflexes.
Problem: Vomiting and aspiration!
Tracheostomy in emergency situations.
Problem: It takes a few minutes even in the hands of experienced surgeons! Procedure of choice: Cricothyroidotomy.

50. EXPERT COMMENTS Common mistakes
External cardiac massage in traumatic cardiac arrest due to blood loss or cardiac tamponade.
Procedure of choice is the resuscitative thoracotomy and internal cardiac massage.

51. EXPERT COMMENTS Common mistakes
Pack or suture open sucking/blowing wounds before thoracostomy tube insertion.
Problem: Tension pneumothorax! If a dressing is needed, apply a square gauze taped on to skin in only 3 sides!

52. EXPERT COMMENTS Common mistakes
Examine a severely injured patient without removing his clothes.
Problem: Serious injuries may be missed!
Omit rectal or vaginal examinations, especially in pelvic fractures. (Do not perform routine vaginal exam in children).

53. EXPERT COMMENTS The 3 most commonly missed injuries: a) Spinal injury;
b) Spinal injury;
c) Spinal injury.
Never directly admit a patient with suspicious mechanism of injury (traffic injuries, falls from significant height) to an orthopedic or neurosurgical unit.
The trauma surgeon should be in charge for at least the first 24 hours.

54. 1 Trauma Management Trauma Code NO MORE ONE MAN SHOW ED Phase
Organized Team Approach
ED Phase
Trauma Code
Procedure:
NO MORE ONE MAN SHOW
Scribe
The scribe is responsible for the full
record of the trauma call.

55. monitor AN
Intubation Cart
with difficult AW RT
ventilator
ICU
Crush Cart RN RN GS
Procedure
Tray RN TL
N.Super P
scr

56. Trauma Code a. Shock / hypotension – SBP < 90 mm/Hg
Definition of Major Trauma-Adult
a. Shock / hypotension – SBP < 90 mm/Hg
b. Respiratory distress /Airway compromise OR Mechanism of injury that could lead to airway compromise (this includes all intubated patients or where there is an inability to intubate)
c. Penetrating Injury of head, neck, torso, groin
d. Unresponsive (Glasgow Coma Scale < 8) with potential for multiple injuries
e. Traumatic arrest
f. Two or more proximal long-bone fractures
g. Open and depressed skull fracture
h. Proximal amputations
Initiate Trauma Code Activation

57. Trauma Code i. Vascular compromise
Definition of Major Trauma-Adult
i. Vascular compromise
j. Stab wound to head, neck, or torso
k. Major burns or burns with trauma
l. Spinal cord injury – with paralysis
m. Crushed pelvis/chest
High energy event
n. Falls > 3 meters.
o. Auto/bike or auto/pedestrian, Rollover mechanism
p. Ejection from vehicle
q. Death at the scene
r. Severe deformity of the vehicle
Initiate Trauma Code Activation

58. Trauma Code s. Penetrating injury to extremity
Definition of Major Trauma-Adult
s. Penetrating injury to extremity
t. Unstable pelvis or Pelvic ring fracture
u. Single femur fracture
v. Spinal fracture
w. Pregnancy > 20 weeks
x. Significant concern for thoracoabdominal injury
y. Burns > 20% TBSA (2nd or 3rd degree) or involving face, airway.
z. Flail chest
Initiate Trauma Code Activation

59. Priorities in Management and Resuscitation2
Trauma Management
Priorities in Management and Resuscitation
ED Phase
Airway/breathing
Shock/external hemorrhage
Impending cerebral herniation
Cervical spine
High-Priority Areas
Neurologic
Abdominal
Cardiac
Musculoskeletal
Soft tissue injury
Low-Priority Areas

60. 3 Trauma Management ED Phase
Assumption of the Most Serious Injury
ED Phase
The TL should give consideration to the worst possible injury and act accordingly until the diagnosis is confirmed or excluded.

61. 4 Trauma Management Treatment before Diagnosis ED Phase
The urgency of the situation in trauma cases often demands treatment based on an initial brief assessment without confirmation by radiographic or laboratory data.

62. 5 Trauma Management Thorough Examination ED Phase
The presence of one injury is no guarantee that a second or third injury does not exist.
Most missed injuries occur in severely injured patients

63. 6 Trauma Management Frequent Reassessment ED Phase
A patient's status is dynamic.
Intoxicated patient
Examples: Delayed presentation like duodenal injuries and lung contusions
Frequent examinations can help detect early changes in the physical findings and thus lead to prompt corrective actions.

64. 7 Trauma Management ED Phase Monitoring V/S continuous pulse oximetry
end-tidal carbon dioxide (CO2) monitoring when applicable.
Precise knowledge of the type and amount of fluid the patient has received is needed in determining subsequent fluid orders.
Certain laboratory tests should also be obtained serially.

65. ? Trauma Management ED Phase Vascular Access & IO
Choice of Resuscitation Fluid
SAFE Study
War literatures
Transfusion.
Fully crossmatched blood may take 30 to 45 minutes to obtain.
Type-specific blood is a safe alternative and is usually ready in 5 to 15 minutes. ?

66. loc Indices of Successful Resuscitation UOP Lactate Clearance
End-tidal CO2
loc
Central Venous Oxygen Saturation
V/S
Perfusion
UOP
Lactate Clearance
• The overall goal of all resuscitation procedures is to improve oxygenation and perfusion of body tissues.
Lactate concentration
Clinical Exam BD

67. Causes of missed injuries
Be Careful
Causes of missed injuries
Trauma severity
Multiple systems
Severe brain injury
Conditions that complicate the complete clinical evaluation
Altered consciousness •    Brain trauma •    Sedation-intubation •    Intoxication
Error
Inadequate physical examination Inaccurate interpretation of diagnostic investigations Inadequate surgical sequence

68. Q? Thank you