Principles of Trauma Symphony of Surgery

1. Principles of TraumaSymphony 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!!! *www.saher.gov.sa

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

6. Mechanisms of Injury • Blunt Trauma • MVC • Fall • PHBC • Penetrating Trauma • 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. 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. Primary Survey • Circulation + Control the bleeding wound • Pulse, BP, bleeding wound • Hemorrhagic shock C

14. Primary Survey • Disability • 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) • 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. 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 • Adjuncts • When to transfer

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