Trauma Management

1. ??? ???? ?????? ?????? Trauma Management

2. Initial Assessment Preparation Triage Primary survey ( ABCDEs ) Resuscitation Adjunct to primary survey & resuscitation Consider need for patient transfer Secodary survey ( head to toe evaluation & patient Hx. ) Adjunct to the secondary survey Continued post-resuscitation monitoring & reevaluation Definitive care

3. Preparation 1- pre-hospital : Coordinate with doctors at the receiving hospital Emphasis on airway , bleeding control & shock , immobilization of patient , transport to closest appropriate facility , minimize the time , reporting information for triage ( Time of injury, patient Hx , mechanisms of injury ,…....) 2- Hospital resuscitation area should be ready with - Airway equipment , I V fluid , Monitoring equipment , laboratory , radiology , STANDARD PRECAUTION ( face mask , eye protection , apron , gloves ,……..)

4. Triage : sorting of patients based on their need for treatment & resources available to provide that treatment 1- Multiple casualties No. of patients & severity of injuries do not exceed the ability of facility care , so patients with life threatening injuries & multiple system injuries patient are treated first .

5. 2- Mass casualties No. of patients & severity of injuries exceed the ability of facility care , so the patient with the greatest chance of survival & requiring the least time , equipment , supplies & personnel are treated frist

6. Primary Survey ( ABCDEs ) A Airway with cervical spine protection B Breathing & ventilation C Circulation with hemorrhage control D Disability : Neurologic status E Exposure / Environmental control : completely undress the patient , but prevent hypothermia

7. A Airway with cervical spine  protection . - The airway assessment is first to be sure patency ( like foreign bodies in mouth , facial , mandibular , treacheal /laryngeal fractures , …..) with cervical immobilization .

8. B Breathing & ventilation Check for chest wall injuries like pneumothorax , hemothorax , flail chest that should be identified during the primary survey.

9. C Circulation with hemorrhage  control . 1- Blood volume & cardiac output : Hemorrhage is the No. one cause of preventable death after injury so look for signs of hemorrhage like decrease level of consciousness , loss of skin color , rapid pulse . 2- Bleeding : by manual pressure on open wound .

10. D Disability : Neurologic status Glasgow Coma scale ( GCS ) AVPU - A Alert - V Vocal stimulus response - P Painful stimulus response - U Unresponsive

11. E Exposure / Environmental  control Undress the patient for evaluation Than cover to control body temperature Room temperature control Warm fluids

12. Resuscitation : Aggressive resuscitation & management of life threatening injuries are essential to maximize patient survival ( also A B C ) A Airway , Definitive airway must be established during resuscitation . B Breathing & Ventilation : it shoud be controled to achieved adequate tissue oxygenation .

13. Circulation : Bleeding must be controlled Minimum of tow large –peripheral I V lines must be established for fluid resuscitation . Initial fluid is Lactated Ringer solution with about 2- 3 L If no response than blood transfusion N. B. the best indicator of adequate fluid resuscitation is urine output .

14. Adjunct to Primary survey &  Resuscitation ECG Urinary catheter Gastric catheter Arterial blood gas ( ABG )analysis Pulse oximetry Diagnostic x- ray studies - cervical x- ray - CXR - Pelvis x-ray

15. Cosider need for patient transfer During primary & resuscitation phase , the evaluating doctor has obtained enough information for transfer .

16. Secondary Survey Is head - to - toe evaluation involving a complete neurologic examination The secodary survey is performed after vital function have been normalized 1- Hx of ( AMPLE ) Allergies Medicine Past injuries , Illness , pregnancy Last meal Events / environment ( mechanism of Injury )

17. 2- Examination : head , skull, maxillofacial area , neck , chest , abdumen , perineum , vagina , rectum , musculoskeletal system , neurological system and every orifice should be checked .

18. Adjunct to the secondary survey To minimize missed injuries X- ray of spine & extremities CT scan of head , chest, abdomen , spine , ……. All these tests shoud be done when patient hemodynamicaly stable

19. Reevaluation To ensure that new finding are not overlooked & to assessment deterioration in previously noted findings . Monitoring vital signs , urinary out put, ABG ,cardiac , …… Relief of sever pain is an important part of treatment in this stage .

20. Definitive care Emergency department & surgical department should use special criteria for patient transfer to trauma center or closest appropriate hospital

21. Musculoskeletal Trauma Primary survey & resuscitation - control hemmorrhage from musculoskeletal injury may be by direct pressure. - femoral fracture may result in up to 4 units blood into the though so splinting of fracture may decrease bleeding by reduction of motion.

22. - open fracture should be covered with sterile pressure dressing. - aggressive fluid resuscitation is an important supplement for that injury.

23. Adjunct to primary survey - Fracture immobilization by traction & than application of immobilization device , the joint dislocation require splinting in the position in which they are found and if closed reduction has successfully than immobilization with spint , pillows or plaster

24. X-ray examination is part of the scodary surevy specially pelvic x-ray after stabilize the patient

25. Secodary survey in musculoskeletal system is history & physical examination Hx. Mechanism of injury , environment , preinjury status & predispsing factors , prehospital observation & care Physical examination completely undress the patient for examination and look for 1- life threatening injury 2- limb threatening injury 3- systemic review to avoid missing injury

26. So for musculoskeletal system examination ( look , feel & move ) 1- skin 2- neuromuscular function 3- circulation 4- skeletal & ligamentous integrity

27. If abnormal bone tender or joint and patient stable so x-ray shuold be done Only indication of manupulation before x-ray are vascular compromise or impending skin breakdown ( like fracture – dislocation ankle )

28. Potential life – threatening extremity injury Major pelvic disruption with hemorrhage Major arterial hemorrhage

29. Crush syndrome ( Traumatic rhabdomyolysis ): myoglobin from crushed muscles lead to renal failure & DIC so aggressive I V fluid with sodium bicarbonate & electrolytes is critical for preventing renal failure .

30. Limb – threatening Injuries Open fracture & joint injury Treatment by : IV fluid , immobilization , antibiotics, tetanus prophylaxis, neurovascular assessment, aggressive debridement operatively

31. Vascular Injury including traumatic amputation - must be recognized & treated emergency - emergency vascular surgeon , plastic surgeon&orthopedic consultation

32. Compartment syndrome When pressure within an osteofascial compartment of muscle cuase ischemia & necrosis - causes : 1- tibial & foearm fracture 2- tight dressing or cast 3- severe crush to muscle 4- prolonged pressure of limb 5-burn 6- excessive exercise

33. - signs& symptoms :   1- pain out of proportion 2- tendernss of compartment 3- pain with passive stretch of muscle 4- altered senstion

34. Emegency treatment Remove of dressing , cast & if no improvement than fasciotomy so surgical consultation for diagnosed or suspected compartement syndrome must be early.

35. Neurological injury secondary to fracture- dislocation

36. Other Extremity injuries contusion & lacerations may be simple or deep , it should be assessed than surgical treatment. joint injury but not dislocation : pain ,swelling , tenderness , N .V examination assessment. X-ray is normal and treatment by immobilization

37. Fracture : defined as break in the continuity of bone cortex Assessment by pain , swelling , deformity, tenderness, crepitation & abnormal motion at fracture site N V examination than splint &x-ray if patient stable Treatment : immobilization with joint above & joint below the fracture than N V examination & finally orthopedic consultation.

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