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TRAUMA

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TRAUMA

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  1. TRAUMA Begashaw M (MD)

  2. Trauma

  3. Introduction • is one of the leading causes of mortality, morbidity and disability • mostly affects people in their productive years • The causes of trauma are various

  4. Deaths due to trauma • Immediate death (50%) • Occur in the first few minutes • injuries to the brain, heart & major blood vessels 2. Early deaths (30%) • Occur in the first few hours • due to the collections and bleedings in the chest and abdomen, extensive fractures and increased intracranial pressure 3. Late deaths (20%) • Occur days or weeks after the injury • due to sepsis and organ failure

  5. DEFINITION _is tissue damage, which occurs due to transfer of different forms of energy • Types of Trauma I- Cause: Homicidal injuries Road traffic accident and falls Industrial accidents, burn II- Mechanism: A/ Blunt Injury: Caused by acceleration, deceleration, rotational or shearing force B/ Penetrating Injury: Caused by a direct breach by penetrating object E.g. Bullet injury, stab injury

  6. Mechanism of Injury • Blunt Force Trauma • Penetrating Trauma

  7. TREATMENT • Advanced trauma life support (ATLS) protocol • The ATLS _primary survey and resuscitation followed by _secondary survey and definitive management

  8. The Flow of the Initial Assessment Primary Survey Resuscitation Reevaluation Reevaluation Detailed Secondary Survey Definitive Care

  9. Initial management

  10. I- The primary survey and resuscitation • Quick evaluation to detect immediately life threatening situations • Institution of measures A Airway and cervical spine B Breathing C Circulation with hemorrhage control D Disability-Dysfunction of CNS E Exposure/Environment

  11. A- Air way-cervical spine • Assess the patency of air way • May be compromised by_backfallen tongue, broken tooth, vomitus, blood • Use_ suctioning, jaw trust, positioning, oropharyngeal tube or endotrachealtube to open it, take care of the cervical spine-hard collar • 100 % oxygen

  12. B- Breathing • Assess adequacy of breathing-“Look, listen, feel” • Compromised by pneumothorax, hemothoraxor multiple rib fractures causing flail chest • Tension pneumothorax-venous cannula through second intercostal space in the mid-clavicular line • If open chest wound seal with occlusive dressing

  13. C- Circulation • Assess the circulatory volume-pulse, capillary refill, neck veins • Look for external hemorrhage and arrest it by pressure, bandaging • Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound • Open a wide bore IV line take blood sample for cross match and start resuscitation with Normal saline or Ringer’s lactate

  14. Dysfunction • Assess level of consciousness using AVPU method A = alert V = responding to voice P = responding to pain U = unresponsive • Glasgow coma scale (GCS) • Look for any Neurological deficit or lateralizing sign

  15. E- Expose • Expose (undress) the patient fully • Avoid hypothermia

  16. II- Secondary survey and definitive management • done after the life threatening conditions have been evaluated and resuscitative measures are instituted • A- Take History _Time of injury _ Mechanism of injury _Amount of bleeding _ Loss of consciousness _Any intervention performed or drugs given

  17. B- Do a proper and systematic examination of all body systems • C- investigations _ hematocrit, cross-match, urinalysis, X-ray, ultrasound, etc. • Never send a patient with unstable vital signs for investigation or referral before resuscitation • D- Appropriate treatment _laparotomy ,POP cast

  18. ROAD TRAFFIC ACCIDENTS (RTA) • is the leading cause of trauma deaths • Several factors contribute to the high magnitude _poor condition and design of roads _traffic mix _poor condition of the vehicles _poor traffic rule enforcement

  19. MVA

  20. Injuries are caused by • sudden acceleration e.g. a pedestrian hit by car • decelerations _ passenger to collide with the interior of car • high risk of serious and multiple injuries: • Presence of flail chest • Roll over • Death of another person in the car

  21. FIREARM INJURIES _due to homicidal violence _missile injuries - bullets from pistols, rifles, machine guns _degree of injury depends on the amount of energy _E=½mv2 (E = energy transferred, m = mass of the missile, v = velocity of the missile)

  22. Classification I- Low- velocity _ missiles fired from hand guns (<400m/s) _Injury is limited to the path of the bullet II- High velocity _bullets fired from rifles, machine guns and blast fragments (>1000m/s) _ small entrance ,a larger exit wound _Tissue damage occurs in the surrounding tissue _Foreign bodies, dirt and clothing in wound

  23. Management • appropriate wound debridement _Excision of all dead tissue _Removal of all dirt, foreign bodies and free bone fragments _irrigation of wound with copious amount of saline • debrided wound should be left open for closure later N.B: Never close missile wounds primarily, not even the very trivial looking ones! _broad spectrum antibiotics _tetanus prophylaxis

  24. BURN • is a coagulation necrosis of tissue due to thermal or chemical injury • Women and children are mostly affected • Types of burns Flame burn Scalding Chemical burn Electrical burn

  25. Severity • Depends _the burn depth (degree) _the extent or percentage of the body surface • Determining the percentage of burn surface is important to calculate the amount of fluid requirement • Determination of burn depth is important for burn wound management

  26. Classification of Burn according to depth (degree) 1- First degree _ involves epidermis _ manifests with erythema 2- Second degree (partial thickness) _involves part of dermis _manifests with blisters, edema, moist surface and pain at the affected site 3- Third degree (full thickness) _ Involves complete burn _charred, white or grayish , pain free

  27. Burn degree

  28. 1st degree (Superficial) burn

  29. Second degree (partial thickness) burn

  30. 3rd degree (full thickness) burn

  31. 4) 4th degree burn - involves the underlying viscera or other organs e.g. bone,liver

  32. Rule of Nine

  33. Management • General _ATLS system _Airway obstruction -rapidly after inhalation injury or delayed for 24-48hours _ Endotracheal intubation or tracheotomy _ Breathing _ Circulation _Analgesia

  34. Fluid resuscitation _Major burn (> 20% body surface area) _Open IV line-normal saline/ringer lactate • Parkland Formula _First 24° _4 mL Lactated Ringer’s X weight in kg X % total body surface area burned _50% of fluid in first 8° _50% over next 16° _ Keep urinary output 0.5 – 1 mL/kg

  35. Criteria for admission  any burn over 20%(adults) & 10%(children) BSA  Special areas e.g. eye, face, hands, feet, perineum  Inhalation injury  Chemical & electrical burns  Full thickness burns where grafting is indicated  Children & elderly pts who require additional medical or social support

  36. Burn wound management • Goals _close wound _prevent infection _reduce scarring and contracture _provide for comfort • Wound cleaning • Debridement • Mechanical • Surgical • Topical antibacterial therapy

  37. Dressing the Burn • The Exposure Method-Open Technique: _wound is cleaned by antiseptic agents _Left exposed to air _used for burns of the face and burns of large surface area • The occlusive method-ClosedTechnique _a thick dressing after cleaning with antiseptics covers the burn wound _used mostly for outpatient treatment of small burns

  38. Wound dressing

  39. Emergency escharotomy and fasciotomy should be done for deep circumferential burns of limbs, neck or trunk • Wound Care: Grafting • Indications for grafting _full thickness burns _priority areas _wound bed pink, firm, free of exudate _bacterial count < 100,000/gram of tissue

  40. Escharotomy Facial and hand burns

  41. Escharotomy

  42. Analgesia • Most burn patients are in severe pain _analgesic doses of IV narcotics regularly to control the pain

  43. Prevention of Infection • impaired resistance against infection • Most deaths occur due to pneumonia and wound sepsis • Prophylactic antibiotics (penicillin) are given for severe burns • Topical antimicrobials e.g. 1% silver sulfadiazine are helpful for deep 2nd and 3rd degree burns

  44. Nutrition _ Naso -gastric tube -more than 25% burn -nausea and vomiting • in catabolic state • lose weight very fast • daily calorie required is 20 Kcal/Kg + 70 Kcal/%burn • Daily protein requirement is 1 gm/kg + 3 gm/%burn.

  45. Contracture

  46. Prophylaxis against tetanus • Prevention of contractures & rehabilitation _move all joints