Intial assessment of truama patient

Steps of management

1. Primary survey
2. Resuscitation
3. Adjuncts to primary survey & Resuscitation
4. Secondary survey
5. Adjuncts to secondary survey and reevaluation
6. Definitive care
   

Step1: Primary survey

A : Airway maintenance with cervical spine protection
B : Breathing and ventilation
C : Circulation with hemorrhage control
D : Disability ; Neurological status
E : Exposure/Environmental control: Completely undress the patient, but prevent hypothermia


Aims of Primary survey: "Early Detection of Immediate Life Threatening conditions"

Immediate Life Threatening conditions

1. Upper airway obstruction
2. Open pneumothorax
3. Tension pneumothorax
4. Severe flail chest
5. Massive hemothorax
6. Cardiac tamponade
   

Step 2: Resuscitation

• Oxygenation and ventilation
• Shock management, IV lines, warm RLS
• Management of life-threatening problems identified in the primary survey is continued
  

Upper airway obstruction
History

• Maxillofacial injury
• Neck traumaLaryngeal trauma
• Foreign body

Physical examination

• Fracture mandible, facial fracture with associated bleeding
• Stridor
• Hoarseness(dysphonia)
• Subcutaneous emphysima

Management of airway

• Chin lift or jaw thrust maneuver
• Clear the airway of foreign bodies
• Insert oropharyngeal or nasopharyngeal airway
• Establish a definitive airway

1) Orotracheal or nasotracheal intubation

2) Surgical cricothyroidotomy


Open pneumothorax

• Large defect of the chest wall
• "Suction wound": 2/3 the diameter of the trachea
• Treatment: 3 sides dressing
  

Tension pneumothorax

• Hx. chest injury
• Chest pain, air hunger, reparatory distress
• Trachycardia, hypotension, tracheal deviation, neck vein distension, unilateral absent breath sound
• Differentiation from cardiac tamponade: Hyperresonant percussion with absent breath sound ; affected hemithorax
• Px: Immediate decompression: large-caliber needle into 2nd ICS midclavicular line
  

Severe flail chest

• Hx. Blunt chest injury
• Fracture Rib ≥ 2 ribs & ≥ 2 place
• Paradoxical chest movement
• Treatment: Oxygenation and Ventilator
  

Massive hemothorax

• Massive bleeding in pleural cavity
  - ≥ 1500 cc
  - ≥ 1/3 total blood volume
  - Continuous bleeding ≥200 cc/hr for 2-4 hrs
• Treatment
  - ICD into 5thICS anterior to mid axillary line
  - Definite : thoracotomy
  

Cardiac tamponade

• Blunt or penetrating chest
• Beck’s triad
  - Neck vein distension
  - Hypotension
  - Muffled heart sound
• Pulsus paradoxus
• May Dx: FAST
• Treatment
  - Pericardiocentesis
  - Subxyphoid pericardial windowPericardiotomy
  

Shock:

• Warm (39°C) Ringer’s lactate solution 2000 ml in adult


• 20ml/kg warm Ringer’s lactate solution bolus in children
  

Estimated fluid and blood losses Based on Patient’s Initial Presentation

(Modified from ATLS® 2005)

Resuscitative thoracotomy

• Emergency department thoracotomy
• Indication

1. Evacuation of pericardial blood causing tamponade
2. Direct control of exsanguinating intrathoracic hemorrhage
3. Open cardiac massage
4. Cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart

Step 3: Adjuncts to primary survey and resuscitation

1. Monitoring

• EKG monitoring
• Pulse oximetry
• Blood pressure

2. Urinary and gastric catheters

3. X-ray and diagnostic studies : “should not interrupt the resuscitation process”

• Chest
• Pelvis
• C-spine
• DPL or FAST

Urinary catheter
Contraindication for transurethral bladder catheterization: “suspected urethral
transection”

1. Blood at penile meatus
2. Perineal ecchymosis
3. Blood in scrotum
4. High-riding or nonpalpable prostate
5. Pelvic fracture
   

Responses to initial Fluid Resuscitation

(Modified from ATLS® 2005)

Diagnostic Peritoneal Lavage (DPL)

Indication

1. Abdominal injury with unconscious
2. Abdominal injury with loss of sensation
3. Injury to adjacent structure (lower rib, pelvis, lumbar spine)
4. Equivocal physical examination
5. Prolong loss of F/U (neuro surgery)
6. Lap-belt sign (abdominal wall contusion) with suspicion of bowel injuries
7. Not available FAST or CT

Contraindication

Absolute

Indicate for laparotomy

Relative

1. Previous abdominal operation
2. Morbid obesity
3. Advanced cirrhosis
4. Preexisting coagulopathy

Procedure

1. Insert DPL catheter
2. Aspiration peritoneal fluid
3. Instill 1 Liter of warmed RLS(NSS) 1000 cc or 10 cc/kg in child
4. Drain peritoneal lavage fluid
5. Adequate fluid return is > 30 % of the infused volume
   

Positive DPL test (Blunt injury)

• Aspiration gross blood > 10 ml
• Gastrointestinal contents
• BileFood particle
• RBC > 100,000 /mm3
• WBC > 500 /mm3
• Gram stain positive Bacteria

Focused Assessment Sonography in Trauma (FAST)

• Detect hemoperitoneum from
• Pericardial sac
• Hepatorenal fossa (Morrison’s pouch)
• Splenorenal fossa Pelvis (pouch of Douglas)

Step 4: Secondary survey

History
AMPLE systems
A: Allergies
M: Medication currently use
P: Past illness/Pregnancy
L: Last meal
E: Event/Environment related to the injury

Special conditions

• Blunt trauma
• Penetrating trauma
• Injuries due to burn and coldHazardous environment

Head to toe evaluation

1. Head
2. Maxillofacial and intraoral
3. Cervical spine and neck
4. Chest
5. Abdomen (include back)
6. Perineum/rectum/vagina
7. Musculoskeletal
8. Neurological examination

Step 5: Adjuncts to secondary survey and reevaluation

Further investigation

• CT scan
• Contrast x-ray study
• Extremities x-ray
• Endoscope and U/S

Reevaluation

• Monitoring
• Stabilization

Step 6: Definitive care

• Observe
• Surgery
• Intervention

- CT scan

- Contrast x-ray study

- Extremities x-ray

- Endoscope and U/S

• Reevaluation

- Monitoring

- Stabilization