Trauma – initial assessement

and management.

Paweł Grala

Klinika Chirurgii Urazowej, Leczenia Oparzeń, Chirurgii Plastycznej AM w

Poznaniu

Kierownik Kliniki: Prof. dr hab. med. Krzysztof Słowiński

“

Trauma

”

- expression comprising a

spectrum of severity of
mechanical violation of

tissues, from a little scratch

to a multiply injured patient.

- also surgical intervention.

seconds to minutes

minutes to hours
GOLDEN HOUR

several days or weeks

Trauma - the leading cause of death in the first four decades of life

Death from trauma has a trimodal
distribution:

within

•Prehospital – control airway, external hemorrhage,

rapid

transport

•Primary survey - initial assesement and

resuscitation of vital

functions, prioritization

(based on ABC

DEFG)

An organized consistent approach to

the trauma patient  optimal

outcome.

The Advanced Trauma Life Support

(ATLS) adopted by the American

College of Surgeons in 1979.

The primary focus of ATLS is on the

first hour of trauma management -

rapid assessment and resuscitation

THE GOLDEN HOUR

The primary survey –

life threatening conditions are

identified and management is

begun simultaneously!

• A - Airway maintenance with cervical spine

control

• B - Breathing and ventilation
• C - Circulation with hemorrhage control
• D - Disability: neurological status
• E - Exposure: completely undress the

patient

Airway / Breathing

All patients should be

transported/treated initially

with supplemental oxygen.

• immobilization of

the C-spine

• combination of a

hard collar and
sandbags on
opposite sides of
the head

Airway / Breathing

• establishing verbal contact with the

patient - clear phonation by the patient

establishes that the airway is patent.

• further intervention depends on:
- neurologic stability
- adequacy of gas exchange and the

potential for airway compromise

Neurological Stability

• decreased level of consciousness is considered to

be intracranial pathology until proven otherwise

(drugs, alkohol)

• brief neuro exam (done during the primary survey):
A - Alert
V - responds to Verbal stimuli
P - responds to Painful stimuli
U - Unresponsive

• Glasgow Coma Scale (GCS):
GCS < 8 requires definite airway intervention to

prevent aspiration pneumonitis, to insure adequate

oxygen delivery and to avoid hypercarbia.

If a patient is responding only to painful stimuli or is

unresponsive/unconscious, the GCS is or has a high

likelihood of being less than 8.

Adequacy of Gas Exchange

• airway patency does not insure

adequate ventilation

LOOK

• nature of the injury: maxillofacial

trauma/airway burns - potential for

airway compromise, obvious airway or

chest trauma (sucking chest wounds,

flail segments), cyanosis

• tachypnea, use of accessory muscles of

respiration or evidence of tracheal shift

Adequacy of Gas Exchange

LISTEN

• stridor  upper airway compromise.
• hyperresonance to percussion/lack of

air entry  pneumothorax

• dullness to percussion/lack of air

entry  hemothorax.

• bowel sounds in the chest 

ruptured diaphragm.

Adequacy of Gas Exchange

FEEL

• hand over the mouth - feel for air exchange.
• Insertion of a finger - sweep to clear the mouth of

any foreign bodies (especially dislodged teeth) and

to evaluate for evidence of maxillofacial trauma.

LAB

• pulse oximetry - haemoglobin saturation;

immediate feedback

pitfalls - motion, peripheral vasoconstriction,

carboxy/methaemoglobinemia.

• ABG`s - more complete picture of the patient;

feedback on oxygenation, ventilation and tissue

perfusion

pitfalls - a defined waiting period (institution

dependent)..

Securing the Airway

-

endotracheal intubation

(inspection of th airway,

suction of blood and secretions, bag mask

ventillation)

- possible spinal cord or direct traumatic tracheal

injuries  surgical airway -

translaryngeal

intubation

• Immediate - apnea

• Emergent - hypoventilation, significant

head injury, cyanosis

• Urgent - burns, maxillofacial injury and

cervical hematomas will likely require a

secure airway to prevent upper airway

obstruction; chest wall and pulmonary

injuries are usually initially well

compensated but may eventually require

mechanical ventilation

there is often time for a history, appropriate

physical exam and cervical radiographs

Securing the Airway

Blind nasotracheal intubation vs direct

orotracheal intubation

Determined by the experience of the physician
Blind nasotracheal intubation:
requires a spontaneously breathing

unconscious or cooperative conscious

patient, unacceptable failure rate (35%) -

requires 3.7 vs. 1.3 oral attempts,

contraindicated if basal skull or mid-face

fracture.

can precipitate epistaxis (may interfere with

subsequent alternative attempts at

intubation if unsuccessful).

high incidence of sinusitis if a tube is left in

place greater than 72 hours.

Assume the cervical spine to

be unstable until proven

otherwise

• up to 50% of patients sustaining C-

spine trauma develop neurologic

abnormalities (nerve root compression

and weakness to quadri- plegia and

death).

• 10% of patients with C-spine injury are

initially neurologically intact, but

develop deficits during the course of

emergency care

• risks of airway management

C-spine evaluation

• bone and soft tissue

• X-ray exam: „one view is no view”, L-all

7C+Th1 (30% inj.C7Th1), AP-vertical

alignment of the spinous and articular process

and abnormalities in joint and disc spaces,

open mouth view - integrity of the atlanto-

occipital and atlanto-axial joints, the odontoid

process, oblique – intervert. foramina

• CT

• lateral cervical spine - sensitivity of about 85%
92% in a three view series
100% when selective CT scanning is employed

Circulation

• BP
• HR
Alghevar scheme - quantification of shock:
SBP / HR

>1 no or minor clinical symptoms

<1 major shock
• Pulses
• Indirect signs: UA, skin, tachypnoe, altered

consciousness, „empty” periferal veins

Large bore IV lines

Circulation

• warmed intravenous infusions
Control:
• external hemorrhage
• internal hemorrhage:
MAST (PASG) suit
Pelvic binders

Surgery  stabilisation  secondary survey

Initial assessement

• Chest and abd. PE
• Orthopaedic PE
• Periferial Neurologic PE
• Labs
• X-rays, US, CT

tertiary trauma survey

• ACS definition - a patient evaluation that identifies

and catalogues all injuries after the initial

resuscitation and operative intervention

• 2 - 50% of combined life threatening and non-life

threatening injuries are missed during primary and

secondary surveys

• timing is institution specific (typically occurs within

24 h after admission and is repeated when the

patient is awake, responsive, and able to

communicate any complaints).

• is a comprehensive review of the medical record

with emphasis on the mechanism of injury and

pertinent co-morbid factors such as age, includes

the repetition of the primary and secondary

surveys, a review of all laboratory data, and a

review of radiographic studies with an attending

radiologist