TRAUMA

Introduction

trauma can be divided into two basic types according to severity:

• Serious and life-threatening injury;

• Significant trauma requiring treatment but not immediately life threatening.

 Types of injury according to mechanism

■ Blunt, e.g. car bonnet

■ Penetrating, e.g. knife

■ Blast, e.g. bomb

■ Crush, e.g. building collapse

■ Thermal

Crush injury

■ Muscle cells die. If reperfused, they release myoglobin

■ Injured tissue sequesters fluid

■ Renal shutdown results

■ Treatment is fluid loading with monitoring of renal output to maintain diuresis

The approach to the traumatised patient is very different

from that of a patient with an undiagnosed medical condition as, in the latter, an extensive history, past medical history, physical examination, differential diagnosis and investigations ordered to confirm or refute this diagnosis are undertaken.

In the trauma setting, it is often not possible to obtain

such information immediately; hence, a standardised protocol of management is required.

The Advanced Trauma Life Support (ATLS) system was therefore created initially in the USA and rapidly taken up globally.

The steps in the ATLS philosophy

■ Primary survey with simultaneous resuscitation – identify

and treat what is killing the patient

AMPLE  HISTORY

■ Secondary survey – proceed to identify all other injuries

■ Definitive care – develop a definitive management plan

WHO IS THE

MULTIPLE TRAUMA PATIENT

Triage

·        Sorting of patients based on the need for treatment and the available resources to provide that treatment

·        Based on ABC

1- pre-hospital triage – in order to despatch ambulance and prehospital care resources;

2- at the scene of trauma;

3-on arrival at the receiving hospital.

Triage

RED  --- FIRST PRIORITY-MOST URGENT

YELLOW---SECOND PRIORITY- URGENT

GREEN --- THIRD PRIORITY – NOT URGENT

BLACK --- FOURTH PRIORITY (DEAD)

Primary survey

   ABC’s - Identified and simultaneous management of the life-threatening conditions

·        A – Airway management with C-spine control

·        B – Breathing

·        C – Circulation & hemorrhage control

·        D – Disability: neurologic status

·        E – Exposure: completely undress the patient

Airway assessment

■ Check verbal response

■ Clear mouth and airway with large-bore sucker

■ If GCS 8, consider  intubation ; otherwise use jaw thrust or oropharyngeal airway.

Inspect the Airway

•      Vomit, blood, teeth, dirt?                              

•      Finger sweep

Clear large amounts and large particles

B – Breathing

·        Adequate gases exchange: O2 transfer & CO2 elimination

·        Involves adequate function of the lungs, chest wall and diaphragm

·        Expose the patient chest

·        Visual inspection  & palpation

·        Auscultation

·        Percussion

Assess for Breathing out of hospital

·        Is the patient breathing?

Look, listen, & feel for 10 seconds

          Ventilation Impair

·        Tension pneumothorax

·        Open pneumothorax

·        Flail chest with pulmonary contusion     -----   TREAT AS NEEDED+

·        START THE PROPER VENTOLATORY SUPPORT + high flow 100%O2

Circulation (assessment and warning signs)

■ Deteriorating conscious state

■ Pallor

■ Rapid thready pulse is a more reliable and earlier warning  sign than a fall in blood pressure

TO STOP OR MINIMIZE FURTHER BLOOD LOSS

VOLUME REPLACEMENT

			•      TO STOP OR MINIMIZE FURTHER BLOOD LOSS
	•      VOLUME REPLACEMENT

 

Resuscitation - IV Fluid therapy

·        Balanced salt solution: Ringer’s Lactate

·        In hypovolemic patient  - 2 l rapidly

·        Blood                     

D--- DISABILITY

·        The GCS allows for a very rapid assessment of the patient’s level of consciousness, pupillary size and reaction, motor function and, therefore, injury level and is also a good prognostic indicator

·        It should be noted, however, that hypoglycaemia,

alcohol and drug abuse may also alter the level of

consciousness and shouldalso be excluded.

                                  Neurologic

GCS Score

 Eye opening

Spontaneous                  4

To voice               3

To pain                2

None                    1

GCS Score

Verbal response

Oriented                                  5

Confused                                 4

Inappropriate words               3

Incomprehensible words                   2

None                                        1

GCS Score

Motor response

Obeys command                    6

Localizes pain                        5

Withdraw (pain)                    4

Flexion (pain)                        3

Extension (pain)                    2

None                                      1

Adjuncts to the primary survey

■ Blood TEST – CBC, urea and electrolytes, clotting screen, glucose, toxicology, cross-match

■ ECG

■ Two wide-bore cannulae for intravenous fluids

■ Urinary and gastric catheters

■ Radiographs of the ,chest and pelvis + cervical spine

E – Exposure / Environmental control

·        Undressing

·        Protection from hypothermia

History

·        A     Allergies

·        M    Medications

·        P     Past illness

·        L     Last meal

·        E     Events/ environment related to the injury

·        Mechanism of injury

·        Types of injury

SECONDARY SERVEY

HEAD TO TOE EXAM

*DO NOT FORGET HEDDEN AREA

* NEEDED INVEVSTIGATIONS

MTP.

*PRIMARY SERVEY

*AMPLE

*SECONDARY SERVEY

*DEFINITIVE  MANAGEMENT

*CONT. RE-EVALUATION

*PATIENT REFFERAL & DISPOSITION.