APPROACH TO TRAUMA

BY : NURUL AQILA BINTI RAMLEE

CASE 1
Name : Mr B
Age : 37 years old
Race : Philiphino
Date of Admission : 12th October 2018

37 yeas of gentleman , NKMI , NKDA , Philipino

Working of log cutter at Kem Babi

Presented with alleged hIt by falling of log onto left anterior chest .

Post trauma – complain of severe left sided chest pain and SOB
- no other injuries / no LOC / no ENT bleeds
- able to move all 4 limbs
 APPROACH OF TRAUMA
TRAUMA

PRIMARY SURVEY SECONDARY SURVEY DEFINITIVE CARE

AIRWAYS HEAD TO TOES ASSESSMENT

BREATHING
CIRCULATION
DISABILITY
EXPOSURE

IMPORTANT TO DETECT LIFE-THREATENING

INJURIES !!!! A T O M F C
AIRWAYS OBSTRUCTION
TENSION PNEUMOTHORAX
OPEN PNEUMOTHORAX
MASSIVE PNEUMOTHORAX
FLAIL CHEST
CARDIAC TEMPONADE
 APPROACH OF TRAUMA
TRAUMA
PRIMARY SURVEY
AIRWAYS
BREATHING
CIRCULATION
DISABILITY
EXPOSURE

IMPORTANT TO DETECT LIFE-THREATENING A T O M C T

INJURIES !!!! A T O M F C
AIRWAYS OBSTRUCTION
AIRWAYS OBSTRUCTION ATLS10THEDITION TENSION PNEUMOTHORAX
TENSION PNEUMOTHORAX UPDATES OPEN PNEUMOTHORAX
OPEN PNEUMOTHORAX MASSIVE HEMOMOTHORAX
MASSIVE PNEUMOTHORAX FLAIL CHEST OUT
CARDIAC TEMPONADE
FLAIL CHEST TRACHEOBRONCHIAL INJURY IN TRACHEOBRONCHIAL INJURY
CARDIAC TEMPONADE
Concept And Overview Of Trauma Death -
Trimodal Distribution
The First Peak of Death is within seconds to
minutes of injury.
70
The Second Death Peak occurs within minutes
60
to several hours after injury.
50 Main focus of Trauma Life Support is in this
peak.
40 This period is referred to as the “Golden
Line 1 Hour”.
30 Conceptionally, “Golden Hour - First Hour”
Characterized by;
20
1. Rapid Transportation
10 2. Rapid assessment and stabilization
3. Rapid definitive care
0
The Third Peak of Death occurs several days or
seconds 30 min 1 hours 4hours 8 hours day 5 week weeks after initial injury

5
APPROACH OF TRAUMA
AIRWAYS - Speaking in phrases , no stridor , trachea central
not deviated . No cervical tenderness
BREATHING - Respiratory rate 27 breath / min . SPO2 92% under
room air . Noted paradoxical breathing on left chest .
Air entry reduce on left side .Chest spring positive
CIRCULATION- Blood Pressure 149/85 . Pulse rate 86. CRT <2
seconds .Good pulse volume , warm peripheries
DISABILITY - GCS 15/15 . Pupil 3/3 reactive . Abdomen soft , non
tender.Pelvic spring negative .
EXPOSURE - No spine tenderness , abrasion wound 3cm at
posterior shoulder,anal tone intact,no high riding
prostate
INVESTIGATION
• FBC : 11.6 (Hb) | 7.2 (twbc) | 211 (platelet)
• BUSE / Cret : 139 (Na) | 4.1 (K) |109 (Cl) | 4.7 (urea) |68
• PT/APTT/INR : 15/42/1.2

• Arterial Blood Gas on HFM : PH 7.54|Po2 69|pCO2 40.1| HCO3 : 27 | BE 0.3

• Arterial Blood Gas on VM 60 % : pH 7.4|pO2 123|pCO2 41.6|HCO3 25|BE 0.5
• Fast scan :

• No Free Fluid seen

• Sliding sign absent at left lung .
• Chest Xray :
• Left rib fracture from 2th to
6th ribs (two segments
fracture)
• Left lung opacity
DIAGNOSIS

• LEFT FLAIL CHEST WITH HEMOPNEUMOTHORAX

• CLOSED LEFT 2ND TO 6TH RIBS FRACTURE
MANAGEMENT
• ANALGESIA AND TETANUS PROPHYLAXIS
• OXYGEN SUPPLEMENTS
• FLUID RESUSCITATION
• CHEST TUBE WAS INSERTED .
• Chest tube size 28Fr inserted .
• Post chest tube inserted , noted gush of blood (300 cc) drained.
• Chest tube flunctuanting afterward .
Post chest tube
insertion
V/S
MANAGEMENT
• ANALGESIA AND TETANUS PROPHYLAXIS
• OXYGEN SUPPLEMENTS
• FLUID RESUSCITATION
• CHEST TUBE WAS INSERTED .
• Chest tube size 28Fr inserted .
• Post chest tube inserted , noted gush of blood (300 cc) drained.
• Chest tube flunctuanting afterward .
• REFERRED TO PRIMARY TEAM .
MANAGEMENT
• Seen by Surgical Team , Planned to CT Thorax , NIV support for
at least 3 days and pain optimization .
• CT Thorax ;
• Massive left pneumothorax with total collapsed of left lung causing shifting of
mediastinum .
• Multiple rib fracture involving 2nd to 6th ribs ribs with non displaced left scapula
neck fracture .
FINAL DIAGNOSIS
• LEFT FLAIL CHEST WITH HEMOPNEUMOTHORAX
• CLOSED LEFT 2ND TO 6TH RIBS FRACTURE

• CLOSED FRACTURE OF LEFT NECK OF SCAPULA

APPROACH TO TRAUMA
THEORY PART
CONTENTS
THERMAL INJURY
HEAD TRAUMA

CHEST TRAUMA PEADIATRIC

TRAUMA

ABDOMINAL &
PELVIC TRAUMA
PREGNANCY

SPINE TRAUMA

MSK TRAUMA GERIATRIC

 HEAD
TRAUMA
What’s New From ATLS 10th Edition ???
What’s New From ATLS 10th Edition ???
THORACIC
TRAUMA
What’s New In ATLS 10th Edition
 THORACIC INJURY ….
PRIMARY SURVEY
• AIRWAYS OBSTRUCTION
• TENSION PNEUMOTHORAX
• OPEN PNEUMOTHORAX
• MASSIVE HEMOTHORAX
• CARDIAC TAMPONADE
• TRACHEOBRONCHIAL INJURY

SECONDARY SURVEY
• POTENTIALLY LIFE THREATHENING INJURY
• Simple pneumothorax
• Hemothorax
• Flail chest
• Pulmonary contusion
• Blunt cardiac injury
• Traumatic aortic disruption
• Traumatic diaphragmatic injury
• Blunt esophageal rupture
• OTHER MANIFESTATION OF INJURY
AIRWAY OBSTRUCTION
• Upper airway
• Etiology
• Laryngo-tracheal injury
• Foreign body aspiration
• Inhalational injury (flame burn)
• Beware of c-spine injury
• When to suspect?
• All neck trauma
• Cough, hoarseness, stridor
• Agitated
• Respiratory distress
• Confirm diagnosis
• Flexible or rigid endoscopy
• Direct laryngoscopy
• Management
• Sweep or Heimlich maneuver
• Nasotracheal or endotracheal intubation
• Cricothyroidotomy (needle or open)
• Tracheostomy
TRACHEOBRONCIAL INJURY
• Injury to the trachea or a major bronchus is an unusual but potentially fatal condition. The majority of
tracheobronchial tree injuries occur within 1 inch (2.54 cm) of the carina .
• Patients typically present with hemoptysis, cervical subcutaneous emphysema, tension pneumothorax,
and/or cyanosis.
• Bronchoscopy confirms the diagnosis. If tracheobronchial injury is suspected, obtain immediate surgical
consultation.
• Immediate treatment may require placement of a definitive airway. Intubation of patients with
tracheobronchial injuries is frequently difficult
• Advanced airway skills, such as fiber-optically assisted endotracheal tube placement past the tear site or
selective intubation of the unaffected bronchus, may be required
• In more stable patients, operative treatment of tracheobronchial Injuries may be delayed until the acute
inflammation and edema resolve.
TENSION PNEUMOTHORAX
• Progressive build up of air within pleural space d/t one-
way-valve effect
• When to suspect?
• Trachea deviated away
• Hyperexpanded chest with hyperresonance
• Distended neck veins
• Clinical diagnosis
• Management
• Needle thoracocentesis
• Chest tube
OPEN PNEUMOTHORAX
• Accumulation of air within pleural space from chest wall wound
• When to suspect?
• Open chest wound + reduced breath sounds
• Sucking sound
• Management
• Occlusive dressing
• Chest tube insertion
MASSIVE HAEMOTHORAX
• Rapid, massive accumulation of blood within pleural
space
• When to suspect?
• Patient in shock
• Stony dullness on percussion
• Trachea deviated away
• Confirm diagnosis
• eFAST
• CXR (>500ml)
• Management
• Chest tube insertion
• Surgical exploration
• Indications
• >1.5L blood upon insertion
• Continued bleeding >200ml/hr, >2 hrs
• Repeated transfusions to maintain hemodynamics
• Open thoracotomy or video-assisted thoracoscopy
Pericardial tamponade
• Accumulation of blood within pericardial space  restricting cardiac
filling  reducing cardiac output
• Beck triad
• Distended neck veins
• Soft/muffled heart sounds
• Hypotensive
• Diagnosis
• FAST
• Management
• Pericardiocentesis
Flail chest
• Fractures of ≥3 ribs at 2 points of each ribs
• Paradoxical movements of chest wall segment
• Requires a significant force over a large area
• Problems
• Pain limits breathing movement
• Loss of chest wall integrity
• Pulmonary contusion
• Management
• Supplemental O2
• Adequate analgesia
• Chest tube to drain pleural effusion
• Mechanical ventilation
ABDOMINAL
& PELVIC
TRAUMA
WHAT’S NEW IN ATLS 10TH EDITION ??
APROACH OF ABDOMINAL TRAUMA
• History
• Mechanism of injury
• Airway : 100% oxygen
• Breathing
• Circulation
•  Fluid resuscitation; 1L crystalloids followed by blood
•  Maintain SBP approximately 90mmHg
•  Permissive hypotension
MANAGEMENT
• Ensure hemodymically stable
• If stable ; proceed for CT Abdomen
• If not stable , for emergency laparotomy
APPROACH OF PEVIC TRAUMA