Principles of Trauma

Symphony of SurgeryDr. Hassan BukhariDepart of Surgery

4-1435

ObjectivesBy the end of this discussion, the doctors will be able to*:

Recognize the impaction of traumaUnderstand the trimodal death distributionunderstand the general principles of Primary and Secondary Survey and managementEstablish the ability to recognize the critical scenarios in trauma patients

*ATLS-Student Course

ContentsMCQ / Scenarios – based lecture

Why trauma is important?

What is the Trimodal death distribution and the golden hours?

Mechanisms of Injury

Primary Survey

Secondary Survey

References

Why Trauma is Important?

Around 5 million deaths worldwide

Motor vehicle crash (MVC)1 million deaths annuallyThe leading cause of death between the age of 1 and 44 in developing countryAlmost 5000 deaths in KSA in one year (1429)*

1 death every one and half hour!!!

*www.saher.gov.sa

Trimodal death phasesImmediate death ( --- )

Brain, spine, CV

Early death ( --- )Brain bleed, rupture organ

Late death ( --- )Infection, organ failure

Mechanisms of InjuryBlunt Trauma

MVCFallPHBC

Penetrating TraumaStabbingGunshot

MCQ #120 year old male pt, involved in MVC, came to ER unconscious and low blood pressure with bleeding wound in the leg. What is the most important initial step?

1. Control airway2. Control blood pressure3. Control bleeding wound4. Order chest x-ray

✓

Initial assessment and management

Prehospital PhaseParamedics

Hospital PhaseTriagePrimary Survey + Resuscitation

Adjuncts to primary survey

Secondary SurveyAdjuncts to secondary survey

Definitive treatment

Primary Survey

Primary Survey Airway control with cervical spine Alignment

Quickest way to assess airway?Types of airways?

A

Primary SurveyBreathing

Look, feel and listenPulse oximetry

B

Primary Survey Circulation + Control the bleeding wound

Pulse, BP, bleeding woundHemorrhagic shock

C

Primary SurveyDisability

GCSPupilsLateralization

Glascow coma scale (GCS): 15

Eye: 4Verbal: 5Motor: 6

Most important predictor of outcomeD

Primary SurveyExposure

Avoid hypothermia

E

MCQ #238 YO Female was hit by a car when crossing the street. She is screaming of pain in her leg. Her HR 98, BP 90/50, good breath sound bilateral, deformed left leg. What is the most appropriate intervention:

1 – Intubate

2 – Insert chest tube

3 – Establish intravenous access and give fluid

4 – Send her home because she is not nice with you

✓

ResuscitationFor each step in Primary survey, you should fix it before you move to the next step

Airway – intubate or not

Breathing – give O2 , insert chest tube

Circulation – give fluid, stop the bleeding

Adjunct to Primary Survey

ECG

Foley catheter + NGT

Blood tests

X-rays

FAST (focused assessment with sonography for trauma)

MCQ # 348 YO Male, fell down a 5 meter ladder. He is talking to you, C/O difficulty in breathing. HR 88, BP 110/90, O2 Sat 92 and he has no breath sound in the right chest. What would be the appropriate initial assessment and management?

1- Breathing, airway, circulation

2-Airway, circulation, breathing

3-Circulation, breathing, airway

4-Insert chest tube immediately after checking the airway✓

Secondary SurveyHistory (AMPLE)

A – AllergiesM – MedicationsP – Past Medical / PregnancyL – Last mealE – Event / Environment

Physical examinationHead – to - Toe

MCQ # 479 YO female. She slipped then fell down the stairs. She is talking to you, comfortable, HR 60, BP 110/70, O2 sat 95. the rest of primary survey is within normal. She told you that she has HTN. What part of AMPLE is very important in this particular patient:

1- Allergy

2- Medication

3- Past Surgical history

4-Pregnancy

✓

Adjuncts to Secondary Survey

Additional X-ray

CT scan

Definitive U/S

Diagnostic peritoneal lavage (DPL)

Definitive TreatmentTransfer to Trauma center when needed

MCQ # 533 YO male was stabbed to left abdomen. Is very drowsy and pale. C/O sever, generalized abdominal pain. You are the only family doctor in a small rural hospital in Al-Hafof. What would be the appropriate management?

1- Rapid assessment followed by admission

2- Rapid assessment then take him to the OR

3- Refuse to see him and transfer him immediately

4- Rapid assessment and initiate the transfer simultaneously ✓

Any Questions

MCQ # 6A 23 YO man has a stab wound just below the left nipple. He is alert and breathing normally. HR 94, BP 111/73. His Chest x-ray is normal. All of the following is correct EXCEPT

1- Repeat CXR in 4-6 hrs

2- FAST (Focused assessment with sonography for trauma)

3- Chest CT scan

4- DPL (diagnostic peritoneal lavage) ✓

In SummaryImportance of trauma

Trimodal death distribution

Mechanisms of trauma

ABCDE of Trauma + ResuscitationAdjuncts

Components of secondary surveyAdjuncts

When to transfer

ReferencesAmerican College of Surgeons. Advance Trauma Life Support for Doctors (ATLS), Student Course Manual, 8th edition 2008.

www.saher.gov.sa

American College of Surgeons. Surgical Education and Self-Assessment Program (SESAP) 13