PRIMARY CARE FOR TRAUMA

Presented by Presented by : Dr Mohammed Haneef

Contents

IntroductionPrincipals of managementSequence of managementPrimary Survey Secondary SurveyConclusion

2

Introduction

Maxillofacial trauma involves injury to the facial soft tissue or its bony structure.

It is commonly associated with multiple system injuries.

The most common mechanisms of injury are blunt or crush injuries caused by personal assault and motor vehicle accidents .

These concomitant injuries include cranial, spinal

upper and lower body injuries

3

Trauma is the leading cause of death in children and young adults. Its effects are protean, affecting not only the victim but also their relatives and society as a whole.

If basic principles of primary care are applied immediately, the contribution can benefit the patient and enhance his chances of survival.

4

The first priority in management of a patient with trauma is obviously the preservation of the life of the patient.

6

TWO OBJECTIVES OF MANAGEMENT

To save lifeTo restore function

7

Principles of Management (Triage System)When a patient with severe traumatic injury is first seen, an immediate general evaluation must be made to determine if emergency treatment is necessary.

Treatment Priorities I. Immediate Intervention (5% main category for reported

deaths) - Maintainance of airway Required- Poly Trauma Patients- Cardiac Conditions like arrest- Management of Shock and Bleeding II. Treatment required urgently ( 10-15%)- Intra – abdominal bleeding - Head injuries - Chest injuries III. Treatment that can wait ( non urgent -80%) Maxillofacial trauma

8

SEQUENCE OF MANAGEMMENT

Trauma (Road traffic accident fall etc.) ↓ Primary Survey -> ABCDE defines the specific prioritized evaluations and

intervention that should be followed in all injured patients

↓Secondary Survey After initial survey has been accomplished and the patient

has been stabilizedInvolves more time – consuming tests and observationsDoes not begin until primary survey is completed

9

Primary survey

For assesment of patients in systemic fashonEstablishment of treatment priorities based

on injuries, vital signs, and injury mechanismIdentification of life threatning conditions

and their managementBased on ATLS protocol.

PRIMARY SURVEY

A-Airway management with cervical spine stabilizationB-Breathing and ventilationC-Circulation with haemorrhage controlD-Disability,neurological statusE-Exposure and prevention of hypothermia

10

“A” AIRWAY PATENCY MANAGEMENT

Maintenance of patency of airway must be given priority consideration, since adequate oxygenation is vital to life.

11

Clinical Signs & Symptoms of Respiratory Distress (Obstructions)

Initially there will be restlessness, apprehension, anxiety.

Tachypnoea, tachycardia, pallor.

Rapid, labored breathing (gasping for breath).

Rapid movement or fluttering of the alae of the nose.

12

Crowing sound, strider, intercostals retraction.

Suprasternal indrawing of the tissues or supraclavicular retraction

Decreasing ventilatory excursions, hypercarbia, hypertension.

Progressive cyanosis (may be present with Hb less than 5 gm.)

13

Causes of respiratory obstructions related to maxillofacial injuries.

Inhalation of blood clot, vomit, saliva, thick mucosa or portions of teeth, bone and dentures

Inability to protrude the tongue, because of the posterior displacement of the anterior fragment of the mandible (Bilateral parasymphysis mandibular fracture)

Occlusion of oropharynx by the soft palate after retroposition of the maxilla (fractured maxilla)

14

16

Systematic approach to airway management

1. Initial assessment : Recognize airway obstruction

2. Perform airway maneuvers, clear the airway, reposition of patient.

3. Use artificial airways, perform bag-valve-mask ventilation.

4. Perform endotracheal intubation.

5. Surgical airway if unable to intubate.

Airway Management

Non –Surgical

Positioning of the patient

Oropharyngeal toilet

Suctioning of Vomitus

Anterior traction of the tongue

Immediate restoration of the position of soft palate.

Surgical

Tracheostomy

Cricothyroidotomy

16

Non Surgical Treatment

1.Position of the Patient.

Semi-prone position- will maintain clear airway mainly by allowin& CSF from the airway & preventing partially avulsed soft tissue g drainage of blood, saliva of the lips or cheeks from obstructing the airway.

17

Supine position with head extended should be deprecated especially in spinal injuries.

18

2. Oropharyngeal Toilet

All blood clot, saliva, thick mucus or foreign bodies etc. should be cleared from the oral cavity and throat by digital exploration or by using cotton swabs, if available.

Fingers of one hand maintain

open mouth while fingers of

other hand sweep through oral

cavity removing any

foreign material

19

3. Suction

If suction machine is available, then catheters should be used to clear the nose, oral cavity and throat.

20

4. Anterior Traction of the Tongue

Control the tongue by the proper positioning of the patient; or the tongue can be pulled out and it can be maintained in the forward position by using tongue suture or towel clip attached to the patient’s shirt collar.

21

5. Immediate restoration of the position of soft palate.

- It can be brought about by doing disimpaction of the maxillary fracture.

- This is achieved by placing index and middle finger into the mouth hooking behind the soft palate and thumb placed on the alveolus in the incisor region.

- Head is stabilized by counter pressure with other hand over the fore head.

- Strong anterior and downward traction will bring the maxilla in normal position.

- Immediately 1 or 2 well lubricated nasopharyngeal tubes should be inserted to maintain the airway

22

6. Mouth to mouth breathing

First ventilation cycle is comprised of four quick, full ventilations of the victim without allowing time for full lung deflation between breaths.

Effective artificial ventilation is noted by expansion of chest of the victim.

In normal adult minimal volume should be 800 ml but need not exceed 1200 ml. of air for adequate ventilation

23

Exhalation is a passive process.

- The rescuer removes his or her mouth from that of the victim, takes in a breath of fresh air, and watches the chest fall.

For Adults : At a rate of one every 5 seconds (12 per minute)

In children One every 4 seconds (15 per minute)

In infants : One every 3 seconds (20 per minute).24

Rescuer places fingers of one hand on bony anterior portion of mandible;other hand is placed on forehead and rotates the head back.It stretches soft tissues of the neck,lifting the tongue off the pharynx and opening the airway.

Head-tilt,chin-lift

26

7. Endotracheal intubation If the airway is compromised or its integrity is deteriorating as a result of haematoma formation, soft tissue swelling, or surgical emphysema.TypesOral & Transnasal Cuffed & uncuffed

27

Criteria for intubation

Clinical Shortened speech

Use of accessory muscles

Subjective air hunger

Change in mental status

Poor inspiratory force

Laboratory

PaO2/fiO2<250

PaCO2>50mmHgPH < 7.25 RR >35

breaths/min

28

INDICATION FOR TRACHEAL INTUBATION(ATLS)

Need for airway protection

Unconscious Severe maxillofacial fractures Risk for aspiration Bleeding Vomiting Risk for obstruction Neck hematoma Laryngeal, tracheal injury Stridor

Need for ventilation

Apnea Inadequate respiratory

effort Tachypnea Hypoxia Hypercarbia Cyanosis

Severe closed head injury with need for hyperventilation

29

In addition, two more indications areA combative patient who exacerbate potential

injuries & who cannot safely be controlled by any other means &

A patient who is likely to have airway or breathing difficulties in the near future.

30

Contraindication Real contraindication to tracheal intubation is the

ability to adequately secure & maintain an airway by less invasive means.

Relative contraindication

Severe midface fractures associated with basilar skull fractures, to the nasal route.

Severe laryngeal trauma with tracheal separation-to orotracheal intubation since placement may further complicate the injury.

This rare injury treated with emergency

tracheostomy

31

Fiberoptic techniques are generaly not successful if there are notable airway secretions, bleeding , or emesis.

Apnea is absolute contraindication to nasal intubation.

Blind intubation in the setting of major upper airway or neck injuries.

32

Orotracheal intubation

Preparation Suction

Airway.

Laryngoscope.

Tube.

Equipments

33

34

Airway management devices: A - oropharyngeal (Guedel) airway; B - nasopharyngeal airway; C - endotracheal tube with inflated cuff; D - laryngoscope; E - Magill forceps

Letter A shows the wrong and letter B shows the correct position of patient's head

35

Position of the patient

36

Technique of direct laryngoscopy and orotracheal intubation.

Curved blade placement in orotracheal intubation.

Technique

Straight blade technique:

37

38

Fiberoptic intubation

Indications:

Routine intubation, difficult intubation, abnormal airway, compromised airway

Neck extension not desirable

Assessment of tube placement

Risk of dental damage

Removal of secretions and mucus plugs

Contraindications:

Lack of skill

Inability to oxygenate patient

Major bleeding in the airway

Benumof JL. Anesthesiology 75:1086, 1991.

39

Surgical airway

Inability to intubate the trachea for any reason is an indication for creation of a surgical airway when less invasive methods have failed to restore an adequate airway.

SURGICAL Tracheostomy

In greek it means creating a window in the anterior wall of the trachea.

Tracheotomy: an incision or cutting into the trachea

It is definative management in upper airway obstruction in maxillofacial injuries.

40

INDICATIONS Major laryngeal trauma with concern that cricothyrotomy or orotracheal intubation might result in retraction of trachea in to mediastinum.

Inability to intubate or perform needle cricothyrotomy in a pediatric patients i.e no airway option available.

Any patient that is adequately stable, and who requires a surgical airway that can be placed in a controlled fashion in the operating room.

Laryngeal foreign body or pathology (e.g tumor) that prohibits cricothyrotomy.

Prolonged ventilation. Facilitation of management of cervical spine injuries or oncologic

resections of head and neck

41

Contraindication

if the patient airway can be safely secured by other means( rescue airway, RSI, needle or open cricothyrotomy, etc)

In an expanding hematoma.

42

Complications

PerioperativeHemorrhagePneumothoraxSubcutaneous

emphysemaEsophageal injuryFalse passageAspiration

Post operative Plugging of the tube

with secretion Hemorrhage Infection Tracheal stenosis Tracheoesophagal

fistula Vocal cord paralysis

43

Procedure

44

45

46 46

47 47

C spine immobilisation

Well fitting hard collar & backboards

“sandbags”

48

49

Cricothyrotomy 1.Needel cricothyrotomy

2. cricothyrotomy

50

Indications

1. Maxillofacial trauma; obstruction of the airway from massive facial trauma is the most common indication for cricothyrotomy.

2. Oropharyngeal obstruction; edema secondary to infection, allergic reaction, thermal and caustic injuries, foreign body, and mass lesions ; when oral or nasal intubation is not possible.

3. Conditions in which tracheal intubation from above is either contraindicated or unsuccessful, such as with congenital malformations, massive hemorrhage, persistent vomiting, intermitting laryngospasm.

Contraindications

1. Age: in children below age 11.

2. Crush injury to larynx: result in laryngeal separation

3. Preexisting laryngeal or tracheal pathology: obstruction secondary to tumor or subglotic stenosis might prevent the establishment of functional airway

51

Needle cricothyrotomy procedure. (A) Positioning (assuming no contraindications) to expose the external anatomy (eg, laryngeal prominence).

(B) Locating the cricothyroid membrane (palpation of the cricothyroid membrane).

(C) Needle puncture of the cricothyroid membrane (anterior and side views).

(D) Seldinger (guidewire) technique for cricothyrotomy (cutaway of side view and side view)

52

Needle cricothyrotomy

Cricothyrotomy

Palate thyroid cartilage-inferior to the mandible & hyoid bone in the midline

Cricoid cartilage – 2 to 3 cm inferior to the thyroid cartilage.

A horizontal incision 2cm long is placed through the skin & subcutaneous tissue.

The incision is made just superior to cricoid cartilage to avoid the anastomosis of the superior thyroid & cricoid arteries.

A tracheostomy tube is placed.

54

Complications Perioperative

Improper tube placementHemorrageProlonged execution timePneumomediastinumSubcutaneous emphysemaThyroid gland injuryEsophageal injuryCartilage fractureRecurrent laryngeal nerve injury

Post operativeDysphonia,hoarnessSubglotic stenosis InfectionHemorrageAspirationOcclusion of tubePersistent stomaVocal cord paralysis

55

ADVANTAGES OF CRICOTHYROTOMY OVER TRACHEOSTOMY

Faster than tracheostomy, generally less than 2 min.

Easier to perform, with less instrumentation required.

Fewer surgical complications & less bleeding Does not require extension of the neck.

56

B: Breathing

Once the patient airway has been established & the breathing sustained, the patient should be placed on supplemental oxygen.

Oxygen can be administered to the patient via nasal cannula, a face mask, or endotracheal tube.

It should be given until PaO2 >60-70mmHg. If administered for prolonged period-oxygen toxicity

57

C:circulation

1. Hypovolemic shock

2. Control of bleeding

3. Fluid resuscitation

4. Blood product replacement.

58

Hypovolemic shock and hemorrage

Hemorrage is the most common cause of hypovolemia in the multisystem injured patient.

Physiologic response can be categorized based on percentage of blood loss.

59

Classes of hemorrhage

CLASS I CLASS II CLASS III CLASS IV

Blood volume loss

Up to 15% 15% to 30% 30-40% >40%

Adult blood volume amount

<750 ml 750-1500ml 2000ml >2000ml

Need for blood transfusion

No Generally no Almost always

Yes

Tachycardia Minimal Present Marked Marked

Systolic pressure changes

None None Decreased Decreased

Diastolic None Decreased Decreased Decreased

Urinary output changes

None Midly affected

Significantly decreased

Negligible urine output

60

While the primary assessment is taking place, ATLS dictates that a minimum of two large-bore(16 to 14 gauge) intravenous catheters should be placed in case of fluid resuscitation.

When blood loss is mild (less than 15% of blood

volume), no volume resuscitation is necessary.

With moderate to severe blood loss, the only effective management of hypovolemia is volume resuscitation.

61

In hypovolemic shock, a standard volume resuscitation approach is to administer 2 liters of crystalloid fluid as a bolus.

If no response, then colloid fluids are added to the regimen.

Colloids are efficient plasma expanders.

There is a 1:1 ratio of colloid replacement to blood loss and a 3:1 ratio for crystalloid replacement.

62

Blood product replacement

Blood transfusion is to increase the oxygen-carrying capacity of the blood

Indicated for hemoglobin less than 6 g/dL. In case of whole blood loss-early replacement with O-

negative blood can be given. Not more 4 units of O-type blood should be administered. A unit of FFP is given for every 5 units of blood to prevent

coagulation abnormalities.

63

If the patient doesn't respond to initial fluid resuscitation and/or blood transfusions, measure CVP with a catheter or evaluation of the neck veins may assist with hypovolemic shock.

Patient is placed in trendelenburg’s position to empty the large capacitance or venous side of the peripheral circulation back to heart.

64

Control of bleeding Prompt control of post traumatic bleeding is a must.

Initial digital compression should be given to control the bleeding-firm & continuous. Compression dressings also can be used. Major vessels which are cut, should be clamped or ligated. Soft tissue wounds which are deep and extensive should be sutured immediately Firm pressure applied proximal to major arteries to control

bleeding.

65

Deep wounds also can be packed with gauze till definite measures are taken.

Nasal bleeding can be stopped by using ribbon gauze packing soaked in 1:1000 adrenaline. In some cases post nasal packing may be necessary

66

Method of insertion of a postnasal pack

A flexible aspiration catheter 3mm in diameter is passed via one nasal aperture and retrieved with Magill forceps from the oropharynx and it is lead out through the mouth.

A pack of about 4cm in diameter is made and is tied with tape.Two ends are left,one of each is passed into the end of catheter which is then withdrawn back through the nose.

The pack is pushed up behind the soft palate and the two ends of the tape secured together firmly below the anterior nares

67

Neurologic Examination(Disability)

A brief neurological evaluation is performed to establish

The patient’s level of consciousness Pupillary size & reaction

Lack of consciousness with altered pupil reaction to light –immediate CT scan of the head-management with mannitol or fluid restrictions

68

The committee on trauma of the American college of surgeons recommends AVPU system

A rapid assessment of neurological disability is made noting patients response on a 4 point scale

A - Responds appropriately, is aware V - Responds to verbal stimuli P - Responds to painful stimuli U - Does not respond, unconscious

In the absence of direct damage to the eye, pupil response

must be recorded.

69

EXPOSURE

Patient should be completely disrobed so that all the body can be visualized, palpated, and examined for injuries or bleeding sites.

70

Conclusion

In the care of the patient with maxillofacial injuries, it is essential that the surgeon have the knowledge and the ability to provide an emergency airway.

Surgeons must be technically prepared and psychologically willing to perform procedures that may be life saving.

71

References

1. Miller’s Anaesthesia. Vol. I2. Oral and Maxillofacial trauma. 2nd edition. eds

RJ Fonseca and RV Walker. 19973. Principles of Oral and Maxillofacial Surgery.

Peterson, Marciani, Roser and Indresano. Vol. I Principles of Surgery. Part V - Principles and Management of Maxillofacial Trauma. 1997

4. Rowe and Williams’ Maxillofacial injuries. Vol. I. 2nd edition. J. Ll. Williams (ed.) 1994.

5. Oral and Maxillofacial Surgery. Vol. 3 – Trauma. RJ Fonseca(ed). 1999.

72

Head Injuries C – consciousness R – respiration A - Trauma N – Neck

Cervical/Carotid Injury

E- Eyes Pupils

Extra ocular muscles

Corneal reflexes

Occulovestibular and occulocephalic reflexes

A - Airway Gag relex

L- Limbs Motor examination

Reflexes

Sensation

HEAD INJURIES These may include injuries of the scalp, skull, brain, and

blood vessels. Scalp Injuries

1. Laceration of the scalp may be associated with significant bleeding. Control with deep sutures and compression dressing. Prophylactic antibiotics for Scalp infections as they may spread intracranially via the emissary veins.

2. Skull fractures are described according to shape, displacement, site and integrity of the overlying skin. Thus we have, for example, linear, stellate, comminuted, depressed, compound, and basilar fractures. A fracture can be diagnosed by digital exploration of the wound,

radiographically or clinically. The diagnosis of basilar fractures is often clinical:

CSF leaking from the nose or ear.

Periorbital ecchymosis (raccoon eyes).

Ecchymosis behind the ear (Battle's sign).

Physical Examination

1. Assess level of consciousness. Use the Glasgow Coma Scale. The minimum score is 3 and the maximum score is 15. An intubated patient has a maximum GCS 11T. A \score of 8 or less signifies severe brain damage and the prognosis is guarded.

2. Check pupils (size, reaction to light).

3. Check ears and nose for bleeding or CSF leakage.

4. Check for ecchymosis around the eyes or behind the ears (basilar fracture).

5. Check cranial nerves.

6. Exclude neck injury (neck pain, stiffness, tenderness, or paralysis are suspicious signs).

7. Limbs (strength, tone, reflexes)

8. Vital signs (blood pressure, pulse, respiration, temperature)

9. Associated injuries

Brain Injuries 1. Concussion: No gross pathology. Transient loss of

consciousness. CT scan is normal.

2. Contusion: Bruising of the brain surface underneath a fracture or at the under-surface of the frontal and temporal lobes, due to shearing forces. Diagnosed on CT scan.

3. Laceration: Tearing of the brain substance. Diagnosed by CT scan.

4. Brain edema: This is localized in the glial cells, myelin sheaths, and intercellular spaces. It causes increased intracranial pressure, which may impair brain circulation, or result in brain herniation. It may be missed in early CT scans. Later CT scans or MRI show edema more reliably.

Brain damage is classified into:1. Primary brain damage. It occurs at the time of injury

and is irreversible (i.e. lacerations, contusions, axonal injuries of the white matter due to shearing forces).

2. Secondary brain damage. It occurs at a later stage due to tissue hypoperfusion and may be preventable and reversible. Conditions that may cause secondary brain damage: Extracranial causes: shock, hypoxia, and electrolyte

abnormalities.

Intracranial causes: hematoma, brain edema, infection, and hydrocephalus

A minimum CPP of 70 mm Hg (or >50 mmHg in young children)

(CPP = mean arterial pressure (MAP) – intracranial)

Intracranial Bleeding

1. Epidural hematoma: Usually due to laceration of the middle meningial artery or venous sinuses. Commonly located in the temporal or parietal region, often with associated fractures. On CT scan it appears as a hyperdense, biconvex-shape lesion.

2. Subdural hematoma: a. Acute subdural: It manifests within the first few hours of injury. It is due to

bleeding from injured brain tissue or from the veins, which bridge the cortex with the cavernous sinus. On CT scan it appears as a crescentshape, hyperdense lesion.

b. Chronic subdural: It may appear many days, weeks or months after the injury. More common in elderly patients. On CT scan it shows as a crescent-shape, hypodense lesion.

3. Intracerebral hematoma: Usually beneath a cortical contusion.

4. Subarachnoid hemorrhage: It often gives symptoms and signs of Meningial irritation: headache, photophobia, neck stiffness, fever. The mental status may vary from confusion to coma. On CT scan it appears as linear, highdensity areas following the sulci, often in the Sylvian fissure. The blood is usually absorbed by the CSF. It may cause late hydrocephalus because of obstruction of the CSF circulation.

A catastrophic complication in patients with intracranial hematomas is herniation of the temporal lobe through the tentorium and compression of the brain stem. Symptoms and signs: 1. Dilatation of the ipsilateral pupil, due to compression of the third nerve. In the

early stages there may be transient constriction due to stimulation of the nerve.

2. Depressed level of consciousness, due to compression of the reticular formation

3. Contralateral hemiparesis, due to compression of the cerebral peduncle

4. Bradycardia

5. Elevated blood pressure

6. Irregular respiration

Ocular function

Reaction of pupils to light

Extraocular muscle function

Oculovestibular and oculocephalic reflexes

Corneal reflex

Gag reflex

Cranial nerve examination Olfactory nerve

Optic nerve

Occlumotar

Trochlear

Abducent

Trigeminal nerve

Facial nerve

Vestibular nerve

Glossopharyngeal nerve

Spinal accesory nerve

Hypoglossal nerve

Upper motor lesion Vs lower Motor lesion

Mucle groups

Rigid

Slight wastine

Flexor spams

Brisks jerks

Plantars extensor

Normal electrical reaction

Individiual

Flaccid

Marked wasting

Fasciculation

Deep jerks absent

Flexor plantars

No or little reaction

Motor nerve examination Grade 0 – no motor activity

Grade 1 – papable muscle contraction

Grade 2 – complete range of motion with gravity eliminated

Grade 3 – complete range of motion against gravity

Grade 4 - complete range of motion against gravity with resistance

Grade 5 – complete range of motion against gravity with complete resistance

Gait •Casual , heal to toe and tandem walking to be examined•Cerebellar dysfunction can cause ataxia of gait•Unilateral cerebellar lesion will produce staggering toward the affected side ( typicall walk with the legs apart)

Coordination•Ability to perform finger to nose, heel to shin, and rapid alternative movements•Hemispheric cerebellar disease usually lateralize, middle vermian lesions affect bilaterally

Sensory system

Grade 0 – absent

Grade 1 – present

Grade 2 – normal

Grade 3 – normal active

Grade 4 – hyperactive

Grade 5 – hyperactive with Clonus

Jaw jerkBicep jerkSuppinator jerkTricep jerkKnee jerkAngle jerkBabinskis sign

Diagnostic tests 1. Plain skull x-rays only if CT scan is not available (may show fractures, foreign

bodies, air in the skull, shifting of calcified midline structures). A linear fracture increases the risk of intracranial hematoma by 400 times.

2. Cervical spine x-rays and CT scan for all unconscious patients and those with suspicious symptoms (local tenderness, neurological signs).

3. CT scan: This is the most important diagnostic tool. Indications: All patients with history of loss of consciousness, amnesia, depressed level of

consciousness, headache and localizing signs should have a CT scan investigation. Subsequent CT scan may be necessary if there is deterioration of the neurological status.

4. Carotid angiogram (limited use). It might be useful in some penetrating injuries, especially with retained knife blades or bullet injuries.

5. Intracranial Pressure (ICP) monitoring: It is an essential diagnostic, monitoring, and therapeutic modality in severe head injuries. The CPP (Cerebral Perfusion Pressure) is much more important than ICP absolute values. Maintain a CPP >70 mmHg or >50 mmHg in young children.

SEND FOR NEUROLOGICAL CONSULTATION

Management of Scalp injuries

Scalp lacertations:Copius irrigation to cleanse the wound, carefull debridement. Closure in layers

Scalp avulsions: copius irrigation, trimming of edges. Primary closure if avulsion is small. Large area to be covered with suitable flap or left with external dressing for secondary healing.

Managemet of Mild Head injuryGCS 14 - 15

• History • Name/Age/Sex• Mechanism of Injur• +/- loss of consciousnes• Level of alertness• Amnesia –

Retrograd/anterograde• Head ache- mild/moderate/sever• +/-seizure

• GPE• Limited

neurological examination

• Cervical spine radiographs

• Blood alcohol• CT scan

• Admit/observe• No CT Scan/Abnormal CT scan• Penetrating Head Injuries• Deteroriting Condition• Moderate/sever head ache• Alcohol intoxification• Skull fracture• CSF leak• Amnesia• H/O unconsciousnes

• Discharge• Schedule follow up

with in 1 week

Management of Moderate head Injury (Flow Chart)

GCS 9-13

Admission

CT Scan of Brain

If patient improves discharge if patient detoriates, manage

as per severe head injury

Management in Case of Sever head injury

GCS score 3-8

• ABC

• Previous history for allergies, medications, past illness, last meals and events leading to head injury

Neurologic Reevaluation

•Eye opening

•Motor response

•Verbal response

•Pupillary light reaction

•Occulo cephalics reflex

•Occulo vestibular reflex

Therapeutic Agents

•Mannitol

•Moderate hyperventilation

•Anticonvulsants if requireed

• CT scans

• Air Venticulogram

• Angiogram

Skull fractures

Skull fracture predispose a conscious to about 400 times the possibility of cranial haematoma and about 20 times in a comatose patient

Classified as: Closed/open

Linear/stellate/communited

Depressed / non depressed

Management

Closed non depressed fractures:- observation and monitoring and medical line of treatment for associated intracranial parenchymal injury

Open non depressed fractures:- close observation, surgical intervation if intracranial bleed is suspected/anticipated

Depressed skull fractures:- observation, if no untoward neurological sign exists than the operation may be delayed and elevation of the fractured segment is done

Basal skull fractures

Associated tear of the dura and arachnoid at the base of the skull/ middle or anterior cranial fossa

Battles sign is suggestive of basal skull fracture

A CSF fistula occurs in 70 % patients with in 48 hours of trauma

98% of fistulae occur with in 3 months

Post traumatic fistulae heal spontaneously with in week, and 80% heal with in 6 months.

Spontaneous reoccurance may be there after initial cessation

Otoroheas almost always resolves spontaneously and delayed otorrhea is rare

Chronic fistulae are indicated for surgical repair

C/F

Headache

Decreased hearing

Salty taste in mouth

Pneumocephalus present in 30% of the patients

Diagnosis

Bed side: ring test

tram line

Lab test: glucose >30mg/dl

protein < 2/l

presence of b2 transferrin

Management There may be presence of meningitis - Prophylactic

antimicrobials (3rd generation cephalosporins)

Head elevated to 30 degrees, cautioned againts blowing nose, forcefull coughing

If leak persists for more than 72 hours, lumbar puncture is indicated to reduce ICP

Fewer than 5% patients require repair. Immediate surgical intervention is indicated only open communited fractures with CSF leak

Delayed surgical repair is indiacted in Persistent or increased CSF leakage over 1 or 2 weeks

Presence of unresolving pneumocephalus for more than a week

meningitis

Cervical Spine Injuries

Only 2% incidence of cervical spine injuries in maxillofacial trauma patients

Identification of obvious fracture , widening of posterior spina process interspace

CT scan is choice of diagnostic radiographic tool

Emergency management include: ABC

C-Spine stabilization using rigid and semi rigid collars

30mg/kg predisonolone bolus followed by 5.4g/kg/hr for 24 hours

Definitive management include skeletal traction, with the use of halo traction with stryker frame with abouts 25 pounds of traction force

Orbital injuries Opthalmic exatmination:

Visual accuity

Enoptholmoses/proptosis/diplopia

Eye movementSize , level and reaction of pupils

Intra occular examination of choroid, anterior chamber, cornea,iris

Extra ocular examination

Lid integrity

Nasolacrimal duct injury

Echymosis

Ptosis

100

Hutchinson’s pupil•Seen in case of cerebral compression•Consists of 3 stages

Pupil of the side of injury contract due to irritation of occulomotor nervePupil on other side -normal

pupil of the injured side becomesdilated due to paralysis of occulomotor nervePupil of other side contracts

Pupils of both sides dilated, no reaction to light

101

Pupillary response inference

Bilaterally reactive pupils that react to both direct & consensual stimuli

Normal pupil

Bilateral small pupils Narcotics, pontine injury, early central herniation on the pons

Bilateral fixed & dilated pupils Inadequate cerebral perfusion,severe elevation of ICP preventing adequate blood flow to brain

Unilateral fixed & dilated pupils. pupil that does not constrict when light is directed at the pupil but constricts when light is directed to contralateral pupil

Traumatic optic nerve injury(Marcus Gun pupil)

A core optic pupil (pupil that appears irregular in shape)

Lack of coordination of contraction of the muscle fibers of the iris and is associated with midbrain injuries

Unilateral dilated pupil that does not respond to either direct or consensual stimulation

Transtentorial Herniation

102

Cranial nerve 3,4,6:

- light reflex

- intorsion and extorsion

Vision-threatening injuries (VTI) These include:

Retrobulbar haemorrhage;

Traumatic optic neuropathy;

Open and Closed globe injuries;

Loss of eyelid integrity;

Chemical injury.

Loss of sight following blunt facial trauma may be crudely considered to be due to the following mechanisms. Direct injury to the globe;

Direct injury to the optic nerve, e.g. bony impingement;

Indirect injury to the optic nerve, e.g. deceleration injury resulting in shearing, stretching forces;

As a result of a generalised or regional fall in tissue perfusion (anterior ischaemic optic neuropathy,

retrobulbar haemorrhage, nutrient vessel disruption);

Loss of eyelid integrity

Retrobulbar haemorrhage

A tense, proptosed globe and a dilated pupil may be the only clues to the presence of a retrobulbar haemorrhage

A lateral canthotomy, with lateral canthal tendon division, can be performed under local anaesthesia in the emergency setting. Lignocaine 1%, with adrenaline (1 in 200,000), is injected into the lateral canthal area of the affected eye, the lateral canthus incised to the orbital rim and the canthal tendon identified and cut. The lower eyelid is then pulled forward and its lateral attachment to the orbital rim divided.

This allows the globe to translate forward, partially relieving the pressure by increasing the retrobulbar volume. If necessary, the same procedure can also be applied to the upper eyelid laterally. Formal decompression is then carried out under a general anaesthesia

CHEST INJURIESRib trauma is occurs in aout 56% of poly trauma patients followed by pneumothorax, flail chest, injuty to heart and major vesslesDegree of injury to chest is not indicative of the severity of injury to inner structures During the Primary Survey, the following life-threatening conditions from the chest should be identified and treated:

1) Tension pneumothorax

2) Fail chest

3) Open, blowing chest wound

4) Massive hemothorax

5) Cardiac tamponade

During the Secondary Survey, the following injuries should be identified and treated: 1) Contained rupture of the aorta

2) Perforation of the tracheobronchial tree

3) Perforation of the esophagus

4) Rupture of the diaphragm/trachea

5) Myocardial contusion

6) Pulmonary contusion

PNEUMOTHORAX

Definition: The presence of free air in the pleural cavity. Symptoms and signs

1. Often asymptomatic.

2. Dyspnea, tachypnea.

3. Diminished breath sounds, hyperresonance, poorly moving hemithorax.

InvestigationsChest x-ray, preferably erect and in expiration

HEMOTHORAX

Definition: Free blood in the pleural cavity.Symptoms and signs

1. Often asymptomatic.

2. Dyspnea, tachypnea, hypovolemia.

3. Diminished breath sounds, dullness on percussion, poorly moving hemithorax

TENSION PNEUMOTHORAX

Definition: Air under pressure in the pleural cavity due to a valve effect. Associated with life-threatening cardiorespiratory compromise due to collapse of the affected lung, compression of the normal lung and decreased venous return.

Symptoms and signsDramatic presentation. Panicky patient. Dyspnea, cyanosis, tachypnea,Shock, distended neck veins. Deviated Trachea to opposite sideAbsent breath sounds, hyperresonance on affected side. Prominent hemithorax with no movement on respiration

Flail Chest Occur as a result of three or more contigous ribs fracturedd at two

points

Lateral type of flail chest is more common

Anteior type occures when ribs become separated at the costrochondral junction, with or without associated fracture of sternum.

The posterior type occurs whe n the posterior ribs are fractured

Pulmonary contusion, hemothorax and pneumothorax may be associated with flail chest,

Mechanical ventilation is indicated Tachyapnea

Shallow rapid breaths

Distended neck veins

hypercapnea

Placement of thoracic tube

Abdominal Injuries

The abdomen is systemically examined by inspection, palpation and auscullation and percussion

Injury to be suspected in deacceleration injuries, blunt trauma apart from penatrative injuries

Presence of haematuria in Routine urine examinatio may indicate a renal/genito urinary trauma

Serum amylase a non specific test in presence of abdominal pain is significant

LFT should also be advised to check liver injuriesDignostics include USG, CT Scan PA abdomen and DPL

DPL (diagnostic peritonial Lavage) Indicated in patients with + H/O abdominal trauma with abdominal

pain /tenderness.

Objective is to obtain fluid from the pelvic fossa for analysis

Bladder should be emptied to avoid injury during DPL.

Aspiration of fluid is done, if no fluid is obtained tha n 20ml/kg of RL is infused upto 1 Litre and removed fluid should atleast be in range of 500-700 ml.

Three methods: Closed type: catheter blindly inserter below the umblicus in to the peritoneal

cavity. Highest incidence of complication, false negative tests and iatrogenic injury to visecral organs

Semiopen type: 2-3 cm infraumblical skin incision, blunt dissection. Incision into fascia. Insertion of trocar

Open technique: insertion of the catheter direct vision. Safest and guarantees intraperitoneal placement

Managemet of abdominal injuries

Physical examination to be repeated every 6 hourly

Management of shock, sepsis

Surgical exploration and intervention when necessary

Monitoring of urine output every hourly

Patient to be NPO

Nutritional support

Urological injuries

Occurs in 10% polytrauma patients

Majority of injuries are non threatning

Evaluation of kidneys, ureter, bladder, urethra and genitila

Excellent healing capibilities of genitourinary tract, if urinary flow can be maintained without obstruction than healing is likely with just medical intervention

Kidney is the most common urologic organ to be injured

CT scan is the gold standard for diagnosing renal injuries

Skeletal injuries

Retrograde intubation

Submental intubation