TRAUMA Begashaw M (MD)
Jan 20, 2016
TRAUMA
Begashaw M (MD)
Trauma
Introduction
is one of the leading causes of mortality, morbidity and disability
mostly affects people in their productive years
The causes of trauma are various
Deaths due to trauma
1. Immediate death (50%) Occur in the first few minutes injuries to the brain, heart & major blood vessels2. Early deaths (30%) Occur in the first few hours due to the collections and bleedings in the chest
and abdomen, extensive fractures and increased intracranial pressure
3. Late deaths (20%) Occur days or weeks after the injury due to sepsis and organ failure
DEFINITION
_is tissue damage, which occurs due to transfer of different forms of energy
Types of TraumaI- Cause: Homicidal injuries Road traffic accident and falls Industrial accidents, burnII- Mechanism: A/ Blunt Injury: Caused by acceleration, deceleration,
rotational or shearing forceB/ Penetrating Injury: Caused by a direct breach by
penetrating object E.g. Bullet injury, stab injury
Mechanism of Injury
• Blunt Force Trauma
• Penetrating Trauma
TREATMENT
• Advanced trauma life support (ATLS) protocol
• The ATLS _primary survey and resuscitation followed by
_secondary survey and definitive management
The Flow of the Initial Assessment Primary Survey
Resuscitation
Detailed Secondary Survey
Definitive Care
Reevaluation Reevaluation
Initial management
I- The primary survey and resuscitation
• Quick evaluation to detect immediately life threatening situations
• Institution of measuresA Airway and cervical spineB BreathingC Circulation with hemorrhage controlDDisability-Dysfunction of CNSE Exposure/Environment
A- Air way-cervical spine
• Assess the patency of air way• May be compromised by_back fallen
tongue, broken tooth, vomitus, blood • Use_ suctioning, jaw trust,
positioning, oropharyngeal tube or endotracheal tube to open it, take care of the cervical spine-hard collar
• 100 % oxygen
B- Breathing
• Assess adequacy of breathing-“Look, listen, feel”• Compromised by pneumothorax,
hemothorax or multiple rib fractures causing flail chest
• Tension pneumothorax-venous cannula through second intercostal space in the mid-clavicular line
• If open chest wound seal with occlusive dressing
C- Circulation
• Assess the circulatory volume-pulse, capillary refill, neck veins
• Look for external hemorrhage and arrest it by pressure, bandaging
• Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound
• Open a wide bore IV line take blood sample for cross match and start resuscitation with Normal saline or Ringer’s lactate
Dysfunction
• Assess level of consciousness using AVPU method
A = alert V = responding to voice P = responding to pain U = unresponsive• Glasgow coma scale (GCS)• Look for any Neurological deficit or
lateralizing sign
E- Expose
• Expose (undress) the patient fully• Avoid hypothermia
II- Secondary survey and definitive management
done after the life threatening conditions have been evaluated and resuscitative measures are instituted
A- Take History_Time of injury_ Mechanism of injury_Amount of bleeding_ Loss of consciousness_Any intervention performed or drugs given
B- Do a proper and systematic examination of all body systems
C- investigations _ hematocrit, cross-match, urinalysis, X-ray, ultrasound, etc.
Never send a patient with unstable vital signs for investigation or referral before resuscitation
D- Appropriate treatment _laparotomy ,POP cast
ROAD TRAFFIC ACCIDENTS (RTA)
• is the leading cause of trauma deaths• Several factors contribute to the high
magnitude _poor condition and design of roads
_traffic mix _poor condition of the
vehicles _poor traffic rule
enforcement
MVA
Injuries are caused by
sudden acceleration e.g. a pedestrian hit by car
decelerations _ passenger to collide with the interior of car
high risk of serious and multiple injuries:• Presence of flail chest• Roll over• Death of another person in the car
FIREARM INJURIES
_due to homicidal violence_missile injuries - bullets from
pistols, rifles, machine guns_degree of injury depends on the
amount of energy_E=½mv2 (E = energy transferred,
m = mass of the missile, v = velocity of the missile)
Classification
I- Low- velocity_ missiles fired from hand guns (<400m/s)_Injury is limited to the path of the bulletII- High velocity_bullets fired from rifles, machine guns and blast
fragments (>1000m/s)_ small entrance ,a larger exit wound _Tissue damage occurs in the surrounding tissue _Foreign bodies, dirt and clothing in wound
Management appropriate wound debridement_Excision of all dead tissue_Removal of all dirt, foreign bodies and free bone
fragments_irrigation of wound with copious amount of saline debrided wound should be left open for closure
laterN.B: Never close missile wounds primarily, not
even the very trivial looking ones!_broad spectrum antibiotics _tetanus prophylaxis
BURN
is a coagulation necrosis of tissue due to thermal or chemical injury
Women and children are mostly affected Types of burns Flame burn Scalding Chemical burn Electrical burn
Severity
Depends _the burn depth (degree) _the extent or percentage of the body
surface Determining the percentage of burn
surface is important to calculate the amount of fluid requirement
Determination of burn depth is important for burn wound management
Classification of Burn according to depth (degree)
1- First degree _ involves epidermis _ manifests with erythema2- Second degree (partial thickness) _involves part of dermis _manifests with blisters, edema,
moist surface and pain at the affected site3- Third degree (full thickness) _ Involves complete burn _charred, white or grayish , pain free
Burn degree
1st degree (Superficial) burn
Second degree (partial thickness) burn
3rd degree (full thickness) burn
4) 4th degree burn - involves the underlying viscera or other organs e.g. bone,liver
Rule of Nine
Management
General_ATLS system_Airway obstruction -rapidly after
inhalation injury or delayed for 24-48hours
_ Endotracheal intubation or tracheotomy_ Breathing_ Circulation_Analgesia
Fluid resuscitation
_Major burn (> 20% body surface area)_Open IV line-normal saline/ringer lactateParkland Formula_First 24° _4 mL Lactated Ringer’s X weight in kg X
% total body surface area burned _50% of fluid in first 8° _50% over next 16° _ Keep urinary output 0.5 – 1 mL/kg
Criteria for admission
any burn over 20%(adults) & 10%(children) BSA
Special areas e.g. eye, face, hands, feet, perineum
Inhalation injury Chemical & electrical burns Full thickness burns where grafting is
indicated Children & elderly pts who require additional
medical or social support
Burn wound management
• Goals _close wound _prevent infection _reduce scarring and contracture _provide for comfort Wound cleaning Debridement Mechanical Surgical Topical antibacterial therapy
Dressing the Burn
The Exposure Method-Open Technique:_wound is cleaned by antiseptic agents _Left exposed to air_used for burns of the face and burns of large
surface area The occlusive method-ClosedTechnique _a thick dressing after cleaning with antiseptics
covers the burn wound_used mostly for outpatient treatment of small
burns
Wound dressing
• Emergency escharotomy and fasciotomy should be done for deep circumferential burns of limbs, neck or trunk
Wound Care: Grafting Indications for grafting_full thickness burns_priority areas_wound bed pink, firm, free of exudate_bacterial count < 100,000/gram of tissue
Escharotomy Facial and hand burns
Escharotomy
Analgesia
• Most burn patients are in severe pain _analgesic doses of IV narcotics regularly to control the pain
Prevention of Infection
• impaired resistance against infection• Most deaths occur due to
pneumonia and wound sepsis• Prophylactic antibiotics (penicillin)
are given for severe burns • Topical antimicrobials e.g. 1% silver
sulfadiazine are helpful for deep 2nd and 3rd degree burns
Nutrition
_ Naso -gastric tube -more than 25% burn -nausea and
vomiting in catabolic state lose weight very fast daily calorie required is 20 Kcal/Kg + 70
Kcal/%burn Daily protein requirement is 1 gm/kg +
3 gm/%burn.
Contracture
• Prophylaxis against tetanus• Prevention of contractures &
rehabilitation _move all joints