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TRAUMA (II)

FMHS

UNIMAS

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HEAD INJURY INTRODUCTION: A major cause of morbidity & mortaity ! "er #$$$$$ are fata %$ of trauma casesT'ird eadi() cause of deat' *ajority+ RTA , -%. fas/ assauts/ s"orts

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0at'o"'ysioo)y C12 s3u "rotect t'e brai(

I(tracra(ia "ressure4IC05 *o(roe+6eie doctri(e

,7oume+"ressure cur7e. Auto re)uatio(

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E

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Cus'i()?s res"o(se R9R decreased H9R decreased 1ystoic 0 i(creased 0use "ressure i(creased

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Cerebra bood o> ;'at is cerebra "erfusio( "ressure= C00 B *A0+ IC0 AUTOREU8ATION

+ re)io(a bood o> i(creasedby ===

+ se7erey disturbed i( 'ead i(jury

+ C00 $ mmH) F "oor outcome

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Cou" & cou(ter cou"

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0rimary brai( i(jury Dama)e caused at time of im"act Ca( be foca or di

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1eco(dary brai( i(jury I(sut im"osed after i(itia i(jury d9t Hy"oGaemia / Hy"erca"(ia 1ystemic 'y"ote(sio( I(tracra(ia 'aematoma I(tracra(ia 'y"erte(sio(

Autore)uatio( of cerebra bood o> isost after 'ead i(jury

Eary treatme(t is reuired

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I(tracra(ia 'aematomas Intrcerebral

+ 'y"erde(se o( CT

+ sma o(e may e(ar)e

+ ar)e o(e may (eed e7acuatio( Extradural

- midde me(i()ea A/ a9f tri7ia trauma

+ sur)ery is esse(tia

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Acute subdural+ most commo(

+ tor( brid)i() 7ei(s or cortica

aceratio( Chronic subdural

- i( c'ibre( & edery

+ "ro)ressi7e (euroo)ica decit+ s'oud be drai(ed if t'ey co(ti(ue

to e(ar)e

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Cassicatio( of 'ead

i(jury 1e7erity Fmi(or C1 K+#%

+ major C1 K *ec'a(ism F bu(t

+ "e(etrati()

0at'oo)y F foca 9 di

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Com"icatio(s a9f 'ead

i(jury 0o brai( i(jury Co(cussio(

Co(tusio( o(e

fra)me(tatio( Di

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*ANAE*ENT PRINCIPE

+ To dia)(ose a "rimary brai( i(jury& "ro7ide t'e o"timum co(ditio(sfor reco7ery

+ *i(imiLe & "re7e(t t'e seco(dary

brai( dama)e by mai(tai(i() brai(tissue oGy)e(atio(

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Causes of atered

co(scious(ess T I 0 0 1

A E I O U

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Additio(a assessme(t 0u"i diameter & i)'t reactio( 0use & 0Tem"erature & res"iratio( *o7eme(t of a imbs

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Diated "u"i

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1i)(s of basa s3u

fracture ood or C12 from (ose or ear 0eriorbita 'aematoma *astoid 'aematoma ,attes si)(. Haemotym"a(um Radioo)ica e7ide(ce of i(tra+cra(ia

air Radioo)ica e7ide(ce of uid e7es i(

si(uses

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0eriorbita 'aematoma

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I(dicatio( for 1R 8oss of co(scious(ess/ am(esia *ec'a(ism of i(jury im"yi()

stro() force of im"act 1e7ere 'eadac'e/ (ausea/diLLi(ess Momiti() 1usce"ted s3u 7aut "e(etratio(

or 2P

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De"ressed s3u Q

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INDICATION 2OR CT Coma "ersisti() after resuscitatio( Deteriorati() co(scious e7e Neuroo)ica decit 2racture s3u >it'

+ co(fusio( or im"aired co(scious(ess

+ e"ie"tic seiLure

+ (euroo)ica sym"toms or si)(s

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O"e( i(jury+ de"ressed com"ou(d fracture

+ s3u base fracture

+ "e(etrati() i(jury

Note : if CT sca( is i(dicated s'oud

be "erformed ur)e(ty >it'i( +S'ours of admissio(P

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EGtradura 'aematoma

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E"idura 'aematoma

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1ubdura 'aematoma

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I(tra cerebra 'aematoma

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attes si)(

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Racoo(?s eye

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Criteria for admissio( 8OC % mi( 2ai() C1 13u fracture Neuroo)ica decit Dicut assess, aco'o i(toGicatio(. No atte(da(t at 'ome Ot'er medica co(ditio(s

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O"e( brai( i(jury

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0e(etrati() 'ead i(jury

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Dru)s i( acute 'ead i(jury 1edatio( & a(a)esics A(tibiotics Fco(tro7ersia

+ i(dicatio(@@@ *a((ito 1teroids F (o cear 7ie> 2or seiLure === Note : RE1T8E11NE11+>ar(i() si)(s

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A(tibiotics i( 'ead i(jury IN"ICATI#NS

asa fracture O"e( 7aut fracture 1us"ected or "ro7e( me(i()itis

A!ENTS

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Referra to (eurosur)ica

u(it Ab(orma CT sca(

Norma CT sca(

ci(icay u(satisfactory "ro)ress

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EG"oratory burr 'oe 8ess "ractice i( moder( ma(a)eme(t O(e t'ird ca( be missed by e7e(

eG"erie(ced (eurosur)eo( O(y i( "re7iousy aert "atie(t F

ra"idy deteriorate & Ged diated

"u"i Deay tra(sfer to (eurosur)ica ce(tre

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CHE1T INJURY % trauma deat' Immediate deat' d9t major disru"tio(

of t'e 'eart or )reat 7esses Eary deat' is d9t air>ay obstructio(/

cardiac tem"o(ade or as"iratio(

*ajority ma(a)ed by sim"e measures O(y #% reuire 1G ma(a)eme(t

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0atter( of c'est i(jury Mauabe i(formatio( Direct F "e(etrati()

+ bu(t + crus'

I(direct F deceeratio(

+ bastNOTE+ se7ere c'est i(jury >it'out

eGter(a e7ide(ce

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0at'o"'ysioo)y *ai(y+ res"iratory &

'aemody(amic ood oss Me(tiatory faiure 8u() co(tusio( or coa"se *ediasti(a dis"aceme(t Hy"oGia + acidosis

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Immediatey ife

t'reate(i()c'est i(juries U""er air>ay obstructio(

O"e( "(eumot'oraGTe(sio( "(eumot'oraG 2ai c'est

*assi7e 'aemot'oraG Cardiac tem"o(ade

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O"e( "(eumot'oraG *ust be treated ur)e(ty 1ea to sto" suc3i() I(tercosta drai( I(tubatio(

00M

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Chest $all in%ur& $ith o'en 'neuothorax

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Te(sio( "(eumot'oraG Air e(ter t'e "eura s"ace but (ot eGit I(creased i(trat'oracic "ressure

*ediasti(a s'ift 1'ort(ess of breat' Hy"oGicTrac'ea "us' to o""osite site 4ate5 Ur)e(t (eede decom"ressio(

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8eft te(sio( "(eumot'oraG

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Tension pneumothorax is a lifethreatening emergencywhichever doctor in traumamust be able to recognizeinstantly and treatimmediately *

+ A consultant in A,E edicine-

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2ai c'est 0aradoGica m9m of c'est >a o(

res"iratio( 1e7ere res"iratory distress If ar)e

F usuay reuire i(tubatio(

+ mec'a(ica 7e(tiatio(

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*assi7e 'aemot'oraG *ost i( "e(etrati() i(juries If se7ere + 'y"o7oaemic s'oc3 Res"iratory distress Du o( "ercussio( Reduced breat' sou(d C'est drai( Moume re"aceme(t

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Haemot'oraG

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Haemo"(eumot'oraG

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Cardiac tem"o(ade 8eadi() cause of deat' i(

Penetratin.cardiac i(juries Rare i( bu(t trauma 0ericardioce(tesis 8oo3 for si)(s of VEC61 TRIADW

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ec3?s triad Diste(ded (ec3 7ei(s *uXed 'eart sou(ds Hy"ote(sio( >it' s'oc3

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0ote(tiay ife t'reate(i()

c'est i(jury 0umo(ary co(tusio( *yocardia co(tusio( Aortic ru"ture Dia"'ra)matic ru"tureTrac'ea9 bro(c'ia i(juries Eso"'a)ea i(juries

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0umo(ary co(tusio( *oderate or se7ere bu(t trauma Usuay reso7e

0ersiste(t air ea3 i( someTo "re7e(t i(fectio(+ eary mobiiLatio(

"ro"'yactic a(tibiotic/ "'ysiot'era"y

If ar)e F i(tubate & 7e(tiate+ assess >it' A

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*yocardia co(tusio( 2racture ster(um 9 ribs D su""orti7e EC Cardiac e(Lymes If se7ere + cardio)e(ic s'oc3 Obser7atio( >it' cardiac

mo(itori()

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Aortic ru"ture

*ajor deceeratio( i(juryTor( at t'e ju(ctio( of = ;'y= I(sta(ta(eous deat' or after se7era

days d9t ad7e(titia 'aematoma D co(trast CT Aorto)ra"'y CR

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CR features su))esti7e of

aortic ru"ture ;ide(ed mediasti(um Haemot'oraG es"eciay at t'e eftTrac'ea de7iated to ri)'t N tube de7iated to t'e ri)'t urri() of aortic 3(uc3e De"ressio( of eft mai( bro(c'us

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;ide( mediasti(um

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Aorto)ram

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Dia"'ra)matic ru"ture

*ost bu(t c'est i(jury 1us"ect i( "e(etrati() F>ou(d site =

Usuay o7er t'e eft 1i)(ica(t res"iratory distress 1'oc3

D by CR F N tube abo7e dia"'ra)m Reuire 1ur)ica re"air

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Dia"'ra)matic ru"ture

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Trac'ea or bro(c'ia

i(jury Ob7ious sur)ica em"'ysema CR

F "(eumomediasti(um

+ "(eumot'oraG 0ersiste(t 'i)' o> ea3a)e of air

from c'est drai(

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Oeso"'a)ea i(jury

Usuay "e(etrati() i(jury 8et'a if u(reco)(iLed b9c mediasti(itis

C9O of sudde( s'ar" "ai( i( t'ee"i)astrium & c'est radiated to bac3

Dys"(oea/ cya(osis/ s'oc3 4 ate5

CR + 'aemo"(eumot'oraG+ "(eumomediasti(um

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I(dicatio( for t'oracotomy

0e(etrati() i(jury 1e7ere 'y"ote(sio( 1'oc3 u(res"o(si7e to uid 1i)(s of cardiac tam"o(ade *assi7e beedi() @

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T'oracotomy

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NOTE :

Fracture of rst / second ribsor

scapula suggest major forceand increased risk ofintrathoracic injury

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ADO*INA8 INJURY

Commo( i( muti"e trauma 1"ee( F commo(est es"P i( bu(t Hi)' morbidity & mortaity Hi)' i(deG of sus"icio( >'e( H9O

su))ests se7ere trauma Ofte( missed 2reue(ty u(der+estimated

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Ty"es

u(t

+ com"ressio(

+ crus'+ seat bet

+ acceeratio(9 deceeratio( i(juries

0e(etrati()+ )u( s'ot

+ stab

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Assessme(t

0rimary sur7ey

+ A

+

+ C

+ D

+ E

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0itfas

$ >it' acute 'aemo"erito(eum(o si)(s i(itiay

u(t trauma dicut to e7auate U(co(scious I(toGicated 1"i(a i(jury

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0rocedures

Ta3e carefu 'istoryT'orou)' "'ysica eGam

+ oo3

+ fee

+ iste(

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09E

8OO6 F eG"ose

+ a(terior as >e as "osterior

+ buttoc3 / "eri(eum

+ aceratio(/ bruises

+ im"ressio( of seat bet

+ e(try or eGit >ou(d

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09E

2ee :

+ dicut for bu(t trauma

+ )uardi() may be >a i(jury+ ri)idity is usuay d9t 7iscera i(jury

+ retro "erito(ea is dicut

8iste(: "rese(ce9 abse(ce P1+ "rese(ce (ot eGcude "erito(ea i(jury

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Recta eGam

Esse(tia 1"'i(cter to(e I(te)rity of recta >a ood i( t'e rectum 0rostate "ositio(

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Ma)i(a eGam

I(te)rity of >aTo detect ob7ious "e7ic fracture

es"eciay i(ferior rami Uret'ra meatus

+a(y bood "articuary i( ma(

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Actio(s

ase i(e bood test

+ Hb/ ;C cou(t/ 0CM

+ serum U&E

+ serum amyase

+ A

+ cross matc'i() & s"ecify (oP ofu(its

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Actio(s

N tube Uret'ra cat'eter +ray c'est & abdome(

+ free i(tra"erito(ea air

+ Q o>er ribs

+ Q tra(s7erse "rocess Additio(a ima)i() F U1/ s"ira CT

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Note

08AIN +ray imited 7aue Q o>er ribs su))ests 'e"atic/

s"e(ic or re(a i(jury O(y after i(itia stabiiLatio( & (o

i(dicatio( for immediate

a"arotomy "roceed to ima)i()

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I(dicatio(s for "erito(ea

a7a)e Eui7oca abdomi(a eGam Dicut to assess 0ersiste(t u(eG"ai(ed 'y"ote(sio(

des"ite adeuate uid re"aceme(t 1tab >ou(d >it' breac' "erito(ium *uti"e i(juries es"eciay i(juries

of c'est "e7is or s"i(a cord

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Co(trai(dicatio(

Absoute

+i(dicatio( for ur)e(t a"arotomy Reati7e

+ "re7ious abdomi(a sur)ery

+ obesity

+ ad7a(ced cirr'osis / coa)uo"at'y

+"re)(a(cy

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0ositi7e resut

% m of bood o( i(itia as"iratio( 2uid drai(s from a( i(tercosta

drai( or uri(ary cat'eter RC #$$ $$$9 mmY

;C %$$9mmY

ie/ bacteria/ faeca materia Ob7ious I co(te(ts

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0itfas

2ase "ositi7e

+ +

+ d9t 7ascuar i(jury

+ "e7ic Q 2ase (e)ati7e

+ retro"erito(ea i(jury

+ badder i(jury

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I(dicatio( for a"arotomy

U(eG"ai(ed s'oc3 Ri)id sie(t abdome( E7isceratio( e7ide(ce of free i(tra"erito(ea air e7ide(ce of ru"tured dia"'ra)m A )u(s'ot >ou(d 0ositi7e resut of "erito(ea a7a)e

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1"e(ic i(jury

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*es' re"air of s"e(ic

i(jury

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8i7er tear

8/10/2019 19. TRAUMA (II).ppt

90/114

ut i(jury

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Re(a & )e(itouri(ary

i(jury Re(a F !$ bu(t i( U6

+ 'i)' i( c'idre(

+ direct :crus' b9t # rib & umber s"i(e+ i(direct: deceeratio( / "edice & 0UJ

K% *INOR

#$ *AJOR % CRITIACA8

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0RE1ENTATION

EGter(a e7ide(ce of trauma 8oi( mass / te(der(ess ross 'aematuria !$ *icrosco"ic 'aematuria Z9+ of "araytic ieus

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*a(a)eme(t

Resuscitate if (ecessary ed rest A(a)esia A(tibiotics 1eria *1U & U11

1URERY F for critica i(jury >it'

u(stabe

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Com"icatio(s

Hy"erte(sio( AM stua Hydro(e"'rosis C'ro(ic "yeo(e"'ritis Re(a faiure 1o foo>+u" is esse(tia

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Re(a i(jury

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IMU IN RENA8 INJURY

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Uret'ra i(jury

*ost F fa astride H9O Dicut to "ass t'e uri(e ood at uret'ra meatus ruised scrotum ruised "eri(eum Hi)' ridi() "rostate

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*a(a)eme(t

No uret'ra cat'eter If u(abe to "ass uri(e

F a(tibiotics + uret'ro)ram

If abe to "ass uri(e

+ a(tibiotics+ disc'ar)e

+ foo>+u"

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1"i(a i(jury

*ost cer7ica & T+8 re)io( Ris3 i( trauma "atie(t

+u(co(scious9 'ead i(jury+ 'i)' s"eed RTA

+ i(jury abo7e t'e ca7ice

+ 1e(sory a(d motor decit

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*a(a)eme(t

At t'e sce(e

F ma(ua immobiiLatio(

+ air >ay "rotectio( at su"i(e "ositio(+ atera reco7ery "ositio(

+ s"i(a board >it' 'ead immobiiser

Tra(sfer+ o) roi()

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At 'os"ita

Air>ay >it' cer7ica s"i(e co(tro Oro"'ary()ea suctio( *o(itor+0/ HR/T/ 1aOR/ EC /Uri(e

O0

If a7aiabe F ET COR

+ CM0

+ MC

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Neuroo)ica assessme(t

1e(sory *otor Auto(omic ReeGes 0ro"rioce"tio(

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Neuro)e(ic s'oc3

1ym"at'etic to(e ost Hy"ote(sio( radycardia 0eri"'era 7asodiatatio( I(otro"ic a)e(t atro"i(e

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1"i(a s'oc3

Immediate "ost i(jury "'ase

+Com"ete oss of fu(ctio(

+2accidity/oss of reeGes 1e7era days or >ee3s ater

+ 1"asticity/ 'y"er+reeGia

+ u" )oi() "a(ter res"o(se

+ reco7ery

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Trauma i( "re)(a(cy

Co(sider for T/#"atie(ts *as3ed shoc0state

Da()er of Su'ine h&'otension Eer.enc& C1S+ ad7a(ced "re)(a(cy Anioticuid ebolis

Abru'tion of'lacenta "irect 2oetal in%ur&

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Notes

VThe obstetrician and paediatricianshould be involved early

In general the best outcome forthe fetus is related to successful

resuscitation of the mother

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0aediatric trauma

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THAN6 YOU