ATLS

Advance Trauma Life Support

Melati Yalti KaustarS(406102025)

Conselor drSjaiful SpB

Definition

bull Advanced Trauma Life Support (ATLS) is a training program for medical doctors in the management of acute trauma cases developed by the American College of Surgeons

bull Originally designed for emergency situations where only one doctor and one nurse are present ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers

Definition

bull Advanced Trauma Life Support (ATLS) is a training program for medical doctors in the management of acute trauma cases developed by the American College of Surgeons

bull Originally designed for emergency situations where only one doctor and one nurse are present ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers

Initial assessment and management 1 Preparation amp Triage2 Primary survey3 Resuscitation4 Adjuncts to primary survey and

resuscitation5 Secondary survey6 Adjuncts to secondary survey7 Post resuscitation monitoring and

reevaluation8 Definitive care

Preparation amp Triage

bull Pre-hospital phase

bull Hospital phase

Pre-hospital phase

bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest

hospitalndash Collect also a description of the incident

causes and history of the patient

Hospital phase

bull The preparation of equipment and medical personel that are needed in the Hospital

Triage

bull The way the selection of patients based on treatment needs and available resources

bull Therapy is based on the needs of ABC

bull Used START method (Simple Treatment and Rapid Treatment)

START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)

bull Airway Try to talk to the patient

bull Breath calculate the repiration rate

bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)

Primary survey

bull A = Airway maintenance with cervical spine protection

bull B = Breathing and ventilationbull C = Circulation with hemorrhage

controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control

completelyndash undress the patientbut prevent

hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Preparation amp Triage

bull Pre-hospital phase

bull Hospital phase

Pre-hospital phase

bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest

hospitalndash Collect also a description of the incident

causes and history of the patient

Hospital phase

bull The preparation of equipment and medical personel that are needed in the Hospital

Triage

bull The way the selection of patients based on treatment needs and available resources

bull Therapy is based on the needs of ABC

bull Used START method (Simple Treatment and Rapid Treatment)

START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)

bull Airway Try to talk to the patient

bull Breath calculate the repiration rate

bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)

Primary survey

bull A = Airway maintenance with cervical spine protection

bull B = Breathing and ventilationbull C = Circulation with hemorrhage

controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control

completelyndash undress the patientbut prevent

hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Pre-hospital phase

bull Which is between the field officer with the doctor The main attention arendash maintenance of airwayndash control bleeding and shockndash immobilization of the patient ndash sending the patient to the nearest

hospitalndash Collect also a description of the incident

causes and history of the patient

Hospital phase

bull The preparation of equipment and medical personel that are needed in the Hospital

Triage

bull The way the selection of patients based on treatment needs and available resources

bull Therapy is based on the needs of ABC

bull Used START method (Simple Treatment and Rapid Treatment)

START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)

bull Airway Try to talk to the patient

bull Breath calculate the repiration rate

bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)

Primary survey

bull A = Airway maintenance with cervical spine protection

bull B = Breathing and ventilationbull C = Circulation with hemorrhage

controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control

completelyndash undress the patientbut prevent

hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Hospital phase

bull The preparation of equipment and medical personel that are needed in the Hospital

Triage

bull The way the selection of patients based on treatment needs and available resources

bull Therapy is based on the needs of ABC

bull Used START method (Simple Treatment and Rapid Treatment)

START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)

bull Airway Try to talk to the patient

bull Breath calculate the repiration rate

bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)

Primary survey

bull A = Airway maintenance with cervical spine protection

bull B = Breathing and ventilationbull C = Circulation with hemorrhage

controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control

completelyndash undress the patientbut prevent

hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Triage

bull The way the selection of patients based on treatment needs and available resources

bull Therapy is based on the needs of ABC

bull Used START method (Simple Treatment and Rapid Treatment)

START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)

bull Airway Try to talk to the patient

bull Breath calculate the repiration rate

bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)

Primary survey

bull A = Airway maintenance with cervical spine protection

bull B = Breathing and ventilationbull C = Circulation with hemorrhage

controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control

completelyndash undress the patientbut prevent

hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

START (Simple Treatment and Rapid START (Simple Treatment and Rapid Treatment)Treatment)

bull Airway Try to talk to the patient

bull Breath calculate the repiration rate

bull Circulation monitor blood pressure pulse or do capiler refill test (normal lt2 minutes)

Primary survey

bull A = Airway maintenance with cervical spine protection

bull B = Breathing and ventilationbull C = Circulation with hemorrhage

controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control

completelyndash undress the patientbut prevent

hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Primary survey

bull A = Airway maintenance with cervical spine protection

bull B = Breathing and ventilationbull C = Circulation with hemorrhage

controlbull D = Disability Neurological statusbull E = ExposureEnvironmental control

completelyndash undress the patientbut prevent

hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway

LOOKbullMotion of the chest and abdomenbullSign of respiratory distressbullMucosal color skinawareness

LISTENBreath of air movement with

FEELBreath of air motion to cheek

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Airway Maintenance

Is the Victim is conscious or not

Conscious

Unconscious

Try to talk to the victims

Can the victim breath(look-listen-feel)

able to talk airway is clear (no obsrtruction)

YesNo

-Give artificial respiration-Give O2

Is there snoringgarglingcrowing

YESSnoring put GuedelGargling do suctionCrowing Intubated

NO

Airway is clear

Put Collar neck until we are sure that there is no servical fracture

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Sign of Obstruction

bull Snoring gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway

bull Gargling sounds liquid inside the mouth

bull Crowing(stridor) spasm edema of the vocal cords

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Collar Neck Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Guedel (Oropharyngeal airway)

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Intubation

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

When are we doing CricothyroidotomyCricothyroidotomy

bull Failed intubation because the airway is blocked

bull Patients can not be given artificial respiration from above (nose mouth)

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

CricothyroidotomyCricothyroidotomy

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Complication CricothyroidotomyCricothyroidotomy

1048708Aspiration 1048708 Creation of false passage 1048708 Subglotticstenosis edema 1048708 Laryngeal stenosis 1048708Hematoma 1048708 Laceration of esophagustrach

ea 1048708 Vocal cord paralysis

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

B = Breathing and ventilation

bull The chest must be examined by ndash Inspection

bull Look is there trachea deviation Lesion Paradoxal breathing JVP (Jugular vein Pressure)

ndash Palpation ndash Percussion

bull Sonor Normalif dull (+)fluid

ndash Ausculationbull VBS (Vesicular Breath Sound) are the

right and left same

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

The aim is to identify and manage five life threatening thoracic conditions asndash Tension Pneumothorax

ndash Massive Haemothorax ndash Open Pneumothorax ndash Flail chest segment with

Pulmonary Contusion ndash Cardiac Tamponade

Flail chest penetrating injuries and bruising can be recognized by inspection

Tension Pneumothorax

bull SpontaneousndashPrimaryndashSecondary

bull COPDbull Infectionbull Neoplasm

bull TraumaticndashBluntndashPenetrating

Tension Pneumothorax

bull One way valve (fenomena ventil)

bull Intrapleura pressure increase

bull The lungs collapsbull The Mediastinum is

displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs

Tension Pneumothorax

bull Respiratory distressbull Distended neck veinsbull Unilateral depression in

breath soundsbull Hyperresonancebull Cyanosis (late)

bull Management ndash Immediate

Decompression with wide bore cannula in 2nd space MCL

ndash Put Chestube 5th ICS the tube connect to bottle that contains water

Massive Hemothoraxbull Sistematic pulmonary

vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck

veinsbull Shock with no breath

sounds and or percussion dullnes

Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention

Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion

defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy

Management - 3 side cover ndash over defect

bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]

- Chest tube- Definitive operation

Open Pneumothorax

Flail chest Pulmonary contusion

bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures

bull Pain and restricted movement

bull Paradoxical movement of chest wall with respiration

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Tension Pneumothorax

bull One way valve (fenomena ventil)

bull Intrapleura pressure increase

bull The lungs collapsbull The Mediastinum is

displaced to the Opposite side decreasing the The venous return and compressing the opposite Lungs

Tension Pneumothorax

bull Respiratory distressbull Distended neck veinsbull Unilateral depression in

breath soundsbull Hyperresonancebull Cyanosis (late)

bull Management ndash Immediate

Decompression with wide bore cannula in 2nd space MCL

ndash Put Chestube 5th ICS the tube connect to bottle that contains water

Massive Hemothoraxbull Sistematic pulmonary

vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck

veinsbull Shock with no breath

sounds and or percussion dullnes

Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention

Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion

defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy

Management - 3 side cover ndash over defect

bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]

- Chest tube- Definitive operation

Open Pneumothorax

Flail chest Pulmonary contusion

bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures

bull Pain and restricted movement

bull Paradoxical movement of chest wall with respiration

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Tension Pneumothorax

bull Respiratory distressbull Distended neck veinsbull Unilateral depression in

breath soundsbull Hyperresonancebull Cyanosis (late)

bull Management ndash Immediate

Decompression with wide bore cannula in 2nd space MCL

ndash Put Chestube 5th ICS the tube connect to bottle that contains water

Massive Hemothoraxbull Sistematic pulmonary

vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck

veinsbull Shock with no breath

sounds and or percussion dullnes

Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention

Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion

defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy

Management - 3 side cover ndash over defect

bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]

- Chest tube- Definitive operation

Open Pneumothorax

Flail chest Pulmonary contusion

bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures

bull Pain and restricted movement

bull Paradoxical movement of chest wall with respiration

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Massive Hemothoraxbull Sistematic pulmonary

vessel distruptionbull Loss blood Over 1500 mlbull Flat versus distended neck

veinsbull Shock with no breath

sounds and or percussion dullnes

Management - Rapid volume restoration- Chest decompression and X-ray- Autotransfusion- Operative Intervention

Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion

defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy

Management - 3 side cover ndash over defect

bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]

- Chest tube- Definitive operation

Open Pneumothorax

Flail chest Pulmonary contusion

bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures

bull Pain and restricted movement

bull Paradoxical movement of chest wall with respiration

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Open Pneumothoraxbull Penetrating blunt traumabull Ventilation perfusion

defectbull Hyperresonancebull Depression Breath soundsbull Tube thoracostomy

Management - 3 side cover ndash over defect

bull adhesive strap [sealed from three sides leaving one side unsealed to allow air exit during expiration amp prevent its entry during inspiration]

- Chest tube- Definitive operation

Open Pneumothorax

Flail chest Pulmonary contusion

bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures

bull Pain and restricted movement

bull Paradoxical movement of chest wall with respiration

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Open Pneumothorax

Flail chest Pulmonary contusion

bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures

bull Pain and restricted movement

bull Paradoxical movement of chest wall with respiration

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Flail chest Pulmonary contusion

bull ldquoFree-floatingrdquo chest segment usually from multiple ribs fractures

bull Pain and restricted movement

bull Paradoxical movement of chest wall with respiration

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Flail chest Pulmonary contusion

bull Reexpand lungbull Oxygenbull Judicioces fluidsbull Intubate as indicatedbull Analgesia

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Cardiac Tamponade

bull Injuries caused by penetrating blunt injury

bull Pericardium filled with blood

bull Pericardial tissue structure with a rigidrarr inhibit the activity and cardiac filling

bull TRIAS BECKndash Venous pressure

increasendash Arterial pressure

decreasendash Muffled heart sound

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Cardiac Tamponade

Management - A = Patent airway intubate- B = Ventilate oxygenasion- C = Fast pericadiocentesisoperation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

C = Circulation with hemorrhage control

bull Hemorrhage is the predominant cause of preventable post-injury deaths

bull Hypovolemic shock is caused by significant blood loss Occult blood loss may be into the chest abdomen pelvis or from the long bones

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

The main set are bull Change the volumebull Stop the bleeding

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

ASSESSMENT OF CIRCULATION

bull Color of the Akralbull Capillary refillbull Pulsebull Blood pressurebull Urine production

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

CLINICAL SIGNS OF SHOCK

bull Rapid breathing nervous consciousness until coma

bull Pulse pressure lt20mmHgbull Skin cold pale wet cyanosisbull Capillary refill timegt 2 secondsbull Urine output lt05 ml kg hour

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Slightly Slightly anxiousanxious

Respirations Respirations 14-20min14-20min

Heart rate Heart rate lt100minlt100min

Urine Urine

30 mLhr 30 mLhr harr harr BPBP

crystalloidcrystalloid

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Mildly Mildly anxiousanxious

Respirations Respirations 20 ndash30min20 ndash30min

UrineUrine

20-30 mLhr20-30 mLhr

Heart rate Heart rate gt100mingt100min harrharr BPBP

darrdarrPulse Pulse pressurepressureCrystalloidCrystalloid

blood blood

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Confused Confused anxiousanxious Respirations Respirations

30-40min30-40min

Urine Urine 5-15 mlhr5-15 mlhr

Heart rate Heart rate gt 120mingt 120min BPBP

Pulse Pulse pressurepressure

Crystalloid Crystalloid blood operationblood operation

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Confused Confused lethargiclethargic

Respirations Respirations gt35mingt35min

Heart rate Heart rate gt140mingt140min

Urine Urine negligiblenegligible

BPBP

Pulse Pulse pressurepressure

Rapid fluids Rapid fluids blood operationblood operation

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Assessment of Stages of Shock

Blood Volume loss

lt 15 15 ndash 30 30 ndash 40 gt40

HR lt100 gt100 gt120 gt140

SBP N N

Pulse Pressure

N or

Cap Refill lt 3 sec gt 3 sec gt3 sec or absent

absent

Resp 14 - 20 20 - 30 30 - 40 gt35

CNS anxious v anxious confused lethargic

Treatment 1 ndash 2 L crystalloid + maintenance

2 L crystalloid re-evaluate

2 L crystalloid re-evaluate replace blood loss 13 crystalloid 11 colloid or blood products Urine output gt05 mLkghr

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Fluid Resuscitation of Shock

bull Crystalloid Solutionsndash Normal salinendash Ringers Lactate solutionndash Plasmalyte

bull Colloid Solutionsndash Pentastarchndash Blood products (albumin RBC

plasma)

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Crystalloid Solutions

bull Normal Salinebull Lactated Ringers Solutionbull Plasmalytebull Require 31 replacement of volume

lossbull eg estimate 1 L blood loss

require 3 L of crystalloid to replace volume

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Colloid Solutions

bull Pentaspanbull Albumin 5 bull Red Blood Cellsbull Fresh Frozen Plasmabull Replacement of lost volume in 11

ratio

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

D = Disability Neurological status

bull A more detailed and rapid neurological evaluation is performed at the end of the primary survey

bull This establishes the patients level of consciousness pupil size and reaction lateralizing signs and spinal cord injury level

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

bull The Glasgow Coma Scale is a quick method to determine the level of consciousness and is predictive of patient outcome

bull Hypoglycemia and drugs including alcohol may influence the level of consciousness If these are excluded changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Glasgow Coma Scale

bull Eye Opening Response ndash bull Spontaneous--open with blinking at baseline 4 points ndash bull To verbal stimuli command speech 3 points ndash bull To pain only (not applied to face) 2 points ndash bull No response 1 point

bull Verbal Responsendash bull Oriented 5 points ndash bull Confused conversation but able to answer questions 4 points ndash bull Inappropriate words 3 points ndash bull Incomprehensible speech 2 points ndash bull No response 1 point

bull Motor Responsendash bull Obeys commands for movement 6 points ndash bull Purposeful movement to painful stimulus 5 points ndash bull Withdraws in response to pain 4 points ndash bull Flexion in response to pain (decorticate posturing) 3 points ndash bull Extension response in response to pain (decerebrate posturing) 2 points ndash bull No response 1 point

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

E = ExposureEnvironmental control completely

The patient should be completely undressed usually by cutting off the garments It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department Intravenous fluids should be warmed and a warm environment maintained Patient privacy should be maintained

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

bull 1 Cloths cut all the cloths using sharp scissors

bull 2 Warmth cover with blankets

bull 3 Intravenous fluids should be warmed and a warm environment maintained

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Secondary survey

bull Aim The secondary survey is a head-to-toe amp front to back evaluation of the trauma patient including a complete history and physical examination including the reassessment of all vital signs X-rays indicated by examination are obtained

bull -If at any time during the secondary survey the patient deteriorates another primary survey is carried out as a potential life threat may be present

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

AMPLE historyndash Allergiesndash Medicationsndash Past medical historyndash Last meal (for fear of aspiration

pneumonia)ndash Event of injury (to predict site amp

extent of injury

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Adittional ExaminationAdittional Examination

bull FAST (Focused Abdominal Sonography for Trauma) or CT may showndash a Injuries to liver spleen kidneys or

pancreasndash b Perisplenic or perihepatic hematomandash c Retroperitoneal hematomandash d Free fluid in peritoneal cavity

bull DPL (replaced by FAST)bull Diagnostic laparoscopy

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Post resuscitation monitoring andreevaluation

bull Repeat ABCDEbull Repeated resuscitation if

necessary

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Definitive care

bull Consult a specialistbull Treatment measures according to

the problembull Operation

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Abdomen Trauma

Blunt trauma is more common bull I Injuries of solid organs [Spleen 46 Liver 33]

ndash Present with picture of internal hemorrhage

bull II Injuries of hollow organsndash Present with picture of peritonitis (usually delayed for 48-

72 hours)

bull Management ndash I All penetrating trauma immediate exploration

(laparotomy)ndash II Blunt trauma

bull a Hemodynamic stable urgent investigationsbull b Hemodynamic unstable immediate exploration

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

bull - Investigations ndash I Plain X-ray fracture ribs ndash air under

diaphragm ndash fluid level in ileus ndash II FAST

bull a Detects free fluid (perihepatic perisplenic pelvic pericardium)

bull b Disadvantagesndash 1 Doesnrsquot detect source of bleedingndash 2 Amount of fluid must be gt 250 mlndash 3 Doesnrsquot detect non-bleeding injuriesndash 4 Canrsquot detect retroperitoneal hematomandash 5 Limitations in obese III CT Gold standard

[DONrsquoT send unstable patient to CT] IV DPL

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Burn Injury

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

bull Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (TBSA)

Rule of Ninesbull Adults Infants head and neck 9 18 each upper extremity

9 9 anterior trunk 18

18 posterior trunk

18 18 each lower extremity

18 14 perineum 1 1 100 100

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Assessment of Burn Depth ndash related to temperature time of exposure and thickness of skinbull 1First degree burn

ndash acaused by sunburn or flash ndash binvolves epidermal layer onlyndash cusually appears red to pinkndash dis painful to touchndash emay become slightly edematousndash fheals in 3-5 days (rarely leaves any scar)ndash gdoes NOT count in the burn size calculation

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

bull Second degree burn (partial-thickness)ndash a Usually caused by flash scalds or brief

contact with hot objectndash b Involves the epidermis and part of the

dermisndash c Has vesicles and bullaendash d Moist appearance ndash usually red to pale pinkndash e Tactile and pain sensibility is intact ndash very

painfulndash f Develops significant edemandash g Heals in 7-21+ days with variable amounts

of scarring

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

bull 3Third degree burn (full-thickness)ndash a Usually caused by flame high intensity

flash electricity chemicals or prolonged contact with hot liquids or hot objects

ndash b Extends through the epidermis and dermisndash c Usually appears white brown or black

may have thrombosed veinsndash d Wound appears dryndash e Elasticity of the wound is destroyed so

wound becomes leathery and feels firm to the touch

ndash f Marked edema and decreased elasticity may necessitate escharotomies

ndash g Generally painless to touch

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Fluid Management Burn Injurybull Parkland formula

bull Initial 24 hours Ringers lactated (RL) solution 4 mlkg burn for adults and 3 mlkg burn for children RL solution is added for maintenance for childrenndash 4 mlkghour for children weighing 0-10 kgndash 40 mlhour +2 mlhour for children weighing 10-20 kg ndash 60 mlhour + 1 mlkghour for children weighing 20 kg or

higher

This formula recommends no colloid in the initial 24 hoursbull Next 24 hours Colloids given as 20-60 of calculated

plasma volume No crystalloids Glucose in water is added in amounts required to maintain a urinary output of 05-1 mlhour in adults and 1 mlhour in children

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Fluid Management

bull Maintance for Adultndash M= 40 cc weight (kg)24 hour

bull Maintance for childrenndash M= 0-10 kg 100cc weight(kg) 24

hourndash M= 10-20 kg 1000+(X 50 ) 24 hourndash M= Over 20 kg 1500 + (X 20) 24

hourbull X = the overmeasure weight

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Fluid Management for Dehydration

bull Grade of Dehydrationndash Mild 4 (adult) 6

(children)ndash Moderate 6 8ndash Severe 8 10

ndash D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

Fluid Management for 24 Hours

bull First 6 hour ndash frac12 D + frac14 M = (X) cc

bull Next 18 hourndash frac12 D + frac34 M = (Y) cc

THANK YOU

THANK YOU