Seminar by dr kahamnuk jamatia

Introductiony Trauma:- one of the most serious as well as the most

preventable health care problem. y Common causes of trauma:1. Road traffic accidents 2. Interpersonal violence 3. Sports injuries 4. War injuries y Death and disability due to trauma is far more greater than all other causes combined.

Trimodal distribution of death due to traumay Immediate deaths:-occurs within seconds or minutes

of injury.50% of all deaths due to trauma.cause can be laceration of heart,major blood vessels,brain,brainstem or spinal cord. y Early deaths:-occur within 2-3 hours of injury.30% of all deaths due to trauma.causes can be epidural and subdural hematoma,hemopneumothorax,pelvic fractures,long bone fractures,abdominal injuries. y Late deaths:-deaths occur days or weeks after trauma.20% of all deaths due to trauma.causes can be infection,sepsis and multiorgan failure.

Phases of trauma carey Prehospital care:1. ABCs 2. Control of heamorrhage 3. Fracture stabilisation 4. Spine stabilisation 5. Rapid transport y Primary assesment and resuscitation:-ABCDEs, and

monitoring,resuscitation. y Secondary survey and diagnosis:-comprehensive physical examination,investigations,continued monitoring and resuscitation y Definitive care y Rehabilitation

Pre hospital carey 2 main objectives:-

Safe removal 2. Rapid transport to the nearest medical facility that can appropriately manage the particular trauma. y GOLDEN HOUR:-It is the time to reach the operating room.time whereby manoeuvres can be done to save the patient.1.

Primary assesment and resuscitationy 5-10% of patients in emergencies are life threatening y Rapid assesment consists of(American college of

surgeons ATLS guidelines):1. Airway with Cervical spine control 2. Breathing and Ventilation 3. Circulation and Hemorrhage control 4. Disability and neurological status 5. Exposure and physical examination

Triagey 1) Those who are likely to live, regardless of what care

they receive; y 2) Those who are likely to die, regardless of what care they receive; y 3) Those for whom immediate care might make a positive difference in outcome.

ASSESSMENT OF SEVERITY OF INJURY

TRIAGE :- EVALUATION SUMMARY FOR TRAUMA( AMERICAN COLLEGEOF SURGEONS COMMITTEE ON TRAUMA)

STEP 1

Measure vital signs & level of consciousness

Glasgow coma scale 20 FT CRASH SPEED > 20 MPH REARWARD DISPLACEMENT OF FRONT AXLE EJECTION OF PATIENT ROLLOVER DEATH OF SAME CAR OCCUPANT & PEDESTRIAN HIT AT > 20 MPH

Yes Take to trauma center

No

y Step 3 y Age55:-

Yess-take to trauma centre 2. No-reevaluate1.

REVISED TRAUMA SCORECHAMPION et al

PHYSIOLOGIC STATUS OF INJURED PATIENT`S: CVS,RESPIRATORY & GCS INCORPORATED TO EVALUATE THE NEUROLOGICAL STATUS & ASSESS DEGREE OF CRANIOCEREBRAL INJURY.

RESPIRATORY RATE(RR)NO. OF RESPIRATION IN 15 SEC.*4 10-29 >29 6-9 1-5 0

CODED VALUE SCORE4 3 2 1 0

A

REVISED TRAUMA SCORERESPIRATORY EFFORTUSE OF ACCESSORY MUSCLES INTERCOSTAL RETRACTION NORMAL RETRACTIVE / NONE

CODED VALUE

SCORE

1 2

B

SYSTOLIC B.PSYSTOLIC CUFF PRESSURE ON EITHER ARM >89 76-89 50-75 1-49 4 3 2 1 C

REVISED TRAUMA SCORECAPILLARY REFILLFOREHEAD / LIP MUCOUS COLOR REFILL IN 2 SEC. NORMAL DELAYED NONE

CODED VALUE SCORE2 1 0 4 3 2 1 0

D

GLASGOW COMA SCALE13-15 9-12 6-8 4-5 3 RTS = A+B+C+D+E

E

RTS25/min Anxiety Intercostal retraction Use of accessory muscles

Establishment of airway with cervical spine controly Clear the airway y Reposition the patient:1. Semi prone position 2. Chin lift 3. Jaw thrust 4. Digital disimpaction of displaced maxilla y Oral and nasopharyngeal airways:-they are designed to displace the tongue anteriorly off the posterior pharyngeal wall. y Endotracheal intubation y Cricothyroidotomy y Tracheostomy

Endotracheal Intubatony INDICATIONS:-

When the airway patency is threatened and non invasive modalities are unsuccessful 2. When patient is in extremes and urgent and surest means of establishing a patent airway is required 3. For tracheal suction or pulmonary toilet 4. For controlled positive pressure ventilation1.

y Contraindications:-

Confirmed or suspected cervical spine injury 2. Presence of cerebrospinal rhinorrhea or fracture of anterior cranial fossa:-oroendotracheal intubation is preferred. 3. Presence of retro pharyngeal swelling. 4. A fractured larynx1.

Techniques of endotracheal intubationy Direct laryngoscopy: can be performed only if cervical spine injury has been ruled out. The patient is put into sniffing position The laryngoscope blade is inserted into right side of mouth,the epiglottis and vocal cords are examined and the endotracheal tube is gently inserted into the trachea. The correct placement is then verified by observing lung expansion on tube to bag ventilation and auscultation of chest and abdomen. Should be accomplished within seconds.if not then attempts should be discontinued.

y Blind endotracheal intubation:-indicated in cases of

suspected or presence of cervical spine injuries. y Fiberoptic laryngoscopy:-alternative to blind nasal intubation. y Retrograde transcricoid intubation

Tracheostomyy Earliest reference found in Rig Veda,published 2000

B.C. y Indications:1. Upper airway obstruction 2. Facilitation of tracheobronchial toilet 3. Anticipated prolonged mechanical ventilation 4. In cases of cervical spine inuries or oncologic resections in head and neck 5. Laryngeal trauma

Anatomical and surgical considerations of tracheostomyy Trachea:-fibrocartilagenious tube.9-10 mm in diameter,9.5-12 cm in length.extent from C6 till upper border of T5. y Emergency tracheostomy: The neck is extended and head supported The cricoid cartilage is palpated and a vertical incision from the level of cricoid cartilage to just above the supra sternal notch is made. Dissect through the superficial layer of deep fascia,until the pretracheal fascia and thyroid isthmus is identified Dissect through the pretracheal fascia,retract the isthmus and incise through the tracheal rings (2nd,3rdand 4th) The tracheostomy tube is inserted and closure is done.

SYSTEMATIC APPROACH TO AIRWAY MANAGEMENT

EMERGENCY TRACHEOSTOMY.

Complications of tracheostomyy Perioperative complications:1. 2. 3. 4. 5. 6.

Hemorrhage Hypoxia Pneumothorax Emphysema Tracheo-esophageal fistula Damage to the recurrent laryngeal nerve

y Post operative complications:1. 2. 3. 4. 5. 6. 7.

Delayed hemorrhage Infection Hypoxia Aspiration Tracheal stenosis Tracheal ulcers and erosions Unsatisfactory esthetic result

Cricothyroidotomyy It was first described by the french surgeon and

anatomist Vicq d Azyr in 1805y It has the following advantages over tracheostomy:-

It can be performed more rapidly,usually 60 mm hg and PCO2