PTC

Primary Trauma

Care

PTC

PTC System

Prevention

Triage

Primary survey

Secondary survey

Stabilisation

Transfer

Definitive care

PTC

What is PTC

Primary Trauma Care

is a 2 day course followed by a one

day instructors’ course,

training doctors and nurses in the

acute management of the severely

injured patient

PTC

PTC Mission Statement

• To train doctors & nurses to treat

severely injured patients quickly &

systematically

• To use what equipment is available, to

prioritise and treat patients safely

• To train clinicians to teach PTC

principles in their hospitals

PTC

Objectives of a PTC

2 day course

- demonstrate the systematic assessment

& treatment of the severely injured

patient

- to train you in the knowledge, skills and

attitudes of the PTC principles

- To consider how these PTC principles

can be adapted to your hospital

PTC

PTC system

Prevention

PTC

PTC system

Triage

Sorting patients according to priority

Priority depends on

• experience

• resources

• severity of injury

PTC

PTC systemPrimary & Secondary Survey

History

Examination

• Look (Inspection)

• Feel (Palpation)

• Listen (Auscultation)

Special Investigations if available

PTC

PTC system

Stabilisation Includes

• Re-assessment

• Optimisation بهینه سازی

• Documentation

• Immunisation

When stable

Transfer for definitive care

PTC

PTC System

PTC

PTC SystemSummary

PTC offers

• a systematic approach

• rapid assessment and

treatment of the injured patient

• adaptability to all healthcare

environments

PTC

Primary Survey

Objectives

• To introduce the elements of

the Primary Survey

• To understand when to perform

the Primary Survey

PTC

Primary Survey

• Rapid sequential look

• 2 minutes

• Treat as you find

• Repeat if at any time unstable

PTC

Primary Survey

• Airway

• Breathing

• Circulation

• Disability

• Exposure

PTC

AirwayAssessment

• Look, listen, feel

• Colour

• Conscious state

• Accessory muscle use

PTC

AirwayBeware

• Airway obstruction

• Chest injuries with breathing difficulties

• Cervical spine injury

PTC

AirwayManagement

• Clear mouth

• Chin lift/jaw thrust

• Guedel / Nasopharyngeal airway

• Intubation

• Cervical spine care

PTC

BreathingAssessment

• Air movement

• Respiratory rate

PTC

Breathing

Beware

• Tension pneumothorax

• Massive haemothorax

• Open pneumothorax

• Flail chest

• Lung contusion

PTC

BreathingManagement

• Oxygen (if available)

• Artificial ventilation

• Decompress pneumothorax

• Drain haemothorax

PTC

CirculationAssessment

• Cardiac output

• Blood volume

• External haemorrhage

PTC

CirculationBeware

• Intra-abdominal injury

• Intra-thoracic injury

• Long bone fracture

• Pelvic fracture

• Penetrating injury

• Scalp wounds

PTC

CirculationManagement

• Stop bleeding

• Large bore intravenous access x 2

• Blood for crossmatch and Hb

• Administer IV fluid

PTC

Disability

• Pupils

• Check awareness

• A Awake

• V Responds to verbal command

• P Responds to pain

• U Unresponsive

PTC

Exposure

• Undress for thorough

assessment

• Prevent hypothermia

PTC

Primary SurveyX-Rays ( if available)

Cervical spine (lateral)

Chest

Pelvis

PTC

Reassessment of

ABCDE

If patient is, or becomes,

unstable

PTC

Primary Survey

PTC

Primary SurveySummary

• Rapid sequential look

• 2 minutes

• Treat as you find

• Repeat at any time if unstable

PTC

Airway and

Breathing

Objectives

• To understand the structured approach to airway and breathing

• To recognise and manage common airway and breathing problems

PTC

Airway Management

• First priority is a patent airway

• Talk to the patient

• Give oxygen (if available)

• Assess the airway

• Cervical spine

PTC

Airway Assessment

• Look

• Listen

• Feel

• Colour

• Respiratory

distress

• Conscious state

• Chest movement

• Breath sounds

• Respiratory

distress

PTC

Airway Assessment Signs Of Obstruction

• Snoring or gurgling

• Stridor

• Agitation (hypoxia)

• Use of accessory muscles

• Paradoxical chest movement

• Cyanosis

PTC

Airway ManagementBasic Techniques

• Chin lift

• Jaw thrust

PTC

Airway ManagementAdjuncts

• Oropharyngeal airway

• Nasopharyngeal airway

PTC

Airway ManagementAdvanced Techniques

• Endotracheal intubation

• Surgical Cricothyroidotomy

PTC

Endotracheal Intubation

if:

• Failure to maintain an airway by other means

• Failure of ventilation by other means

Consider:

Risk of aspiration

Control CO2 (eg head injury)

PTC

Remember

1. Cervical spine

2. Patients die from lack

of oxygen not lack of an

ETT

PTC

Surgical Cricothyroidotomy

Consider if:

• Intubation attempted and failed

and still needed

• Patient cannot be ventilated

PTC

Breathing

(Ventilation)

PTC

BreathingAssessment

• Inspection (LOOK)

• Palpation (FEEL)

• Auscultation (LISTEN)

• Resuscitate

PTC

Breathing Look

• Respiratory rate

• Accessory muscle use

• Cyanosis

• Penetrating injury

• Flail chest

• Sucking chest wound

PTC

Breathing Feel

• Tracheal shift

• Rib fractures

• Subcutaneous emphysema

• Percussion

PTC

BreathingListen

• Breath sounds

• Heart sounds

• Bowel sounds

PTC

Tension PneumothoraxSigns

• Respiratory distress

• Tachycardia

• Hypotension

• Distended neck veins

• Resonant percussion note

• Tracheal deviation

• Air entry

PTC

Tension Pneumothorax Management

• Immediate decompression

• Large bore needle

• Second intercostal space

• Mid clavicular line

• Formal chest drain must follow

PTC

Tension Pneumothorax

• Should be a clinical diagnosis

• Treat before X-ray

PTC

BreathingManagement

• High flow oxygen if available

• Assist ventilation if necessary

• Treat pneumothorax +

haemothorax

PTC

Airway and Breathing

PTC

Airway and Breathing

Summary

• Open the airway

• Consider intubation

• Do not forget cervical spine

• Oxygen if available

• Assist ventilation as required

PTC

Circulation

Objectives

• To understand the structured approach to circulation problems

• To recognise and manage shock

PTC

CirculationAssessment

• Blood pressure

• Heart rate

• Capillary refill

• Peripheral temperature

• Peripheral colour

• Urine output

PTC

Shock

• Inadequate organ perfusion and

tissue oxygenation

• Most often due to hypovolaemia

in trauma

PTC

Circulation Types of shock

Hypovolaemic

Cardiogenic

Neurogenic

Septic

Anaphylactic

PTC

ShockSites of blood loss

Closed Femoral # 1.5-2 litres

Closed Tibial # 500 ml

Pelvic # 3 litres

Rib # (each) 150 ml

Haemothorax 2 litres

Hand sized wound 500 ml

Fist sized clot 500 ml

PTC

Shock

Concealed blood loss

• Abdominal Cavity

• Pleural Cavity

• Femoral Shaft

• Pelvic Fractures

• Scalp (children)

PTC

Types of Bleeding

• Compressible

- usually peripheral

• Non-compressible

- e.g. intra-abdominal

- Surgery required

PTC

ShockClinical Signs

• Altered mental state : anxiety to coma

• Pulse present ?

- radial systolic > 80 mmHg

- femoral systolic >70 mmHg

- carotid systolic > 60 mmHg

• Tachycardia

• Pulse pressure narrowed

PTC

ShockClinical Signs

• Skin - cold, pale, sweaty, cyanosed

• Capillary refill time > 2 seconds

• Blood pressure

• JVP

• Urine output < 0.5 ml/kg/hr

• Respiratory rate

PTC

Clinical Signs in Shock Blood Loss

Heart rate

Blood Pressure

Capillary Return

Resp Rate

Mental State

<750

<100 Normal Normal Normal Normal

750-1500

>100 Systolic Normal

Prolonged 20-30 Mildly Anxious

>1500-2000

>120 Decreased Prolonged 30-40 Anxious Confused

PTC

Blood Loss < 750ml

Heart rate <100

Blood pressure normal

Capillary refill normal

Respiratory rate normal

Mental state normal

PTC

Blood loss 750-1500ml

Heart rate >100

Blood pressure systolic normal

Capillary refill prolonged

Respiratory rate 20-30

Mental state mild concern

PTC

Blood loss >1500ml

Heart rate >120

Blood pressure decreased

Capillary refill prolonged

Respiratory rate >30

Mental state axious/confused/coma

PTC

Cardiogenic Shock

• Myocardial contusion

• Cardiac tamponade

• Tension pneumothorax

• Penetrating wound of heart

• Myocardial infarction

PTC

Circulation Management

• A + B, oxygen (if available)

• Two large bore i/v cannulae

• Stop obvious bleeding

• Fluid replacement

• Maintain temperature

• Analgesia

PTC

CirculationStop bleeding

• Chest

• Drain tube and re-expand lung

• Emergency thoracotomy rarely

• Abdomen

• Laparotomy if hypotensive after fluids

• Limbs

• Pressure dressing

• Tourniquet last resort

PTC

CirculationFluid replacement

• Warm fluids if possible

• Colloids or crystalloids?

• Consider hypotensive resuscitation if

haemostasis not secure

• Consider oral resuscitation

PTC

CirculationFluid replacement - How much?

1000-2000ml 0.9% Saline or Ringer’s

Reassess

1000-2000ml 0.9% Saline or Ringer’s

Reassess

Consider blood

Consider surgery

Aim for systolic BP>90 + HR <100

PTC

Circulation

Consider blood transfusion if:

• Haemodynamic instability in spite of

fluids

Haemoglobin <7g/dl and patient still

bleeding

PTC

Circulation

PTC

Circulation

Summary

• Careful assessment

• Stop the bleeding

• Replace volume

PTC

Secondary Survey

Objectives

• To understand how and when to

perform the secondary survey

PTC

Secondary Survey

• Thorough head to toe examination

• On completion of primary survey

• When ABC’s are stable

• Aim to find any injury that may threaten life or limb

• Return to primary survey if any deterioration

PTC

Secondary SurveyHead examination

• Scalp (bruising, lacerations)

• Skull (tenderness, depression)

• Eyes (pupils, fundi, lens, conjunctiva)

• CSF or blood from ear, nose, mouth

PTC

Secondary SurveyNeck

• Assume neck is injured

• Immobilise in neutral position

PTC

Secondary SurveyNeck

• Penetrating wounds

• Subcutaneous emphysema

• Tracheal deviation

• Neck veins

PTC

• Glasgow Coma Score

• Motor Function

• Sensation

• Reflexes

Secondary SurveyNeurological examination

PTC

Secondary SurveyChest

• Inspection

• Palpation

• Percussion

• Auscultation

• CXR (if not done, and if possible)

• ECG ( if available)

PTC

• Potentially Difficult

• Beware “hidden haemorrhage”

• Look, listen, feel

• Remember rectal examination

Secondary SurveyAbdomen

PTC

Secondary SurveyAbdomen

• Penetrating wound surgical

exploration

• Blunt trauma - naso/orogastric tube

• Urinary Catheter if no meatal blood

• Reassess frequently

PTC

Secondary SurveyExtremities

• Look : deformity, bruising, laceration

• Feel : tenderness, pulses

• Remember compartment syndrome

PTC

Secondary Survey

Don’t forget the back!

PTC

Secondary SurveyLog Roll

• 4 people

• Airway/neck controller in charge

• Clear timing and instructions

• Allows back examination

PTC

Secondary SurveyX-Rays

• In secondary survey if not already

done

• Chest

• Cervical spine - all 7 vertebrae + T1

• Pelvis

• Others as indicated by examination

PTC

Secondary Survey

PTC

Secondary Survey

Summary

• Thorough head to toe examination

• Return to primary survey if any

deterioration

• Don’t forget the back

PTC

Chest Injuries

Objectives

• Recognise common life threatening chest injuries

• Understand principles of management of chest injuries

PTC

Chest InjuriesInitial assessment

Airway

Breathing

Circulation

PTC

Chest Injuries

• Cause of ~25% of trauma deaths

• Immediate deaths due to major

disruption of heart and great

vessels

• Early deaths due to airway

obstruction, cardiac tamponade or

aspiration

PTC

Chest Injuries

• Pneumothorax (simple, tension, open)

• Haemothorax

• Pulmonary contusion

• Rib fractures

• Flail chest

• Pericardial tamponade

• Myocardial contusion

PTC

Chest InjuriesTension Pneumothorax

• Air enters the pleural space but cannot leave

• Intrathoracic pressure

• Mediastinal shift

• venous return + cardiac output

• Respiratory distress and hypoxia

PTC

Flail Chest

PTC

Flail Chest +

Hemothorax

PTC

• Chest InjuriesFlail Chest

• Unstable segment

• Paradoxical movement with ventilation

• May severe respiratory distress

Adequate analgesia vital

• Give oxygen (if available)

• Consider intubation and IPPV

PTC

Flail Chest• Free floating segment of ribs

• 3 or more rib fx.s broken in 2 places

• Look for paradoxical chest wall motion

• Inhaleinward

• Exhaleoutward

• Decreased air entry

PTC

Flail Chest• Stabilization of the flail segment by

positioning the person with the injured side down or placing a sand hag on the affected segments

• .

PTC

Flail Chest

• Oxygen

• Cardiac & oximetry monitors if available

• Analgesia & intercostal nerve block

• Restrict IV fluids.

• Observation for signs of an associated injury such as tension pneumothorax

• Ventilatory support: shock, 3 or more injuries, head injury, pulmonary disease, 8 or more fx.’s, >65 yrs

PTC

PTC

Chest Injuries

Tension Pneumothorax

• Life threatening emergency

• Clinical diagnosis

• Urgent decompression

PTC

Tension PneumothoraxSigns

• Respiratory distress

• Tachycardia

• Hypotension

• Distended neck veins

• Resonant percussion note

• Tracheal deviation

• air entry

PTC

Tension PneumothoraxManagement

• Immediate decompression

• Large bore needle

• Second intercostal space

• Mid clavicular line

• Formal chest drain to follow

PTC

Lt. Side Tension

Pneumothorax

PTC

Rt. Side Tension

Pneumo-thorax

PTC

Bi-lat. Tension

Pneumothorax

PTC

Needle Decompression

PTC

Chest InjuriesSimple Pneumothorax

• X-Ray to confirm and size

• Chest drain

• Treat if considering IPPV

PTC

PTC

PTC

Open

(Communicating)

Pneumothorax

(Sucking Chest

Wound)

PTC

Chest InjuriesOpen Pneumothorax

• “Sucking” chest wound

• Other signs of pneumothorax

present

• Occlude wound (3 sides only)

• Air escapes on expiration

• Urgent insertion of chest drain

PTC

Chest InjuriesHaemothorax

• Commoner in penetrating than in blunt trauma

• May Hypovolaemic shock

• Large bore chest drain

• Lung re-expansion may stop bleeding

• Consider thoracotomy if bleeding continues > 200-300 ml/hr

PTC

Supine Hemothorax

PTC

Erect Hemothorax

PTC

Lt. subclavian Artery

Stab

PTC

Indications for Closed-tube

Thoracostomy

• Traumatic cause of the pneumothorax

• Moderate-to-large pneumothorax

• Respiratory symptoms regardless of the size of the pneumothorax

• Increasing size of the pneumothorax after initial conservative therapy

PTC

Tube Thoracostomy

• The clamp is

inserted through

the incision & is

tunneled up to the

next intercostal

space.

PTC

Tube Thoracostomy

• The clamp is

inserted through

the incision & is

tunneled up to the

next intercostal

space.

PTC

Most Frequent Reasons for Failure

to Evacuate a Pneumothorax

Rapidly & to Completely Expand the

Lungs

1) Improper connections or leaks in the external tubing or water-seal collection apparatus

2) Improper position of the chest tube(s)

PTC

Most Frequent Reasons for Failure to

Evacuate a Pneumothorax Rapidly & to

Completely Expand the Lungs

3) Occlusion of bronchial by secretions

or a foreign body

4) A tear of one of the large bronchi

5) A large tear of the lung parenchyma

PTC

Most Frequent Reasons for Failure to

Evacuate a Pneumothorax Rapidly & to

Completely Expand the Lungs

• If a pneumothorax persists in spite of 1 or 2 well-placed chest tubes & there is a large leak, emergency bronchoscopy should be performed to clear the bronchi & identify any damage to the tracheobronchial tree that may need repair.

PTC

Most Frequent Reasons for Failure to

Evacuate a Pneumothorax Rapidly & to

Completely Expand the Lungs

• High-frequency oscillation is indicated for bronchopleural fistula & may substantially slow the leak.

• Continued large air leakage & failure of the lung to expand adequately in spite of these measures is an indication for early thoracotomy to control the air leak.

PTC

PTC

Eosophage

al Rupture

&

Mediastina

l Air

PTC

A Widened Mediastinum

PTC

Pulmonar

y

Contusio

n

PTC

PTC

PTC

PTC

Lt. Diaphragm Rupture +

stomach & Spleen Herniation +

Rib Fx.

PTC

Clues to Dx. of Blunt Cardiac

Injury

• Ph. Ex.

• Tachycardia out of proportion to other findings

• Hx.

• High-speed MVA

• Crush steering wheel

• Angina-like CP

• Any dysrhythmia

• Any part of Beck triad

• Evidence of severe ant chest injury

• Any evidence of HF

• Radiography

• Fractured sternum or first 2 ribs

• Widened pericardial silhouette

PTC

Clues to Dx. of Blunt Cardiac

Injury

• Lab• Elevated CPK-MB levels

• ECG• Dysrhythmias or conduction disturbance

• Elevated ST segments

• Other studies• Impaired motion of ant heart on 2-dimensional

echocardiogram or radionuclide angiography

• Pulmonary artery catheter monitoring showing elevated PAWP, low CO, &/or poor response to fluid

PTC

ARDS after Pulmonary

Contusion

PTC

Tension Viscerothorax After

Blunt Abd Trauma

PTC

PTC

PTC

Outcome of ED

Thoracotomy

PTC

Indications for Closed-tube

Thoracostomy

• Recurrence of the pneumothorax after removal of the initial chest tube

• Patient requires ventilator support

• Patient requires general anesthesia

• Associated hemothorax.

• Bilateral pneumothorax regardless of size

• Tension pneumothorax

PTC

PTC

Chest InjuriesPulmonary Contusion

• Potentially life threatening

• Occurs with blunt and penetrating trauma

• Suspect if rib fractures

• Onset often slow and progressive over 24 hours

PTC

Chest InjuriesRib Fractures

• Associated with pulmonary

contusion

• Associated with pneumothorax

• May result from simple trauma

in the elderly

• Remember analgesia

PTC

Chest InjuriesMyocardial Contusion

• Common in blunt trauma

• May mimic myocardial infarction

• Can cause sudden death

• ECG monitoring (if available)

PTC

Chest InjuriesOther Injuries

• Pericardial tamponade

• Great vessel injury

• Airway rupture

• Oesophageal trauma

• Diaphragmatic injury

PTC

Chest Injuries

PTC

Chest Injuries

Summary

• Management is ABC

• Recognise life threatening

problems in primary survey

• Surgical intervention rarely needed

PTC

Abdominal Trauma

Objectives

• Recognise common life threatening

abdominal injuries

• Understand principles of

management of abdominal injuries

PTC

Abdominal TraumaInitial Assessment

Airway

Breathing

Circulation

PTC

Abdominal Trauma

• Common site of injury

• Assessment can be difficult

• Site of “hidden haemorrhage”

• Continual reassessment important

• Early surgical consultation if

possible

PTC

Blunt Abdominal

Trauma

Flank ecchymosis from internal

bleeding

PTC

Abdominal TraumaMechanism of injury

Penetrating (gunshot, stabbing)

-Entry/exit wounds may not be obvious

-Surgical opinion / laparotomy

Non-penetrating

-Good history important

-Compression, crush, seat belt,

acceleration, deceleration

PTC

Abdominal TraumaSite of injury

• Liver

• Spleen

• GIT

• Pancreas

• Kidney and urinary tract

PTC

Abdominal TraumaRemember

Intra-peritoneal cavity extends up

to 4th intercostal space in

thorax

PTC

Abdominal TraumaLook

• Lacerations

• Penetrating injury

• Distension

• Bruising may indicate significant

injury

• External urethral meatus

PTC

Abdominal TraumaFeel

• Be gentle (especially children)

• Tenderness

• Rigidity

• Rectal examination (blood, tone,

prostate)

PTC

Abdominal TraumaManagement

• Airway

• Breathing

• Circulation• IV access

• Fluid resuscitation

• ? Laparotomy

PTC

Abdominal TraumaManagement

• Gastric decompression and

aspiration

- Especially in children

- Look for blood

• Urinary catheterisation

- After exclusion of urethral trauma

PTC

Abdominal TraumaLaparotomy ?

• Penetrating trauma

• Haemodynamic instability with

- obvious intra-abdominal injury

- no other obvious cause

• Seek Early Surgical Advice

PTC

PTC

Liver trauma: protocol

J Trauma 2002;52:1091–1096

PTC

Liver trauma: protocol

J Trauma 2002;52:1091–1096

PTC

Liver trauma: protocol

J Trauma 2002;52:1091–1096