TRAUMA

Begashaw M (MD)

Trauma

Introduction

is one of the leading causes of mortality, morbidity and disability

mostly affects people in their productive years

The causes of trauma are various

Deaths due to trauma

1. Immediate death (50%) Occur in the first few minutes injuries to the brain, heart & major blood vessels2. Early deaths (30%) Occur in the first few hours due to the collections and bleedings in the chest

and abdomen, extensive fractures and increased intracranial pressure

3. Late deaths (20%) Occur days or weeks after the injury due to sepsis and organ failure

DEFINITION

_is tissue damage, which occurs due to transfer of different forms of energy

Types of TraumaI- Cause: Homicidal injuries Road traffic accident and falls Industrial accidents, burnII- Mechanism: A/ Blunt Injury: Caused by acceleration, deceleration,

rotational or shearing forceB/ Penetrating Injury: Caused by a direct breach by

penetrating object E.g. Bullet injury, stab injury

Mechanism of Injury

• Blunt Force Trauma

• Penetrating Trauma

TREATMENT

• Advanced trauma life support (ATLS) protocol

• The ATLS _primary survey and resuscitation followed by

_secondary survey and definitive management

The Flow of the Initial Assessment Primary Survey

Resuscitation

Detailed Secondary Survey

Definitive Care

Reevaluation Reevaluation

Initial management

I- The primary survey and resuscitation

• Quick evaluation to detect immediately life threatening situations

• Institution of measuresA Airway and cervical spineB BreathingC Circulation with hemorrhage controlDDisability-Dysfunction of CNSE Exposure/Environment

A- Air way-cervical spine

• Assess the patency of air way• May be compromised by_back fallen

tongue, broken tooth, vomitus, blood • Use_ suctioning, jaw trust,

positioning, oropharyngeal tube or endotracheal tube to open it, take care of the cervical spine-hard collar

• 100 % oxygen

B- Breathing

• Assess adequacy of breathing-“Look, listen, feel”• Compromised by pneumothorax,

hemothorax or multiple rib fractures causing flail chest

• Tension pneumothorax-venous cannula through second intercostal space in the mid-clavicular line

• If open chest wound seal with occlusive dressing

C- Circulation

• Assess the circulatory volume-pulse, capillary refill, neck veins

• Look for external hemorrhage and arrest it by pressure, bandaging

• Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound

• Open a wide bore IV line take blood sample for cross match and start resuscitation with Normal saline or Ringer’s lactate

Dysfunction

• Assess level of consciousness using AVPU method

A = alert V = responding to voice P = responding to pain U = unresponsive• Glasgow coma scale (GCS)• Look for any Neurological deficit or

lateralizing sign

E- Expose

• Expose (undress) the patient fully• Avoid hypothermia

II- Secondary survey and definitive management

done after the life threatening conditions have been evaluated and resuscitative measures are instituted

A- Take History_Time of injury_ Mechanism of injury_Amount of bleeding_ Loss of consciousness_Any intervention performed or drugs given

B- Do a proper and systematic examination of all body systems

C- investigations _ hematocrit, cross-match, urinalysis, X-ray, ultrasound, etc.

Never send a patient with unstable vital signs for investigation or referral before resuscitation

D- Appropriate treatment _laparotomy ,POP cast

ROAD TRAFFIC ACCIDENTS (RTA)

• is the leading cause of trauma deaths• Several factors contribute to the high

magnitude _poor condition and design of roads

_traffic mix _poor condition of the

vehicles _poor traffic rule

enforcement

MVA

Injuries are caused by

sudden acceleration e.g. a pedestrian hit by car

decelerations _ passenger to collide with the interior of car

high risk of serious and multiple injuries:• Presence of flail chest• Roll over• Death of another person in the car

FIREARM INJURIES

_due to homicidal violence_missile injuries - bullets from

pistols, rifles, machine guns_degree of injury depends on the

amount of energy_E=½mv2 (E = energy transferred,

m = mass of the missile, v = velocity of the missile)

Classification

I- Low- velocity_ missiles fired from hand guns (<400m/s)_Injury is limited to the path of the bulletII- High velocity_bullets fired from rifles, machine guns and blast

fragments (>1000m/s)_ small entrance ,a larger exit wound _Tissue damage occurs in the surrounding tissue _Foreign bodies, dirt and clothing in wound

Management appropriate wound debridement_Excision of all dead tissue_Removal of all dirt, foreign bodies and free bone

fragments_irrigation of wound with copious amount of saline debrided wound should be left open for closure

laterN.B: Never close missile wounds primarily, not

even the very trivial looking ones!_broad spectrum antibiotics _tetanus prophylaxis

BURN

is a coagulation necrosis of tissue due to thermal or chemical injury

Women and children are mostly affected Types of burns Flame burn Scalding Chemical burn Electrical burn

Severity

Depends _the burn depth (degree) _the extent or percentage of the body

surface Determining the percentage of burn

surface is important to calculate the amount of fluid requirement

Determination of burn depth is important for burn wound management

Classification of Burn according to depth (degree)

1- First degree _ involves epidermis _ manifests with erythema2- Second degree (partial thickness) _involves part of dermis _manifests with blisters, edema,

moist surface and pain at the affected site3- Third degree (full thickness) _ Involves complete burn _charred, white or grayish , pain free

Burn degree

1st degree (Superficial) burn

Second degree (partial thickness) burn

3rd degree (full thickness) burn

4) 4th degree burn - involves the underlying viscera or other organs e.g. bone,liver

Rule of Nine

Management

General_ATLS system_Airway obstruction -rapidly after

inhalation injury or delayed for 24-48hours

_ Endotracheal intubation or tracheotomy_ Breathing_ Circulation_Analgesia

Fluid resuscitation

_Major burn (> 20% body surface area)_Open IV line-normal saline/ringer lactateParkland Formula_First 24° _4 mL Lactated Ringer’s X weight in kg X

% total body surface area burned _50% of fluid in first 8° _50% over next 16° _ Keep urinary output 0.5 – 1 mL/kg

Criteria for admission

any burn over 20%(adults) & 10%(children) BSA

Special areas e.g. eye, face, hands, feet, perineum

Inhalation injury Chemical & electrical burns Full thickness burns where grafting is

indicated Children & elderly pts who require additional

medical or social support

Burn wound management

• Goals _close wound _prevent infection _reduce scarring and contracture _provide for comfort Wound cleaning Debridement Mechanical Surgical Topical antibacterial therapy

Dressing the Burn

The Exposure Method-Open Technique:_wound is cleaned by antiseptic agents _Left exposed to air_used for burns of the face and burns of large

surface area The occlusive method-ClosedTechnique _a thick dressing after cleaning with antiseptics

covers the burn wound_used mostly for outpatient treatment of small

burns

Wound dressing

• Emergency escharotomy and fasciotomy should be done for deep circumferential burns of limbs, neck or trunk

Wound Care: Grafting Indications for grafting_full thickness burns_priority areas_wound bed pink, firm, free of exudate_bacterial count < 100,000/gram of tissue

Escharotomy Facial and hand burns

Escharotomy

Analgesia

• Most burn patients are in severe pain _analgesic doses of IV narcotics regularly to control the pain

Prevention of Infection

• impaired resistance against infection• Most deaths occur due to

pneumonia and wound sepsis• Prophylactic antibiotics (penicillin)

are given for severe burns • Topical antimicrobials e.g. 1% silver

sulfadiazine are helpful for deep 2nd and 3rd degree burns

Nutrition

_ Naso -gastric tube -more than 25% burn -nausea and

vomiting in catabolic state lose weight very fast daily calorie required is 20 Kcal/Kg + 70

Kcal/%burn Daily protein requirement is 1 gm/kg +

3 gm/%burn.

Contracture

• Prophylaxis against tetanus• Prevention of contractures &

rehabilitation _move all joints