1. The Golden Hour of Trauma Period immediately following trauma in which rapid assessment, diagnosis, and stabilization must occur. Primary Survey Initial assessment and resuscitation of vital functions. Prioritization is based on ABCs of trauma car.

2. Airway(With cervical spine precautions) Breathing and Ventilation Circulation Disability (Neurologic Status) Exposure/Environment control Foley 3. Assespatency of airway Use jaw thrust or chin lift initially to open airway Clear foreign bodies Insert oral or nasal airway when necessary Obtunded/unconscious patients = intubated Surgical airway = Cricothyroidotomy used whenunable to intubate. 4. Inspect,Auscultate, & Palpate the chest Ensure Adequate ventilation & identify &treat injuries that may immediately impairventilation: Tension pneumothorax Flail chest & Pulmonary Contusion Massive Hemothorax Open Pneumothorax 5. Placetwo large-bore peripheral (14- or 16-gauge) IVs. Draw blood at time of IV placement Assess circulatory status (capillaryrefill, pulse, skin color) Control of life-threatening hemorrhageusing direct pressure. 6. Rapid neurologic exam Establish pupillary size & reactivity & levelof consciousness using the AVPU ofGlasgow Coma Scale. 7. Completely undress the patient. 8. Placement of a urinary catheter isconsidered part of the resuscitative phasethat takes place during the primary survey. Foley is contraindicated when urethraltransection is suspected, such as in thecase of a pelvic fracture. If transection issuspected, perform retrogradeurethrogram before foley. 9. Signs of Urethral Transection Blood at the meatus A high-riding prostate Perineal or scrotal hematoma Be suspicious with any pelvic fracture 10. Placement of nasogastric (NGT) or orogastric tubes (OGT). May reduce the risk of aspiration by decompressing stomach, but still does not assure full prevention. 11. Begins during the primary survey Life-threatening injuries are tended to as they are identified. Fluidtherapy should be initiated with up to 2L of an isotonic (lact. ringer or NSS) crystalloid solution. Peds Pts should receive and IV bolus of 20 cc/kg 12. 3-to-1 rule Used as a rough estimate for the total amount of crystalloid volume needed to replace blood loss. Shock Inadequate delivery of oxygen on the cellular levelsecondary to tissue hypoperfusion In traumatic situations, shock is the result ofhemorrhage until proven otherwise. 13. Shock Hypovolemic * Loss of volume Hemmorhagic* Blood loss = Loss of volume Hypoglycemic Septic Neurogenic * Sudden loss of ANS control Cardiogenic* Failure of the ventricles to function correctly 14. X-raysof the chest, pelvis, & lat. Cervical Spineusually occur concurrently during the resuscitationefforts, but should never interrupt them. Diagnostic peritoneal lavage & focused abd.Sonogram for trauma (FAST) are tools used for therapid detection of intra-abdominal bleeding thatoften occurs early in the resuscitative process. CT scans should be done only for patients who arehemodynamically stable. 15. Beginsonce the primary survey is complete & resuscitative efforts are well underway. When possible get an AMPLE history: Allergies Medications Past medical history/Pregnant? Last meal Events surrounding the mechanism of Injury 16. Head-to-toe evaluation of the trauma patient;frequent reassessment is key. Neurologic examination including glascowcoma scale, procedures, radiologicexamination & laboratory testing occur at thistime if not already accomplished. Tetanus prophylaxis immunize as needed 17. ABCs NuerologicExam Oriented to person, place, time Pupillary reflex CT MRI Look for sudden changes in level ofconsciousness. Recognize and treat herniation Assume spinal injury until ruled out! 18. Divided into three zones Zone I = lies below the cricoid cartilage. Zone II = lies between zones I & III. Zone III = lies above the angle of the mandible. Thesedivisions help drive the diagnostic and therapeutic management decisions for penetrating neck injuries Penetrating Neck Injury: Any injury to the neck that violates the platysma. 19. Vascular Injuries Very common and life threatening. Can lead to exsanguination, hematoma formation w/ compromise of the airway, & cerebral vascular accidents (E.g. from transection of the carotid artery or air embolus.) 20. NonvascularInjuries Injury to the larynx & trachea including fracture of the thyroid cartilage, dislocation of the tracheal cartilages & arytenoids leading to airway compromise & often a difficult intubation Esophageal injury does occur & as with penetrating neck injury, does not often manifest initially. (Very high morbidity/mortality if missed!) 21. Obtain soft tissue films of the neck for clues tothe presence of soft tissue hematoma &subcutaneous emphysema & a CXR for possiblepneumothorax. Surgical Exploration is indicated for Expanding hematoma, Subcutaneousemphysema, Tracheal deviation, Change is voicequality, Air bubbling through the wound. Pulses should be palpated to identify deficits & thrills &auscultated for bruits. A Neurologic exam should be performed to identify brachialplexus and/or CNS deficits as well as Horners Syndrome. 22. ZoneII Injuries with instability or enlarging hematoma require exploration in the operating room. Injuries to Zones I or III may be taken to OR or managed conservatively using a combination of angiography, bronchoscopy, esophagosco py, gastrografin or barium studies, & CT scanning. 23. Primarytreatment focus on the ABCs of resuscitation General observation: Abrasions, Laceration,deformities. Palpation for localization of pain Neurological examination Cranial nerves Motor & Sensory function Reflexes Rectal tone Balbacavernosus Reflex Incontinence (Loss of control of bladder, bowel) 24. Pericardial Tamponade Sonogram Needle Pericardiocentesis Blunt Cardiac Trauma ECG MVA, Fall, Crush, Blast, Direct violent trauma Pneumothorax Upright CXR Chest Tube (thoracostomy) confirmed by x-ray Tension Pneumothorax Upright CXR Needle decompression then tube thoracostomy Hemothorax > 200cc blood for costophrenic angle to be seen on CXR 25. Gunshotwound creates damage via 3 mech. Direct injury from the bullet itself Injury from fragmentation of the bullet Indirect injury from the resultant shock wave Stab wound is limited to direct damage ofobject of impalement. Blunt injuries also have three mechanisms Injury from the direct blow Crush injury Deceleration injury 26. Physical Examination Seat-Belt Sign ecchymotic area found in the distribution of thelower ant. abd. Wall & can be associated with perforation of thebladder or bowel as well as lumbar distraction fracture. Cullen Sign (Periumbilical ecchymosis) indicative ofintraperitoneal hemorrhage Grey Turners Sign (Flank ecchymosis) indicative ofretroperitoneal hemorrhage Kehrs Sign L. shoulder or neck pain 2 to splenic rupture. Itincreases when pt. is in trendelenburg position or with L. upperquadrant palpatation (Caused by diaphragmatic irritation). Tests Perforation: AXR & CXR to look for free air. Diaphragmatic injury: CXR looking for blurring of the diaphragm,hemothorax, or bowel gas patterns above the diaphragm 27. Other Tests Diagnostic Peritoneal Lavage (DPL) CT scanning Angiography Serial Hematocrits Should be obtained during the observation period of thehemodynamically stable patient Laparoscopy 28. Mechanism Largely penetrating (GSW>>Stab wound) 75% of pts. With penetrating injury to the pancreas willhave associated injuries to the aorta, portal vein, orinferior vena cava. Diagnosis Inspect pancreas during laparotomies for other indications Check Amylase CT look for parenchymal fracture, intraparenchymal hematoma,lesser sac fluid, fluid between splenic vein & pancreatic body,retroperitoneal hematoma or fluid Endoscopic Retrograde Cholangiopancreatography (ERCP) ifstable. 29. Diagnosisdone in a retrograde fashion Work your way up from the urethra to the kidneys and renalvasculature. Signs& Symptoms Flank or groin pain, blood @ urethral meatus, ecchymoses onperineum and/or genitalia, evidence of pelvic fracture, rectal bleeding,a high-riding or superiorly displaced prostate. U/A Gross Hematuria = GU injury & often pelvic fracture as well Should be done to check for microscopic hematuria Microscopic hematuria is usually self-limited RetrogradeCystogram & Urethrogram Take pre-injection KUB film and take before foley placement. Contrast into pouch of douglas = intraperitoneal Contrast into behind bladder = extraperitoneal bladder rupture 30. Bladder Rupture Intraperitoneal Usually occurs 2 to blunt trauma to a full bladder. Tx. Surgical Repair. Extraperitoneal Usually occurs 2 to pelvic fracture Tx. Nonsurgical management by Foley drainage. Ureteral injury Least common GU injury, surgical repair, dx. IVP or CT duringsearch for renal injury RenalInjury Commonly diagnosed by CT w/ contrast Grade IV & V operative, the rest are non-surgically managed. 31. GradeInjury DescriptionRenalInjury ScaleI ContusionHematuria, urologic studies normalHematoma Subcapsular, nonexpanding w/o parenchymal laceration.IIHematoma Nonexpanding perirenal hematoma in retroperitoneumLaceration