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INITIAL ASSESSMENT AND PRIMARY MANAGEMENT IN
TRAUMA
DR.ARUN VPG OMFS
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contents Golden hour ABCDE
Airway managementShock management
AMPLE history
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TIME AND TIDE WAITS FOR NONE
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Accurate and systematic approach
25% to 30% of deaths caused by trauma can be prevented
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GOLDEN HOUR AR Cowley The first hour following a trauma during which
aggressive resuscitation can improve the chances of survival and restore the normal functions.
Early pre-hospital care, early transport, aggressive resuscitation and interventions
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PLATINUM MINUTES
“THE PLATINUM TEN MINUTES”
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Three categories severe -5% of all injuries, but more than 50%
of all trauma deaths urgent - 10% to 15% Non urgent – 80 %
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Assessment principles – American College of Surgeons
1. Preparation and transport2. Primary survey and resuscitation, including monitoring and radiography3. Secondary survey, including special investigations,such as CT scanning or angiography4. reevaluation5. Definitive care
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PREHOSPITAL PHASE The trauma ambulance and paramedics
Convey the status and number of victims to the hospital
Provide on site care
ventilation and spine stabilization
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Pneumatic antishock garments and the establishment of intravenous lines
administration of fluid should be reserved for transport times greater than 30 minutes or patients bleeding in excess of 50 mL per minute.
Long bone fracture – traction splint
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Multiple casualties No. of patients and the severity of their
injuries do not exceed the ability of the facility to provide care.
MASS CASUALTIES The no. of patients and the severity of
their injuries exceed the ability of the facility to provide care.
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TRIAGE A method of quickly identifying
victims who have immediately life-threatening injuries AND who have the best chance of surviving
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red - Immediate (critical) yellow - Delayed (urgent) green - Minor (ambulatory) White – those who do not require
treatment Black - Deceased
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START system
Simple Triage And Rapid Transport respiratory status, perfusion status, and
mental status
"immediate," "delayed," or "minor" category
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HOSPITAL PHASE
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Primary Survey A - Airway (with C-spine precautions) B – Breathing and ventilation C – Circulation and hemorrhage
control D – Disability + neurological status E – Exposure + environment
F- Frequent reassessment
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AIRWAY MAINTENANCE WITH CERVICALSPINE CONTROL
Suspect cervical spine injury in all patients unless other vise proven
High chance in high speed impact, and in patients with altered consciousness
15% patients with supraclavicular injuries and 5 % with head injury
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Hyperextension or hyperflexion of the patient’s neck should be avoided
Cervical collars or neck support
Neuronal deficit and paralysis
SUSPECT,PROTECT& DETECT
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Assessment of airway As a general rule – if patient talks properly
airway is patent (A) breathing is adequate (B) sufficient delivery of oxygen through circulation (C) to transport the oxygen to the brain (D)
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Look, Listen,and Feel Look agitated or obtunded. Agitation suggests hypoxia, and
obtundation suggests hypercarbia. pattern of breathing and use of
accessory muscles of ventilation
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Listen abnormal sounds. Noisy breathing, Snoring, gurgling -
partial obstruction of the pharynx or larynx.
Hoarseness laryngeal obstruction. abusive patient -hypoxic
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Feel location of the trachea and determine
whether it is in the midline
foreign objects (e.g.,fractured teeth, fillings, dentures) should be removed.
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Reasons for airway obstruction Tongue fall aspiration of foreign bodies regurgitation of stomach contents facial, mandibular, tracheal and
laryngeal fractures retropharyngeal hematoma resulting
from cervical spine fractures Traumatic brain injury
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jaw thrust or chin lift procedure
jaw thrust knuckles of the index fingers are placed behind the angle of
the mandible with thumbs apply pressure on the cheek bones at the same time lifts and displaces the mandible forward.
breathing spontaneously high-flow oxygen via the facemask
not breathing a facemask with a bag-valve device (AMBU bag) and is continuously bagged
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Chin lift
mandible is gently lifted upward using the fingers of one hand placed under the chin. The thumb of the same hand lightly depresses the lower lip to open the mouth
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suction should be used to clear any secretions
nasogastric tube or soft suction catheter may be used in patients without suspected midface or cranial base - tubes inadvertently passed into the cranial vault.
oral or nasal airway - keep the airway patent nasal airway is better tolerated in an awake
patient.
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Airway devices Supraglottic Infra glottic
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oropharyngeal airway OPA should extend from the corner of
the mouth to the angle of the mandible. introduced upside down so that its
concavity is directed upward, until the soft palate
the device is rotated 180 degrees to direct the concavity down and the airway is slipped into place over the tongue
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Nasopharyngeal airway inserted in the nostril that appears to be
unobstructed and passed gently into the posterior
oropharynx approximate distance between the end of the
patient’s nose and the ear lobe
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laryngeal mask airway if orotracheal intubation has failed or bag-mask
ventilation is not maintaining sufficient oxygenation
No cuff – chances of gastric distension and aspiration
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multilumen esophageal airway two tubes, - occlusion of the esophagus
to reduce the risk of aspiration.
does not have a cuffed tube in the trachea -not a definitive airway
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injuries to the larynx and trachea neck swelling, dyspnea, voice alteration, or
frothy hemorrhage
tenderness, and laryngeal or tracheal crepitus
Endotracheal intubation / surgical airway
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Definitive Airway defined as an inflated cuffed tube in the trachea.
Orotracheal Naso tracheal
Contra indicated - frontal sinus fractures, base of skull fractures, and ant cranial fossa fractures
surgical
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indications
Oral & Maxillofacial trauma – Fonseca Walker
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Contraindications ability to maintain a patent airway in a less
invasive manner
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LEMON
42Oral & Maxillofacial trauma – Fonseca Walker
43Oral & Maxillofacial trauma – Fonseca Walker
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Rapid-sequence induction with anesthetic agents, neuromuscular blocking drugs, and esophageal occlusion by cricoid pressure
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7 Ps Preparation Pre oxygenation Pre medication Paralysing Pressure (Cricoid) Placement Position Post intubation care
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Premedication - LOAD L: Lidocaine O: Opioids (typically fentanyl) A: Atropine D: Defasciculating agent
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Laryngoscopy
flexion of the neck, to align the pharyngeal and laryngeal axes.
head is extended at the atlanto-occipital joint so that the oral axis is in line with the other two
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STOP MAID S: Suction T: Tools (e.g., blade, handle.) O: Oxygen P: Positioning M: Monitors (electrocardiogram [ECG], O2,
CO2, blood pressure [BP]) A: Assessment, airway devices, assistant I: IV access D: Drugs
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Surgical Airway Needle Cricothyroidotomy Insertion of a wide-bore needle (or IV
cannula) via the crico-thyroid membrane into the airway
Intermittent insufflation (1 second on and 4 seconds off)
Maximum 30-45 minutess
Inadequate ventilation
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Surgical Cricothyroidotomy
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Surgical Cricothyroidotomy 3 cm long skin incision Cut down through the cricothyroid membrane
tracheal dilator is inserted to open up the incision, separating the thyroid and cricoid cartilages and enabling visualization of the trachea
tracheostomy tube is inserted
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tracheostomy laryngotracheal trauma fractures of the thyroid or cricoid
cartilage or hyoid bone Prolonged ventilation upper airway obstruction
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Thyroid cartilage, cricoid cartilage and tracheal rings are palpated
skin incision should be marked while the patient’s head is in a normal position
Vertical/horizontal skin incision
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BREATHING Assess breathing and ventilation
Ventilation is compromised not only by airway obstruction but also altered ventilatory mechanics or CNS depression.
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Direct trauma to the chest - # ribs - rapid, shallow breathing and hypoxemia
Intracranial injury - abnormal patterns
spinal cord injury – paralysis of intercostal muscles – unable to meet increased demand
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life-threatening thoracic injuries A: Airway obstruction T: Tension pneumothorax O: Open pneumothorax M: Massive hemothorax F: Flail chest C: Cardiac tamponade
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Tension Pneumothorax Air accumulation within the pleural
space Collapse of affected lung Pushing of other contents of
mediastinum to the opposite side Compression of heart and major vessels
and reduced venous return
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Tension Pneumothorax
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positive-pressure ventilation worsens tension pneumothorax
Maybe seen as complication of central line insertion in polytrauma
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C/F chest pain air hunger respiratory distress tachycardia Hypotension tracheal deviation unilateral absence of breath sounds hyper resonant percussion note
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Collins J, Stern EJ. Chest Radiology: The Essentials. Lippincott Williams & Wilkins; 2012. 360 p.
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immediate decompression by insertion of a large-bore needle into the second intercostal space
Definitive treatment - insertion of a chest drain into the fifth intercostal space
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Needle Thoracocentesis Identify the second intercostal space in the
midclavicular line on the affected side Insert large bore catheter (12-14 gauge) over
the top of rib into ICS Puncture the parietal pleura and push 1 cc of air
so as to remove tissue tag at the end of catheter Remove the plunger of syringe attached to
catheter Sudden escape of air happens
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Chest Drain Insertion Identify the insertion site at the nipple level (fifth intercostal
space) anterior to the midaxillary line on the affected side.
Make a 3-cm transverse incision and bluntly dissect through the subcutaneous tissue just above rib.
Puncture the parietal pleura perform a finger sweep with a gloved finger through the
incision, to avoid injury to other organs and to clear adhesions and clots.
Insert the tube and advance into the pleural space to the desired length
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Massive Hemothorax rapid accumulation of more than 1500 mL of
blood in the chest cavity. Damage to great vessels Dull percussion note Hypovolemia
Drainage followed by thoracotomy
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Flail Chest result of trauma associated with multiple
rib fractures with a number of ribs being fractured in two places
chest wall loses bony continuity with the rest of the thoracic cage
disruption of the normal chest wall movement
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injury to the underlying lung parenchyma - pulmonary contusion
paradoxical breathing asymmetrical and uncoordinated movement
of chest wall Crepitus
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Treatment adequate ventilation Splinting the area with sandbag/ iv fluid
bag administration of humidified oxygen fluid resuscitation Good analgesia
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Cardiac Tamponade Penetrating/ blunt injury pericardium fills with blood from the
heart, great vessels interfere with cardiac filling
Beck’s triaddistended neck veinsdecline in arterial pressuremuffled heart sounds
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Kussmaul’s sign (a rise in venous pressure with inspiration when breathing spontaneously)
Aspiration of pericardial blood - pericardiocentesis
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Puncture the skin 1 to 2 cm inferior and to the left of the xiphochondral junction, at a 45-degree angle to the skin.
Carefully advance the needle upward, aiming toward the tip of the left scapula
Once needle enters the blood-filled pericardial space, withdraw as much blood as possible
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C: CIRCULATION AND HEMORRHAGE CONTROL Acute blood loss - 0% to 40% of trauma
deaths Leads to Shock Clincal state of cardiovascular
collapse characterized by acute reduction of effective circulating blood volume, inadequate perfusion of cells & tissues.
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Shock is of 2 types
Primary (initial)Secondary (true) Primary –
transient attack resulting from sudden reduction of venous return
It occurs immediately following trauma, severe pain, emotional over reaction
pale & clammy limbs, weak & rapid pulse& low BP Secondary- due to hemodynamic
derangements with hypoperfusion of cells.
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PRIMARY (Initial Shock) SECONDARY (True Shock)
HEMATOGENIC/HYPOVOLAEMIC/OLIGAMIC SHOCK
OBSTRUCTIVE SHOCK / TRAUMATIC SHOCK
NEUROGENIC SHOCK CARDIOGENIC SHOCK SEPTIC SHOCK
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CLINICAL FEATURES
General Clinical Features Of Shock
o Hypotension (Systolic BP<70mmHg)oTachycardia (>100/min)oCold , Clammy SkinoRapid,Shallow RespirationoDrowsiness,Confusion,IrritabilityoOliguria (Urine Output<30ml/hour)oMulti-Organ Failure
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STAGES IN SHOCK 3 STAGES INITIAL SHOCK PROGRESSIVE SHOCK IRREVERSIBLE SHOCK
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inadequate tissue perfusion and oxygenation and anaerobic glycolysis results in lactic acid production
coagulation factor and platelet dysfunction combined with coagulation factor consumption a profound coagulopathy
Triad ofMetabolic acidosisHypothermiacoagulopathy
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stop hemorrhage minimize contamination restore near-normal physiology
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Initial Management of Hemorrhagic Shock Prevention of further blood loss and the earliest restoration of tissue perfusion
External hemorrhage is identified and controlled by direct manual pressure
Occult bleeding -thoracic and abdominal cavities, the pelvis, the retroperitoneal space
pneumatic antishock garment (PASG)
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Long bone fractures – approx 750 ml blood loss
Femur fracture – approx 1500 ml Pelvic fracture – 2000-2500ml
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Management Peripheral cannulae – large bore
cannulae rate of flow proportional to 4th power of radius
venous cut-down, made 2 cm anterior and superior to the medial malleolus into the greater saphenous vein
central line into the femoral or subclavian vein
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Crossmatch,full blood count; RFT,LFT and electrolytes; ABG
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Fluid Replacement restore critical organ perfusion 2 L of RL / 20 ml/kg RL
3 type of responses Responder:vital signs return toward
normal Loss of less than 20% of circulating
volume and are not actively bleeding
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Transient responder: The vital signs initially improve but then deteriorate. still actively bleeding from an occult site.require transfusion with bloodIdentify source of bleeding
Nonresponders: The vital signs do not improve. blood loss is continuing at a rate at least equal to the
rate of fluid replacement.Central lineImmediate surgery and transfusion
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Crystalloid, colloid and blood Colloids - larger molecular weight, and hence
expand the intravascular compartment more effectively – 1:1 ratio
improve oxygen transport, myocardial contractility and cardiac output
More risk of anaphylactic complications
Crystalloids are cheap and safe 3-4 times greater volume is required Causes hypothermia and dilution of clotting factors
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Isotonic saline Corrects both water and electrolyte
imbalance
1. Water and salt depletion as in vomiting, diarrhoea
2. Hypovolemic shock.
CONTRA-INDICATIONS :1. Hypertensive patients2. Patients with edema due to CCF
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RL Rapidly expands intravascular volume. The most physiological IV fluid. Sodium lactate metabolises to provide bicarbonate
1. severe hypovolemia.2. For replacing fluid in post-op patients3. For diarrhoea induced hypovolemia.4. Diabetic ketoacidosis.
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CONTRA-INDICATIONS 1. In severe CHF.2. Severe metabolic alkalosis.
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colloids ADVANTAGES :i. More effective in treating
hypotension than crystalloids.ii. Increase in plasma volume is for a
prolonged period.iii. Improve the hemodynamic status.iv. Higher systemic oxygen delivery.
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DISADVANTAGES :i. Expensive.ii. Anaphylactic reactions
INDICATIONS :i. To treat sudden hypotension due to
major blood loss, till blood is awaited , or to avoid blood transfusion.
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Type of fluid Effective plasma volume expansion/100ml
duration
5% albumin 70 – 130 ml 16 hrs
25% albumin 400 – 500 ml 16 hrs
6% hetastarch 100 – 130 ml 24 hrs
10% pentastarch 150 ml 8 hrs
10% dextran 40 100 – 150 ml 6 hrs
6% dextran 70 80 ml 12 hrs
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Crystalloids – recommended as the initial fluid of choice in resuscitating patients from hemorrhagic shock
Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 - 141
COCHRANE Collaboration in critically ill patients – “ No evidence from RCT that resuscitation with colloids reduces the risk of death, compared with crystalloids in patients with trauma or burns after surgery” Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD 000567, 2004
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Blood transfusion
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Hb concentrations below 6 g/dL
no significant differences were found in 30-day mortality rates between those in whom ‘restrictive’ transfusion therapy was used and those in whom the transfusion therapy was applied ‘liberally’ (triggering Hb values between 7-8 g/dL and around 10 g/dL, respectively
Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.
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Blood transfusion
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MABL = (Starting pt Hct – 25) X Estimated blood vol
Starting pt Hct
MABL= [EBV x (H initial- H final)]/H initial
H final = 30
Estimated blood volume – males 75 ml/kg females 65 ml/kg
Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.
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Incompatible fluids Electrolyte and colloid solutions containing any calcium (e.g. Haemaccel, lactated Ringer’s solution)
5 % dextrose hemolyses RBCs
Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.
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Adverse reactions 1. Immediate
acute haemolytic reactionsfebrile non-haemolytic reactionsAnaphylaxistransfusion-related acute lung injury – TRALI
2. Delayeddelayed haemolytic reactions
3. Immediate non-immunologicalbacterial contaminationcirculatory overloadAir embolism/hypothermia
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hypotensive resuscitation target mean arterial pressure (MAP) of 50
mm Hg
decrease postoperative coagulopathy and lower the risk of early postoperative death and reduce the amount of blood product transfusions and overall IV fluid administration.
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D: DISABILITY Level of consciousness
– Best indicator of central perfusion & deterioration of patient status
Pupils GCS
A: Alert V: responds to Vocal stimuli P: responds to Painful stimuli U: Unresponsive to all stimuli
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13-15 mild head injury8-12 moderate<8 severe
revised in 1976- sixth point - “withdrawal from painful stimulus
Jennett and Teasdale in the early 1974
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Infants & children
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AVPU/ACDU
Alert Confused Drowsy Unresponsive
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MAYO HEAD INJURY CLASSIFICATION SYSTEM FOR TRAUMATIC BRAIN INJURY Category A moderate to severe (definite) TBI:1. Death caused by this TBI2. LOC of 30 minutes or longer3. Post-traumatic anterograde amnesia of 24 hours or longer4. Worst GCS full score in the first 24 hours less than 135. One or more of the following present: EDH, SDH, Contusion Category B1. Loss of consciousness of momentary to less than 30 minutes2. Post-traumatic anterograde amnesia of momentary to less than 24 hours3. Depressed, basilar or linear skull fracture
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Injury Severity Score
Abbreviated injury score
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Revised Trauma Score (RTS)
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR
range 0 to 7.8408 RTS < 4 – severe injury
1981 by Champion et al.
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Mainz score
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Acute Physiology and Chronic Health Evaluation Score (APACHE) II
clinical decision-making particularly for ICU patients
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EXPOSURE Complete exposure is a must avoid
hypothermia
warm ambient room, overhead heating, and warmed IV fluids
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ADJUNCTS TO THE PRIMARY SURVEY assessment of pulse and respiratory
rates; systolic and diastolic blood pressures; pulse oximetry; Temperature ECG monitoring urinary catheter recording of urine
output NG tube aspiration
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SECONDARY SURVEY complete and comprehensive head to- toe evaluation history and circumstances leading to the injury physical examination of the patient reassessment of all vital signs.
Six potentially lethal injuries that should be evaluated Pulmonary contusion aortic disruption tracheobronchial disruptionesophageal disruption traumatic diaphragmatic hernia myocardial contusion
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HISTORY A: Allergies M: Medications currently used P: Past illnesses and Pregnancy L: Last meal E: Events and Environment related to
the injury
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Physical examination Scalp
LacerationsContusionshematomas bone surface irregularities
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Eyes pupillary response - shape, equality, and light
reaction of the pupils eye injury - blunt or penetrating Direct injury to the optic nerve
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Neck and Cervical Spine
unstable cervical spine injury – unless otherwise proven
Cervical spine tenderness, subcutaneous emphysema
laryngeal fracture
Lateral and AP views -seven cervical vertebrae and the first thoracic vertebra (C1- C7/T1 junction)
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Chest Pain, dyspnea, and hypoxia pneumothorax and large flail segments Contusions and hematomas occult
pulmonary or cardiac injury Distended neck veins cardiac
tamponade or tension pneumothorax
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Abdomen Intra abdominal bleed should be
suspected if there are fractures of the ribs that overlie the liver and the spleen
Blunt/penetrating trauma Lap belts Focused assessment with sonography
for trauma - FAST
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Perineum, Rectum, and Vagina contusions,hematomas, lacerations, and
urethral bleeding.
Must before catheterization
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Musculoskeletal Assessment Contusions, lacerations, deformities
Peripheral pulses Motor and sensory impairement
Pelvic fractures are suggested by:ecchymosis over the iliac wings, pubis, vagina, or
scrotum. pain on palpation.mobility of the pelvis in response to gentle
anteroposterior pressure in the unconscious patient
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Spinal Cord Assessment
electrical shock–like pain radiating down the spine or into the limbs nerve root compression
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Conclusion With meticulous and rapid assessment
and management it is possible to add years to peoples life
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References Oral & Maxillofacial Trauma – Fonseca
Walker – 4th edition Maxillofacial trauma and esthetic facial
reconstruction – Wardbooth, Eppley
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