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Med 542 Review
Trauma
Ken Stewart MD, FRCSC
Assistant ProfessorDivision of Thoracic Surgery, University
of Alberta
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Trauma
Precipitous, ubiquitous phenomenon
affecting all ages, races.
Various forms (blunt, penetrating, burns)
Disease or process in evolution
Outcomes based on severity of injury, pre-
existing conditions, and timing andappropriateness of treatment.
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Objectives
Describe theprinciples ofassessment of theinjured patient
Describe theprinciples ofresuscitation of theinjured or critically-ill
patient
Describe the
indications for and
the important steps in
the procedure ofemergency
cricothyroidotomy
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Objectives --2
Outline the principles
of assessment and
management of blunt
and penetrating injuryof the chest
List the indications for
trauma thoracotomy
List the indications fortube thoracostomy
Describe the propertechnique for tubethoracostomy
List the indications foremergency needledecompression of thechest
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Objectives --3
Define shock, andlist the signs andsymptoms of thedifferent types of
shock
Describe themanagement of thedifferent types of
shock
Outline the principles
of assessment and
management of blunt
and penetrating injuryof the abdomen
List the indications for
a trauma laparotomy
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Internet Resources
American College of Surgeons
www.FACS.org
Links to ATLS
Trauma.org
www.trauma.org
trauma care website with links to care
related areas
http://www.facs.org/http://www.trauma.org/http://www.trauma.org/http://www.facs.org/7/28/2019 Surgery 542 Trauma
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ATLS
Advanced Trauma Life Support
Program developed by the American
College of Surgeons Emerged as a result of experience with
conflict, and health care revision in the US.
Need for organized approach torecognition, assessment and treatment of
all types of trauma
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ACS outline on ATLS
Injury is precipitous and indiscriminate
The doctor who first attends to the
injured patient has the greatestopportunity to impact outcome
The price of injury is excessive in
dollars as well as human suffering
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ATLS--2
Program: CME program developed by theACS Committee on Trauma
One safe, reliable method for assessing andinitially managing the trauma patient
Revised every 4 years to keep abreast ofchanges
Audience: Designed for doctors who carefor injured patients Standards for successfulcompletion established for doctors
ACS verifies doctors' successful course
completion
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ATLS--3
Benefits: An organized approach for
evaluation and management of
seriously injured Patients A foundation of common knowledge for
all members of the trauma team
Applicable in both large urban centersand small rural emergency departments
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ATLS--4
Objectives: Assess the patient's conditionrapidly and accurately
Resuscitate and stabilize the patientaccording to priority
Determine if the patient's needs exceed afacility's capabilities
Arrange appropriately for the patient'sdefinitive care
Ensure that optimum care is provided
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ATLS--5
Trauma Team, and Team Leader
concept
One person responsible for makingdecisions and starting treatment
Organized into algorithms for the benefit
of systematic recognition and treatment
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Assessment and Treatment
Ongoing assessment from the time of
original notification to response to any
treatment measures.
Mechanism of injury, timing and pre-
existing conditions are importanthistorical features
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Systematic Assessment by
Trauma Team Leader
Primary SurveyAirway
Ensure patency
Breathing Rule out distress
Circulation Provision for large
bore (14-16 gauge)IV access
Crossmatch for bloodfor severely injured
Secondary Survey
ABC again
Disability C-spine precautions and
neuro assessment
Exposure
exam front and back ofpatient, then keep warm
Fingers in every orifice
and foley catheter
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Assessment Principles
Primary survey
Try to recognize the immediately life-threatening
injuries1. Tension Pneumothorax
2. Massive Hemothorax
3. Open Pneumothorax
4. Cardiac Tamponade
5. Flail Chest
Airway,Breathing,Circulation
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Assessment Principles
Secondary Survey
More detailed and complete examination,
aimed at identifying all injuries andplanning further investigation and
treatment.
Airway,Breathing,Circulation, Disability, Exposure, Fingers, Foley
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Resuscitation/Treatment
After airway and breathing have been assured, infuse IVfluids, keep npo and decide on relevant imaging, andlab testing.
C-spine immobilization and any limb injuries need to beaddressed with dressings, splints and fracturereduction if vascular or nerve injury apparent.
Decision on where patient should be treated definitivelyneeds to be determined. Consideration of personel and resources.
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Airway Assessment
Midline position of trachea
Stridor,presence of hemoptysis
Work of breathing Use of accessory muscles
Respiratory rate
SaO2and hypoxemia and hypercapnea on ABG
Level of consciousness Depressed GCS--inability to protect the airway
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Airway--treatment
Classified as Simple to Surgical
Mask, Oropharyngeal airway,
nasopharyngeal airway, laryngeal
mask, endotracheal tube,
cricothyrotomy, tracheostomy
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Airways
QuickTime and aTIFF (Uncompresse d) decompress or
are needed to see this picture.
QuickTime and aTIFF (Uncompress ed) decompress or
are needed to see this picture.
QuickTime and aTIFF (Uncompres sed) decompressor
are needed to see this picture.
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Endotracheal intubation
QuickTime and aTIFF (Uncompresse d) decompresso
are needed to see this picture.
QuickTime and aTIFF (Uncom pressed) decompressor
are needed to see this picture.
QuickTime and aTIFF (Uncompresse d) decompress
are needed to see this picture.
QuickTime and aTIFF (Uncompress ed) decompress or
are needed to see this picture.
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Endotracheal intubation
Indications Hypoxemia
Hypercapnea
Impending respiratoryarrest
Cardiac arrest, multitrauma
Readying for OR
Need suction,Laryngoscope, Muscleparalysis (?rapidsequence induction)
QuickTime and aTIFF (Uncompresse d) decompressor
are needed to see this picture.
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Surgical Airways
Cricothyroidotomy
Needle
tube
Tracheostomy
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Cricothyroidotomy
Indications Severe facial or nasal injuries (that
do not allow oral or nasal intubation)
Massive midfacial trauma
Anaphylaxis Chemical inhalation injuries
Contraindications inability to identify landmarks
(cricothyroid membrane)
Underlying anatomical abnormality
(tumor)
Tracheal transection, acutelaryngeal disease by infection ortrauma
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Cricothyroidotomy
technique1.With a scalpel, create a 2 cm
horizontal incision through thecricothyroid membrane
2.Open the hole by rotating the scalpel90 degrees or by using a clamp
3.Insert a size 6 or 7 endotrachealtubeor tracheostomy tube
4.Inflate the cuff and secure the tube
5.Provide venilation via a bag-valvedevice with the highest availableconcentration of oxygen
6.Determine if ventilation wassuccessful (bilateral ausculation andobserving chest rise and fall)
7.No attempt should be made to removethe endotrachealtube in aprehospital setting.
QuickTime and aTIFF (Uncompres sed) decompressor
are needed to see this picture.
http://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Tracheostomyhttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Tracheostomyhttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tube7/28/2019 Surgery 542 Trauma
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Assessment of treatment
Auscultate
CXR
End tidal CO2
SaO2
QuickTime and aTIFF (Uncompress ed) decompressor
are needed to see this picture.
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Tracheostomy
Definitive surgical
airway
Dedicted appliance or
endotracheal tube
Indications similar for
cricothyroidotomy
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Chest trauma
Assessment with physical exam, CXR,
ABGs and SaO2monitoring
CT scan
Echocardiography, ECG
Serum studies for cardiac injury
(troponin and creatinine kinaseMB
fraction)
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Tension Pneumothorax
Typically from penetrating trauma.
Can be spontaneous
Bronchopleural fistula from lacerated, ordisrupted lung, open pneumothorax
Symptoms of dyspnea, syncope, surgical
emphysema, impending doom
Signs of hypotension, tachypnea, tachycardia,
distended neck veins, cyanosis
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Hemodynamic mechanism
Axis of the cavae,
point of fixation with
the aorta and greatvessels
Lack of right heart
filling, leading to
shock
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Tension pneumothorax
Treatment Suspected: needle
decompression
14 gauge angiocath Midclavicular line
Use syringe withplunger removed
Leave in place and theninsert standard chest
tube thoracostomy What to do if patient is
too thick?
What if there is notension noted with needle
insertion?
QuickTime and aTIFF (Uncompressed) decom pressor
are needed to see this picture.
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Tension pneumothorax vs
Cardiac tamponade In contrast to a pericardial tamponade in
setting of penetrating chest trauma
Pulse--both elevated Percussion-- tympani with tension
Pulsus paradoxus with tamponade
Neck veins distended with both Trachea shifted with tension
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Chest tube thoracostomy
Indications Pneumothorax
Hemothorax
Unstable patientfollowing blunt orpenetrating trauma
Non trauma Pleural effusion,
chylothorax,
empyema,postoperative
Relativecontraindication=diaphragm disruption
Technique Local anesthetic*
Sterile field*
Scalpel, kelly orhemostat forcep
Chest tube andpleurevac device
Securing suture
*if time permits
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Chest tube insertion
Location is typically,nipple height, mid-axilla sparing the
latissimus, andpectoralis muscle
No tunnels needed
CXR post procedure Connect topleurevac
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Trauma thoracotomy
Emergency situation
with penetrating
chest injury Rarely of benefit inblunt trauma
Suspect major
vessel laceration orcardiac laceration
QuickTime and aTIFF (Uncompressed) d ecompressor
are needed to see this picture.
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Indications
Penetrating injury to
chest, abdomen or
retroperitoneum
Signs of life prior to
assessment in ER
then shock normothermia
Clamp aorta
Defibrillate heart
Internal cardiacmassage
Pericardialdecompression
Repair of laceratedvessel or heart
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Shock
Hypovolemic
Following blood loss
Burns andhypothermia
Cardiogenic
Pump failure
Ischemia, contusion,acute valvular
dysfunction
Distributive Sepsis
Neurogenic
Obstructive Pulmonary embolism
Tamponade, tensionpneumothorax
Endocrine Manifests like distributive
shock
Hypothyroidism,hypoadrenalism
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Diagnosis
Mechanism of injury,
illness
CXR Bloodwork
ABG, lactate, Hgb,
Creatinine
Response to trial of
IV fluids
Monitoring of blood
pressure
CVP SVRI from swan
ganz catheter
measurements
Response to
vasopressor therapy
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Treatment
Directed at specificdiagnosis Fluid resuscitation
Crystalloid, colloid
Blood and bloodproducts
Vasopressors
Specific agents forspecific types ofshock
Definitive treatment
where possible
depending onetiology.
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Blunt Injuries to the
abdomen Physical signs
Distension
Peritonitis
Retroperitoneal
bleeding
Intraabdominal
pressure ( measured
with foley catheter
and tonometer)
Diagnosis
Fast scan
(ultrasound)
CT scan
Hemodynamic
monitoring
Diagnostic peritoneallavage
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Diagnostic peritoneal lavage
Used to assess need for
laparotomy following
trauma
Cutdown technique tomidline of abdomen
Initial aspiration, if
clear..
Infusion of one litre of
saline with IV tubing and
then collection
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Diagnostic peritoneal lavage
Indications forlaparotomy GI contents on aspirate
or lavage Feces, bile, peas andcorn
Urine on aspirate
Blood 10 mLs of gross blood
on aspirate >100 000 rbc/ mL on
analysis (newspapertest)
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Role of CT scan
Use for blunt injurymanagementAssess liver and
spleen injuries Presence of
pneumoperitoneum,free fluid
Vascular injuries Retroperitoneal
injuries
QuickTime and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Indications for laparotomy
following trauma Blunt
Hemodynamic instability
despite resuscitation
Positive DPL Findings on CT scan
High grade spleen or
liver injury
Pneumoperitoneum
Retroperitoneal organinjury
Vascular injury
Penetrating
Hemodynamic
instability despite
resuscitation
Evisceration,
pneumoperitoneum
Positive DPL
CT scan findings
similar to blunt