Trauma Surgery

Management of patients with multiple trauma

Dr. Ahmed Khan

Hospital care

ATLS approach (Advanced Trauma Life Support)

• Primary survey: initial assessment & management

  • Treat the greatest threat to life
  • Immediate intervention as the threat to life identified
  • Detailed history not essential
  • Re-evaluation of initial management

• Secondary survey: a head to toe evaluation

Primary survey- “a team approach”

• Multiple providers
• Simultaneous diagnosis & treatment
• Reduces the time to assess & stabilize
• Team is organized before patient arrival.
• Leadership & unity of command-essential

Primary survey- “one clinician”

Do not perform subsequent steps in the primary survey until after addressing life-threatening conditions in the earlier steps.

Primary survey

A B C D E

• Airway & cervical spine protection
• Breathing & ventilation
• Circulation with control of external bleeding
• Disability (neurologic assessment)
• Exposure & Environmental control- undress, prevent hypothermia

Adjuncts to Primary Survey & resuscitation

• Oxygen
• Pulse oximetry
• BP monitoring
• ECG monitoring
• NG tube, urinary catheter (urine sample)
• Ventilatory rate
• ABG levels
• X-ray- chest & pelvis (AP)
• FAST, ? DPL

Secondary Survey

• Only after completion of primary survey - Once all life threatening injuries dealt & - Normalization of vital signs

• Secondary Survey:

  • AMPLE history (Allergies, Medication, Past/Pregnacy, Last meal, Events of trauma)
  • Examination (Head to toe)
  • Continuous reassessment of vital signs
  • Additional laboratory/ radiological tests.
  • Additional tubes, lines and monitoring devices
  • Priorities and plan definitive management of all injuries

Types of injuries

• Head injury

• Spinal cord injury

• Thoracic injury

  • Tension pneumothorax.
  • Open pneumothorax (open chest wound).
  • Flail chest with underlying pulmonary contusion.
  • Massive Hemothorax.

• Abdominal injury

• Bowel Injury

• Splenic Injury

• Liver injury

• Pancreatic Injury

• Renal Injury

other medical emergencies

Emergency TherapeuticsY

Epidemiology

• Most common cause of death (ages 1 and 44 years).
• Affects a disproportionate number of young people
• Burden to society- lost productivity, premature death, & disability.
• A major public health issue.

RTA

Arab News

• 20 deaths daily on the Kingdom’s roads.
• Last year- 707 amputations due to RTA.
• Accidents increased by 78% in the KSA recently
• Affecting mostly young (18 and 22 years)
• Around 30% of injured- permanently disabled.
• The state spent SR21 billion treating such patients

Mobile phones leading cause of road deaths

Types of trauma

• Blunt trauma: an impact from blunt object.

• Penetrating trauma: an sharp object piercing the body. Assessment & diagnosis: blunt injuries more difficult than of penetrating injuries

• Multi-trauma: injury affecting simultaneously different organ and body system

Causes of trauma

• RTA or MVA
• Pedestrian trauma
• Fall from height
• Assault
• Firearm injuries
• Knife
• Industrial accidents
• Natural disasters
• Explosions

Trimodal death in trauma

• Immediate: Deaths within seconds or minutes after injury. 50% deaths due to injury to the aorta, heart, brainstem, or spinal cord or by acute respiratory distress. // prevention

• Early: Death within hours of injury- approx. 30% of deaths. Half die of hemorrhage, the other half due to CNS injury. Can be saved by appropriate treatment- golden hour.

• Late: Deaths in days to weeks.

  • Infection & multi organ failure.
  • Care provided earlier impacts the outcome.

ALTS Manual

Improvement in mortality

• Early deaths:
  • Prevention and control program
  • Legislation & behavior modification

• Later deaths:
  • Trauma centers providing better care.
  • Better understanding of pathophysiology of multiple organ failure and brain injury

Pre-hospital care

• Deliver to hospital as rapidly as possible- scoop & run

• Only Critical interventions at the scene:

• Airway, hard collar, spine board, control external bleeding.

• Infusion on way to the hospital

Triage (sort out)

Definition: To Prioritize victims (Multiple) based on – — severity of injury, — likelihood of survival, & — urgency of care.

Goals:

• Identify high-risk injured patients who would benefit from the resources available.
• Limit the excessive shifting of non-severely injured patients so that the trauma center is not over crowded.

Special attention!

• Children: anatomic/ physiologic variations
• Pregnant: anatomic/ physiologic variations, 2 patients!
• Elderly: limited physiological reserves, co-morbidities, medications
• Obese: intubation , ultrasound, diagnostic peritoneal lavage & CT scan are difficult. Limited cardiopulmonary reserve.

ILO’s

At the end of this presentation students will be able to describe:

• Incidence of trauma
• Causes & types of trauma
• Timing & mode of death in trauma & its effect on management.
• Pre-hospital care & triage
• Hospital care: Primary survey & initial management
• Secondary survey
• Pathophysiology of common injuries
• Investigations during primary and secondary survey
• A brief outline of management of major injuries.