Assessment and Management of

Emergency Trauma Cases

dr. I Gede Suwedagatha, Sp.B(K)Trauma

Epidemiology

 Injury is not an “accident” but rather a disease, much like malaria, tuberculosis and other
public health problems, or cancer and heart disease.
 Injury, like other diseases, has variants such as blunt or penetrating. It has degrees of
severity, rates of incidence, prevalence, and mortality that can differ by race and other
sociodemographic factors.
 Injuries have a predictable pattern of occurrence related to age, sex, alcohol and other
drugs, and again, sociodemographic factors, among others.
 Injuries can result from acute exposure to physical agentssuch as mechanical energy,
heat, electricity, chemicals, andionizing radiation in amounts or rates above or below the
threshold of human tolerance.
Epidemiology
Outline of Trauma Patients

 When treating injured patients, clinicians rapidly assess injuries and institute life-preserving
therapy.
 Because timing is crucial, a systematic approach that can be rapidly and accurately applied is
essential.
 This approach, termed the “initial assessment,” includes the following elements:
 Preparation
 Triage
 Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries
 Adjuncts to the primary survey and resuscitation
 Consideration of the need for patient transfer
 Secondary survey (head-to-toe evaluation and patient history)
 Adjuncts to the secondary survey
 Continued post-resuscitation monitoring and reevaluation
 Definitive care
Prehospital Care Overview

• After assessing the scene, EMS personnel perform a

primary survey of the patient
• While it is taught in a stepwise A–B–C–D–E approach,
one must remember that many aspects of this
evaluation can be done simultaneously.
• A consensus group has recommended a “THREAT”
approach. This procedure consists of steps as follows:
• threat suppression,
• hemorrhage control,
• rapid extrication to safety,
• assessment by medical providers, and
• Transport to definitive care.
Primary Survey

The primary survey encompasses the

ABCDEs of trauma care and identifies
life-threatening conditions by adhering
to this sequence:
• Airway maintenance with restriction
of cervical spine motion
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability(assessment of neurologic
status)
• Exposure/Environmental control
A (Airway)
 A (Airway)

If the patient is not talking or responding normally, has a

severely altered mental status, or is unresponsive, assume that
the airway is or may become closed.
The airway is opened and maintained by using, as needed,
any or all of the following techniques:
 Manual airway maneuvers to prevent the tongue and
epiglottis from blocking the airway: the head-tilt, chin-lift
maneuver or the jaw-thrust maneuver.
 The head-tilt, chin-lift maneuver is used for medical patients
in whom you do not suspect the possibility of a spinal injury.
The jaw-thrust maneuver is used for trauma patients in
whom you suspect a possible spinal injury.
 Suction and/or finger sweeps to remove blood, vomitus,
food, secretions, or foreign objects.
 Airway adjuncts to maintain a patent airway: the
oropharyngeal airway or the nasopharyngeal airway.
 Manual thrusts to the abdomen (Heimlich maneuver),
 A (Airway) Damage Control Resuscitation

The criteria for establishing a definitive airway are based on

clinical findings and include:
 A :Inability to maintain a patent airway by other means,
with impending or potential airway compromise (e.g.,
following inhalation injury, facial fractures, or
retropharyngeal hematoma)
 B: Inability to maintain adequate oxygenation by
facemask oxygen supplementation, or the presence of
apnea
 C: Obtundation or combativeness resulting from cerebral
hypoperfusion
 D: Obtundation indicating the presence of a head injury
and requiring assisted ventilation (Glasgow Coma Scale
[GCS] score of 8 or less), sustained seizure activity, and the
need to protect the lower airway from aspiration of blood
or vomitus
A (Airway) Damage Control Surgery
B (Breathing)
B (Breathing)
B (Breathing)
B (Breathing)
B (Breathing)
B (Breathing) Damage Control
Rescusitation
B (Breathing) Damage Control Surgery
B (Breathing) Damage Control Surgery
B (Breathing) Damage Control Surgery
C (Circulation)
C (Circulation) Damage Control
Rescusitation
 C (Circulation)

• All patients with suspected abdominal trauma

should receive two large-bore intravenous
cannula.
• Blood should be taken for cross-matching, full
blood count and coagulation screen with
other tests as indicated.
• Inspect the abdomen and look for signs such
as the bruising associated with seatbelt marks
or entry and exit wounds associated with
gunshot injuries.
• Palpation may reveal tenderness associated
with organ injury or peritoneal irritation after
visceral damage.
• Abdominal examination may change with
time and therefore should be repeated at
regular intervals.
 C (Circulation)

• If abnormal vital signs continue despite a

normal examination of the anterior
abdomen, the patient should be log
rolled to assess the posterior abdomen
and perineum.
• The opportunity should be taken to
perform a rectal examination at the
same time. This is to check the integrity of
the rectal wall and assess for the
presence of blood.
• A high-riding prostate indicates urethral
damage. Vaginal examination may also
be necessary to check the integrity of
the vaginal vault.
C (Circulation) Damage
Control Surgery

 The abbreviated laparotomy in

“damage control” surgery controls
bleeding and limits further
contamination from the gastrointestinal
tract before the patient is transferred to
the intensive care unit (ICU).
Stages of Damage Control Surgery:
 Prehospital (Ground Zero)
 Abbreviated Initial Operation
 Resuscitation in the ICU
 Reoperation
 Closure of Abdominal Wall
D (Disability)
D (Disability)
Classifications of Head Injury
Types of Hematomas
D (Disability) Damage Control
Resuscitation
 Adjuncts to Primary Survey:
Chest X-Ray

 In the patient with an abnormal chest physical

examination (ie, tachypnea, desaturation, significant chest
deformity) or hemodynamic instability, the CXR provides a
rapid means of identifying hemo- or pneumothoraces, a
ruptured diaphragm or the suggestion of aortic injury.
 Additionally, pulmonary contusions or multiple rib fractures
that can be seen on the screening CXR may predict later
respiratory failure and the need for admission to a
monitored bed for more comprehensive care.
 Lastly, the CXR confirms placement of both endotracheal
and chest tubes.
 Thus, while routine CXR may not be warranted in every
hemodynamically stable patient with a normal physical
examination, it remains an integral and invaluable part of
the primary survey in patients with physiologic
derangements or positive physical examination findings.
 Adjuncts to Primary Survey:
Pelvis X-Ray

 There are multiple studies demonstrating

lack of utility for routine pelvic x-ray (PXR) as
a standard adjunct to the primary survey.
 This conclusion was reflected in the most
recent edition of ATLS, where PXR is no
longer considered a mandatory adjunct to
the primary survey.
 In our own practice, we have now focused
our efforts in those patients with
unexplained hypotension in which a simple
intervention such as pelvic binding might be
beneficial or those with obvious skeletal
injuries where a hip dislocation may be
considered.
Adjuncts to Primary Survey:
Focused Assessment of Sonography in
Trauma

 Its use has essentially replaced (DPA/DPL)

as the prime adjunct for triage of the
abdomen in the unstable patient.
 FAST includes examination of four regions:
the pericardial sac, hepatorenal fossa,
splenorenal fossa, and pelvis or pouch of
Douglas
 FAST can be performed at the bedside in
the resuscitation room at the same time
other diagnostic or therapeutic
procedures are performed.
 Adjuncts to Primary Survey:
Diagnostic Peritoneal Lavage

 DPL is another rapidly performed study to

identify hemorrhage.
 Note that DPL requires gastric and urinary
decompression for prevention of
complications.
 The technique is most useful in patients who
are hemodynamically abnormal with blunt
abdominal trauma or in penetrating trauma
patients with multiple cavitary or apparent
tangential trajectories.
 In settings where CT and/or FAST are
available, DPL is rarely used because it is
invasive and requires surgical expertise.
 Adjuncts to Primary Survey:
CT Scan

 CT is a diagnostic procedure that requires transporting

the patient to the scanner, administering IV contrast,
and radiation exposure.
 CT is a time-consuming (although less so with modern CT
scanners) procedure that should be used only in
hemodynamically normal patients in whom there is no
apparent indication for an emergency laparotomy.
 Do not perform CT scanning if it delays transfer of a
patient to a higher level of care.
 CT scans provide information relative to specific organ
injury and extent, and they can diagnose retroperitoneal
and pelvic organ injuries that are difficult to assess with a
physical examination, FAST, and DPL.
 CT can miss some gastrointestinal, diaphragmatic, and
pancreatic injuries.
Adjuncts to Primary Survey:
Laboratory

 Although, decisions as to appropriate testing can be made based on the severity/

perceived severity of the patient, it is often useful to have a “trauma panel” that includes
a CBC, coagulation profile, and alcohol level.
 Point of care testing should be considered as the results are more rapidly available.
 All patients should have a type and cross match sent.
 After that, there may be some utility in obtaining an arterial blood gas in those patients
meeting the highest level of trauma activation. This should ideally be able to provide the
standard values like pH and base deficit but lactate as well.
THANK YOU