Trauma is a global problem and continues to be a leading cause of disability and death. Approximately 25% to 30% of deaths caused by trauma can be prevented when a systematic and organized approach is used. The main goal of the initial assessment Recognize the patient who does have life-threatening injuries Establish treatment priorities, and Manage them aggressively

1. PRIMARY EVALUATION OF TRAUMA
PATIENTS
MODERATOR: PRESENTED BY:
DR ROHIT CHANDRA DR KAMINI DADSENA

2. Outline
• Introduction
• Goals of initial evaluation
• Golden hour
• Platinum 10 min
• ABCDE
• Secondary survey
• Conclusion
• References

3. Introduction
• Trauma is a global problem and continues to be a
leading cause of disability and death.
• Approximately 25% to 30% of deaths caused by
trauma can be prevented when a systematic and
organized approach is used.
• The main goal of the initial assessment
• Recognize the patient who does have life-threatening
injuries
• Establish treatment priorities, and
• Manage them aggressively

4. Trimodal Distribution of Death
Lacerations
Brain
Brain stem
Aorta
Spinal cord
Heart
Epidural
Subdural
Haemopneumothorax
Pelvis fracture
Long bone fracture
Abdominal injury
Sepsis
Multiple Organ Failure

5. GOLDEN HOUR PLATINUM 10 MIN
The first 60 minutes after traumatic injury has
been termed the “golden hour.” because these
patients may be saved with rapid assessment
and management of their injuries.

6. Nonurgent
immediately life threatening
and interfere with vital
physiologic functions;
Compromised Airway
Inadequate Breathing
Haemorrhage & Circulatory
System Damage or Shock.
5% of patient injuries 50%
of all trauma deaths
UrgentSevere
Injuries to the Abdomen
Orofacial Structures
Chest, or Extremities that
Require Surgical
Intervention or Repair,
Their Vital Signs are
Stable.
10 to15% of all injuries
No immediate threat to
life
The exact nature of the
injury may not become
apparent until after
significant evaluation
and observation.
80% of all injuries
Not immediately life
threatening

7. Assessment Principle
1. Preparation
2. Triage
3. Primary survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey and resuscitation
6. Consideration of the need for patient transfer
7. Secondary survey (head-to-toe evaluation and patient history)
8. Adjuncts to the secondary survey
9. Continued postresuscitation monitoring and reevaluation
10. Definitive care
ATLS Student course manual 9th edition

8. Assessment Principle

9. Triage
MASS CASUALITYMULTIPLE CASUALITY
when the number of patients and the
severity of their injuries do not exceed the
ability of the facility to provide care.
Patients with life-threatening problems
and those sustaining multiple system
injuries are treated first.
When the number of patients and the
severity of their injuries exceeds the
capability of the facility and the staff.
Those patients with the greatest chance
of survival with the least expenditure of
time, supplies equipment and personnel
are managed first.

10. Red - Immediate (Critical)
Yellow - Delayed (Urgent)
Green - Minor (Ambulatory)
White – Those Who Do
Not Require Treatment
Black - Deceased

12. Primary Survey
Airway with
C-spine
control
Breathing
and
ventilation
Circulation
and
hemorrhage
control
Disability
+
neurological
status
Exposure
+
environment
F Frequent reassessment

13. Airway & cervical spine control
Cervical spine immobilization.
patients with altered consciousness
15% patients with supraclavicular
injuries and 5 % with head injury
Hyperextension or hyperflexion of
the patient’s neck should be
avoided

14. Factors that compromise airway
1. Obstruction of the nasal and oral airways by blood clot, with saliva, bone, teeth
and parts of dentures
2. Inhalation of any of the above.
3. Regurgitation of stomach contents
4. Obstruction of the nasopharynx and oropharynx by backward displacement of
the tongue and its attachments in symphyseal fractures of the mandible
5. Occlusion of the oronasopharynx by downward and backward displacement of a
fractured maxilla
6. Tracheal and/or laryngeal fractures, bleeding, a retropharyngeal hematoma
resulting from cervical spine fractures. or traumatic brain injury.
7. Low GCS/ Unconciousness

15. Assessment of airway
15
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)

16. jaw-thrust
Chin-lift

17. Look, Listen,and Feel
• Look for chest movement, use of accessory
muscles of ventilation
• Listen at the victim’s mouth for abnormal sounds
Snoring, gurgling, and crowing sounds
(stridor)-partial occlusion of the pharynx or
larynx.
Hoarseness (dysphonia) implies functional
laryngeal obstruction
• Feel for air on your cheek.
17

18. • 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.
18
Jaw Thrust

19. Chin lift
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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

20. oropharyngeal airway
20

21. Nasopharyngeal airway
21

22. 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
22

23. 23

24. injuries to the larynx and trachea
• neck swelling, dyspnea, voice alteration, or frothy
hemorrhage
• tenderness, and laryngeal or tracheal crepitus
• Endotracheal intubation / surgical airway
24

25. Indications for definitive airway
Oral & Maxillofacial trauma – Fonseca Walker 25

26. BREATHING
• Assess breathing and ventilation
• Ventilation is compromised not only by airway
obstruction but also altered ventilatory mechanics or
CNS depression.
• 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
26

27. 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
27
• positive-pressure ventilation worsens tension
pneumothorax
• Maybe seen as complication of central line
insertion in polytrauma

28. Tension Pneumothorax
28

29. C/F
• chest pain
• air hunger
• respiratory distress
• tachycardia
• Hypotension
• tracheal deviation
• unilateral absence of breath sounds
• hyper resonant percussion note
29
• 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

30. 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
30

31. Flail chest
31
• paradoxical breathing, asymmetrical
and uncoordinated movement of
chest wall
• injury to the underlying lung
parenchyma - pulmonary contusion
Mx
• adequate ventilation
• Splinting the area with sandbag/ iv
fluid bag
• administration of humidified oxygen
• fluid resuscitation
• Good analgesia

32. Cardiac Tamponade
• Penetrating/ blunt injury
• pericardium fills with blood from the heart, great vessels
• interfere with cardiac filling
• Beck’s triad
• distended neck veins
• decline in arterial pressure
• muffled heart sounds
32
• Kussmaul’s sign (a rise in venous pressure with
inspiration when breathing spontaneously)
Mx
• Aspiration of pericardial blood - pericardiocentesis

33. C: CIRCULATION AND
HEMORRHAGE CONTROL
• Acute blood loss - 0% to 40% of trauma deaths
• Leads to Shock
• Clinical state of cardiovascular collapse
characterized by acute reduction of effective
circulating blood volume, inadequate
perfusion of cells & tissues.
33

34. 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.
34

35.  PRIMARY (Initial Shock)
 SECONDARY (True Shock)
 HEMATOGENIC/HYPOVOLAEMIC/OLIGAMIC
SHOCK
 OBSTRUCTIVE SHOCK / TRAUMATIC SHOCK
 NEUROGENIC SHOCK
 CARDIOGENIC SHOCK
 SEPTIC SHOCK
35

36. CLINICAL FEATURES
General Clinical Features Of Shock
o Hypotension (Systolic BP<70mmHg)
oTachycardia (>100/min)
oCold , Clammy Skin
oRapid,Shallow Respiration
oDrowsiness,Confusion,Irritability
oOliguria (Urine Output<30ml/hour)
oMulti-Organ Failure
36

37. 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
37
• Long bone fractures – approx 750 ml blood loss
• Femur fracture – approx 1500 ml
• Pelvic fracture – 2000-2500ml

38. 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
38
• Crossmatch,full blood count; RFT,LFT and
electrolytes; ABG

39. Fluid Replacement
39
• 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
• Transient responder: The vital signs initially improve but then
deteriorate.
• still actively bleeding from an occult site.
• require transfusion with blood
• Identify 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 line
• Immediate surgery and transfusion

40. Blood transfusion
40

41. 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
41

42. 13-15  mild head injury
8-12 moderate
<8  severe
42
revised in 1976- sixth point - “withdrawal
from painful stimulus
Jennett and Teasdale in the early 1974

43. AVPU/ACDU
•Alert
•Confused
•Drowsy
•Unresponsive
43

44. EXPOSURE
• Complete exposure is a must to assess patient
• Followed by cover patient to avoid hypothermia
• warm ambient room, overhead heating, and
warmed IV fluids
44

45. 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
45

46. 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.
46

47. HISTORY
• A: Allergies
• M: Medications currently used
• P: Past illnesses and Pregnancy
• L: Last meal
• E: Events and Environment related to the injury
47

48. Physical examination
• Scalp
• Lacerations
• Contusions
• hematomas
• bone surface irregularities
48

49. Eyes
• pupillary response - shape, equality, and light reaction
of the pupils
• eye injury - blunt or penetrating
• Direct injury to the optic nerve
49

50. 50

56. 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)
56

57. 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
57

58. 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
58

59. Perineum, Rectum, and Vagina
• contusions,hematomas, lacerations, and urethral
bleeding.
• Must before catheterization
59

60. 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
60

61. Spinal Cord Assessment
• electrical shock–like pain radiating down the spine
or into the limbs nerve root compression
61

62. 62

63. Conclusion
Patients are assessed and treatment priorities are
established based on patients’ injuries and the
stability of their vital signs. In any emergency
involving a critical injury, logical and sequential
treatment priorities must be established on the basis
of overall patient assessment.

64. References
• Oral & Maxillofacial Trauma – Fonseca Walker – 4th
edition
• Maxillofacial trauma and esthetic facial
reconstruction – Wardbooth, Eppley
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