- The timeline concept in trauma management emphasizes that there is a critical time window to intervene before loss of compensatory mechanisms, and assessment and response should occur prior to irreversible damage.
- The primary survey follows the ATLS protocol of ABCDE to address life threats, while the secondary survey is a full head-to-toe examination.
- For physiologically compromised patients, a damage control approach may be necessary to stop bleeding and contamination before full treatment, while resuscitation continues simultaneously.
Cardiac Output, Venous Return, and Their Regulation
Assessment of trauma
1. ASSESSMENT OF TRAUMA
Moderator
Dr. M. Amir
Assistant Professor
Department of General Surgery
MIMS,Barabanki
Speaker
Dr.Pooja Pandey
P.G.Resident -1st yr
Department of General Surgery
MIMS,Barabanki
2. Learning Objectives
Timeline concept
Assessment of trauma patient
Responding to a patient with trauma
Selection of early total care and damage control
surgical strategies
3. To get the right patient to the
right place at the right time.
Goal
4. “He who wishes to be a surgeon must first go to war”
-Hippocrates (460-377BC)
5. French and Indian war
• Wound contraction during healing
American civil war
• Primary amputation
• Whole blood transfusion
World war I
• Laparotomy for penetration abdominal trauma
World war II
• Guillotine amputation and delayed primary closure
• Exteriorization of colon injuries
Korean war
• Limb salvage surgery
Vietnam war
• Aeromedical transfer
Enduring freedom operation of Iraq
• DCR
• Re-emergence of tourniquet use
Sabiston text book of surgery 20th ed
6. Trauma, or injury, is defined as cellular disruption caused by
environmental energy that is beyond the body’s resilience, which is
compounded by cell death due to ischemia/reperfusion.
Trauma is the most common cause of death for all individuals
between the ages of 1 and 44 years, and is the third most common
cause of death regardless of age.
What is Trauma?
Schwartz’s principle of surgery 11th edition
7. Magnitude of the problem
Majorities of injuries are not life or limb threatening.
Older patients with fragility fractures pose an additional
burden to the health care system.
Severe trauma continues to be a major cause of death in
young patients .
8. Magnitude of the problem contd..
Bailey &Love’s short practice of surgery 27th edi
9. Magnitude of the problem contd..
Globally, approximately 10 000 people die daily as a result of an injury.
Major vector –Road traffic accident [Bailey &love 27th ed]
Each year 1.35 million people are killed globally in RTA [cdc.gov]
In India- 2/3rd of road traffic injury deaths are reported in the age group 15-
44years .
[ncbi.nlm.nih.gov]
The crash death rate is over 3 times higher in low income countries than in
high income countries .
[cdc.gov]
11. When analysis of the relationship of the formula ‘mechanism +
patient = injury’ does not seem to add up, then the hidden information
may be contained in the mechanism.
Hidden mechanism
12. Not to miss non-accidental
injury (NAI) in children
Characteristic patterns
14. Abbreviated Injury Scale (AIS)
It has been the most used anatomic system of
injury classification since it was first released in
1971.
It demonstrates the body region and the associated first
digit code within the AIS lexicon that allow users of this
system to clearly know the location of the injury.
15. Post - dot code range
1 (minimum severity )
6 (presumably fatal)
16. In 1974, Baker and colleagues presented the Injury Severity Score (ISS), calculated
by summing the squares of the AIS severity codes for the three most severely
injured body regions
The ISS ranges from 1 to 75, with severity groupings being defined as
Minor Injury (ISS less than 9),
Moderate Injury (ISS between 9 and 16),
Serious Injury (ISS between 16 and 25),
Severe Injury (ISS more than 25).
The ISS has been commonly used to quantify the overall burden of injury
sustained by a patient.
Injury severity score (ISS)
17. Revised Trauma Score (RTS)
is another well-studied physiologic scoring system that
18. Timeline concept
There is a critical time window in which we can intervene for a
positive treatment outcome, before the loss of compensatory
mechanisms.
Patient is at their normal baseline, which can be called
time zero.
The ATLS (Advanced Trauma Life Support) system
delineates an order of priorities set by ABCD; that is, airway,
breathing, circulation and disability (neurology).
This hierarchy of priorities is instituted upon the
‘time dependence’ principle.
19. Timely, prioritized interventions
are necessary to prevent death and disability.
Golden Hour
The timeline concept is an essential component of
trauma management .
Asssessment should be completed within a set time
The time to respond is limited.
Both assessment and response should take place in
the time window prior to irreversible damage or
death .
20.
21. Triage
The process was first used in 1792 by Baron Dominique Jean Larrey.
Derived from the French verb ‘trier’, triage means ‘to sort’ and is the
cornerstone of the management of mass casualties.
‘The greatest good for the greatest number’.
22. A good water supply, lighting and ease of access are
useful.
Separate areas should be reserved for patient holding,
emergency treatment and decontamination (in the event of
discharge of hazardous materials).
Triage area
23. Accurate documentation is an inseparable part of triage and should
include basic patient data, vital signs with timing, brief details of
injuries (preferably on a diagram) and treatment given.
A system of colour-coded tags attached to the patient’s wrist or
around the neck should be employed by the emergency medical
services.
The colour denotes the degree of urgency with which a patient
requires treatment
Documentation for triage
27. ATLS provides a structured approach to the trauma patient with
standard algorithms of care
1.Primary survey /Concurrent resuscitation
2.Secondary survey/ Diagnostic evaluation
3.Definitive care
3.Tertiary survey
28. Primary survey
Goal - to identify and treat conditions that
constitute an immediate threat to life.
cABCDE
A B C
Airway Breathing Circulationc: Exsanguinating external
haemorrhage
Disability Exposure
29.
30. Exsanguinating External Haemorrhage From Massive Arterial Bleeding Needs To Be Controlled
Even Before The Airway Is Managed
Application Of Packs And Pressure
Haemostatic Dressings That Contain Agents That Augment Local Coagulation
Application Of A Tourniquet Proximal To The Wound.
Urgent Surgical control of the bleeding in order to reperfuse the limb.
c: Exsanguinating external haemorrhage
31. Identification of source of haemorrhage
Computed tomography (CT) from the head to pelvis with IV
contrast, the so called ‘whole body CT’ (WBCT) is the gold
standard investigation in patients with signs or symptoms of
multiple injury or deranged physiology
A focused abdominal sonography for trauma (FAST) scan (if
immediately available) may also be useful in this scenario to
locate the major source of haemorrhage.
34. A: Airway management with cervical spine protection
all patients with blunt trauma require cervical spine immobilization until
injury is excluded.
Hard cervical collar Sanbdbag
37. B:- Breathing and Ventilation
Once a secure airway is obtained, adequate oxygenation and ventilation must be ensured.
All injured patients should receive supplemental oxygen and be monitored by pulse oximetry.
Threat to life due to inadequate ventilation and should be recognized during the primary survey:
tension pneumothorax,
open pneumothorax,
flail chest with underlying pulmonary contusion,
massive hemothorax, and
major air leak due to a tracheobronchial injury
38. C: Circulation With Hemorrhage Control.
Blood pressure and pulse should be measured at least every 5 minutes
in patients with significant blood loss until normal vital sign values are
restored.
Intravenous (IV) access for fluid resuscitation
and medication administration is obtained with
two peripheral catheters
For patients in whom peripheral
angiocatheter access is difficult,
intraosseous (IO) needles should be rapidly
placed in the proximal humerus or tibia.
40. In the seriously injured patient arriving in shock
Arterial blood gas for base deficit (BD)
Cross-matching for possible blood component (RBC and
plasma) transfusion
Coagulation panel/viscoelastic hemostatis assay (e.g.,
TEG, ROTEM) should be obtained.
41. D: Disability
The Glasgow Coma Scale (GCS)
The GCS is a quantifiable determination of neurologic function that is
useful for triage, treatment, and prognosis
42. Patients are managed with cervical spine protection (cervical collar and
blocks) and protection of the thoracolumbar spine using standard log roll
techniques until a spinal injury has been excluded.
Log-rolling should not occur until a pelvic fracture has been radiographically
excluded. If patients need to be moved during their primary survey, such as
when moving on to the CT scanning gantry, a 20° roll with inline spinal
stabilisation should be used.
Modern ‘Scoop Stretchers’ mean that there is no requirement to roll any patient
more than 20° until a pelvic fracture has been excluded.
D: Disability contd…
44. Seriously injured patients must have all of their clothing
removed to avoid overlooking limb- or life-threatening
injuries, but warmed blankets should be placed
immediately to avoid hypothermia.
E:Exposure
45. Once the immediate threats to life have been addressed, a thorough history
is obtained, and the patient is examined in a systematic fashion.
The patient and surrogates should be queried to obtain an AMPLE history
(Allergies, Medications, Past illnesses or Pregnancy, Last meal, and Events
related to the injury).
The physical examination should be literally head to toe, with special
attention to the patient’s back, axillae, and perineum, because injuries here
are easily overlooked.
Secondary survey/Diagnostic evaluation
46. The original work by Bone et al. in the 1980s, demonstrating the benefits
of early fracture fixation of all injuries, led to the acceptance and wide
application of the so called ‘early total care’ (ETC) philosophy.
This practice became the gold standard of treatment for patients with
multiple injuries.
However, in some specific patient groups, for example those with severe
chest and/or head injuries or those in an extreme physiological state (with
ongoing bleeding from different sources such as abdomen, pelvis and
chest), it was observed that the ETC concept led to early complications and
mortality.
Concept of early total care (ETC)
47. Damage control surgery
two goals:
●● stopping any active surgical bleeding;
●● controlling any contamination.
49. Take home message
The early assessment and management of trauma patients should follow
established ATLS principles.
A WBCT scan, from the head to the pelvis, with IV contrast is the gold standard
investigation for major trauma patients and should be performed early and
whenever possible.
Trauma patients requiring surgery should have an early decision made whether
a damage control or ETC approach is required.
Surgical procedures in physiologically compromised patients should be limited
to those required to save the life and/or limb of the patient, while simultaneous
resuscitation is continued
50. References
Bailey &Love’s 27th ed
Schwartz’s principle of surgery 11th edition
Sabiston text book of surgery 20th ed
cdc.gov
ncbi.nlm.nih.gov
Hinweis der Redaktion
Advancement in the management of the injured patient is seen during the war times.
Because of
the high burden on injury sustained during conflict, the management
of the injured patient has been advanced the most during
wartime. Box 16-1 lists some major contributions to trauma care
that were developed during major U.S. wars.
Trauma originates from the Greek word meaning ‘wound’.
About 42% of all deaths are the result of brain
injury, but some 39% of all trauma deaths are caused by major
haemorrhage, usually from torso injury
No child is exempt but some children are at particular risk,
including those under 3 years of age and those with disabilities
in a family who are suffering socioeconomic deprivation.
A careful clinical assessment is required (Figure 39.43 and
Table 39.23). Characteristic patterns should warn the clinician
to consider the possibility of NAI (Table 39.24).
Child abuse occurs in different forms: emotional, physical,
sexual and neglect. When suspected it should be discussed
with the relevant child safeguarding team. All injuries should
be documented carefully. It may be prudent to admit the child
until further checks have been made
Abbreviated Injury Scale (AIS) dictionary
consists of a greater level of detail (including more than 2000
injury codes) and assigns to every injury a severity score
between 1 (mild) and 6 (maximum). This can be summated into the so called Injury Severity Score (ISS), providing an
image of the anatomical severity of injury suffered by the individual
patient.
Injuries are characterized by a six-digit
taxonomy that describes the body region, type of anatomic structure,
and specific anatomic detail of the injury. Table
This seventh digit describes the severity and potential risk
of death for each injury in the AIS system. Post-dot codes range
from 1 (minimal severity) to 6 (presumably fatal)
The AIS represents the foundation for other scoring systems
that are better able to account for the severity of multiple combined
injuries. In 1974, Baker and colleagues presented the Injury
Severity Score (ISS), calculated by summing the squares of the
AIS severity codes for the three most severely injured body
Frequently used to cohort injuries and to compare outcomes
ISS= A2+B2+C2 sum of square for the highest AIS grades in three most severly injured ISS body regions.
Major trauma >15
Majority of hospital admissions with injury have low ISS values, ranging between the values 4 and 8, and are secondary to single isolated limb fractures and isolated mild head injury.
<4- transfer the patient to the trauma centre
The Advanced Trauma Life Support (ATLS) course of the
American College of Surgeons Committee on Trauma was
developed in the late 1970s, based on the premise that appropriate
and timely care can improve the outcome for the injured patients .
‘timeline concept’ of prompt
assessment and response (treatment) can be crucial in cases
where there is vascular injury, a compartment syndrome due
to internal bleeding or even joint penetration that could lead
to septic arthritis. a fall from a height of
1 metre with a twisting moment as the foot hits the ground
can lead to a spiral fracture of the distal tibia. In this situation,
the vector of the force was transmitted through the body’s
tissues to a location some distance away from its original
point of application. In this case, other injuries should also
be looked for, such as a fibular fracture or even an ipsilateral
tibial plateau fracture, around the knee joint area. Similarly, a
motor vehicle crash associated with direct trauma of the knee
joint of the driver on the dashboard of the car could induce
a fracture dislocation of the acetabulum and hip joint (transmission
of force from the knee joint to the hip socket – an
indirect blunt mechanism)
It aims to identify the patients who will benefit the most by
being treated the earliest, ensuring ‘the greatest good for the
greatest number’. Triage is the earliest example of clinical risk management. This is done on the basis of need so that resources can be allocated by good prioritisation. The process
was first used in 1792 by Baron Dominique Jean Larrey, Surgeon in Chief to Napoleon’s Imperial Guard. The concept of triage emerged from the French Service
de Sante so that resources could be used to the optimum – “most for the most”.
TACDA-the American civil defence association .
MET-TAGS-Medical emergency triage tags
ABCs” (Airway
with cervical spine protection, Breathing, and Circulation).
The timing of emergent intubation in the hypovolemic patient
remains controversial because of the risk of further compromising
cardiac function.
This is essential because efforts to restore cardiovascular
integrity will be futile unless the oxygen content of
the blood is adequate. Simultaneously, all patients with blunt
trauma require cervical spine immobilization until injury is
excluded. This is typically accomplished by applying a hard
cervical collar or placing sandbags on both sides of the head
with the patient’s forehead taped across the bags. Soft collars
do not effectively immobilize the cervical spine. For penetrating
neck wounds, however, cervical collars are not recommended
because they provide no benefit and may interfere with assessment
and treatment.
But the timing of endotracheal intubation may be critical
in the hypovolemic patient because positive airway pressure
may further compromise cardiac function and precipitate
cardiac arrest; thus, Circulation may take priority over Airway.
cricothyroidotomy is relatively
contraindicated due to the risk of subglottic stenosis, and
tracheostomy should be performed.
Patients may have distended neck veins due to impedance
of venous return, but the neck veins may be flat due to concurrent
systemic hypovolemia
A provisional ‘hot report’ can be
issued within minutes to identify immediate life-threatening
pathology to the trauma team. A more detailed definitive
report should be available within 30–60 minutes
Some patients will be so haemodynamically unstable on
arrival that they need immediate surgical control of their
haemorrhage before a CT scan. The most likely sources are
abdominal or pelvic bleeding.
All patients undergoing immediate laparotomy
in the operating room should have a pelvic binder applied
and not removed. A correctly positioned pelvic binder at the
level of the greater trochanters does not obstruct trauma laparotomy.
The effective radiation dose to all organs from a single
full-body CT is 12–16 millisieverts (mSv). Survivors of the
atomic bomb whose radiation dose ranged 5–100 mSv had
a statistically significant increase in the risk of solid cancers.
Overall, the risks associated with one scan are relatively
modest, approximately 1 in 1250, or 0.08%. However, it has
been reported that widespread liberal CT use is responsible
for 1.5–2.0% of all cancers in the USA. Of interest, WBCT
equates to 76 chest x-rays or 6 months of background radiation.
It has been suggested that it should be requested wisely
and that developing a triaging protocol can minimise the
critisim of its overuse.
Focused abdominal sonar for trauma (FAST) is a technique
whereby ultrasound (sonar) imaging is used to assess the
torso for the presence of free fluid, either in the abdominal
cavity, and is extended into the thoracic cavities and pericardium
(eFAST). There should be no attempt to determine
the nature or extent of the specific injury. eFAST is usually
a rapid, reproducible, portable and non-invasive bedside test
and can be performed at the same time as resuscitation. eFAST
is accurate at detecting >100 mL of free blood; however, it is
very operator dependent and, especially if the patient is very
obese or the bowel is full of gas, it may be unreliable. Hollow
viscus injury and solid organ injury are difficult to diagnose,
even in experienced hands, as small amounts of gas or fluid
are difficult to assess, and eFAST a low sensitivity (29–35%)
for organ injury without haemoperitoneum. eFAST is also
unreliable for excluding injury in penetrating trauma. If there
is doubt, the eFAST examination can be repeated
Retroperitoneum
Injury to the retroperitoneum is often difficult to diagnose,
especially in the presence of other injury, when the signs may
be masked. Diagnostic tests (such as ultrasound and DPL)
may be negative. The best diagnostic modality is CT, but this
requires a physiologically stable patient. The retroperitoneum
is divided into three zones
For penetrating
neck wounds, however, cervical collars are not recommended
because they provide no benefit and may interfere with assessment
and treatment.
With a secure airway
and adequate ventilation established, circulatory status is the next
focus. An initial approximation of the patient’s cardiovascular
status can be obtained by palpating peripheral pulses. In general,
systolic blood pressure (SBP) must be 60 mmHg for the
carotid pulse to be palpable, 70 mmHg for the femoral pulse, and
80 mmHg for the radial pulse. Any episode of hypotension
(defined as a SBP <90 mmHg) is assumed to be caused by hemorrhage
until proven otherwise. Patients with rapid massive blood
loss may have paradoxical bradycardia.
A. The proximal
tibia or humerus is the preferred location. Alternatively, the
distal femur can be used if the tibia is fractured. B. The position is
satisfactory if bone marrow can be aspirated and saline can be easily
infused without evidence of extravasation.
Although safe for
emergent use, the needle should be removed once alternative
access is established to prevent potential osteomyelitis
Standard Saphenous vein is consistently found 1 cm anterior and 1 cm superior to the medial malleolus
14-gauge catheters can be quickly placed, even in an
exsanguinating patient with collapsed veins. In severely injured
children younger than 6 years of age, the preferred venous
access is peripheral intravenous catheters followed by an IO
needle. Central venous catheter placement or saphenous vein
cutdown may be considered as the third choice of access based
upon provider experience
femoral artery cannulation,
however, may result in limb-threatening arterial spasm.
A rule of thumb to consider for secondary access is placement
of femoral access for thoracic trauma and jugular or subclavian
access for abdominal trauma. Internal jugular or subclavian
catheters provide a more reliable measurement of central venous
pressure (CVP), which may be helpful in determining the volume
status of the patient and in excluding cardiac tamponade
Scores range
from 3 (the lowest) to 15 (normal). Scores of 13 to 15 indicate
mild head injury, 9 to 12 moderate injury, and ≤8 severe injury.
The GCS is a quantifiable determination of neurologic function
that is useful for triage, treatment, and prognosis.
Subtle changes in mental status can be caused by
hypoxia, hypercarbia, or hypovolemia, or may be an early sign
of increasing intracranial pressure.
The presence of an
open book pelvic fracture, a lumbar spine fracture, a femoral
fracture, a liver laceration and a tarsometatarsal dislocation
are examples of outstanding injuries waiting treatment
