“Trauma” = Injury of one or more systems,that results in excessive bleeding and mayaffect the normal body functioning. Defined as cellular disruption caused by anexchange with environmental energy that isbeyond the body's resilience.

1. ??
TRAUMA

2. Prepared by:
RN Arpana
Bhusal
BNS

3. Content
 Introduction
 Trauma Team
 Types of Trauma
 Trauma peak death
 Basics of Trauma assessment
 Trauma management
 References

4. Introduction
 Injury: The result of harmful event that
arises from the release of specific forms
of energy.
 “Trauma” = Injury of one or more
systems,
that results in excessive bleeding and
may
affect the normal body functioning.
 Defined as cellular disruption caused by
an
exchange with environmental energy that
is

5. Trauma teams
ED Physicians
Anesthesiology
Surgeons
– General and Trauma and Critical
Care
– Neurosurgery
– Orthopedics
Medical Students
Nurses
Radiology Techs
Radiologists

6. Types of trauma

7. Types of Trauma
Blunt injuries
– Energy exchange between an object
and body without breaking skin.
• MVC motor vehicle collisions
• Pedestrian vs Vehicle
• Falls
Penetrating injuries
– External force in which tissue is
penetrated by an object.
• Gun shot wounds
• Stab wounds
• Impalement

8. Blunt

9. Blunt

10. Blunt

11. Impalement injury

12. Types of Trauma
 Deceleration injuries
– Caused by a sudden stop of body’s
forward motion
 External force injuries
– Caused by forces that violate body
tissues
– Injury depends on anatomic area,
mass, and velocity of foreign object

13. Penetrating

14. External

15. External

17. MAJOR TRAUMA
 Trauma mechanism:
• A fall >3 meters
• Road traffic accident: net speed >30
km/h
• Thrown from or trapped in a vehicle
• Pedestrian or cyclist hit by a car
• Unrestrained occupant of a vehicle
• Injury from high or low velocity
weapon

18. MAJOR TRAUMA
 Physical findings:
• Airway or respiratory distress
• Blood pressure <100 mmHg
• Glasgow Coma Scale <13/15
• Penetrating injury
• More than 1 area injured
Make a full primary and secondary
survey of any patient who is injured,
especially if major trauma

19. Trauma deaths
FIRST PEAK
• Within minutes of injury
• Due to major neurological or vascular
injury
• Medical treatment can rarely improve
outcome

20. SECOND PEAK
 Occurs during the 'golden hour‘
 Due to intracranial haematoma, major
thoracic or abdominal injury
 Primary focus of intervention for the
Advanced Trauma Life Support
(ATLS) methodology

21. THIRD PEAK
 Occurs after days or weeks
 Due to sepsis and multiple organ
failure

22. Basics of Trauma Assessment
 Preparation
– Team Assembly
– Equipment Check
 Triage
– Sort patients by level of acuity
(SATS)
 Primary Survey
– Designed to identify injuries that are
immediately life threatening and to
treat
them as they are identified

23.  Resuscitation
– Rapid procedures and treatment to
treat injuries found in primary survey
before completing the secondary survey
 Secondary Survey
– Full History and Physical Exam to
evaluate for other traumatic injuries
 Monitoring and Evaluation, Secondary
adjuncts
 Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another
facility

24. Trauma management

26. MANAGEMENT GOALS
 Primary survey
• Examine, diagnose, treat life-
threatening injuries as soon as
they are diagnosed
• Use simplest treatment possible to
stabilize patient’s condition
 Secondary survey
• Perform complete, thorough patient
examination to ensure no other
injuries are missed

27. ITS MAIN GOALS ARE:
 The process of categorizing victims or
mass casualties based on their need
for treatment and the resources
available.
 Prevent avoidable deaths.
 Ensure proper initial treatment with a
minimal time frame.
 Avoid misusing asserts on hopeless
cases.

28. Trauma management
Preparation and triage
• Primary Survey
• Adjuncts to primary survey
• Secondary Survey
• Adjuncts to secondary survey
• Definitive treatment
• Records, Consent, Forensic

32. Triage
 Doing the greatest good for the
greatest
number.
 Four common triage categories
– Immediate (red)
– Delayed (yellow)
– Minimal (green)
– Expectant (black)

35. Assessment of the injured
patient
Primary survey and resuscitation
 A = Airway and cervical spine
 B = Breathing
 C = Circulation and hemorrhage
control
 D = Disability or Dysfunction of the
central nervous system
 E = Exposure

36. Airway and Protection of Spinal
Cord
Assess for
– Loss of airway can result in death in <
3 minutes
– Prolonged hypoxia = Inadequate
perfusion, End-organ damage
Airway Assessment
– Vital Signs = RR, O2 sat
– Mental Status = Agitation, Coma
– Airway Patency = Secretions, Stridor,
Obstruction
– Ventilation Status = Accessory muscle
use, Retractions, Wheezing

37. Airway
 Always assess the airway
• Talk to the patient
– A patient speaking freely and clearly
has an open airway
• Look and listen for signs of
obstruction
– Snoring or gurgling
– Stridor or noisy breathing
– Foreign body or vomit in mouth
• If airway obstructed, open airway
and clear obstruction

38. Clinical
• Patients who are speaking normally
generally do not have a need for
immediate airway management
• Hoarse or weak voice may indicate a
subtle tracheal or laryngeal injury
• Noisy respirations frequently indicates
an obstructed respiratory pattern

39. Airway Interventions
 Maintenance of Airway Patency
– Suction of Secretions
– Chin Lift/Jaw thrust
– Nasopharyngeal Airway
– Definitive Airway
 Airway Support
– Oxygen
– NRBM (100%)
– Bag Valve Mask
– Definitive Airway
 Definitive Airway
– Endotracheal Intubation
 In-line cervical stabilization
– Surgical management

40. Breathing and Ventilation
General Principle
Adequate gas exchange is required to
maximize patient oxygenation and
carbon dioxide elimination
Breathing/Ventilation Assessment:
Exposure of chest
General Inspection
Tracheal Deviation
Accessory Muscle Use
Retractions
Absence of spontaneous breathing

41. Auscultation to assess for gas
exchange
Equal Bilaterally
 Diminished or Absent breath sounds
 Palpation
 Deviated Trachea
 Broken ribs
 Injuries to chest wall

42. Circulation
 Shock
– Impaired tissue perfusion
– Tissue oxygenation is inadequate to meet
metabolic demand
– Prolonged shock state leads to multi-organ
system failure and cell
death
 Clinical Signs of Shock
– Altered mental status
– Tachycardia (HR > 100) = Most common sign
– Arterial Hypotension (SBP < 120)
 Femoral Pulse – SBP > 80
 Radial Pulse – SBP > 90
 Carotid Pulse – SBP > 60

43. Inadequate Tissue Perfusion
 Pale skin color
 Cool clammy skin
 Delayed cap refill (> 3 seconds)
 Altered LOC
 Decreased Urine Output (UOP < 0.5 mL/kg/hr)

44. Circulation
Emergency Nursing Treatment
– Two Large IV Lines
– Cardiac Monitor
– Blood Pressure Monitoring
General Treatment Principles
– Stop the bleeding
Apply direct pressure
Temporarily close scalp lacerations
– Close open-book pelvic fractures
Abdominal pelvic binder/bed sheet
– Restore circulating volume

45. Crystalloid Resuscitation (2L)
Administer Blood Products
Immobilize fractures
Non-responders
consider other source for shock state
or operating room for control of
massive hemorrhage

46. Disability
Baseline Neurologic Exam
– Pupillary Exam
– Dilated pupil
AVPU Scale
Alert
Verbal: Responds to verbal
stimulation
Pain: Responds to pain
Unresponsive

47. Gross Neurological Exam – Extremity
Movement
Equal and symmetric
Glasgow Coma Scale: 3-15
Note: If intubation prior to neuro-
assessment, consider quick neuro-
assessment to determine degree of
injury

48. Disability
 Key Principles
 Precise diagnosis is not necessary at this point in
evaluation
 Prevention of further injury and identification of
neurologic injury is the goal
 Decreased level of consciousness = Head injury until
proven otherwise
 Maintenance of adequate cerebral perfusion is key
to prevention of further brain injury
– Adequate oxygenation
– Avoid hypotension
– Involve neurosurgeon early for clear intracranial
lesions

49. Exposure
Remove all clothing
– Examine for other signs of injury
– Injuries cannot be diagnosed until seen by
provider.
Logroll the patient to examine patient’s back
– Maintain cervical spinal immobilization
– Palpate along thoracic and lumbar spine
– Minimum of 3 people, often more providers
required.
Avoid hypothermia
– Apply warm blankets after removing clothes
– Hypothermia = Coagulopathy
Increases risk of hemorrhage

50. Adjuncts to the Primary Survey
Exams during or after primary survey to
aid in identifying life-threatening injuries
- ECG
- Pulse oximetry
- Chest x-ray
- Pelvis x-ray
- ABGS
- Catheters
- Focused abdominal sonogram for
trauma (FAST)
Resuscitation may be required in some
cases.

51. Secondary Survey
• Secondary Survey is completed after
primary survey is completed and
patient has been adequately
resuscitated.
• No patient with abnormal vital signs
should
proceed through a secondary survey
• Secondary Survey includes a brief
history
and complete physical exam

52. History
AMPLE History
–Allergies
–Medications
–Past Medical History, Pregnancy
–Last Meal
–Events surrounding injury, Environment
• Physical examination
• Reassessment of all vital organs
History may need to be gathered from family
members or ambulance service

53. Adjuncts to Secondary Survey
Radiology
– Standard emergent films
– C-spine, CXR, Pelvis
– Focused Abdominal Sonography in
Trauma
(FAST)
Additional films
Ct scan imaging
Angiography
Pain Control
Tetanus Status
Antibiotics for open fractures

54. Adjuncts to secondary survey

55. Definitive Treatment
Treatment plans, especially for
multiple injuries, based on clinical
status and specific injuries.
• AFTER identifying the patients injury.
• Managing life threatening problems
• Obtaining special studies.
• If the patients injuries exceed the
capabilities of the institution.

56. Patient Referral
and Transport

57. STABILIZATION AND TRANSFER
• Resuscitation completed
• Analgesia administered
• Laboratory specimen sent
• Fractures immobilized
• Documentation completed
• Transfer
– Ward
– Operating theatre
– Higher level of care centre
• Patient safety & decision making
• Informed consent

58. RECORD KEEPING
 Essential that patients receive written
note describing diagnosis, procedure
performed.
 All records should be clear, accurate,
complete, signed
Admission note/preoperative note
Delivery book
Operating theatre records
Post-operative note
Progress note
Discharge note

60. References
 https://www.atls.in/
 https://www.who.int/surgery/publicatio
ns/s16382e.
 Primary and secondary survey. Cited
on 18th oct. 2014. available from:
www.rch.org.au/paed_trauma/.../12_pri
mary_secondary_survey
 www.steinergraphics.com/surgical/ma
nual01.html