Practical approach to traumatic patients at ER

Trauma ER

24 .
ER (alert), (competent)
(well-planed)
(mass casualty)
,
1-2

Trauma 3
1. Accident
(motorcycle
accident) 1 (Car accident) (fall),
(burn)
2. Homicide Blunt
trauma ,
Penetrating trauma
3. Suicide
ER
Trauma ER

1.
(Multiple injuries) (good
physical examination)
back, axilla, perineum
( high index of suspicion)
( Misdiagnosis) (Delayed diagnosis)
2. Trauma (severity)

3. (save life first) ER
threatening conditions)
Trauma (Life (jmmediate resuscitation) Life-threatening conditions

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-

airway obstruction
cardiac temponade
open pneumothorax
tension pneumothorax
shock
active hemorrhage - internal, external
intracranial lesion with brain herniation

4. Trauma
(delayed onset) (observe)
(serial physical examination by same doctor)


5.
24 .

(increase morbidity and mortality rate)
6. ER
Hemodynamic unstable

7.

Trauma ER
trauma 5 Primary survey, Resuscitation, Secondary survey,
Diagnostic investigation Definitive treatment ER trauma

ER (Emergency
medical service, EMS) (Mass casualty) ER

ER

trauma (
trauma
6
code 333 11 code 999 )

trauma TRIAGE
trauma
4

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Run number Patient identification

1
-
-
2
3
-
4
- BRAIN DEATH


, 4

TRIAGE trauma 5

PRIMARY SURVEY = rapid assessment to find life threatening conditions

AIRWAY
ABCD

A = AIRWAY

- (Uncincious) Airway


-
, (maxillofacial injuries)
,
-
- Larynx, trachea

B = BREATHING, VENTILATION

- Tention pneumothorax
- Massive hemothorax
- Open pneumothorax or sucking chest wound
- Flail chest

C = CIRCULATION

Shock Blood supply

(inadequate tissue perfusion) Hypotension,

impairment of consciousness,
cyanosis, oliguria

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1 Classification of hemorrhage
Item
Class 1
Class 2
% blood Loss
<15%
15-30%
Blood volume
<750 ml
750-1500
Pulse rate
<100
<120
Pulse pressure
N
dec
Respiratory rate
14-20
20-30
Urine output/hr.
>30 ml
20-30
Mental status
N
Mild anxious

Class 3
30-40%
1500-2000
>120
dec
30-35
5-20
confuse

Class 4
>40%
>2000
>140
Dec
>35
No
lethagic

Shock in traumatic patients

2
1. Hemorrhagic shock

1.1 External hemorrhage

1.2 Internal hemorrhage ,

1.3 2

10%
fluid

hypovolemia

sympathetic adrenaline
pale,tachycardia,peripheral vasoconstriction
vital organ function impairment brain , kidney
, lung
4 grade
Hemorrhage grade 1 - 15% blood volume ( 70 ml/ kg)
750 .
Hemorrhage grade 2 - 15-30 % blood volume 7501,500 .
postural hypotension, peripheral vasoconstriction
crystalloid fluid

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Hemorrhage grade 3 - 30 40 % blood volume 2,000 .
crystalloid,

blood
transfusion
Hemorrhage grade 4 - 40 % blood volume

2. Non-hemorrhagic shock

2.1 Cardiogenic shock cardiac temponade
venous return cardiac output
Myocardial contusion

2.2 Tension pneumothorax
mediastinal shift cardiac
output
2.3 Neurogenic shock spinal cord
venous return
2.4 Hypovolemic shock
hypovolemia serum,extracellular fluid
2.5 Septic shock 3 4
sepsis multiple

organ failure
D = DISABILITY / NEUROGENIC
,
- Primary brain damage-cerebral, brain stem contusion, laceration, hemorrhage
- secondary Expanding lesion
- epdural, subdural hematoma Brain Herniation
Brain stem Cushings reflex Bradycardia, systolic hypertension
Increase Intracranial Pressure Impairment of consciousness , Hemiplegia, pupillary dilation

RESUSCITATION
1

1 2
(hemodynamic stable) 3 Primary survay
ABCDE

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A = AIRWAY MANAGEMENT WITH CERVICAL SPINE PRECAUTION
Airway obstruction
Fracture Of cervical Spine
-
,
- Glasgow coma score 9 Oropharyngeal airway
O2 mask
- Definitive airway Endotracheal intubation
1. Glasgow coma score < 9
2. severe maxillofacial or neck injury
3. severe flail chest
4. inhalation burn
5. cardiopulmonary failure
- Endotracheal tube Surgical crico- thyroidotomy
Tracheostomy

B = BREATHING

* TENSION PNEUMOTHORAX

No.14-16 Second
intercostal space; midclavicular line
Chest Drainage
th
ICD 5 intercostal space midaxillary line
* MASSIVE HEMOTHORAX
ICD 5th intercostal space; midaxillary line Rapid bolus of IV
RLS Transfusion

1. 1,500 ml ICD
2. 200
ml/hr 3-4 . Hemodynamic unstable
3. caked hemothorax clot pleural cavity
* OPEN PNEUMOTHORAX
pleural cavity
Vaseline gauze 3
Tension pheumothorax
ICD ICD

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* FLAIL CHEST
severe blunt chest trauma free
segment
pulmonary contusion
(Respiratory
distress) endotrachial tube volume respirator
pulmonary contusion internal
immobilization 3
C = CIRCULATION


vascular access severe hypovolemia
2
venous cutdown basilic v. saphenous v.
central line internal jugular v.,subclavian v.
crystalloid solution Ringer lactated solution
2 15
(stable) rapid response
transient response
non-response 40
50% RLS 2
1 3 .
class 3,4 colloid Hemaccel


D = DISABILITY / NEUROGENIC
Brain
herniation
Brain death
1. Endotracheal intubation Hyperventilation PCO2 30-35 mmHg

2. 30 venous
drainage
3. Furosemide mannitol
4. remove intracranial hematoma
E = EXPOSURE / ENVIRONMENT

(Good exposure)
misdiagnosis

Hypothermia

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TRUAMA SCORING
(measurement)

1. (Field triage)
3
1 (Level 1 Trauma center) 2
3
2.
,
(outcome)
3. prognosis

Trauma Scoring Revised

Trauma Score (RTS)

(Standard of physiologic measurement)
(
1) ( )
0-7.84
1 Revise Trauma Score (RTS)
Clinical Parameter
Respiratory rate
(breaths/min)

Systolic blood
Pressure mmHg

Glasgow Coma Scale

Category
10-29
>29
6-9
1-5
0
>89
76-89
50-75
1-49
0
13-15
9-12
6-8
4-5
3

Score
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0

x weight
0.2908

0.7326

0.9368

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SECONDARY SURVAY
trauma 1 2
Hemodynamic stable
3

Retroperitoneal injury trauma

DIAGNOSTIC INVESTIGATION
-

- CT SCAN Hemodynamic
unstable
- Basic investigation trauma multiple injuries
* CBC, PT, PTT, BUN, Cr, C/M for Blood transfusion
* U/A
*CXR-PA, lateral , C-spine lateral view, pelvis-AP
- investigation

- Serial hematocrit Internal

bleeding
- Single shot IVP Renal injuries
- Bronchoscope tracheal, bronchial injury
- Esophagogram water soluble contrast media esophageal injury
- Esophagoscope esophagogram esophageal Injury 90
- Abdominal injury Equivocal sign
Blunt abdominal trauma investigation 1st line investigation

* ultrasound of abdomen

Solid organ liver, spleen kidneys non-invasive test ER,
,

bowel ileus
* Diagnostic peritoneal lavage ( DPL ) blunt abdominal
trauma
- Equivocal abdominal sign
- Unexplained hypotension

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-

Impaired mental status

- Paraplegia or spinal cord injuries

DPL
explor laparotomy 15%
specific organ injuries
peritoneal catheter cul de sac isotonic saline 1,000 ml

700 ml
explor laparotomy
Criteria for positive DPL
- >10 ml of gross blood from first aspiration in blunt trauma
- >1 ml of gross blood first aspiration in penetrating trauma
- RBC count >100,000/mm3 for blunt trauma
- RBC count > 10,000/mm3 for penetrating trauma
- WBC count > 500/mm3
- Amylase > 200u/mm3
- Smear show bacteria or enteric content
ultrasound DPL 2nd line investigation
CT SCAN Diagnostic laparoscopy(DL)

* CT scan CT scan solid organs, retroperitoneal
organs liver ,spleen,pancreas ,kidneys ,great vessels surgical skill ,

* Diagnostic laparoscopy (DL)
,
explor laparotomy 25%
General anesthesia, , invasive procedure

missed or
delayed diagnosis

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- penetrating abdominal injury
anterior flank Local wound exploration under local
anesthesia positive indication DPL
DL

- Stub wound of back anterior flank
retroperitoneal organs local wound exploration
peritoneum
serial physical examination, double
contrast CT SCAN .
DEFINITIVE TREATMENT
Trauma


Some Specific injuries
1. Neck injury
Penetrating injury stab Sharp cut wound

Neck anatomical zone 3 zone
Zone 1 clavicle thoracic inlet cricoid
Zone 2 cricoid angle of mandible
Zone 3 angle of mandible base of skull
zone 2
explor neck zone 1 zone 3 surgical exposure
a. jugular
zone 2 carotid
v. larynx, trachea, pharynx esophagus explor neck
homodynamic stable angiography,

esophagography , bronchoscopes
esophasoscopes zone 1 zone 3
angiography CT scan

1.
(Probe, Canulate) local wound exploration
clot vascularinjury airembolism
explor neck
active
bleeding direct digital pressure
2. airway management
3. hemodynamic stability trauma stable
investigation

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2.CHEST INJURY
Chest injuries trauma 25
morbidity Hypoxic

brain damage

1. chest trauma
misdiagnosis

2. 90 CXP-PA
3. Life-threatening conditions in chest trauma needle tube chest
drainage
4. Hypoxic Hypovolemia
life-threatening condition in chest trauma
1. Immediate life-threatening condition
*Airway injuries trachobronchial rupture, obstruction
*Tension pneumothorax
*Open pneumothorax
*Massive pneumothorax
*Flail chest
*Cardiac tempanade
2. Potential life-threatening conditions
*Myocardial Contusion
*Pulmonary contusion
*Esophageal rupture
*Diaphragmatic rupture
*rupture of great vessel



1. Chest wall injuries
2. Pleuropulmonary injuries
3. Cardiovascular injuries
4. Diaphragmatic injuries

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15,047

Chest wall injuries
45 %
Pulmonary
26
Hemothorax
25
Pneumothorax
20
Heart
9
Diaphragm
7
Aorta,great vessels
4
Esophagus
0.5

1. Blunt chest injuries
2. Penetrating chest injuries
(Early
diagnosis)

20%

- ,
- , ,
- ,,
-
-
-
-
- ,
-
- (Subcutaneous emphysema)
TENSION PNEUMOTHORAX
air pleural cavity
one way valve
positive pressure pleural cavity ,

111

tension pneumothorax
lung collapse,mediastinal shift

kinking of central veins

decrease venous return,cardiac output

shock,hypoxia
,,

- Dyspnea
- Cyanosis
- Engorged neck veins
- Elevated the affected chest wall,decrease movement
- Hyperresonance on percussion
- Trachea shift to contralateral side
- Decrease vocal resonance
- Hypotension

1. x-ray
2. pressure pleural cavity intercostal space 2
midclavicular line
3. intercostal chest drain intercostal space 5 midaxillary line 1 2 .
4. pneumothorax

vaseline gauze

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Flail chest
severe blunt chest trauma multiple ribs fracture
2 free segment negative

pressure pleural cavity free segment negative pressure

positive pressure pleural cavity
free segment
free segment paradoxical
movement hypoventilation, hypoxia
severe
flail chest pulmonary contusion


paradoxical movement of flail segment

- adequate ventilation endotrachial tube ,on volume

respirator
- PaO2 < 65 mmHg
- PCO2 > 55 mmHg
- RR > 35 /min
- Tidal volume < 6 ml/kg
- pain control intercostal nerve block continuous thoracic epidural
block
chest wall stabilization
1. External stabilization
-
- strapping
2. Internal stabilization
- volume respirator 3 6
volume respirator respiratory insufficiency ,pulmonary contusion
stabilization
3. Open reduction and internal fixation of fracture ribs

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OPEN PNEUMOTHORAX




Sucking

chest wound



vaseline gauze 3
1 1 tension

pneumothorax
ICD
6-8 .

HEMOTHORAX
,
Intercostal vessels, blunt
penetrating injuries

decrease breath sounds,decrease vocal fremitus,vocal resonance,dullness on percussion,tachypnea
chest x-ray 300 .
blunt costophrenic angle
haziness

pleural

tapping
blunt costophrenic angle pleural tapping
intercostal chest drainage
thoracotomy

hemothorax
1. ICD 1500 .
2 200
-300 .. 4 .
3 (caked hemothorax)
3. ABDOMINAL INJURIES
Trauma 20 Blunt

sign Retroperitoneal trauma

trauma Peritoneal

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Trauma
1.
(negative)
2.
(equivocal sign)
(obvious sign)
3.
Hemodynamic stability Hypotension Trauma Penetrating
wound Blunt trauma Hypotension 2
Investigation
Hypotension

Serial physical examination
(Equivocal

sign)
Hypotension
Investigation

1. Serial physical examination
2. Serial hematocrit
3. Ultrasound FAST (focused abdominal sonography for truama)
4. Diagnostic peritoneal lavage
5. CT scan
6. Diagnostic laparoscope

Blunt trauma
(fracture of pelvic bone) X-ray Pelvis
Fracture of pelvis Associated organ injuries
- Rupture of membranous urethra
- Rupture of bladder
- Rupture of rectum
- Rupture of left dome of diaphragm
- Gross hematuria Blood dripping from urethral meatus
Investigation
1. Retrograde urethrography urethral rupture catheter
urethral orifice 2 . water soluble contrast media 10 . x-ray AP,
lateral view
2. Retrograde cystography rupture of bladder
3. IVP excretory function anatomy upper urinary tract kidney

injuries
4. CT scan retroperitoneal kidney pancreaticoduodenal injuries

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Stab wounds of abdomen

Peritoneum

1. (Anterior, flank)
2. (back) Midaxillary line 2
Landmark Peritoneum

Hypotension
(Equivocal)
- Local wound exploration under local anesthesia

Peritoneum

- Ultrasound Diagnostic peritoneal lavage Homodynamic stable
Negative
Stab wound of back
Peritoneum (retroperitoneal organ) Local
wound exploration
Hematuria Abdominal sign
Investigation CT scan Double contrast
24 .

RETROPERITONEAL HEMATOMA
Retroperitoneal hematoma
3 zone
1. Central zone
Aorta, IVC, pancreas duodeneum
2. Lateral zone
2 kidneys, ureter
bladder, rectum, iliac vessels
3. Pelvic zone
Central zone Zone
Expanding hematoma Hollow viscus injuries
NONOPERATIVE MANAGEMENT OF LIVER, SPLEEN INJURIES
Blunt abdominal trauma
,


1. Hemodynamic stable Shock
continued bleeding

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2. Multiple injuries
3. Underlying disease Cardiopulmonary disease
4. 24 .
24 .
5. CT SCAN
6. Grade 2
3 ., 10 . hematoma 10 . subcapsular hematoma 50%
surface area
Nonoperative Management Liver, Spleen Injuries 50-80%
95%