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TRAUMA MANAGEMENT

S Scene size up safety, hazard


If obstruct airway, brain dead
I Initial assessment no. of casualty
within 3 minutes
G General impression 5S - during scene size up
1. P Priority dispatch Safety / hazard If breathing problem, brain
a. Personaldead within
PPE (3G61M)
minutes
glove,
H History
P Physical examination If hemorrhage, brain boot
gown, goggle, mask, apron, dead
I Initial Mx and Tx b. Patient within 9 minutes
T Transfer Agonal breathing = nazak (not
c. Bystander
O Ongoing Assessment considered
d. Mechanism of injuryas breathing
anymore)
e. Determine no of pt
2. Screening (ETHANE)
a. E exact location
b. T type of injury / disaster (MVA, flood, landslide, explosion)
c. H hazard (risiko)
d. A Accessibility ; how to reach there traffic jammed / air / land
e. N No. of casualty
f. E Emergency services available JPAM, police, bomba
3. Send info GCS, SBP, RR
4. Setup triage - Dropzone, medical base, ambulance, back up
5. Start action

Mechanism of injury
High risk injury
o Penetrating injury to chest, abdomen, head, neck, groin
o Burns >15% facial injury + airway problems
o High energy impact:
Fall from 20ft height (2 tingkat); kalo children, double of his/her height
Velocity of crash >20 mph (50km)
Ejection of victim from vehicle
Rollover
Death of another person in same car
Low risk injury : blunt trauma

TRIAGE
Process of sorting the patients according to priority of tx
a) Mass casualty incident
b) 2 types: field / hospital
c) Categorized into - colour coding system
o Red life-threatening, critical, 1st priority, any issue with ABCD
A airway choking
B breathing tachypnea
C circulation shock, reduce consciousness level, hypoT
D disability semi-consciousness
o Yellow intermediate, semi-critical, cannot walk
o Green mild, pt can wait, G1 (elderly >60 , child <5 years) / G2 / G3 / G4 / G5

PRIMARY SURVEY (ABCDE) / Life-threatening


NEXUS criteria
Initial assessment and resuscitation of vital functions -GCS Score
Only in living person, so make sure pt is alive! -- AVPU (alert, verbal, pain, unresponsive)
CNS manifestation
o if unresponsive CPR (activate BLS) (focal neurological
o Position & posture, behavior, obvious injury & deformity deficit)
Cervical tenderness
Airway & Cervical Spine Control Altered level of
consciousness
Intoxication (drug,
Limahabs-sofy alcohol)
Distracting injury
(pelvicinjury)
Make sure airway is patent
Signs of compromised airway: stridor, noisy breathing, cyanoses --- intubate!
Inspect nasal opening & mouth: deformity, bleeding, mechanical obstruction
Use chin lift or jaw thrust to open airway (+ neck immobilization)
Check oral cavity
o vomitus, debris, blood suction, FB
o Floppy tongue check gag reflex absent oropharyngeal airway

o E;g: maxillofacial injury, laceration


Assess adequate ventilation
o Listen & feel air expelled out
Cervical collar for whom? Use NEXUS criteria for cervical spine imaging
In-line immobilization

Breathing
Inspection
o bruises, bleeding, breathing pattern, RR, symmetrical chest movement, paradoxical chest
movement (during inhalation, chest compressed)
flail chest # 3 consecutive ribs
major ms diaphragm, internal intercostals ms
o open chest wound = sucking chest wound
apply 3 way occlusive dressing (in hospital setting)
if emergency chest tube!
Examination
o Palpate apex beat, chest expansion, tenderness, crepitation (air in btw soft ts; d/t torn
pleura)
o Percussion
Hyper resonance tension pneumothorax
Stony dullness pleural effusion
o Spring test - # ribs
o Auscultate - apex beat, heart sound, air entry, abnormal sound

Circulation
General
o Cold, clammy periphery, pallor, int/ext haemorrhage
Specific - Abdominal / Pelvic region
o bruises, laceration, abdominal distention, pelvic deformity, large hematoma, scrotal swelling,
bleeding at groin/ from anal/ meatal opening, open wound/ sucking (long bone)
o tenderness on palpation 9Q/4Q
o Pelvic spring test
Intervention
o Skin colour/ temperature/ BP/ CRT/ Pulse rate, rhythm, paradoxus
o Identify exsanguinated hage (bleeders)
o Apply cardiac monitor, pulse oximeter
Management
o Control bleeding site
o 2 large bore branula, GXM blood, Blood tranfusion
o Chest tube insertion
o Apply pelvic immobilization device - pelvic binders

Disability
Glasgow coma scale (EVM): mild 13-15/ moderate/ severe <8
Intervention AVPU

Limahabs-sofy
Assess pupil size, reactivity, equity
Neurological integrity - posture, limb movement, ms tone

Exposure
Make sure significant injury not missed
Examine thoroughly - expose head to toe
Avoid hypothermia esp in child blanket
Log roll
o Examine back, anal tone, whether neurogenic shock/not

ADJUNCT TO 1 SURVEY
U/S TAS, FAST (focus abdominal sonography in trauma)
ECG
Blood Ix - Dxt/ FBC/ GSH
Vital signs S = Symptoms
Xray chest, pelvic
A = Allergies
2 Tubes - Ryules/ CBD
M = Meds / Mechanism of injury
SECONDARY SURVEY - Re-evaluation P = PMH/ Pregnant?
Head to toe examination including neurological examination
Identify other injury L = Last meal
SAMPLE history
Any finding? appropriate ix E = Events surrounding the injury

DEFINITIVE CARE

Life-threatening CLINICAL FEATURES MX


(ATOM FC)
Airway obstruction Reassess airway
(lower)
Tension Resp exam Needle thoracocentesis with large
pneumothorax Inspection bore branula (14/16G)
Distended neck vein -@ 2nd ics, hear hiss sound
Trachea deviation Chest tube
Palpation
Symmetry of movement - unequal Ant: Post:
Tender chest Lat B Pec Major Ant B Latissimus
Percussion Dorsal
Hyper-resonant
Auscultation
Reduce air entry Base: 5th rib
Absent ipsilateral breath sound

Distributive shock --hypotension


Respiratory distress, tachycardic
Open chest wound Resp exam Cover the wound with any sterile/
Inspection clean porous dressing tape only on 3
Chest wall - wounds side leaving one side free to act as a

Limahabs-sofy
Palpation flutter valve
Symmetry of movement unequal
Tenderness - rib fracture Do not tape on all sides --- may create
Crepitus - displaced fractures tension pneumothorax
Percussion
Resonant
Auscultation
Reduce air entry

Sucking wound especially if > 2/3 of tracheal


diameter, preferential flow through wound ---
sucking pneumothorax
Massive hemothorax Resp exam - Blood transfusion and correction
Inspection coagulopathy
Defined as blood loss of Cyanoses, pale - Tube thoracostomy on the affected
> 1500ml inside the Palpation side (do not drain > 1 litre of blood
chest Symmetry of movement unequal at any one time at this will lead to
Percussion acute hemodynamic instability)
Dull - Beware of sudden cessation of
Auscultation blood drainage
Reduce air entry

Hypotensive
Flail chest Resp exam - Ensure adequate o2 supp
Inspection - Provide judicious fluid therapy
2 contigous ribs Chest wall - paradoxical movement,
- Administer adequate analgesic
fractured in 2 flail chest
places Palpation
Symmetry of movement unequal
Percussion
Resonant
Auscultation
Reduce air entry

May be associated with significant u/l lung


contusion and progressive hypoxia
Cardiac tamponade Resp exam Tx pericardiocentesis
Inspection
Blood in pericardium Distended neck vein
(Haemopericardium) Palpation
Symmetry of movement - unequal
Auscultation
Reduce air entry

The heart blocked by the blood in the


pericardium compromise heart fx
Cardinal sign; Becks triad
o JVP/ distended neck vein
o Silent/ muffled HS
o BP

WOUND CARE

Limahabs-sofy
- Wound = Any break in the continuity of body tissue
o Examples: grazes, burns, surgical incisions, stabs, leg ulcers, decubitus ulcers ( pressure
sores)
o Can be acute / chronic
Chronic pysiologically impaired in wound healing. Eg: bedsore

- Management
o ABCDE
o AMPLE hx
o Treat life-threatening injury 1st
o Remove ring, jewelery, clothing
o If amputated cover with moist NS (gauze) put in ice bag

- Wound assessment
o Mechanism of injury
o Age of injury
o Identify possible contamination / FB
o Assessment of extent wound many position
o Neurovascular compromise / tendon injury
o Need for tetanus

Wound

Clean Contaminated

< 10 years > 10 years < 5 years > 5 years

ATT + Ig
No ATT ATT ATT
(toxoid)

- The most predictive factors for infection of wound


o Wound location
o Wound age
o Depth bite, puncture
o Configuration
o Contamination
o Keloid
o History of smoking

- Wound examination
o Neutral position during injury
o Clenched fist injury tx as human bites

- Antibiotics

Limahabs-sofy
o Contaminated wound by debris, feces
o Puncture / bite
o Tissue destruction or in avascular area
o Neglected wound
o Overlying joint and cartilage

- Anesthesia (LA)
o 2 point discrimination differentiate numbness
o SBP comparison arterial injury

- Homeostasis
o Compress bleeding
o Skin
o Raneys clip (scalp)
o Figure of 8th suturing / horizontal mattress suture
o Chemical (LA + adrenaline)
o Physical gelatin, cellulose, collagen sponge

- Skin disinfection
o Suppress bacterial growth, but impair host defense
o Consist of: wound irrigation, ts debridement, FB removal
o Use NS, povidone
o Irrigation
Low pressure
0.5 PSI
About 1 gallipot
For clean wound, loose ts around scrotum & eyelids
High pressure
7 PSI
Syringe + 18G IV branula
For contaminated wound

- Debridement
o Prepare wound bed to facilitate good healing process
Autolytic
Mechanical
Irrigation
Wet to dry dressing
Excision
Biologic maggots

- Ideal wound dressing


o Provide an optimum environment for moist wound healing
o Allow gaseous exchange of oxygen, carbon dioxide and water vapour
o Maintains optimum temperature for cell regeneration -- 37C
o Debrides necrotic tissues
o Impermeable to micro-organisms
o Non-adherent
o Safe to use (non toxic, non sensitizing and non-allergenic)
o High absorption properties absorb excess fluid, exudate
o Cost effectiveness
o Allows monitoring of the wound transparent, change colours
o Mechanical protection - further trauma, bact invasion, UV light, radiation

Limahabs-sofy
o Non inflammable, sterile
- Closure
o Primary closure acute, <24 hours, clean wound, suture / staple
o Delayed primary closure contaminated wound, after dressing then close it

- Healing
o 1st intention
o 2nd intention

- Suture
o Absorbable for mucosa
o Non-absorbable skin
o Interrupted VS continuous
Interrupted - if infected, easy to open up
o Ideal distant
0.5cm (face), 1cm (others)
o STO depends on site
Face: 3-5 days
UL & LL: 1 weeks (UL) 2 weeks (LL), joint area: max 2 weeks

- After care
o Keep dry
o Diabetic control
o Infected wound dressing!
o Compliance STO

- When to consult expert (plastic surgery / ortho)


o Severe contaminated wound
o Concern / cosmetic
o Tendon / nerve / BV require repair
o

- Why? Because no collateral artery

Limahabs-sofy
BASIC LIFE SUPPORT
American Heart Associations Guideline for CPR and ECC (Emergency Cardiovascular Care)

Common problems in:


- Adult heart
- Children respiratory

Why CPR fail?


- Delay CPR or defib
- No ALS follow up
- Terminal disease / unmanageable dx
- Improper technique

When to stop CPR?


- Victim revives
- Trained help arrives
- Rescuer too exhausted
- Unsafe scene
- Cardiac arrest >30 minutes

Limahabs-sofy