Managment of Trauma Patent in

ER
 Objectives
 Epidemiology of Trauma Care
 Mechanisms of Injury
 Basics of Trauma Management
–  Primary Survey
–  Resuscitation
–  Secondary Survey

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 TRAUMA ???

REAL
LIFE
AND
DEATH
Poten/al life lost
Accident Epidemiology
Jumlah Kecelakaan, Koban Mati, Luka Berat, Luka Ringan, dan Kerugian Materi yang Diderita Tahun 1992--2011

Kerugian Materi
Tahun Jumlah Kecelakaan Korban Mati Luka Berat Luka Ringan
(Juta Rp)
1992 19.920 9.819 13.363 14.846 15.077
1993 17.323 10.038 11.453 13.037 14.714
1994 17.469 11.004 11.055 12.215 16.544
1995 16.510 10.990 9.952 11.873 17.745
1996 15.291 10.869 8.968 10.374 18.411
1997 17.101 12.308 9.913 12.699 20.848
1998 14.858 11.694 8.878 10.609 26.941
1999*) 12.675 9.917 7.329 9.385 32.755
2000 12.649 9.536 7.100 9.518 36.281
2001 12.791 9.522 6.656 9.181 37.617
2002 12.267 8.762 6.012 8.929 41.030
2003 13.399 9.856 6.142 8.694 45.778
2004 17.732 11.204 8.983 12.084 53.044
2005 91.623 16.115 35.891 51.317 51.556
2006 87.020 15.762 33.282 52.310 81.848
2007 49.553 16.955 20.181 46.827 103.289
2008 59.164 20.188 23.440 55.731 131.207
2009 62.960 19.979 23.469 62.936 136.285
2010 66.488 19.873 26.196 63.809 158.259
2011 108.696 31.195 35.285 108.945 217.435

Sumber : Kantor Kepolisiian Republik Indonesia

 In ours
•  Grafik TRISS
 Epidemiology
Trimodal Distribution of Trauma Deaths
   Golden Hour = 80% of trauma deaths
50 in first hour after injury
%   Rapid trauma care has greatest level
of impact in these patients

30%
20%

Immediately Hours Days/Weeks

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 Mechanisms of Injury

Mechanism of Injury :
•  Frontal Impact Collisions
•  Lateral Impact Collisions
(T bone)
•  Rear Impact Collisions
•  Rollover Mechanism
•  Open Vehicle or
Motorcycle
•  Pedestrian Vs. Car
 Mechanism of Injury :
•  Penetrating Injury
(Guns vs. Knives)
•  Falls
 Basics of Trauma Assessment
 Preparation
 Triage
 Primary Survey
 Resuscitation
 Secondary Survey
 Monitoring and Evaluation, Secondary
adjuncts
 Transfer to Definitive Care
LIFE IS MATTER !!!
•  Pa/ent alive if they
come to big hospital or
trauma center
 Trauma Team
“Doin it 24/7”
•  ED Physicians
•  Anesthesiology
•  Surgeons
 –  General and Trauma and Cri@cal Care
–  Neurosurgery
–  Orthopedics
•  Medical Students
•  Nurses
•  Radiology Techs
•  Radiologists
•  Lab techs
Preparation for Patient Arrival
Key to sucsessful for trauma team
As long as the ins/tu/on
and the staff is
commiVed to mee/ng
the challenges involved
in the care of the
trauma pa/ent, and
have a rigorous
performance
improvement process,
outcomes will be
successful.
What happens when this

pa@ent comes to the ER

where you are
moonligh@ng?
Don’t panic!
•  Air goes in & out!
•  Oxygen is good!
•  Blood goes round & round!
•  Stop bleeding!
•  Put things back where and
how they belong!
 Ini@al Assessment:
Prerequisites
•  Wide--angled view

•  PaRern recogni@on skills

•  Ability to triage and set priori@es

•  Organized structure
TRIAGE
 Primary Survey
 Airway and Protection of Spinal Cord
 Breathing and Ventilation
 Circulation
 Disability
 Exposure and Control of the Environment

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 Primary Survey
 Key Principles
– When you find a problem during the
primary survey, FIX IT.
– If the patient gets worse, restart from the
beginning of the primary survey
– Some critical patients in the Emergency
Room may not progress beyond the
primary survey

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 Airway and Protection of Spinal Cord
 Why first in the algorithm?
–  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, Somnolent, Coma
–  Airway Patency = Secretions, Stridor, Obstruction
–  Traumatic Injury above the clavicles
–  Ventilation Status = Accessory muscle use, Retractions, Wheezing
 Clinical Pearls
–  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
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Airway Interventions
  Maintenance of Airway Patency
–  Suction of Secretions
–  Chin Lift/Jaw thrust Dept. of the Army, Wikimedia Commons

–  Nasopharyngeal Airway
–  Definitive Airway
  Airway Support
–  Oxygen
–  NRBM (100%) Ignis, Wikimedia Commons
–  Bag Valve Mask
–  Definitive Airway
  Definitive Airway
–  Endotracheal Intubation
 In--line cervical stabilization
–  Surgical Crichothyroidotomy
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons 24
 C--spine Immobilization
 Return head to neutral position
 Maintain in--line stabilization
 Correct size collar application

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 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
  Paradoxical chest wall movement
–  Auscultation to assess for gas exchange
  Equal Bilaterally
  Diminished or Absent breath sounds
–  Palpation
  Deviated Trachea
  Broken ribs
  Injuries to chest wall

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 Breathing and Ventilation
  Identify Life •  Hemothorax
Threatening Injuries
–  Tension Pneumothorax

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 Breathing and Ventilation
•  Flail Chest  Open Pneumothorax
–  Sucking Chest Wound
–  Large defect of chest

wall
  Shock
Circulation
–  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
–  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)

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 Circulation
  Types of Shock in Trauma
–  Hemorrhagic
  Assume hemorrhagic shock in all trauma patients until proven
otherwise
  Results from Internal or External Bleeding
–  Obstructive
  Cardiac Tamponade
  Tension Pneumothorax
–  Neurogenic
  Spinal Cord injury
  Sources of Bleeding
–  Chest
–  Abdomen
–  Retroperitoneal
–  Pelvis
–  Bilateral Femur Fractures

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 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
  Crystalloid Resuscitation (2L)
  Administer Blood Products
–  Immobilize fractures
  Responders vs. Nonresponders

–  Transient response to volume resuscitation = sign of ongoing blood loss

–  Non--responders = consider other source for shock state or operating room
for control of massive hemorrhage

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 Disability
  Baseline Neurologic Exam
–  Pupillary Exam
  Dilated pupil – suggests transtentorial herniation on ipsilateral side
–  AVPU Scale
  Alert
  Responds to verbal stimulation
  Responds to pain
  Unresponsive
–  Gross Neurological Exam – Extremity Movement
  Equal and symmetric
  Normal gross sensation
–  Glasgow Coma Scale: 3--15
–  Rectal Exam
  Normal Rectal Tone
  Note: If intubation prior to neuro assessment, consider quick
neuro assessment to determine degree of injury

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 Disability
 Key Principles

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–  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

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 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

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Exposure

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 Trauma Logroll
 One person =
Cervical spine
 Two people =
Roll main body

 One person =
Inspect back
and palpate
spine

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 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

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 Secondary Survey
•  Pa@ent history
•  Head to toe physical exam
•  Radiography
–  Lateral C--spine, C--xray, pelvis
–  One cavity above/below entrance/exit wounds
–  FAST
•  Urinary bladder drainage
•  NGT
•  Blood sampling/monitoring
 SCORING SYSTEM
•  Revised Trauma Score
•  Injury Severity Score
•  Trauma Revised Injury Severity Score
Calculate the score than you can predict...
 Definitive Care
  Secondary Survey followed by radiographic
evaluation
–  CtScan
–  Consultation
Neurosurgery
Orthopedic Surgery
 Vascular Surgery
  Transfer to Definitive Care
–  Operating Room
–  ICU
–  Higher level facility

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Thank you