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Advanced Trauma Life


Support



Dr Osama Bawazir
Assistant Professor , Consultant Pediatric surgeon
FRCSI, FRCS(Ed), FRCS (glas), FRCSC,
FAAP,FACS.

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DEFINITION 0F TRAUMA

A term derived from the Greek for WOUND
I t refers to any bodily injury.
It defined as tissue injury due to direct effects of
externally applied energy. Energy may be
mechanical, thermal, electrical, electromagnatic or
nuclear.
Included:burns, drowning, smoke, inhalation,
slip & fall.
Excluded: poisoning/toxic ingestion.
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TRIMODAL DISTRIBUTION OF TRAUMA DEATHS.
THE FIRST PEAK OF DEATHS OCCURS WITHIN FEW SECONDS
TO MINUTES AFTER INJ URY(50% OF ALL DEATHS). Virtually
inevitable & very little can be done.
THE SECOND PEAK OCCURS BETWEEN A FEW MINUTES AND
AN HOUR AFTER INJ URY. Can be reduced by prompt initial care in the
pre-hospital phase,by early hospital resuscitation and by prompt and
competent definitive care.This period has been labelled as THE GOLDEN
HOUR. Management at this time will affect the third peak of deaths.
THE THIRD PEAKOCCURS SEVERAL DAYS OR WEEKS AFTER
THE INITIAL INJ URY.
The second and third peaks should be regarded as potentially
preventable.


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GENERAL CATEGORIES OF TRAUMA.
DIVIDED INTO THREE CATEGORIES:
I MMEDI ATELY LI FE THREATENI NG.
AFFECT ABOUT 5%,ACCOUNT FOR 50% OF ALL I N-HOSPI TAL
TRAUMA DEATHS.
URGENT.
COMPRI SES APPROXI MATELY ABOUT 10-15 % OF ALL PATI ENTS.
NON-URGENT.
APPROXI MATELY 80 % OF ALL I NJ URI ES.


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1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring & re-evaluation
9. Definite care.
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1. PREPARATION
A Pre-hospital phase
Receiving hospital is notified first.
Send to the closest, appropriate facility.
B In Hospital Phase
Advanced planning for the trauma pt arrival.
Method to summon extra medical assistance
Transfer agreement with verified trauma center established.
Protect from communicable disease.

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2. TRIAGE

A Multiple Casualties
no of severity & pt do not exceed the ability of
the facility.
B Mass Casualties
no & severity of pt EXCEED the capability of
the facility & staff.
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3. PRIMARY SURVEY

A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment (temp control)
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PRIMARY SURVEY
Priorities for the care of Adult , Pediatrics
& Pregnancy women are all the same.
During the primary survey life threatening
conditions are identified and management is
instituted SIMULTANEOUSLY.
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A. Airway Maintenance with Cervical Spine
Protection.
* GCS score of 8 or less require the placement of definite
airway.
*Protection of the spine & spinal cord is the important
management principle.
*Neurological exam alone does not exclude a cervical spine
injury.
*Always assume a cervical spine injury in any pt with multi-
system trauma, especially with an altered level of consciousness
or blunt injury above the clavicle.

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B. Breathing & Ventilation
* Airway patency does not assure adequate ventilation.
C. Circulation with Hemorrhage Control.
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin color
c. Pulse.
2. Bleeding
*external bleeding is identified & controlled in the
primary survey.
*Tourniquets should not be use.
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D. Disability ( Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli

Not forget to use also Glascow Coma Scale.

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E. Exposure / Environmental Control
*It is the pts body temp that is most important, not he
comfort of the health care provider.
*Intravenous fluid should be warm.
*Warm environment (room tem) should be maintained.
*early control of hemorrhage.

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4. RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts ability to
maintain airway integrity.
B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen
C. Circulation
*control bleeding by direct pressure or operative intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm.
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5. ADJUNCT TO PRIMARY SURVEY &
RESUSCITATION
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
1. Urinary catheter.
Urethral injury should be suspected if
*Blood at the penile meatus
*Perineal ecchymosis
*Blood in the scrotum
*High riding or nonpalpable prostate
*Pelvic fracture
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C. Monitoring
1. Ventilatory rate & ABG
2. Pulse oximetry
does not measure ventilation or partial O2 pressure
3. Blood pressure
poor measure of actual tissue perfusion.
D. X-Ray & Diagnostic Studies
C-spine, CXR, Pelvic film
Essential x-ray should not be avoid in pregnant pt.

*** Consider the need for patient transfer.
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6 SECONDARY SURVEY
Does not begin until the primary survey (ABCDEs)
is completed, resuscitative effort are well established
& the pt is demonstrating normalization of vital sign.
* Head to Toe evaluation & reassessment of all vital
signs.
* A complete neurological exam is performed including
a GCS score.
* Special procedure is order.
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History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.
*blunt trauma/penetrating trauma/injuries due
to cold & burn/hazardous environment?
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PHYSICAL EXAMINATION
1. Head
Visual acuity
Pupillary size
Hemorrhage of conjunctiva and fundi
Penetrating injury
Contact lenses(remove before edema occurs)
Dislocation of lens
Ocular movement
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2. Maxillofacial Injury
no NG tube, definite airway?
3. Cervical Spine & Neck
*Pt with maxillofacial or head trauma should be presumed
to have and unstable cervical spine.
4. Chest
*elderly pt are not tolerant of even relatively minor
chest injury.
*Children often sustain significant injury to the
intrathoracic structure without evidence of thoracic
skeletal trauma.
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5. Abdomen
*excessive manipulation of the pelvic should be avoided.
6. Perineum/rectum/vagina
7. Musculoskeletal
8. Neurologic
* Protection of spinal cord is required at all times until a
spine injury excluded, especially when the pt is transfer.


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7. ADJUNCT TO THE SECONDARY SURVEY
include additional x-ray and all other special procedure.
8. RE-EVALUATION
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1mg/kg/hr
*Pain relief -- IM should be avoid.
9. DEFINITE CARE

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Indication For Definite Airway
* Unconscious
* Severe maxillo-facial fracture
* Risk for aspiration : Bleeding/ vomiting
* Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
* Apnea : Neuromuscular paralysis/unconscious
* Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
* Severe closed head injury need for hyperventilation

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Normal Blood Amount:
Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight
Hemorrhage Classification :
Class I Hemorrhage : up to 15% loss
Class II Hemorrhage : 15-30% loss
Class III Hemorrhage : 30-40% loss
Class IV Hemorrhage : >40% loss

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3 for 1 Rule

a rough guideline for the total amount of
crystalloid volume acutely is to replace each
ML of blood loss with 3 ML of crystalloid
fluid, thus allowing for restitution of plasma
volume lost into the interstitial &
intracellular space

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Initial Fluid Therapy

Lactated Ringer is preferred
* For adult 1-2 liters bolus
* For child 20ml/kg bolus

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Intraosseous Puncture/Infusion

Children less than 6 y/o for IV access is
impossible due to circulatory collapse or
for whom percutaneous peripheral venous
cannulation had failed on two attempt.
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Head Injury Classification:

Mild : GCS 14-15
Moderate : GCS 9-13
Severe : GCS 3-8

Coma = GCS score of 8 or less
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Diagnostic Peritoneal Lavage Indication

A. Change in sensorium--Head injury/alcohol/drug.
B. Change in sensation--Spinal cord injury.
C. Injury to adjacent structure--lower
ribs/pelvic/lumbar spine.
D. Equivocal physical examination.
E. Prolong loss of contact with patient anticipated.
*** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3
or Gram Stain with bacteria
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Determining the level of quadriplegia

a. Raise elbow to level of shoulder -- Deltoid C5
b. Flexes the forearm -- Biceps C6
c. Extend the forearm -- Triceps C7
d. Flexes wrist & finger -- C8
e. Spread finger -- T1

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Determine the level of paraplegia

a. Flexes the hip -- Iliopsoas L2
b. Extend knee -- Quadriceps L3
c. Dorsiflexes ankle -- Tibialis anterior L4
d. Plantar flexes ankle -- Gastrocnemius S1
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Thoracic Trauma
8 lethal Injury
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheo-bronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Mediastinal traversing wounds.

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Fluid Therapy in
2nd or 3rd Degree Burn

Total amount of first 24 hours:
4 ml of Ringer lactate x BW(kg) x BSA
* give 1/2 in first 8 hrs
* 1/2 in remaining 16 hrs

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Referral to Burn Center

* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o
* 2nd or 3rd degree burn > 20% BSA in other age group
* 2nd or 3rd degree burn of face/eye/ear/hands/feet/
genitalia/perineum or major joints
* 3rd degree burn >5% in any age group
* Significant electrical/lightning injury
* Significant chemical burn
* Inhalation injury
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Color Codes Triage Tag

RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury

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Priorities with multiple injuries

1. Thoracic trauma or tamponade
2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury