COMMON ERRORS IN TRAUMA

CARE
PROF. R.N.MANGAUL
H.O.D SURGERY
M.K.C.G.MEDICAL
COLLEGE

SIGNIFICANCE
Serious public health problem.

Leading cause of death &

disability in 1st 4 decades of
life.

3rd most common cause of

death overall.

EPIDEMOLOGY

3%
4%
5%
8%
8%
14%

2% 2%
28%

26%

MVA(28%)
FALL
SPORTS
PEDESTRIAN
BIKE
ATV
ASSAULT
STRUCK
BURN
STAB

STATISTICS
INTERNATIONAL ( U.S ) (www.cdc.gov)
Number of unintentional injury deaths :
123,706
Deaths per 100,000 population: 41.0
Cause of death rank: 5
INDIAN ( traumaindia.org )
nearly 80,000 lives were lost and
330,000 people were injured
78% were men in age group of 20-44 years,
causing significant impact on productivity

Trauma Mortality: A Trimodal Distribution

Immediate deaths- Occur within

first
hour
Early deaths
- Occur
within hours
after injury
Late deaths
- Occur after
3 days
&

 Trauma care

THE PERFECT

STORM FOR
ERRORS
UNSTABLE PATIENTS
INCOMPLETE HISTORIES
TIME CRITICAL DECISIONS
CONCURRENT TASK
MANY DISCIPLINES
LONG WORKING HOURS
6

SWISS CHEESE MODEL

Phases of Trauma Care

Pre hospital care at the site of
trauma and in transit
Emergency Departments and Trauma
Centers
Rehabilitation Facilities

Prehospital Care
Triage decision scheme to determine
best level of care required
Initiation of care based on protocols
Attempt to stabilize patient
Rapid transport
9

Color Codes
Triage Tag
RED
: Most
critical injury
YELLOW : Less critical
injured
GREEN
: No life or
limb threatening injury
BLACK/BLUE
:
Death or obviously fatal
injury
10

11

Emergency Departments
From tertiary hospitals to very small community
hospitals
All responsible for initiation of management
ATLS designed primarily as a regimented,
prioritized approach to trauma care (in particular
for survival in small center with little staff)
Inter hospital agreements to care for injuries
beyond resources
12

Advanced Trauma Life Support

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 & reevaluation
9. Definite care.
13

MOST COMMON ERRORS IN

In-Patient TRAUMA DEATHS
1. AIRWAY ISSUES 16%
2. ABDOMEN AND PELVIC
HEMORRHAGE 16%
3. THORACIC HEMORRHAGE
9%
4. DVT PROPHYLAXIS AND
GI CARE 9%
5. LENGHTY INITIAL
OPERATION -8%
6. OVER-RESUSCITATION 5%
7. COMPLICATIONS OF
FEEDING TUBE - 5%
14

HEAD TRAUMA
PRIMARY BRAIN
INJURY

CONTUSION
DIFFUSE AXONAL
INJURIES
FALSE ATTRIBUTION
CORTICAL
CT
LACERATIONS
MISINTERPRETATION

SECONDARY BRAIN
INJURY
HYPOXIA
HYPOTENSION
RAISED ICP > 20mm
Hg
LOW CEREBRAL
PERFUSION
PRESSURE
PYREXIA
SEIZURES
METABOLIC
DISTURBANCES
15

NICE Guidelines for CT Scan

GCS < 13 AT ANY
POINT
GCS 13 OR 14 AT 2
HRS
FOCAL NEUROLOGICAL
DEFICIT
SUSPECTED OPEN,
DEPRESSED OR BASAL
SKULL #
SEIZURE
VOMITING > 1
EPISODE

URGENT CT SCAN IF:

AGE >65 YRS
COAGULOPATHY
DANGEROUS
MECHANISM OF INJURY
ANTEGRADE AMNESIA
> 30 MIN

16

SPINAL TRAUMA
OVER RELIANCE ON
PHYSICAL SIGNS
INADEQUATE
DIAGNOSTIC
IMAGING
HIGH SUSPICION IF:
NEUROLOGICAL
DEFICIT
MULTIPLE INJURIES
FACIAL INJURIES
HIGH ENERGY INJURY

2ND

SPINAL INJURY IN 10%

EVERY TRAUMA PATIENT

HAS A SPINAL INJURY
UNTILL OTHERWISE
PROVED AND FULL SPINAL
IMMOBILISATION TO BE
ALWAYS PRACTISED

17

18

AIRWAY
ISSUES
OESOPHAGEAL
INTUBATION
AIRWAY FLAIL
BEST
SURGICAL
AIRWAY

19

NEEDLE
CRICOTHYROIDOTOMY

OPEN
CRICOTHYROIDOTOMY

20

FAILURE TO RECOGNIZE
HEMORRHAGIC SHOCK
COMPENSATED
4
CATEGORIES SHOCK
NORMAL
RESPONDERS
TRANSIENT
RESPONDERS
NON
RESPONDERS

MISINTERPRETAT
ION
EXTREMES OF
AGE

21

B P FLUCTUATION IN
ONGOING BLOOD LOSS
SAW TOOTHED GRAPH

22

OVER & UNDER

RESUSCITATION
UNDER
OVER
RESUSCITATION
EXTENSIVE OEDEMA
PUL. OEDEMA
COMPARTMENT SYN
ARDS

RESUSCITATION
ACIDOSIS
COAGULOPATHY
PROLONGED
SHOCK STATE
ARDS
MULTI ORGAN
FAILURE
23

GROIN AND CVP

LINES

SUBCLAVIAN AND
INT. JUGULAR
VIEN LINES
PNEUMOTHORAX

VENOUS INJURY
ARTERIAL INJURY
FALSE PASSAGE
INFECTION

24

CARDIAC TAMPONADE

Classically, Becks triad:

distended neck veins
muffled heart sounds
hypotension
Shock, JVP , pulsus
paradoxus
CRITICAL PRELOAD
RANGE
25

26

27

TENSION
PNEUMOTHORAX
Air enters pleural space
and cannot escape
Rx: emergency
decompression before
CXR
Either large bore cannula
in 2nd ICS, MCL or insert
chest tube
CXR to confirm site of
insertion
28

COMPLICATIONS OF
CHEST TUBE
MISPLACEMENT
INFECTION
LUNG, LIVER AND
SPLEEN INJURY
INTERCOSTAL
INJURY
OCCLUSION
29

ASSESSMENT OF ABDOMEN
M.C ERROR IN TRAUMA
MANAGEMENT
UNSTABLE PATIENT
FAST OR DPL
STABLE PATIENT
CT SCAN
WHOLE BODY CT SCAN FOR
SEVERELY INJURED
30

PELVIC FRACTURE
M.C.C OF DEATH MANAGEMENT
IS HEMORRHAGE
MULTIDISCIPLINA
RY
ORGANISATIONA
L

PELVIC BINDER
PELVIC PACKING
EXTERNAL
FIXATION
ANGIOGRAPHY
AND
EMBOLISATION
31

32

CAUSES OF MISSED
INJURIES
TRAUMA SEVERITY
MULTIPLE SYSTEMS
SEVERE BRAIN
INJURY
ALTERED
CONSIOUSNESS
SEDATION
INTOXICATION
EARLY SURGERY

IMPROPER
ATTENTION
REFERRAL
WORKLOAD
EXCESS
INADEQUATE
EXAMINATION
INACCURATE
INTERPRETATION
33

PAEDIATRIC TRAUMA
BE READY WITH AGE/SIZE SPECIFIC
EQUIPMENTS
MORE SUSCEPTIBLE TO HYPOTHERMIA
GREATER PHYSIOLOGIC CAPACITY
RAPID DETERIORATION
RESPIRATION TOP PRIORITY
COMMONEST CAUSE OF DEATH HEAD
INJURY
CHILD ABUSE
34

TRAUMA IN ELDERLY
MINIMAL PHYSIOLOGIC RESERVE
THERAPEUTIC WINDOW OF PRELOAD
DENTITION STATUS, NASOPHARYNGEAL
FRAGILITY, C-SPINE AND TMJ ARTHRITIS
120/80 MAY BE ABNORMAL
CORTICAL ATROPHY
MI SECONDARY TO PAIN OR OVER
TRANSFUSION
DECREASE IN CONNECTIVE TISSUE INTEGRITY
BETA-BLOCKERS AND CCB MASK TACHYCARDIA
35

TRAUMA IN PREGNANCY
URINE PREGNANCY TEST IS
A MUST
FAST DONE OVER UTERUS
EARLY DIAGNOSIS OF
PLACENTAL INJURY AND
DIRECT FETAL INJURY
DANGER SIGNS
ABNORMAL FH, VAGINAL
BLEEDING, RUPTURED
MEMBRANE AND
DISTENDED PERINEUM
TREAT THE MOTHER TO
TREAT THE FETUS
36

REDUCING ERRORS
INTENTION ERRORS ARE REDUCED
BY PROTOCOLS AND ALGORITHMS
DIAGNOSTIC LABELLING
FALSE NEGATIVE PREDICTION
FALSE ATTRIBUTION
ASSUME NOTHING , TRUST NO ONE
MISSED INJURIES AND DELAYED
DIAGNOSIS
37

GENERAL PRINCIPLES IN
TRAUMA MANAGEMENT

1. MANAGE
ACCORDING TO
THE WORST
REASONBLE CASE
SCENARIO

38

2. LISTEN CAREFULLY
BUT A BIT
SKEPTICAL

39

3) LOOK CAREFULLY

40

4. CONSTANTLY
REASSESS
AND NEVER
ASSUME

41

5. TRAUMA CARE IS
A TEAM SPORT

42

6. MAINTAIN CLOCK
SPEED

43

7. NEVER BECOME
MARRIED TO
INITIAL DIAGNOSIS

44

THANK YOU

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