I nitial

M anageme
nt
in T rauma
Phakawat Chunthong,MD

Trimodal distribution of death

Timing of Death Resulting from

Trauma
The first peak
50%
Death at the time of injury
Primary injury to major organs such as
brain,heart,great vessels
The injuries are irrecoverable, rapid treatment
and transfer may salvage some patients
Primary prevention

Timing of Death Resulting from

Trauma
The second peak
30%
From the end of the first peak to several hours
GOLDEN HOUR
Morbidity and mortality are prevented by avoidance of
a secondary injury due to
hypoxia,hemorrhage,inadequate tissue perfusion
Intracranial hematoma,major hemorrhage from
viscera,bones and vessels or hemothorax
ATLS [Advanced Trauma Life Support]
9%
Prehospital and in hospital

Timing of Death Resulting from

Trauma
The third peak

20%
Death occurs days or weeks after the injury
Sepsis and multiple organ failure
Advances in intensive care reduce deaths
Improvements in initial management on
admission reduce morbidity and mortality

ATLS guideline
1. preparation
2. triage
3. primary survey[ABCDE]
4. resuscitation
5. adjuncts to primary survey and resuscitation
6. secondary survey
7. adjuncts to secondary survey
8. continued post resuscitation monitoring and
reevaluation
9. definitive care

Preparation
1.Prehospital phase [EMS]

Notify receiving hospital

Airway maintenance, control of external
bleeding and shock, immobilization of the
patient

2.Inhospital phase

Resuscitation area
Equipment, monitor,warmed fluid
Trauma team
Protective communicable disease

Cap

Gown

Gloves

Mask

Shoe Covers

Goggles / face
shield

Triage
Sorting of patients according to

ABCDEs

Available resources

Multiple

Mass

Primary survey and resuscitation

identify immediately treatable life threatening
injury with initial resuscitation
A airway maintenance with cervical spine
control
B breathing and ventilation
C circulation and bleeding control
D disability:neurologic status
E exposure/environmental control:complete
undress the patient but prevent hypothermia

A airway maintenance with

cervical spine control

Talk to the patient

Check the airway patency: secretion,
blood, stridor
C-spine protection

A airway maintenance with

cervical spine control

Basic airway management

1.remove of foreign material from mouth
and pharynx
2.Chin lift and jaw thrust
3.Oropharyngeal or nasopharyngeal airway

A airway maintenance with

cervical spine control

Definitive airway
1.orotracheal intubation
2.nasotracheal intubation
3.surgical airway
3.1 cricothyroidotomy
3.2 tracheostomy

A airway maintenance with

cervical spine control

orotracheal
intubation

cervical spine
injury in-line
stabilization

nasotracheal
intubtion

A airway maintenance with

cervical spine control

A airway maintenance with

cervical spine control
surgical airway
failure endotracheal intubation
maxillofacial injury,blunt or penetrating neck
injury intubate
Cricothyroidotomy
1.Needle cricothyroidotomy
2.Surgical cricothyroidotomy
Tracheostomy

A airway maintenance with

cervical spine control

1.Needle cricothyroidotomy
2.Surgical cricothyroidotomy

A airway maintenance with

cervical spine control

C-spine protection
unconscious
GCS 8
Neck pain
Quadriplegia, paraplegia, hemiplegia

B breathing and ventilation

Respiration
Chest movement
RR
Tracheal position
Breath sound
Subcutaneous emphysema
Inspection of neck vein and wound

B breathing and ventilation

Tension pneumothorax
Flail chest
Open chest wound
Massive hemothorax

Tension pneumothorax

Tension pneumothorax

Chest pain
Air hunger
Respiratory distress
Tachycardia
hypotension

Tracheal deviation
Unilateral absence of
breath sound
Neck vein distention
Cyanosis

Tension pneumothorax

Tension pneumothorax
Management
Immediate decompression: needle
thoracocentesis ( Rapidly inserting a largebore needle into the 2nd intercostal space ,
midclavicular line of the affected side)

Definitive treatment: chest tube

Flail chest
2 1 3

1 costochondral separation
fracture sternum
lung contusion,pneumothorax,hemothorax
paradoxical respiration
hypoventilation (
pain) hypoxia( pulmonary contusion
hemo-pneumothorax)

Flail chest

Flail chest

Open chest wound

sucking chest wound
2/ 3
trachea

respiratory distress
sterile occlusive
dressing plaster 3
chest tube
endotracheal tube

Open chest wound

Open chest wound

Massive hemothorax
1,500 ml
tension pneumothorax
chest drain fluid
resuscitation
indication for thoracotomy
chest
tube 1,500 ml
chest tube 100-200
ml. ( 4-6 .)

Massive hemothorax

C circulation and bleeding control

BP, PR, LOC
Skin color, capillary refill
External bleeding site
Internal bleeding site: thorax, abdomen,
pelvis, extremities

Class 1

Class 2

Class 3

Class 4

Blood loss (ml)

750

750-1,500

1,500-2,000

> 2,000

Blood loss (% )

15

15-30

30-40

>40

<100

>100

>120

>140

normal

normal

Pulse pressure

Capillary refill

normal

Slow (>2s)

Slow (>2s)

undetectable

14-20

20-30

30-40

>35

Urine
output(ml/hr)

>30

20-30

5-15

negligible

Mental status

slightly anxious

mildly anxious

anxious/confused

confused/
lethargic

Fluid
replacement

crystalloid

crystalloid

crystalloid
plus blood

Crystalloid
plus blood

Pulse
BP

RR

C circulation and bleeding control

Warmed Balnced salt solution
2 large bore
2 liters in 10-15 mins, child bolus 20
ml/kg
G/M

C circulation and bleeding control

Hemorrhagic shock
Cardiogenic shock
neurogenic shock

Hemorrhagic shock
Initial fluid therapy

hypotension bolus
2 10-15
bolus 20 ml/kg

1.Rapid response
2.Transient response
3.Minimal or no response

Hemorrhagic shock
Rapid response



fluid maintenance
20%

Hemorrhagic shock
Transient response
initial fluid bolus
fluid

fluid
20-40%

Hemorrhagic shock
Minimal or no response
fluid

pump
failure cardiac injury cardiac
tamponade
CVP,EKG

Cardiogenic shock
Myocardial dysfunction tension
pneumothorax, myocardial contusion, cardiac
tamponade, air embolism, myocardial
infarction
Cardiac tamponade penetrating
injury
Becks triad venous
pressure elevation, hypotension, distance heart
sound tension pneumothorax
myocardial contusion blunt chest injury

Cardiogenic shock

neurogenic shock
spinal cord injury mid
thoracic
head injury

hypovolemic shock severe brain
injury
loss symphathetic tone
vasodilatation

neurogenic shock
hypotension heart rate
initial treatment fluid resuscitation
adequate resuscitation
hypotension vasopressor
drug
CVP monitoring
fluid resuscitation

D disability:neurologic status
GCS
Pupils size and light reaction

GLASGOW COMA SCALE

Variables
Eye opening

Score
Spontaneous
To speech
To pain
None

4
3
2
1

Verbal response
Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
None

5
4
3
2
1

Best motor response

Obeys commands
Localizes pain
Normal flexion
Abnormal flexion
Extension
None

6
5
4
3
2
1

E exposure/environmental control
Undressed
Exam back region
All entry and exit wound
Prevent hypothermia( warming light,
warm blankets, warm resuscitation fluid,
warm inspired air)
Patients right, closed area

adjuncts to primary survey and

resuscitation
Vital signs
ECG
O2 sat,pulse oximeter
Uinary and gastric catheter
Urine out put
Trauma film:lateral c-spine,CXR,pelvis
DPL/FAST

Primary survey and resuscitation

Protect and secure airway
Ventilate and oxygenate
Stop the bleeding!
Vigorous shock therapy
Protect from hypothermia

secondary survey
The complete
history and
physical
examination

Secondary survey
History
Physical exam: head to toe
tubes and fingers in every orifice
Complete neurological exam
Special diagnosis tests
reevaluation

Secondary survey
History
AMPLE
A:Allergies
M:Medication currently being taken by the
patient
P:Past illness and operations,pregnancy
L:Last meal
E:Event/Environment related to the injury

Secondary survey
Mechanism of injury

Secondary survey
HEAD
Signs of skull base
fracture
Pupillary size
Hemorrhages of
conjunctiva/fundi
Visual acuity
Penetrating injury

Contact lens
Dislocation of lens
Hyphaema
Ocular movement
Posterior scalp
laceration

Secondary survey
MAXILLOFACIAL
Associated with airway obstruction or
major bleeding
Fracture cribriform plate
No NG tube [performed oral route]

Secondary survey
NECK
Cervical tenderness, subcutaneous
emphysema
Oesophageal injury
Tracheal/laryngeal injury
Carotid injury (penetrating/blunt)

Secondary survey
CHEST

Inspect

Palpate

Percuss

Auscultate

Obtain x-rays

Secondary survey
ABDOMEN

Inspect

Auscultate

Palpate

Percuss

Reevaluate

Special studies

Secondary survey
Perineum:contusion,hematoma,
laceration,urethral blood
Rectum:sphincter tone,high riding
prostate,pelvic fracture,rectal wall
integrity,blood
Vagina:blood,laceration

Secondary survey
Musculoskeletal
Contusion, deformity
Pain
Perfusion
Peripheral
neurovascular status
X-ray

Secondary survey
Neurologic: brain
GCS Score

Lateralizing signs

Frequent reevaluation

Prevent secondary brain injury

Secondary survey
Neurologic: spine and cord
Complete motor and sensory exams

Imaging as indicated

Reflexes

Adjuncts to secondary survey

Special diagnostic tests as indicate
CT
Contrast x-ray studies
Extremity x-ray
Endoscopy
Ultrasound

Monitoring and revaluation

Minimize missed injury
High index of suspicion
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1ml/kg/hr
Pain relief -- IM should be avoid

Definitive care
OR
ICU
Refer