TRAUMA

TEXT BOOK READING

INITIAL EVALUATION AND RESUSCITATION

OF THE INJURED PATIENT

Primary Survey
Airway Management with Cervical Spine Protection

All patients with blunt trauma require cervical spine immobilization until injury is
excluded.

This is typically accomplished by applying a hard collar or placing sandbags on both

sides of the head with the patients forehead taped across the bags to the backboard.

For penetrating neck wounds, however, cervical collars are not believed useful because
they provide no benefit, but may interfere with assessment and treatment.

In general, patients who are conscious, without tachypnea,and have a normal voice are
unlikely to require early airway intervention.

Exceptions are penetrating injuries to the neck with an expanding hematoma; evidence
of chemical or thermal injury to the mouth, nares, or hypopharynx; extensive
subcutaneous air in the neck; complex maxillofacial trauma; or airway bleeding.

 In the comatose patient, the tongue may fall backward and

obstruct the hypopharynx; this can be relieved by either a chin
lift or jaw thrust.

An oral airway or a nasal trumpet is also helpful in maintaining

airway patency, although the former is not usually tolerated by
an awake patient.

Establishing a definitive airway (i.e., endotracheal intubation) is

indicated in patients with apnea; inability to protect the airway
due to altered mental status; impending airway compromise
dueto inhalation injury, hematoma, facial bleeding, soft tissue
swelling, or aspiration; and inability to maintain oxygenation.

Altered mental status is the most common indication for

intubation. Agitation or obtundation, often attributed to
intoxication or drug use, may actually be due to hypoxia.

 Options for endotracheal intubation include

nasotracheal,orotracheal, or operative routes.

Nasotracheal intubation can be accomplished only in patients

who are breathing spontaneously.

Although nasotracheal intubation is frequently used by

prehospital providers, the application for this technique in the
ED is limited to those patients requiring emergent airway
support in whom chemical paralysis cannot be used.

Orotracheal intubation is the preferred technique used to

establish a definitive airway. Because all patients are
presumed to have cervical spine injuries, manual in-line
cervical immobilization is essential

Cricothyroidotomy (Fig. 7-1) is

performed through a generous vertical
incision, with sharp division of the
subcutaneous tissues.
Visualization may be improved by
having an assistant retract laterally on
the neck incision using army-navy
retractors.
The cricothyroid membrane is verified
by digital palpation and opened in a
horizontal direction.
The airway may be stabilized before
incision of the membrane using a
tracheostomy hook; the hook should
be placed under the thyroid cartilage
to elevate the airway.

Breathing and Ventilation

Once a secure airway is obtained, adequate
oxygenation and ventilation must be
ensured.
All injured patients should receive
supplemental oxygen and be monitored by
pulse oximetry.
The following conditions constitute an
immediate threat to life due to inadequate
ventilation and should be recognized
during the primary survey: tension
pneumothorax, open pneumothorax, flail
chest with underlying pulmonary
contusion, and massive air leak.
All of these diagnoses should be made
during the initial physical examination

Circulation with Hemorrhage Control

With a secure airway and adequate ventilation
established, circulatory status is the next
priority.
An initial approximation of the patients
cardiovascular status can be obtained by
palpating peripheral pulses.
In general,systolic blood pressure (SBP) must
be 60 mm Hg for the carotid pulse to be
palpable, 70 mm Hg for the femoral pulse,
and 80 mm Hg for the radial pulse. Any
episode of hypotension (defined as a SBP <90
mm Hg) is assumed to be caused by
hemorrhage until proven otherwise.
Patients with acute massive blood loss may
have paradoxical bradycardia.

Current indications and contraindications for

emergency department thoracotomy

GCS & Signs and Symptons of advanching stages of

hemorrhagic shock

SECONDARY SURVEY
1.AMPLE history
2.The physical examination should be literally head to toe, with special
attention to the patients back, axillae, and perineum, because injuries here
are easily overlooked.
3.All potentially seriously injured patients should undergo digital rectal
examination to evaluate for sphincter tone, presence of blood, rectal
perforation, or a high-riding prostate; this is particularly critical in patients
with suspected spinal cord injury, pelvic fracture, or transpelvic gunshot
wounds.
4.Vaginal examination with a speculum should be performed in women with
pelvic fractures to exclude an open fracture.

Adjuncts to the physical examination include vital sign and CVP

monitoring, ECG monitoring, nasogastric tube placement, Foley catheter
placement, radiographs, hemoglobin, urinalysis, and base deficit
measurements, and repeat FAST exam.
A nasogastric tube should be inserted in all intubated patients to decrease
the risk of gastric aspiration but may not be necessary in the awake
patient.
Nasogastric tube placement in patients with complex mid-facial fractures
is contraindicated; rather, a tube should be placed orally if required
Selective radiography and laboratory tests are done early in the
evaluation after the primary survey.
For patients with severe blunt trauma, chest and pelvic radiographs
should be obtained.
Historically, a lateral cervical spine radiograph was also obtained, hence
the reference to the big three films, but currently patients preferentially
undergo CT scanning of the spine rather than plain film radiography.

Mechanisms and Patterns of Injury

In general, more energy is transferred over a wider area during blunt
trauma than from a penetrating wound.
As a result, blunt trauma is associated with multiple widely distributed
injuries, whereas in penetrating wounds the damage is localized to the path
of the bullet or knife. In blunt trauma, organs that cannot yield to impact
by elastic deformation are most likely to be injured, namely, the solid
organs (liver, spleen, and kidneys).
For penetrating trauma, organs with the largest surface area when viewed
from the front are most prone to injury (small bowel, liver, and colon).
Additionally, because bullets and knives usually follow straight lines,
adjacent structures are commonly injured

Algoritme directing the use of resuscitative

thoracotomy

American association for the surgery of trauma

garding scales for solid organ injuries

 With the advent of CT scanning, nonoperative management of solid organ

injuries has replaced routine operative exploration.
Those patients who do require operation may be treated with less radical
resection techniques, such as splenorrhaphy or partial nephrectomy.
Additionally, the type of anastomosis has shifted from a doublelayer closure
to a continuous running single-layer closure; this method is technically
equivalent to and faster than the interrupted multilayer techniques

Transfusion Practices
Injured patients with life-threatening hemorrhage develop an acute
coagulopathy of trauma (ACOT).
Cohen et al have shown convincingly that activated protein C is a
key element, although the complete mechanism remains to be
elucidated.
Fibrinolysis is another important component of the ACOT; present
in only 5% of injured patients requiring hospitalization, but 20% in
those requiring massive transfusion.
Fresh whole blood, arguably the optimal replacement, is not
available in the United States.
Rather, its component parts, packed red blood cells (PRBCs), freshfrozen plasma, platelets, and cryoprecipitate, are administered.

 The traditional thresholds for blood component replacement in the patient

manifesting a coagulopathy have been INR >1.5, PTT >1.5 normal, platelet count
> 50,000/ L, and fibrinogen >100 mg/dl.
Such guidelines are designed to limit the transfusion of immunologically active
blood components and decrease the risk of transfusion-associated lung injury
and secondary multiple organ failure.
This approach calls for administration of various components in a specific ratio
during transfusion to achieve restoration of blood volume and correction of
coagulopathy.
Although the optimal ratio is yet to be determined, current scientific evidence
indicates a presumptive 1:2 red cell:plasma ratio in patients at risk for massive
transfusion (10 units of PRBCs in 6 hours)

Operative Approaches and Exposure

Cervical Exposure Operative exposure for
midline structures
of the neck (e.g.,trachea, thyroid, bilateral
carotid sheaths) obtained through a collar
incision; this is typically performed two
finger breadths above the sternal notch, but
can be varied based on the level of
anticipated injury.
After subplatysmal flap elevation, the strap
muscles are divided in the midline to gain
access to the central neck compartment.
More superior and lateral structures are
accessed by extending the collar incision
upward along the sternocleidomastoid
muscle; this may be done bilaterally if
necessary

Emergent Abdominal Exploration Abdominal exploration in

Adults is performed using a generous midline incision because of its
versatility.
For children under the age of 6, a transverseincision may be advantageous.
Making the incision is faster with a scalpel than with an electrosurgical unit;
incisional abdominal wall bleeding should be ignored until intra-abdominal
sources of hemorrhage are controlled.
Liquid and clotted blood are evacuated with multiple laparotomy pads to
identify the major source(s) of active bleeding. After blunt trauma the
spleen and liver should be palpated first and packed if fractured, and the
infracolic mesentery inspected to exclude a zone.

VASCULAR INJURIES