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DR.MUHAMMAD ABDUL SHAKOOR
TRAINEE REGISTRAR SURGICAL UNIT
1
SHEIKH ZAYED HOSPITAL LAHORE

 An effective trauma system needs the teamwork of EMS, emergency
medicine, trauma surgery, and subspecialists.
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.

Development of pre-hospital Emergency Medical Services
(EMS) with three purposes:
Get to the patient quickly.
Fix what we can fix .
Quickly get the patient to the right hospital.

 Golden Hour = 80% of trauma deaths in first hour after injury
 Rapid trauma care has greatest level of impact in these patients
4
Immediately Hours Days/Week
50%
30% 20%

The "Golden Hour" concept, the period of 60 minutes or less
following injury when immediate definitive care is crucial to a
trauma patient's survival.

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.

Color
Codes
Triage Tag
RED : Most
critical injury.
YELLOW :
Less critical
injured.
GREEN : No
life
threatened
injury.
BLACK :
Death or
obviously
fatal injury.

RADIOGRAPHER
ANAESTHESIST
NURSE 1
GENERAL SURGEON
ED PHYSICIAN
ORTHO REGISTRAR
WARDS PERSON
NURSE 2
TEAM LEADER
ANAESTHETIC ASST.

• ANATOMICAL
• PHYSIOLOGICAL
• MECHANISM

ANATOMICAL
 INJURY TO 2/ MORE BODY REGIONS
 FRACTURE 2/ MORE LONG BONES
 SPINAL CORD INJURY
 AMPUTATION OF LIMB
 PENETRATING INJURY TO HEAD, NECK TORSO/ PROX. LIMB
 BURNS> 15% IN ADULTS, >10% IN CHILDREN, AIRWAY BURNS
 AIRWAY OBSTRUCTION

PHYSIOLOGICAL
SBP<90mm Hg/ PR- >130 per min.
RR<10/ >30 PER MIN
DEPRESSED CONSCIOUSNESS
AGE>70YR WITH CHEST INJURY
PREGNANCY>24 WEEKS WITH TORSO INJURY

MECHANISM
BIKER/ PEDESTRIAN HIT BY VEHICLE>30KM/HR
FALL>5 METRE
FATALITY IN SAME VEHICLE
MOTOR VEHICLE CRASH WITH EJECTION

 Trauma team activation prior to arrival
 Name tags worn
 Universal precaution in place
 Lead gowns in place
 X-ray cassette in place
 Warmed i.v fluids hanging
 O-neg blood ready, blood warmer and rapid infuser ready
 Trauma surgeon notified if SBP<90mm Hg
 Theatre notified
 Radiology notified

PRIMARY SURVEY:
• Airway maintenance with cervical spine protection.
• Breathing and ventilation.
• Circulation with hemorrhage control.
• Disability: Neurologic status.
• Exposure/Environmental control.

AMPLE history.
Allergies
Medications (Anticoagulants, insulin and cardiovascular medicine).
Past medical/surgical history
Last oral meal (Time)
Events /Environment surrounding the injury.

The tertiary survey is a repeat clinical examination along
the lines of the primary and secondary surveys.
 It is performed with the aim of identifying injuries that
have been missed during initial assessment.
This survey consists of a structured and comprehensive re-
examination that takes place within 48-72 hours.

GCS score of 8 or less.
Inappropriate verbal response.
Protection of the spine.

Pt. with maxillofacial or head trauma should be presumed
to have and unstable cervical spine.
The neck should be immobilized until all aspects of the
cervical spine have been adequately studied and an injury
has been excluded.

 Maintenance of Airway
Patency
– Suction of Secretions
– Chin Lift/Jaw thrust
– Nasopharyngeal Airway
– Definitive Airway
 Airway Support
– Oxygen 100%
– Bag Valve Mask
 Definitive Airway
– Endotracheal Intubation
In-line cervical
stabilization
– Surgical
Crichothyroidotomy

LEMON
Assessment for
Difficult Intubation
– Look externally
– Evaluate 3-3-2 rule
– Mallampati
classification
– Obstruction
– Neck mobility

To secure the airway with
direct laryngoscopy,
manual in-line
stabilization (MILS) of
the neck is the standard
care of these patients in
the acute stage.
MILS is best
accomplished by having
two operators in addition
to the physician who is

 Do not confuse airway problem for ventilation problem
 Patent airway does not equal adequate ventilation.
 Need good gas exchange
• Oxygen in
• CO2 out
Rapid assessment of
 RR
 SPO2
 TRACHEA
 CHEST EXPANSION
 PERCUSSION
 AUSCULTATION

 INSPECT:Equal chest rise,paradoxical chest movements,contusion,sucking chest
wound,distended neck veins
 PALPATE:Trachea,chest wall tenderness,subcutaneous emphysema,sternal and
rib fracture
 PERCUSS:dullness,hyperresonance
 AUSCULTATE: equal breath sounds,absence of breath sounds

Respiratory Distress
Hyperinflated Chest
Deviated Trachea
Decreased Movement
Decreased Breathsound
Tachycardia
Hypotension
NEEDLE THORACOSTOMY VIA 2ND ICS IN MCL
FOLLOWED BY DEFINITIVE CHEST TUBE (4TH- 5TH ICS JUST
ANTERIOR TO MAL CONNECTED TO WATER UNDER SEAL DRAIN)

Signs Similar To Tension Pneumothorax Except Dullness On
Percussion
Shock
T/T- Tube Thoracostomy
• Thoracotomy In
 >1500ml DRAIN IMMEDIATELY
 >200ml/Hr FOR 4 HOURS
• Contact CTVS Early.

 Chest Tube At Site Separate To
Defect
 Cover Wound With 3 Sides Gauze
 Definitive Debridement In OT

 >2 Rib Fractures
In 2 Or More Places
 Paradoxical Chestwall Movement
 Adequate Ventilation
 Reexpand Lungs: Intubation,,
CTVS Consultation

 Penetrating Injury
 Becks Triad
 Echo/ FAST
 Pericardiocentesis.
 Emergency Room Thoracotomy/
Urgent Thoracotomy
HYPOTENSION
DISTENDED
NECK VEINS
MUFFLED
HEART
SOUND

Assess-
• Pulse .
• Skin Colour And Temperature
• Conscious Level(GCS)
• Capillary Refill Time
• Decreased Urine Output
• Hypotension-a Late Sign When≥ 30% Blood Volume Lost.
Stopping The Bleeding : Most Important Priority

External hemorrhage
• Apply direct pressure
• No tourniquets except for traumatic amputations
Be aware of possible sources of internal bleeding both from
blunt and penetrating trauma
• Chest
• Abdomen
• Pelvic Fractures
• Long Bone Fractures

Primary Survey - Circulation
Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial
Presentation
Class I Class
II
Class
III
Class
IV
Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000
Blood loss (percent blood
volume)
Up to 15 15–30 30–40 40
Pulse rate <100 100–120 120–140 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg) Normal or
increased
Decreased Decreased Decreased
*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.

Control bleeding with direct pressure
Splint limb fractures
Insert 2 large bore IV cannulas in adults or cut down on long
saphenous v
Send off blood-cross match,coagulation screen,Hb,
Hct,biochemistry,blood alcohol level if req
Intraosseous needle in children upto 10 yrs

Fluid replacement:adults upto 2-3 Lt crystalloid/colloid,
Children- 20 ml/kg
Blood replacement
O neg group specific or fully cross matched packed cells
Remember other blood product requirements: FFP, cryoppt, platelets

Elderly - limited ability to increase HR
• BP often has little correlation to Cardiac output
Children - abundant reserve, appear stable then crash
Medication use (Beta Blockers)

Abbreviated neurological exam :
• Level of consciousness
• Pupil size and reactivity
• GCS

Simple Mnemonic to describe level of consciousness
• A : Alert
• V : Responds to Vocal stimuli
• P : Responds to Painful stimuli
• U : Unresponsive to all stimuli

Spinal cord injury
• High dose steroids if within 8 hours.
ICP monitor- Neurosurgical consultation.
Elevated ICP
• Head of bed elevated
• Mannitol
• Hyperventilation
• Emergent decompression

You can’t treat what you don’t find!
If you don’t look, you won’t see!

 CONTRAINDICATED IN URETHRAL INJURY
 SUSPECT URETHRAL INJURY
• INABILITY TO VOID
• UNSTABLE PELVIC FRACTURE
• BLOOD AT MEATUS
• SCROTAL HEMATOMA
• PERINEAL ECCHYMOSIS
• HIGH RIDING PROSTATE

 Relieve Gastric Dilatation
 Decompress Stomach
 Reduce Risk Of Aspiration
 N.G Tube – C.I. In Basal skull #

CXR
PELVIS AP
LATERAL C-SPINE
DPL
FAST

The secondary survey does not begin until the primary survey
(ABCDEs) is completed, resuscitative efforts are underway,
and the normalization of vital functions has been demonstrated.
Head to Toe evaluation & reassessment of all vital signs.
AMPLE history

Thoracic Trauma.
Abdominal and Pelvic Trauma.
Head Trauma with TBI.

A GOOD BEGINNING ALMOST ASSURES
SUCCESS!!!
EMERGENCIES DON’T GIVE US A
SECOND CHANCE…..

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