Chapter 1 : Initial Assessment & Management 1. Primary survey: A-- Airway + Restriction of cervical spine motion B- Breathing + Ventilation C - Circulation + Hemorrhage Control D- Disability E- Exposure & Environment control ~ Major area internal : chest, abdomen, retroperitoncum, pelvis, long bones. - Immidiate management : chest decompression, application of a pelvic stabilizing device, extremity splint. - Initial assessment : IL fluid (isotonic solution), unresponsive : blood transfusion ~ Severe injury patient : administer traxenamic acid (demonstrate improve survival within 3 hours of injury and follow up over 8 hours) ~ Adequacy patient’s respiratory : end tidal CO2 (Capnograpy, calorimetry, capnometry) - Decompression of stomach reduce sk of aspiration, if fracture in cribform insert gastric tube orally (nasal dangerous) Adjuncts to primary survey: a. pulse oxometry/ capnopgraphy ». ABG ¢. urinary catheter 4. gastric catheter for decompression e xray (CXR and pelvic cray) £ FAST/ extended - FAST (FAST) sca, DPL (intraabdominal blood, pneumothorax, hemothorax) 2. ECG * transurethral catheter contraindict in suspected urethral injury. How to suspect? - blood at urethral meatus - perineal ecchymosis/ swelling 2. Secondary survey (i) History : A.M.P.LE. history A- Allergies M- Medications P- past illness/pregnancy L- last meal E- events/ environment related to injuries ‘Mechanism of injury : Blunt injury (automobile collision fracture, pneumothorax, contusio, cervical fracture, soft tissue damage) Penetrating injury (cardiac tamponade, hemothorax, hemopneumothorax, pneumothorax, abdominal visceral injury) Gunshot (trajectory from GSW, neurovascular injury, fracture) Thermal (Occult trauma, cardiac arrytmias, CO2 poisoning, pulmonary edema, upper airway swelling) (ii) head - to - toe examinations Ocular trauma : snellen chart, examination visual acuity, pupil, hemorrhage conjunctiva, dislocation Maxillofacial : palpation at bony, assessment of occlution, intraoral examination (gastric intubation could Pass) Cervical Neck : Evaluation need CT scan series with competent doctor. Inspection Cervical tendesness, subcutaneous emphysema, tracheal deviation, laryngeal fracture, Palpation Carotid artery and auscultation for bruits. CT angiography, angiography and duplex ultrasonography for detect major cervical vascular. Chest : significant chest injury make pain, dyspnea and hypoxia. Distant heart sound and decreased pulse pressure can indicate cardiac temponade Abdomen and pelvis : pelvic fracture identification bt ecchymosis over theiliac wing, pubis, labia and scrotum, DPL and USG abdomen (if hemodynamic normal can CT) considered candidate for unexplained hypotension, neurologic injury, impaired sensorium, alcohol, equivocal abdominal. Perineum rectum and vagina : perineum looking for contusion, hematoma, laseration. Musculoskeletal system : Significant extremity injuries : X-Ray. Musculo injury need examination by patients back to complete founding. Neurological system : GCS for early detection. Early consult with neurosurgeon for head injury. Evidence of sensation, paralysis and suggest to major injury spinal column need documented. Adjuncts to secondary survery: specific diagnostic test : X-ray of spine and extermities; CT of head, chest, abdomen, spine; Contrast urography and angiograpy; Transesophageal USG; Broncoscopy; Esophagoscopy Reevaluation : continuous monitoring vital sign. Periodic ABG analysis for some patient. Efective analgesia required as opiate or anxiolytic. Transfer definitive Care Chapter 2: Airway Management and Ventilation L.Objective sign of airway obstruction (a) agitated (suggesting hypoxia) (b) obtunded (suggesting hypercarbia) (c) cyanosis (d) retraction/ use of accessory muscle (©) abnormal sounds! noisy breathing (8) abusive 2, Maxillofacial trauma Hemorrage, swelling, increased secretion. Airway obstructed find with supine position 3. Neck Trauma Penetrating injury can make significant hematoma. Neck injury involving trachea and larynx can cause partial obstruction. Definitive airway required, insert endotracheal tube 4, Laryngeal trauma ~ hoarseness of voice ~ subcutaneous emphysema ~ palpable fracture Can make full obstruction, to help fror promptly need flexible endoscopic intubation, And if unsuccessful emergency tracheostomy indicated. If fracture larynx founded CT scan can help. ventilation (a) Asymmetrical chest rise (b) Listen movement of air. Decrease/ absent of breath sound both hemithoraces should alert (c) Use Pulse oxymetry (@) Use of capnography in intubated patient to check ventilation 4 Predicting difficult airway management: (a)C- spine injury (b)Severe arthritis of C-spine (©)Significant maxilofacial/ mandibular trauma (@)Limited mouth opening (©)Obesity (8) Anatomical variation (g)Paediatric patient 5 .L.E.M.O.N assessment of difficult airway: L-look externally E- Evaluate 3-2-2 rule 3 FB - in between incisor’s teeth 2 EB - from hyoid bone to chin 2 EB - from thyroid notch to floorof mouth M - Mallapati’s score O- obstruction N - neck mobility 6.Airway maintainance technique: (1) chin lift Gi) Jaw thrust ii) nasopharyngeal airway - contraindicated in cribiform plate fracture (iv) oropharyngeal airway (don’t use in children) (v) extraglottic/supraglottic device (LMA, laryngeal tube airway, multilumen esophageal airway) 7.Definitive airway: (a) Endotracheal tube Radiological studies can be applied Chapter 3: Shock ‘A Initial management of Hemorrhagic shock 1 . Follow ABCDE 2.Obtain vascular access: - minimum of 18 gauge caliber - short large peripheral IV line is preferred (Poiscuille’s law: The rate of flow is proportional to the foourth power of the radius of the cannula and inversely related to it’s length) 3.Initiating fluid theraphy: = IL bolus of crystalloid (warm) for adult ; 20mls/kg for paediatric (< 40kg) - assess pt respond to fluid: (a) rapid responder (b) transient responder (©) minimal or no response - balancing goal of organ perfusion + tissue oxygenation + avoidance of rebleeding (permissive hypotension) 4 Prevention of hypothermia 5 .Prevention of coagulopathy - Role of tranxemic acid within 3 hours of injury ( Ist dose given for 10min then 1g over 8 hours) after establishing a definitive airway. There is no need radiogical evaluation of the C-spine. (b) nasotracheal tube (©) surgical airway ( cricothyroidectomy, tracheostomy) 8.Criteria establishing for definitive airwawy (a) inability to maintain patent airway with impending or potential airway compromise (b) inability to maintain adequate oxygenation / presence of apnea (©) obstundedcombasiveness resulting from cerebral hypoperfusion (@) obstunded indicating presence of head injury (GCS less or equal 8 or sustained seizure. * massive transfusion: Definition: > 10 units of pRBC within Ist 24 hours of admission OR > 4units of pRBC transfused over 1 hour - administration of pRBC, FFP, Pit in balanced ratio (1:1:1) may improve survical (damage control resuscitation) * special consideration: LAdv age : - deficit receptor response to cathecholamines ~ cardiac compliance reduce with age ~ artherosclerotie vasscular disease make vital organ more sensitive in slight reduction in blood flow ~ reduced pulmonary compliance, reduce diffusion cpacity + generalised weakness of respiratory muscles limits ability to cope with increase demand of gas exchanges 2.Athelete : - have remarkable ability to compesate blood loss, may not manifest the usual response to hypovolaemia3.Pregnancy - hypovolaemia might be reflected in decrease in fetal perfusion 4.Pacemaker - unable to response to blood loss as expected (HR remain as device’s set rate) Chapter 4: Thoracic Trauma 1 Primary survey life threatening injuries: A.Airway obstruction B.Tracheobronchial injury C.Tension pneumothorax D.Open pneumothorax E.Massive hemothorax F Cardiac tamponade 2.Secondary survey potential life threatening injuries A Simple pneumothorax B.Hemothorax C.Flail chest Pulmonary Contusion E.Blunt cardiac injury F Traumatic Aortic disruption G. Traumatic diaphragmatic injury v) respiratory distess vi) tachycardic vii) chest pain viii) air hunger ix) elevated hemithorax with respiratory movement x) cyanosis (late signs) - immediate treatment: needle decompression (Sth ICS slightly anterior to mid-axillary line) + definitive rx: chest tube C.Open pneumothorax, = occurs whenopening of chest wall approximate 2/3 of diameter of trachea ~ immediate Rx: sterile occlusive dressing (secured tape at 3 edges) - definitive Rx: chest tube insertion D.Massive Hemothora - Definition: (i) initial output of more ‘H.Blune esophageal rupture ‘A.Trancheobronchial injury = majority occurs within 1 inch (2.54cm) from carina ~ signs & symptoms: (1) Hemoptysis (11)Cervical subcutaneous emphysema (11D) Tension pneumothorax (1V)Cyanosis, (V) Continous air leak after placement of chest tube ~ Confirmational dx: Bronchoscopy - Immediate treatment: definitive airway if indicated (advanced airway skill might require due to anatomical disruption) - Operative intervention is indicated B-Tension pneumothorax ~ Do not delay treatment to obtain radiological confirmation - Symptoms and signs: i)Hypotension i) tracheal deviation from affected side ) neck vein distension iv) unilateral absence of breath sound than 1500m1 (ii) continous blood loss of 200mi/hr for 2-4 hours ~ immediate Rx; chest tube - if blood loss as per mentioned above - thoracotomy is indicated - chest wound medial to nipple line or posterior wound medial to scapula, have to suspect great vessl injury and have to keep an eye for thoracotomy E.Cardiac tamponade - Beck’s triad : muffled heart sound, hypotension and distended neck vein - may not be present/not easily to detect - FAST scan rapid and accurate to detect the problem - Rx: emergency thoracotomy/sternotomy, if surgical intervention not possible - to proceed with pericardiocentesis,F Flail chest & Pulmonary Contusion ~ Flail chest : two or more consecutive ipsilateral rib fratures ~ Pulmonary contusion : bruising of lung cause by thoracic trauma ~Rx: (1) adequate analgesia (ii) adequate ventilation/O2 supplementation (iii) cautious fluid resuscitation G.Blunt cardiac injury - can result in myocardial muscle contusion, cardiac chamber rupture (will cause cardiac tamponade), coronary artery dissection, valvular disruption ~ presence of cardiac troponins can be of myocardial infarction = = typical symptoms : chest discomfort - patient with blunt injury to heard diagnose by conduction abnormalities are at risk fo dysarythymia - should be monitor for first 24 hours H.Traumatic aortic disruption - Radiographic sign (high index of suspeious: (a)Widened mediastinum (b)obliteration of aortic knob (©)Deviation of trachea to right (Depression of left mainstem bronchus (©)Elevation of right mainstem bronchus (#)Obliteration of aortopulmonary window (g)Deviation of esophagus to right (h)Widened paratracheal stripe )Widened paraspinal interfaces ())Presence of pleural or apical cap (k)Left hemothorax ()Fracture of Ist/2nd/scapula - CT scan prove as accurate screening - TEE appear useful as non invasive tools - HR + BP control can reduced likelihood of rupture - Rx: open or endovascular repair LTraumatic diaphragmatic injury = common on right side - Rx: endoscopic (laparoscopic or thoracoscopy) with direct repair of the defect J.Blunt esophageal rupture ~ may present with Left pneumo/hemothorax without a rib fracture who has received severe blow over sternu,/epigastrium ~ presence of mediastinal air direct repair Chapter 5: Abdominal and Pelvic Trauma A. Assessment: 1. History 2. Physical examinations: - inspection, percussion, palpation and auscultation of abdomen - pelvic assessment - features suggestive of pelvic fracture: i) ruptured urethra (scrotal haematoma/ blood at meatus) ii) discrepancy of limb length iii) rotational deformity of leg without obvious fracture * gentle palpation on bony pelvis * repeated manipulation of fractured pelvis can aggrevate haemorrhage - urethral, perineal, rectal, vaginal and gluteal examination i) suspect urethra ~ blood at meatus - ecchymosis/ haematoma of scrotu or perineum ii) rectal exam - check for sphincter tone - check for rectal mucosa integrity jury if: 3. Adjunct to physical examinations:a) Gastric tubes ~ to reduce incidence of aspiration - relief of acute gastric dilatation b) urinary catheter ** indication of retrograde urethrogram: i) unable to void ii) require pelvic binder (pelvie injury) ili) blood at meatus iv) scrotal haematoma v) perineal ecchymosis ©) imaging stu i) xray : erect CXR and pelvic ii) FAST scan iii) DPL iv) CT sean v) diagnostic laparoscopy vi) contrast study (urethrogram, cystography, IV pyelogram, GI contrast study) B. Evaluation of specific penetrating juries 1. Most abdominal gun shot wound : ~ manage laparotomy - incidence of significant intraperitoneal injuries : 98% 2. Stab wound - indication for laparotomy. i) haemodynamic abnormality 7. Free air, retroperitoneal air or rupture of hemidiaphrgam 8 CT scan demonstrate rupture GI tract, intraperitoneal bladder injury, renal pedicle injury or severe visceral parenchymal injury after trauma 9, Blunt/penetrating trauma with aspiration of GI contents, vegetable fibers, or bile from DPL or aspiration of 10ce or more blood in haemodynamic abnomal pt. C. Evaluation of other specific injuries 1. Diaphragm ii) gunshot wound with transperitoneal trajectory iii) signs of peritoneal irritation iv) sign of peritoneal penetration (c.g: evisceration) 3. Anterior abdominal wound - indication for laparotomy : i) hypotension ii) peritonitis iii) evisceration of omentum or small bowels 4, Flank and back injuries - thickness of flank and back protects underlying viscera = less invasive tools is prefered INDICATIONS FOR LAPAROTOMY: 1. Blunt trauma with : hypotension, +ve FST scan and clinical evidence of intraperitoneal bleeding or without another source of bleeding 2, Hypotension with abdominal wound that penetrate anterior fascia 3. Gunshot wound that transverse peritoneal cavity 4, Evisceration 5. Bleeding from stomach, rectum or genitourinary following penetrating trauma 6. Peritonitis - abnormalities in xray include : i) blurring of hemidiaphragm ii) hemothorax iii) abnormal gas shadow that ‘obsecure the hemidiaphragm iv) gastric tube portion seen in chest = confirm with laparotomy/laparoscopy/ thoracoscopy 2. Duodenal injuries - suspect when: bloody gastric aspirate or retroperitoneal air on AXR - upper GI xray series, double contrast CR or emergency laparotomy is indicated oft high risk patient3. Pancreatic - an early normal serum amylase doesnt exclude ,ajor pancreatic trauma - double CT contrast may not identified significant pancreatic trauma in immediate post injury (up to 8 hours) - surgical exploration may be consider following equivocal diagnostic studies 4, Genitourinary - contusions, haematoma, ecchymosis of back or flank are markers of potential underlying renal injury - either to go with CT scan or IVP an anterior pelvic fracture usually present with urethral injuries 5, Hollow viscus: ~ a transverse linear ecchymosis on abdominal wall (seat-belt sign) ot lumbar distraction fracture (Chance fracture) should alert possibility of intraperitoneal injury 6. Solid organ - injuries to liver, spleen, kidney that result in shock, haemodynamic abnormal or evidence of continuing haemorrhage -> urgent laparotomy 7. Pelvic a) Type: ~ AP compression (15-20%) - Lateral compression (60-70%) - Vertical shear (5-15%) - combined mechanism b) Management i) haemorrhage control - mechanical stabilization of pelvic ring -external counter presure ** haemodynamic unstable (angiographic embolization or preperitoneal packing if embolization is not available) ii) fluid resuscitation (see chapter : Shock)