Trauma SURGERY

most commo cause of death

road traffic

Primary Survey

- •Rapid assessment of ABCDE :

•A: Airway maintenance and cervical spine protection

•B: Beathing and ventilation

•C: Circulation and hemorrhage control

•D: Disability (Neurological status assessment)

•E: Exposure and Environmental control

spine stabilizing in what?

A

Airway management:

-•Chin lift or jaw thrust. With face mask.

•Nasopharyngeal airway. → gag reflex

•Oropharyngeal airway → coma patient

right

Airway management:

-•Chin lift or jaw thrust. With face mask.

•Nasopharyngeal airway. →

•Oropharyngeal airway →

Airway management:

-•Chin lift or jaw thrust. With face mask.

•Nasopharyngeal airway. → gag reflex

•Oropharyngeal airway → coma patient

Airway management:

-

Airway management:

-•Chin lift or jaw thrust. With face mask.

•Nasopharyngeal airway. → gag reflex

•Oropharyngeal airway → coma patient

what is Definitive Airway?

inserrtion direct into trachea

•Endotracheal intubation

•Surgical Airway/Cricothyroidoto my

Definitive Airway

Definitive Airway

•Endotracheal intubation

•Surgical Airway/Cricothyroidoto my

•Endotracheal intubation

head inury

•Surgical Airway/Cricothyroidoto my

open trachea

•Inspection: B/L chest rises, respiratory efforts, neck veins

distention and cyanosis.

•Palpation: tracheal position, ribs tenderness.

•Percussion: hyperresonance vs. Dullness….?

Auscultation:equalbreath entry

Breathing

•Identify life threatening deficits in breathing mechanism

•Tension pneumothorax → resonant

•Massive hemothorax → dull

•Open pneumothorax (“sucking chest wound”)

•Cardiac tamponed

correct

•Identify life threatening deficits in breathing mechanism

•Identify life threatening deficits in breathing mechanism

•Tension pneumothorax → resonant

•Massive hemothorax → dull

•Open pneumothorax (“sucking chest wound”)

•Cardiac tamponed

Circulation and hemorrhage control:

→ •Assessment of adequate blood profusion to tissue and identify signs of systemic shock.

• •Assessment:

  -Level of consciousness/mental status. Heart rate.

  -Blood pressure.

  -Skin perfusion/Capillary refilling.

• - Abdominal and pelvic examination.

correct

Circulation and hemorrhage control:

→ •Assessment of adequate blood profusion to tissue and identify signs of systemic shock.

• •Assessment:

  -Level of consciousness/mental status. Heart rate.

  -Blood pressure.

  -Skin perfusion/Capillary refilling.

• - Abdominal and pelvic examination.

Circulation and hemorrhage control:

→ •Assessment of adequate blood profusion to tissue and identify signs of systemic shock.

• •Assessment:

  -Level of consciousness/mental status. Heart rate.

  -Blood pressure.

  -Skin perfusion/Capillary refilling.

• - Abdominal and pelvic examination.

• •Assessment:

  -Level of consciousness/mental status. Heart rate.

  -Blood pressure.

  -Skin perfusion/Capillary refilling.

• - Abdominal and pelvic examination.

Circulation and hemorrhage control:

heamorrage →
•External hemorrhage

•

•Internal hemorrhage   Chest   Abdomen   Pelvis

Long bone

right

shock in trauma?

•Hypovolemic/hemorrhagic

•

•Obstructive/Cardiogenic

•

•Distributive /neurogenic

•Direct pressure on external bleeding

corredct

????????????? on external bleeding

•Direct pressure on external bleeding

what fluid give in the trauma?
how much?

•Initial 1-2 liter bolus of crystalloid fluid

•Initial 1-2 liter bolus of crystalloid fluid

what fluid give in the trauma?
how much?

what fluid give in the trauma?
how much?

•Initial 1-2 liter bolus of crystalloid fluid

•Rapid response??

•Rapid response : 15% blood volume lost

•

•Transient response:
how much?
need what?

•Transient response: 15%-40% blood volume lost, likely need PRBC

transfusion

•No-responders: need immediate definitive care (surgery or angioembolization) to control ongoing bleeding.

•No-responders:
need what?

•No-responders: need immediate definitive care (surgery or angioembolization) to control ongoing bleeding.

heamorragic shock calsses:

class I

Blood loss (mL) → 750 ML

Blood loss (% blood volume) → 15

Pulse rate (per minute) < 100

Blood pressure ( NORMAL)

Pulse pressure (mm Hg)

Respiratory rate (per minute) → 14 TO 20

Urine output (mL/hour) → > 30 ML/HOUR

Central nervous system/ mental status → slight anxious

corrdct

class I

Blood loss (mL) →

Blood loss (% blood volume) →

Pulse rate (per minute) <

Blood pressure

Pulse pressure (mm Hg)

Respiratory rate (per minute) →

Urine output (mL/hour) →

Central nervous system/ mental status →

class I

Blood loss (mL) → 750 ML

Blood loss (% blood volume) → 15

Pulse rate (per minute) < 100

Blood pressure ( NORMAL)

Pulse pressure (mm Hg)

Respiratory rate (per minute) → 14 TO 20

Urine output (mL/hour) → > 30 ML/HOUR

Central nervous system/ mental status → slight anxious

class I
Blood loss (mL) →

Blood loss (% blood volume) →

Pulse rate (per minute) <

Blood pressure

Blood loss (mL) → 750 ML

Blood loss (% blood volume) → 15

Pulse rate (per minute) < 100

Blood pressure ( NORMAL)

class I
Pulse pressure (mm Hg)

Respiratory rate (per minute) →

Urine output (mL/hour) →

Central nervous system/ mental status →

Pulse pressure (mm Hg)

Respiratory rate (per minute) → 14 TO 20

Urine output (mL/hour) → > 30 ML/HOUR

Central nervous system/ mental status → slight anxious

class II

Blood loss (mL) → 750 TO 1500

Blood loss (% blood volume) → 15 to 30

Pulse rate (per minute) 100 to 120

Blood pressure normal

Pulse pressure (mm Hg) low

Respiratory rate (per minute) → 20 to 30

Urine output (mL/hour) → 20 to 30

Central nervous system/ mental status → mild anxious

right

class II

Blood loss (mL) →

Blood loss (% blood volume) →

Pulse rate (per minute)

Blood pressure

Pulse pressure (mm Hg)

Respiratory rate (per minute) →

Urine output (mL/hour) →

Central nervous system/ mental status →

class II

Blood loss (mL) → 750 TO 1500

Blood loss (% blood volume) → 15 to 30

Pulse rate (per minute) 100 to 120

Blood pressure normal

Pulse pressure (mm Hg) low

Respiratory rate (per minute) → 20 to 30

Urine output (mL/hour) → 20 to 30

Central nervous system/ mental status → mild anxious

class III

Blood loss (mL) → 1500 to 2000

Blood loss (% blood volume) → 30 to 40

Pulse rate (per minute) → 120 to 140

Blood pressure → decreased

Pulse pressure (mm Hg) decreased

Respiratory rate (per minute) → 30 to 40

Urine output (mL/hour) → 5 to 15

Central nervous system/ mental status → confused

correct

class III

Blood loss (mL) →

Blood loss (% blood volume) →

Pulse rate (per minute) →

Blood pressure →

Pulse pressure (mm Hg)

Respiratory rate (per minute) →

Urine output (mL/hour) →

Central nervous system/ mental status →

class III

Blood loss (mL) → 1500 to 2000

Blood loss (% blood volume) → 30 to 40

Pulse rate (per minute) → 120 to 140

Blood pressure → decreased

Pulse pressure (mm Hg) decreased

Respiratory rate (per minute) → 30 to 40

Urine output (mL/hour) → 5 to 15

Central nervous system/ mental status → confused

class IV

Blood loss (mL) → > 2000

Blood loss (% blood volume) → > 40%

Pulse rate (per minute) → high

Blood pressure → low

Pulse pressure (mm Hg) → low

Respiratory rate (per minute) → > 40

Urine output (mL/hour) → nwgligble

Central nervous system/ mental status → confused

right

class IV

Blood loss (mL) →

Blood loss (% blood volume) →

Pulse rate (per minute) →

Blood pressure →

Pulse pressure (mm Hg) →

Respiratory rate (per minute) →

Urine output (mL/hour) →

Central nervous system/ mental status →

class IV

Blood loss (mL) → > 2000

Blood loss (% blood volume) → > 40%

Pulse rate (per minute) → high

Blood pressure → low

Pulse pressure (mm Hg) → low

Respiratory rate (per minute) → > 40

Urine output (mL/hour) → nwgligble

Central nervous system/ mental status → confused

urine output
I → > 30
II → 20 TO 30
III → 5 TO 15
IV → NOTHING

RRIGHT

urine output
I → >
II →
III →
IV →

urine output
I → > 30
II → 20 TO 30
III → 5 TO 15
IV → NOTHING

BP
I → normla
II → normal
III → low
IV → low

corrdct

BP
I →
II →
III →
IV →

BP
I → normla
II → normal
III → low
IV → low

blood loss
I → 750
II → 750 to 1500
III → 1500 to 2000
IV → > 2000

right

blood loss
I
II →
III →
IV → >

blood loss
I → 750
II → 750 to 1500
III → 1500 to 2000
IV → > 2000

blood loss %
I → 15 %
II → 15 to 30%
III → 30 to 40%
IV → > 40%

right

blood loss %
I →
II →
III →
IV → >

blood loss %
I → 15 %
II → 15 to 30%
III → 30 to 40%
IV → > 40%

respiratory rate?
I → 14 to 20
II → 20 to 30
III → 30 to 40
IV → > 40

right

respiratory rate?
I →
II →
III →
IV → >

respiratory rate?
I → 14 to 20
II → 20 to 30
III → 30 to 40
IV → > 40

Damage control Surgery → •A shift from definitive surgeries to surgery with a goal of   stabilizing the patient and then another surgery for definitive   management.

correct

Damage control Surgery → •A shift from ???

Damage control Surgery → •A shift from definitive surgeries to surgery with a goal of   stabilizing the patient and then another surgery for definitive   management.

Goals of damge control surgery?

•Stop bleeding

•Control contamination

•Temporary abdominal closure

right

Goals of damge control surgery?

Goals of damge control surgery?

•Stop bleeding

•Control contamination

•Temporary abdominal closure

indications for damage control surgery?

•Indications

•Unstable patients with blunt or penetrating abdominal trauma or chest   trauma.

•Signs of abdominal pathology (free air, peritonitis)

•Hemothorax with >1500 cc of blood out initially.

SurgicalinjuriesidentifiedwithFAST/DPLorimaging

correct

Surgical injuries identified with???

FAST/DPLorimaging

Disability ( neurological status)

→ •Rapid assessment of neurologic status to identify life-threatening injury

•Pupil size and response

•Mental status (Glascow coma scale)

•Motor and sensory exam

co0oret

Disability ( neurological status)

→

Disability ( neurological status)

→ •Rapid assessment of neurologic status to identify life-threatening injury

•Pupil size and response

•Mental status (Glascow coma scale)

•Motor and sensory exam

•GCS ≤ 8 is a “coma ” and requires intubation for airway protection

correct

•GCS ≤ 8 is a

•GCS ≤ 8 is a “coma ” and requires intubation for airway protection

•GCS ≤ 8 is a “coma ” and requires ??

•GCS ≤ 8 is a “coma ” and requires intubation for airway protection

eyes, motor, verbal response (Glasgow coma scale)

correct

E4
4= spontaneous
3= to touch
2= to pain
1= no response

M6
6 oriented
5 moves toward the pain
4 withdrawal flexion from pain
3 abnormal flexion ( decortate )
2 abnormal extentions ( decerberate )
1 no response

V5
5 oriented
4 confused
3 incomperehensive words
2 incomperehensive sounds
1 no response

correct

E4
4= spontaneous
3= to touch
2= to pain
1= no response

right

E4
4=
3=
2=
1=

E4
4= spontaneous
3= to touch
2= to pain
1= no response

M6
6 oriented
5 moves toward the pain
4 withdrawal flexion from pain
3 abnormal flexion ( decortate )
2 abnormal extentions ( decerberate )
1 no response

M6
6 oriented
5 moves toward the pain
4 withdrawal flexion from pain
3 abnormal flexion ( decortate )
2 abnormal extentions ( decerberate )
1 no response

M6
6
5
4
3
2
1

M6
6 oriented
5 moves toward the pain
4 withdrawal flexion from pain
3 abnormal flexion ( decortate )
2 abnormal extentions ( decerberate )
1 no response

M 2?

2 abnormal extentions ( decerberate )

M3

3 abnormal flexion ( decortate )

M4

4 withdrawal flexion from pain

M5

5 moves toward the pain

V4

confused

V2

SOUNDS

Exposure?

Head to toe visualization of the patient for injury

•Critical point

•Maintenance of spine precautions

•Prevention of heat loss

•Under cervical collar

•Log Roll and digital rectal exam

•Back and flanks exam

ccorrect

Exposure?

Exposure?

Head to toe visualization of the patient for injury

•Critical point

•Maintenance of spine precautions

•Prevention of heat loss

•Under cervical collar

•Log Roll and digital rectal exam

•Back and flanks exam

•Maintenance of spine precautions

•Prevention of heat loss

•Under cervical collar

•Log Roll and digital rectal exam

•Back and flanks exam

Exposure?

Head to toe visualization of the patient for injury

•Critical point

•Maintenance of spine precautions

•Prevention of heat loss

•Under cervical collar

•Log Roll and digital rectal exam

•Back and flanks exam

Contraindication to folly catheter

1.blood through meatus

2.high riding prostate

3.perineal ecchymosis

1.blood through meatus

2.high riding prostate

3.perineal ecchymosis

correct

.perineal ecchymosi

Contraindication to folly catheter

2.high riding prostate

Contraindication to folly catheter

1.blood through meatus

Contraindication to folly catheter

Secondary Survey:
ALLERGY
MEDIICATION
Ppast history
Llast meal
Eevents

Allergies, Medications, Past history, Last meal, Events leading to injury)

right

2ndry survey?

Aleergy
Medication
Past history
Last meal
Events

The goal is to identify missed injuries

2ry survey

2ry survey goal?

The goal is to identify missed injuries

Complete history and physical examination

Head-to-toe evaluation of trauma patient.

Reassessment of all vital signs

correct
2ry

2ry survey

Complete history and physical examination

Head-to-toe evaluation of trauma patient.

Reassessment of all vital signs

When to move to Secondary Survey ?

•Primary survey (ABCDE) is completed

•Resuscitative efforts are under way

•Improvement of the patient's vital functions has been demonstrated

correct

•AMPLE history

Allergies

Medications

Past Medical History

Last meal

Events leading to trauma/Mechanism of injury

right

M2
M3
M4

2→ decerebrate extension
3 → flecion decorticare
4 → WITHDRAWAL FELXION