Trauma: Definition, Pathophysiology, and Management

1. WELCOME

2. TRAUMA Presented by: Reviewed by: Mr. Santhosh Thomas Prof. Shashkumar Lecturer, HOD,MSN Department, YNC YNC Updated Date: 19-03-2019.

3. Learning objectives. • The students will be able to: • Define trauma. • Narrate Etiology of trauma. • Explain the Pathophysiology of trauma. • Enumerate the clinical manifestations of trauma. • Explain the classification , diagnosis and management of trauma.

4. Trauma. •  An injury (such as a wound) to living tissue caused by an extrinsic agent • Psychological Trauma •  A disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury.

5. Trauma is the Greek word for "wound". Although the Greeks used the term only for physical injuries. INCIDENCE

6. INCIDENCE • About 5.8 million people die each year as a result of injuries. This accounts for 10% of the world's deaths, 32% more than the number of fatalities that result from malaria, tuberculosis and HIV/AIDS combined. • Nearly one third of the 5.8 million deaths from injuries are the result of violence and nearly one quarter are the result of road traffic crashes. • Injuries affect all age groups but have a particular impact on young people.

7. Classification of Trauma. • Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. • A minor trauma is defined both in the Statutory Accident Benefits Schedule (SABS) and the MIG as a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associated sequelae.

8. Classification of major trauma.

9. Causes. • Rape • Domestic violence • Natural disasters • Severe illness or injury • The death of a loved one • Witnessing an act of violence • Road traffic accidents.

10. Pathophysiology

11. Signs and symptoms • Signs include night terrors, edginess, irritability, poor concentration and mood, anxiety. • Symptoms of trauma include denial, anger sadness and emotional outbursts.(Psychological) • Some common physical signs of trauma include paleness, lethargy, fatigue, poor concentration and a racing heartbeat. 

12. Trauma can be Scary • Keep your cool • We all set the tone • Know your role, follow the leader • Follow an algorithm • Don’t get distracted • You know this stuff • Traumatic arrest have around 99% mortality.

15. Diagnostic evaluation.

17. Primary Survey • Advanced Trauma Life Support • Assess and address life threatening injuries in order • “ABCDE of trauma” • Airway • Breathing • Circulation • Neurologic “deficit” • Exposure of patient

18. Airway • Identify airway obstruction • Maintain cervical spine immobilization • May require definitive airway • Orotracheal intubation • Blind nasotracheal intubation • Cricothyroidotomy • Tracheotomy

19. Breathing • Identify life threatening deficits in breathing mechanism • Simple pneumothorax • Tension pneumothorax • Massive hemothorax • Open pneumothorax (“sucking chest wound”) • Flail chest

20. Circulation • Or, identification of shock Definition of shock – inadequate organ perfusion • Causes of shock • Hemorrhage/hypovolemia • Compressive • Cardiogenic • Neurogenic • Sepsis

22. Circulation • Treatment of shock • Direct pressure on external bleeding • Initial 2 liter bolus of crystalloid fluid • Responders • Non-responders • Transient responders • Definitive management for ongoing hemorrhage

23. Neurologic “deficit” • Rapid assessment of neurologic status to identify life-threatening injury • Pupil size and response • Mental status (Glascow coma scale) • Motor and sensory exam

24. Glascow Coma Scale • 3 – 15 point scale to assess mental status only • Best observed response • Modified scale for children • GCS ≤ 8 is a “coma” and requires intubation for airway protesction

25. Eye opening • None = 1 • To painful stimuli only = 2 • To voice only = 3 • Spontaneously open = 4 Verbal response • None = 1 • Incomprehensible sounds = 2 • Incomprehensible words = 3 • Confused = 4 • Oriented = 5 Motor response • None = 1 • Decerebrate (extension) posturing = 2 • Decorticate (flexion) posturing = 3 • Withdraws to pain = 4 • Localizes pain = 5 • Follows commands = 6

26. Exposure Head to toe examination of the patient for injury • Pitfalls • Maintenance of spine precautions • Prevention of heat loss • Under cervical collar • Back and flanks

27. TRIAGE RELATED TO TRAUMA. • Priority 1 (P1) or Triage 1 (T1): immediate care needed - requires immediate life-saving intervention. Colour code red. • P2 or T2: intermediate or urgent care needed - requires significant intervention within two to four hours. Colour code yellow. • P3 or T3: delayed care - needs medical treatment, but this can safely be delayed. Colour code green. • Dead is a fourth classification and is important to prevent the expenditure of limited resources on those who are beyond help. Colour code black.

29. Adjuncts to the Primary Survey • Exams during or after primary survey to aid in identifying life-threatening injuries • Chest x-ray • Pelvis x-ray • Focused abdominal sonogram for trauma (FAST) • Diagnostic peritoneal lavage (DPL)

30. Secondary Surveyand Definitive Treatment • The secondary survey is a complete head to toe evaluation of the patient • Adjuncts to the secondary survey include CT’s, plain radiographs, blood tests • Treatment plans, especially for multiple injuries, based on clinical status and specific injuries

31. Resuscitation • Restoring organ perfusion • How much is enough? What are the endpoints of resuscitation? • Heart rate, blood pressure, urine output • May lead to “compensated shock” • Organ-specific indicators of perfusion • ie gastric tonometry • Global indicators of perfusion • Lactic acid, base deficit • Cardiac output, oxygen delivery, oxygen consumption • Mixed venous O2 saturation (SvO2)

32. Damage-control laparotomy • A shift from definitive management of abdominal injuries to stabilizing the patient for resuscitation • Goals • Stop bleeding • Control contamination • Temporary abdominal closure

33. Prevention of Trauma. • Seat-belts, helmets and enforced blood alcohol limits to prevent road traffic injuries; • Home hazard modification to prevent falls among the elderly; • Pool fencing to reduce the risk of drowning; • Treatment of depression to prevent suicide; • School-based educational programmes to prevent intimate partner violence • Home visitation programmes to reduce child maltreatment.

34. Complications of Trauma. • The Big Five Complications"—hemorrhage, respiratory failure, renal failure, sepsis, and multiorgan failure. • Post traumatic stress syndrome.

35. Recapitulation. • What is trauma, Explain. • What are the clinical manifestations of trauma. • Write its pathophysiology and management of trauma.

36. Refrences. • Brewer M. Five keys to successful nursing management. Philadelphia: Williams & Wilkins, 2003. • Lee RI, Jone LW. The fundamentals of good medical care. Chicago: University of Chicago Press, 1983.