580 likes | 1.31k Views
TRAUMA. Begashaw M (MD). Trauma. Introduction. is one of the leading causes of mortality, morbidity and disability mostly affects people in their productive years The causes of trauma are various. Deaths due to trauma. Immediate death (50 %) Occur in the first few minutes
E N D
TRAUMA Begashaw M (MD)
Introduction • is one of the leading causes of mortality, morbidity and disability • mostly affects people in their productive years • The causes of trauma are various
Deaths due to trauma • Immediate death (50%) • Occur in the first few minutes • injuries to the brain, heart & major blood vessels 2. Early deaths (30%) • Occur in the first few hours • due to the collections and bleedings in the chest and abdomen, extensive fractures and increased intracranial pressure 3. Late deaths (20%) • Occur days or weeks after the injury • due to sepsis and organ failure
DEFINITION _is tissue damage, which occurs due to transfer of different forms of energy • Types of Trauma I- Cause: Homicidal injuries Road traffic accident and falls Industrial accidents, burn II- Mechanism: A/ Blunt Injury: Caused by acceleration, deceleration, rotational or shearing force B/ Penetrating Injury: Caused by a direct breach by penetrating object E.g. Bullet injury, stab injury
Mechanism of Injury • Blunt Force Trauma • Penetrating Trauma
TREATMENT • Advanced trauma life support (ATLS) protocol • The ATLS _primary survey and resuscitation followed by _secondary survey and definitive management
The Flow of the Initial Assessment Primary Survey Resuscitation Reevaluation Reevaluation Detailed Secondary Survey Definitive Care
I- The primary survey and resuscitation • Quick evaluation to detect immediately life threatening situations • Institution of measures A Airway and cervical spine B Breathing C Circulation with hemorrhage control D Disability-Dysfunction of CNS E Exposure/Environment
A- Air way-cervical spine • Assess the patency of air way • May be compromised by_backfallen tongue, broken tooth, vomitus, blood • Use_ suctioning, jaw trust, positioning, oropharyngeal tube or endotrachealtube to open it, take care of the cervical spine-hard collar • 100 % oxygen
B- Breathing • Assess adequacy of breathing-“Look, listen, feel” • Compromised by pneumothorax, hemothoraxor multiple rib fractures causing flail chest • Tension pneumothorax-venous cannula through second intercostal space in the mid-clavicular line • If open chest wound seal with occlusive dressing
C- Circulation • Assess the circulatory volume-pulse, capillary refill, neck veins • Look for external hemorrhage and arrest it by pressure, bandaging • Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound • Open a wide bore IV line take blood sample for cross match and start resuscitation with Normal saline or Ringer’s lactate
Dysfunction • Assess level of consciousness using AVPU method A = alert V = responding to voice P = responding to pain U = unresponsive • Glasgow coma scale (GCS) • Look for any Neurological deficit or lateralizing sign
E- Expose • Expose (undress) the patient fully • Avoid hypothermia
II- Secondary survey and definitive management • done after the life threatening conditions have been evaluated and resuscitative measures are instituted • A- Take History _Time of injury _ Mechanism of injury _Amount of bleeding _ Loss of consciousness _Any intervention performed or drugs given
B- Do a proper and systematic examination of all body systems • C- investigations _ hematocrit, cross-match, urinalysis, X-ray, ultrasound, etc. • Never send a patient with unstable vital signs for investigation or referral before resuscitation • D- Appropriate treatment _laparotomy ,POP cast
ROAD TRAFFIC ACCIDENTS (RTA) • is the leading cause of trauma deaths • Several factors contribute to the high magnitude _poor condition and design of roads _traffic mix _poor condition of the vehicles _poor traffic rule enforcement
Injuries are caused by • sudden acceleration e.g. a pedestrian hit by car • decelerations _ passenger to collide with the interior of car • high risk of serious and multiple injuries: • Presence of flail chest • Roll over • Death of another person in the car
FIREARM INJURIES _due to homicidal violence _missile injuries - bullets from pistols, rifles, machine guns _degree of injury depends on the amount of energy _E=½mv2 (E = energy transferred, m = mass of the missile, v = velocity of the missile)
Classification I- Low- velocity _ missiles fired from hand guns (<400m/s) _Injury is limited to the path of the bullet II- High velocity _bullets fired from rifles, machine guns and blast fragments (>1000m/s) _ small entrance ,a larger exit wound _Tissue damage occurs in the surrounding tissue _Foreign bodies, dirt and clothing in wound
Management • appropriate wound debridement _Excision of all dead tissue _Removal of all dirt, foreign bodies and free bone fragments _irrigation of wound with copious amount of saline • debrided wound should be left open for closure later N.B: Never close missile wounds primarily, not even the very trivial looking ones! _broad spectrum antibiotics _tetanus prophylaxis
BURN • is a coagulation necrosis of tissue due to thermal or chemical injury • Women and children are mostly affected • Types of burns Flame burn Scalding Chemical burn Electrical burn
Severity • Depends _the burn depth (degree) _the extent or percentage of the body surface • Determining the percentage of burn surface is important to calculate the amount of fluid requirement • Determination of burn depth is important for burn wound management
Classification of Burn according to depth (degree) 1- First degree _ involves epidermis _ manifests with erythema 2- Second degree (partial thickness) _involves part of dermis _manifests with blisters, edema, moist surface and pain at the affected site 3- Third degree (full thickness) _ Involves complete burn _charred, white or grayish , pain free
4) 4th degree burn - involves the underlying viscera or other organs e.g. bone,liver
Management • General _ATLS system _Airway obstruction -rapidly after inhalation injury or delayed for 24-48hours _ Endotracheal intubation or tracheotomy _ Breathing _ Circulation _Analgesia
Fluid resuscitation _Major burn (> 20% body surface area) _Open IV line-normal saline/ringer lactate • Parkland Formula _First 24° _4 mL Lactated Ringer’s X weight in kg X % total body surface area burned _50% of fluid in first 8° _50% over next 16° _ Keep urinary output 0.5 – 1 mL/kg
Criteria for admission any burn over 20%(adults) & 10%(children) BSA Special areas e.g. eye, face, hands, feet, perineum Inhalation injury Chemical & electrical burns Full thickness burns where grafting is indicated Children & elderly pts who require additional medical or social support
Burn wound management • Goals _close wound _prevent infection _reduce scarring and contracture _provide for comfort • Wound cleaning • Debridement • Mechanical • Surgical • Topical antibacterial therapy
Dressing the Burn • The Exposure Method-Open Technique: _wound is cleaned by antiseptic agents _Left exposed to air _used for burns of the face and burns of large surface area • The occlusive method-ClosedTechnique _a thick dressing after cleaning with antiseptics covers the burn wound _used mostly for outpatient treatment of small burns
Emergency escharotomy and fasciotomy should be done for deep circumferential burns of limbs, neck or trunk • Wound Care: Grafting • Indications for grafting _full thickness burns _priority areas _wound bed pink, firm, free of exudate _bacterial count < 100,000/gram of tissue
Escharotomy Facial and hand burns
Analgesia • Most burn patients are in severe pain _analgesic doses of IV narcotics regularly to control the pain
Prevention of Infection • impaired resistance against infection • Most deaths occur due to pneumonia and wound sepsis • Prophylactic antibiotics (penicillin) are given for severe burns • Topical antimicrobials e.g. 1% silver sulfadiazine are helpful for deep 2nd and 3rd degree burns
Nutrition _ Naso -gastric tube -more than 25% burn -nausea and vomiting • in catabolic state • lose weight very fast • daily calorie required is 20 Kcal/Kg + 70 Kcal/%burn • Daily protein requirement is 1 gm/kg + 3 gm/%burn.
Prophylaxis against tetanus • Prevention of contractures & rehabilitation _move all joints