Traumatology Lecture Notes PDF

Traumatology 1 Lecture no. 4 DR.QUTAIBA MUNER  DEFINITION OF TRAUMA Trauma originates from the Greek word meaning ‘wound’. It means that a physical force exerted on a person has led to a physical injury. External forces that can lead to injury include chemical, thermal, ionizing ra...

Traumatology 1 Lecture no. 4 DR.QUTAIBA MUNER  DEFINITION OF TRAUMA Trauma originates from the Greek word meaning ‘wound’. It means that a physical force exerted on a person has led to a physical injury. External forces that can lead to injury include chemical, thermal, ionizing radiation and, most frequently, those of mechanical origin. Major trauma there are injuries to more than one body region and organ system. Trauma remains the most common cause of death and disability in children and young adults in many countries. The degree and severity of trauma sustained can depend upon the magnitude of force exerted.. Trauma: the magnitude of the problem 1- The vast majority of injuries are not life or limb threatening 2- Severe trauma continues to be a major cause of death in young patients 3- Older patients with fragility fractures pose an additional burden to the healthcare system 4- Look for important features of injuries that could influence the outcome The assessment of trauma The initial assessment of the trauma patient, besides the clinical examination, should include analysis of the interactions between the 1 – patient, 2- the mechanism of injury and the 3-extent of The Injury sustained. For instance, a 50-year-old male passenger in a car involved in a head-on collision with another vehicle may sustain rib fractures, a sternal fracture, thoracic spine fracture and possibly cardiac contusion. Abdominal injuries could also be suspected but, overall, the clinician, knowing the mechanism, Can Proceed Quickly In Making The Diagnosis And initiating treatment. 1-Mechanisms Mechanisms may be blunt, penetrating or even of a combined nature A - Blunt trauma can be categorized as 1- direct or2- indirect. And continues to be the most common mechanism. In a direct mechanism, the damage is localized to the site of injury in an indirect mechanism the damage occurs at a distant site. B - Penetrating mechanisms can be divided into those caused by:- a - sharp objects, The sharp object, for example a pair of scissors, will cause damage to the underlying tissues that it contacts (skin, subcutaneous fat, fascia, etc.). Local examination will confirm the extent of the injury and the need for wound exploration. B- Firearms induce penetrating injuries, which are more difficult For instance, a high velocity projectile (bullet) causes extensive damage to the tissues as it travels, 2- Patient factors 1- age Children and adults of different ages will sustain different injuries as a result of the same mechanism. 2- Past medical history, medication And allergy risk will direct not only The clinical assessment but also the treatment. ROLE OF THE TRAUMA TEAM All hospitals managing severe trauma should have a dedicated Trauma team who are available immediately to attend and manage patients presenting with severe trauma. The composition of the team will invariably involve doctors from the emergency department, anesthetics and/or critical care, orthopedics and general surgery. Increasingly, radiology and hematology doctors are contributing to the trauma team, as part of the patient’s initial assessment and management. THE MANAGEMENT OF TRAUMA The first step in management of trauma patients is := 1- performing the primary survey, the goal of which is to identify and treat conditions that constitute an immediate threat to life first and follows c ABCDE. c: Exsanguinating external haemorrhage Experience from war zones has shown that exsanguinating external haemorrhage from massive arterial bleeding needs to be controlled even before the airway is managed. Most of these injuries are due to gunshot wounds or blasts and are mainly seen in military practice. 1- Bleeding must be controlled immediately by the application of packs and pressure directly onto the bleeding wound and artery 2- Failure to control bleeding in the limb by direct pressure should be followed by the application of a tourniquet proximal to the wound. the time for which the tourniquet is applied must be recorded. A - Airway Management With Cervical Spine Protection. `All trauma patients should have their cervical spine immobilized And Protected throughout. An immediate Assessment Of The patient’s airway is made. A compromised airway requires a stepwise progression, first clearing the airway by suctioning secretions or blood, followed by simple airway maneuvers such as a jaw thrust, chin lift and insertion of an oropharyngeal or nasopharyngeal airway. Advanced airway maneuvers necessitate the insertion of a cuffed endotracheal tube. This may require an anesthetic with rapid sequence induction B: Breathing and ventilation All patients should receive high-flow oxygen. Life-threatening chest pathology such as tension pneumothorax, massive hemothorax and flail segment should be diagnosed and Managed immediately. C: Circulation and hemorrhage 1 - All patients require adequate intravenous access with at least two large-bore intravenous (IV) cannulae.. 2- Blood should be taken for cross-match and laboratory assessment, including hemoglobin and venous lactate. 3- Equipment and expertise for insertion of central venous access should be available where peripheral access is not easily obtainable. 4- An assessment of the haemodynamic status should be made to identify shocked patients: the skin may be pale, cool and sweaty, the pulse rate raised to over 100 per minute and the blood pressure low. Hypotensive trauma patients are treated as hypovolemic until proven otherwise. The initial aim of resuscitation is to maintain the blood supply to the vital organs: the brain, heart and kidneys. For a short time, this can be achieved with a target systolic blood Of 70–90 mmHg, although a higher pressure of >90mmHg should be the target if a head injury is suspected. Small boluses of IV fluids (e.g. 250 mL of O negative blood, or normal saline if blood is not immediately available) should be Administered to Achieve This target, 5- The primary source of hemorrhage must be identified and controlled as soon as possible. Identification and management of Hemorrhage:- The sites of major hemorrhage in trauma patients are the chest, abdomen, pelvis, long bones and external hemorrhage. Blunt trauma patients frequently have multiple sources of hemorrhage. Clinical examination and investigations should aim rapidly to confirm or exclude significant bleeding from each of these sites Computed tomography (CT) from the head to pelvis with IV contrast, the so called ‘whole body CT’ (WBCT) is the gold standard investigation in patients with signs or symptoms of multiple injury. Traditionally, chest and pelvis radiographs have been obtained early in the assessment of patients with polytrauma but these investigations are increasingly omitted in favor of obtaining a rapid CT scan Most trauma centers now have rapid access to CT scanners located within, Some patients will be so hemodynamically unstable on arrival that they need immediate surgical control of their hemorrhage before a CT scan. The most likely sources are abdominal or pelvic bleeding. D- Disability On admission, a- the Glasgow Coma Scale (GCS score) should be calculated the pupils assessed for size and reaction to light.B- the patient observed to determine whether they are moving all four limbs. C- The core temperature must be recorded. E - Exposure The patient must be adequately exposed to allow a thorough and systematic clinical examination during the secondary survey but they must be kept warm. Severe degloving injuries to the upper and lower limbs following a high-speed road traffic accident. Every effort should be made to maintain normal temperature by minimizing unnecessary exposure of The patient, The cABCDE of trauma care c – Control of massive external haemorrhage A – Airway with cervical spine protection B – Breathing and ventilation C – Circulation and hemorrhage control: D – Disability (neurological status) E – Exposure (assess for other injuries) SECONDARY SURVEY All severely injured patients require a detailed top to toe examination after life- threatening injuries have been identified and managed during the primary survey to identify any missed ‘minor’ injuries.These injuries have the potential to cause significant long-term disability. The following things are done in secondary survey. i. Intravenous line is secured with a wide bore cannula (16 Fr), preferably in the upper limb if not already secured. ii. Blood is drawn and sent for the following urgent investigations. Hemoglobin, packed cell volume. Blood grouping and cross matching of blood. If this is a problem, then one can administer O negative blood. Blood sugar, urea and electrolytes (Na, K), Renal failure can occur early in hypovolemic shock. iii. Nasogastric tube aspiration to empty the stomach. iv. Foley catheter, CVP line, pulse oximeter and continues ECG monitoring are indispensable in the severely injured patient. v. Peritoneal lavage is a technique that enables the clinician to investigate the possibility Of Intraperitoneal bleeding. vi. Investigations: X-rays of skull, cervical spine, chest, pelvis and the limbs are commonly required. CT scan, MRI, US abdomen are other imaging studies. vii. Other general measures Nil by mouth and consent if the patient has to be taken up for surgery. Strict intake output chart is maintained. There should be a urine output of 30ml/ hour in an adult Pain relief—Morphine and pethidine are effective drugs; nowadays diclofenac sodium injections are also used. They do not produce sedation Prophylactic broad spectrum antibiotics are started immediately H2 blockers are given intravenously as a prophylactic against gastrointestinal bleeding induced by major trauma.  Trauma patients are at risk for venous thromboembolism and its associated morbidity and mortality patients at higher risk for venous thromboembolism are those with 1- multiple fractures of the pelvis and lower extremities,2- spinal cord injury,3- Morbidly obese patients and 4- those over 55 years of age are at additional risk. Administration of low molecular weight heparin (LMWH) is initiated as soon as bleeding has been controlled.. Definitive Care Phase During this phase, the comprehensive care of the patient is planned according to the site and type of injury, e.g. laparotomy for doubtful diagnosis or visceral injury in case of abdominal trauma, fracture stabilization, transfer of the patient to a referral trauma