INITIAL

MANAGEMENT OF
THE TRAUMA
PATIENT I
Hadi Munib
Oral and Maxillofacial Surgery Resident
Outline

 Introduction
 Assessment of the severity of injury
 Primary Survey: Airway
 Primary Survey: Breathing
 Primary Survey: Circulation
 Neurological Examination
 Secondary Assessment
 References
Introduction
 Nearly 25% to 33% of deaths caused by injury can be
prevented when an organized and systematic approach is
used.
 Severe injuries are immediately life-threatening and interfere
with vital physiologic functions; examples are compromised
airway, inadequate breathing, hemorrhage, and circulatory
system damage or shock.
 Approximately 5% of patient injuries but represent over 50%
of injuries associated with all trauma deaths.
 Urgent injuries make up approximately 10% to 15% of all
injuries and offer no immediate threat to life; such as injuries
to the abdomen, orofacial structures, chest, or extremities
that require surgical intervention or repair, but their vital
signs are stable.
Introduction

 Immediate Deaths: within seconds or minutes of the injury; lacerations of the

brain, brainstem, upper spinal cord, heart, aorta, or other large vessels.
 Early Deaths: within the first few hours after injury. “golden hour” because
these patients may be saved with rapid assessment and management of their
injuries; central nervous system (CNS) injury or hemorrhage.
 Late Deaths: days or weeks after the injury and is usually due to sepsis,
multiple organ failure, or pulmonary embolism.
Assessment of Severity of Injury

 “The goal of triage is to rapidly and accurately

identify patients with life-threatening injuries
and to manage these patients with the available
resources to achieve the greatest possible
outcome, while at the same time avoiding
unnecessary immediate transport of less
severely injured patients”
Glasgow Coma Scale
 Developed in 1974 by Teasdale and Jennet.
 It was the first attempt to quantify the severity of head injury.
 Best motor response is a reflection of the level of CNS function
 Best verbal response shows the CNS’s ability to integrate information
 Eye opening is a function of brainstem activity.
 The use of the letter T designates that the patient was intubated at the time of
the examination.
 Weaknesses: it does not take into account focal or lateralizing signs, diffuse
metabolic processes, or intoxication.
Trauma Score and Revised Trauma Score

 The Trauma Score was developed by Champion and colleagues to quickly

assess the extent of injury to vital systems and the severity of the injury to
provide proper triage and treatment of the patient.
 It was later modified by Champion and coworkers to become the Revised
Trauma Score in 1989.
 The Trauma Score provided a means of characterizing the physiologic
status of injured patients’ cardiovascular, respiratory, and neurologic
systems.
 The Trauma Score incorporated five variables: GCS, respiratory rate,
respiratory expansion, systolic blood pressure, and capillary refill.
 The Revised Trauma Score omitted respiratory expansion and capillary refill
owing to difficulty assessing these elements in the field and the wide
margin for interpretation
Trauma Score and Revised Trauma Score

 With the original Trauma Score, the total points added to give a trauma
score of 1 to 15;
 The higher the score, the better the prognosis.
Trauma Score and Revised Trauma Score

 In Revised Trauma Score:

 A value of 0 to 4 is assigned for each variable to give a total range of 0 to
12, with lower scores representing an increasing severity of injury.
 Trauma scores of around 8 indicate an approximate 33% probability for
mortality.
Injury Severity Score

 Each injury is evaluated and categorized according to the injured organ

system (respiratory, CNS, cardiovascular, abdominal, extremities, and skin)
and graded according to the severity of the injury:
 1 is minor
 2 moderate
 3 severe non–life-threatening;
 4 life-threatening, survival probable
 5 survival not probable
 6 fatal cardiovascular, CNS, or burn injuries.
High Probability of Life-Threatening Injuries

 Evidence of a collision involving high-energy dissipation or rapid

deceleration.
 A fall of 6 m or more.
 Evidence that the patient was in a dangerous environment when injured
(e.g., a burning building or icy water).
 An automobile accident in which it takes more than 20 minutes to remove
the patient, there is significant damage to the passenger compartment,
rearward displacement of the front axle has occurred, the patient is ejected
from the vehicle, a rollover occurs, or other passengers have died.
High Probability of Life-Threatening Injuries

 Anatomic factors that correlate with mortality include:

 Penetrating trauma to the head, neck, torso, groin, or thigh
 Flail chest
 Major burns
 Amputations
 Two or more proximal long bone fractures; and paralysis.
 Concurrent disease or factors such as age of younger than 5 years or older
than 55 years and known cardiac or respiratory disease may sharply
worsen a patient’s prognosis, even in the presence of only a moderately
severe injury
Primary Survey: ABCs

 A: Airway
 B: Breathing
 C: Circulation
 D: Degree of Consciousness
 E: Exposure
 Are there any contraindications to performing Primary Survey?
 Circulation first? new classification
 Airway Maintenance and C-Spine control
 The highest priority in the initial assessment of the trauma patient is the
establishment and maintenance of a patent airway.
 Upper airway obstruction may be due to:
 Bleeding from oral or facial structures
 Aspiration of foreign materials
 Facial fractures, airway structure trauma, or regurgitation of stomach contents.
 The upper airway is obstructed by the position of the tongue, especially in the
unconscious patient; Head-Tilt,Chin-Lift
 Jaw Thrust (Safest Method of Manipulation in regards to suspicion of cervical
spine fracture)
Airway Maintenance and C-Spine Control

 Using the fingers in sweeping motion to remove debris, vomitus, blood,

dentures that may be responsible for the obstruction.
 A tonsillar suction tip is helpful to remove accumulations from the pharynx.
 Patients who may have basilar skull fractures or fractures of the cribriform
plate may, with the use of a soft suction catheter or nasogastric tube, be
compromised because these tubes may inadvertently be passed into the
contents of the cranial vault during attempts at a pharyngeal suction.
Airway Maintenance and C-spine Control

 The use of soft or semi-rigid collars allows, at best, only 50% stabilization of
movement.
 Cervical spine injury should be assumed present and protected against until
the patient can be stabilized and cervical injury can be ruled out during the
secondary survey.
 Oral airway devices are usually preferred with patients with decreased
levels of consciousness
 Breathing
 If the patient is breathing spontaneously—confirmed by feeling and listening for
air movement at the nostrils and mouth— supplemental oxygen may be
delivered by facemask.
 The exchange of air does not guarantee adequate ventilation.
 The chest wall of a patient with a pneumothorax, flail chest, or hemothorax may
move but not ventilate effectively.
 Very slow or rapid rates of respiration usually suggest poor ventilation.
 If signs of adequate ventilation deteriorate, a secure airway should be placed
(ideally an endotracheal tube) and assisted ventilation should be started
 Breathing

 Changes in intrathoracic pressure may convert a simple pneumothorax into a

tension pneumothorax.
 There should be equal expansion of the chest wall without intercostal and
supraclavicular muscle retractions during spontaneous respiration.
 Signs of chest injury or impending hypoxia are frequently subtle and include
anxiety, an increased rate of breathing, and a change in breathing pattern,
frequently toward shallower respirations
Breathing

 The chest wall should also be inspected for bruising, flail chest,
and bleeding, and the neck should be evaluated for evidence
of tracheal deviation, subcutaneous emphysema, and
distended jugular veins.
 The chest should be palpated for the presence of rib or sternal
fractures, subcutaneous emphysema, and wounds.
 Auscultation of the chest may reveal a lack of breath sounds in
an area, suggestive of inadequate ventilation.
 Distant heart sounds and distended neck veins are suggestive
of cardiac tamponade.
 Arterial oxygen tension should be maintained between 80 and
100 mmHg.
Immediate life-threatening conditions and should be
quickly identified and treated.

 Open pneumothorax
 Flail chest
 Tension pneumothorax
 Massive hemothorax
 Small 15 – 60%
 Large >60%
Pneumothorax

 The presence of a pneumothorax should be considered in patients who:

 Rapidly become acutely ill
 Develop severe respiratory distress
 Exhibit decreased breath sounds
 Hyper-resonance on one side of the chest
 Distended neck veins
 Deviation of the trachea away from the involved side.
 Open Pneumothorax
 Defect in the chest wall, allowing air to be moved in and out of the pleural
cavity with each respiration. Open wound
 The involved lung collapses on inspiration and slightly expands on expiration.
 Causing air to be sucked in and out of the wound; sucking chest wound.
 If the opening in the chest wall is approximately two thirds of the diameter of
the trachea, air will pass through the path of least resistance— the chest wall
defect.
 With the collapse of the involved lung and a loss of negative pleural pressure,
the expired air from the normal lung passes to the involved lung instead of out
of the trachea, and it returns to the normal lung on inspiration.
 Results in large functional dead space in the normal lung and, combined with
loss of the involved lung, may develop into a severe ventilation-perfusion
problem
Open Pneumothorax

 Coverage of the defect with Sterile Occlusive Dressing secured on three

sides to the chest
 Unsecured side: one-way valve; air escape on expiration
 Air accumulation in the thoracic cavity and Tension Pneumothorax; if all
edges are secured
 petrolatum gauze; Temporary dressing
Open Pneumothorax

 A chest tube must be placed in a distant site on the affected chest wall to
avoid development of a tension pneumothorax, and the wound must
eventually be closed in the operating room.
 If the lung does not expand after closure of the defect or if signs of poor
ventilation persist, the patient should be placed on a ventilator with positive
end-expiratory pressure (PEEP) to expand the lung.
 Closed Pneumothorax
 Blunt trauma to the chest or a lung laceration, possibly from a fractured rib.
 Air escapes from the lung into the pleural space.
 As the pressures equalize, the affected lung collapses.
 A ventilation-perfusion deficit occurs because the blood circulated to the
affected lung is not oxygenated.
 With a pneumothorax, percussion of the chest shows hyper-resonance.
 Breath sounds are usually distant or absent.
 Pneumothorax is confirmed and evaluated with upright chest radiographs.
Management

 Small; Admission and close observation

 The patient is otherwise healthy
 Symptom free
 Does not need general anesthesia or positive-pressure ventilation
 If the size of the pneumothorax is not increasing as measured on serial 24-
hour chest radiographs.
 Rarely the case
 Chest Tube
 Chest Tube Insertion

 3- cm long incision
 The intercostal muscles are separated with a large Kelly clamp
 The chest tube is inserted over the superior margin of the fifth rib to avoid the
neurovascular bundle traveling on the inferior margin of the fourth rib and
advanced superiorly and posteriorly into the pleural cavity
 Upright posteroanterior and lateral chest radiographs should be taken to
confirm the position of the chest tube, the position of the last drainage hole on
the tube, and the position and amount of air or fluid remaining in the pleural
cavity.
 Chest Tube

moderate-
sized chest
tube (32–40 Fr
in adults or
26–30
Fr in children)
Midaxillary line is
preferred for
cosmetic reasons
 Tension Pneumothorax
 When the injury acts as a one-way valve through the chest wall or from the lung
into the pleural cavity without equilibration with the outside atmosphere.
 A dangerous progressive increase of intra-pleural pressure develops as air
enters the pleural cavity on inspiration but cannot escape on expiration,
causing complete collapse of the affected lung.
 As the pressure increases, the trachea and mediastinum are displaced to the
opposite pleural cavity and impinge on the normal lung.
 The positive intra-pleural pressure compresses the vena cava, leading to
decreased cardiac output.
 The compression of the normal lung causes shunting of blood to non-ventilated
areas and severe ventilatory disturbances.
Tension Pneumothorax

 These changes develop into a rapid onset of hypoxia, acidosis, and shock
 The most common causes of tension pneumothorax are:
 Mechanical ventilation with PEEP
 Spontaneous pneumothorax in which emphysematous bullae have failed to
seal
 Blunt chest trauma in which the parenchymal lung injury has failed to seal
Tension Pneumothorax

 If untreated, a tension pneumothorax results quickly in death.

 If a developing tension pneumothorax is suspected, the positive intra-
pleural pressure should be released as quickly as possible.
 The pressure can be released by inserting a large-bore needle (14–16
gauge) anteriorly into the affected hemi-thorax through the 5th intercostal
space in the midclavicular line.
 This quickly converts the tension pneumothorax to a pneumothorax, which
can be treated with placement of a chest tube
Right Pneumothorax
 Hemothorax
 The collection of blood in the pleural cavity.
 It is commonly the result of penetrating injuries that disrupt the vasculature
 It can result from blunt trauma that tears the vasculature.
 The initial loss of blood collected in the pleural cavity may come from lung
injuries, but because of low pulmonary arterial pressure, the blood loss is
usually slowed.
 Massive Hemothorax usually results from injuries to the aortic arch or
pulmonary hilum; may result from injuries to the internal mammary arteries or
intercostal arteries, which are branches of the aorta.
 A hemothorax may dangerously reduce the vital capacity of the lung and
contribute to hypovolemic shock.
Hemothorax

 A Hemothorax is usually associated with a pneumothorax.

 The subsequent blood loss causes:
 Hypotension
 Decreased cardiac output
 Metabolic acidosis; which when combined with the ventilatory compromise,
results in hypoxia and respiratory acidosis.
 Hemothorax
 A Hemothorax should be suspected after penetrating or blunt chest trauma if
the patient is in shock with reduced breath sounds and with a chest dull to
percussion on one side.
 The neck veins may be flat because of severe hypovolemia or distended as a
result of the mechanical effects of a chest full of blood.
 With the loss of a small amount of blood (<400 mL), the diagnosis is difficult
because there may be little or no change in the patient’s appearance, vital
signs, or physical findings.
 Fluid collections greater than 200 to 300 mL can usually be seen on a good
upright chest radiograph as blunting of the costophrenic angle.
 The supine radiograph is less accurate
 Hemothorax
 Treatment:
 Restoration of the circulating blood volume with transfusion of fluids or blood
products through large-bore intravenous lines
 Control of the airway and support of the ventilation as required
 Drainage of the accumulated blood from the pleural cavity.
 A large chest tube (36–40 Fr) should be inserted and directed posteriorly and
superiorly to avoid damage to a possibly elevated diaphragm.
 The chest tube should be connected to an underwater seal and steady suction
(20–30 cmH2O).
 Hemothorax
 If the chest tube becomes clotted and fails to drain, another chest tube should
be placed rather than an attempt made to irrigate the first tube.
 With massive bleeding, auto-transfusion of the drained blood is possible until
banked blood is available.
 Persistent hemorrhage requires surgical exploration.
 Thoracotomy for intrathoracic bleeding is indicated for the following:
 Initial thoracostomy tube drainage greater than 1500 mL of blood
 Persistent bleeding at a rate greater than 200 mL
 Increasing hemothorax seen on chest radiographic studies
 Persistent hypotension despite blood replacement with other sites of blood loss
having been ruled out or the patient decompensating after an initial response to
resuscitation.
Hemothorax

 Emergency thoracotomy may be necessary for control of blood loss but

mortality from this procedure is very high.
Hemothorax
Hemothorax
 Flail Chest
 Multiple Rib fractures at several sites along the rib (3 or more ribs in at least 2
locations)
 Resulting unstable segment of chest wall moves paradoxically during
respirations—inward with inspiration and outward with expiration.
 A flail chest may affect respiratory ability to the point at which hypoxemia
occurs.
 The pain associated with the respiratory effort may also compromise the
ventilatory compliance of the patient.
 The fractured ribs may have punctured the lung, causing a tension
pneumothorax or hemithorax.
 The contused lung may be asymptomatic in the initial presentation but develop
complications later with gas exchange.
Flail Chest

 Little abnormal breathing may be apparent immediately after the injury.

 Later, as fluid moves into the lung with the developing contusion, lung
compliance falls, and more pressure is needed to inflate the lungs.
 The pulmonary contusion underlying major chest wall injuries may be the
primary cause of hypoxia and morbidity in patients with flail chest.
 Mortality in patients sustaining severe blunt chest trauma remains relatively
high at 12% to 50%
 Flail Chest
 A flail chest is usually apparent on visual examination of the unconscious
patient.
 It may not be initially apparent in the conscious patient because of splinting of
the chest wall.
 The patient moves air poorly as a result of paradoxical breathing, and
movement of the thorax is asymmetrical and uncoordinated.
 The region of the fractures may be tender to palpation
 Recommended management of flail chest involves three treatment
considerations:
 Pain management
 Supplemental oxygen delivery
 Ventilation control.
Flail Chest

 Prolonged relief is best obtained with intercostal nerve blocks to block the
pain from the fractured ribs, thereby allowing the patient to breathe deeply
and cough.
 The use of narcotic medications must be limited to avoid respiratory
depression.
 A volume-cycled respirator with endotracheal intubation is indicated to
provide PEEP ventilation and intermittent mechanical ventilation (IMV).
 This “internal splinting” with ventilatory support effectively manages the
inadequate depth of ventilation, improves oxygen absorption in the
segments of pulmonary contusion, and decreases atelectasis.
 If proper management with ventilatory assistance is initiated early, the
respiratory support may be required for only 2 to 4 days.
Flail Chest

 If management is delayed until the patient demonstrates respiratory

difficulty, prolonged therapy for up to 14 days may be necessary.
 The use of mechanical ventilation may cause further injury resulting in
pneumothorax, airway injury, alveolar damage, or ventilator-associated
pneumonia.
 Circulation
 The most common cause of shock in the traumatized patient is hypovolemia
caused by hemorrhage, either externally or internally into body cavities.
 Inadequate tissue perfusion can cause irreversible damage to vital organs such
as the brain or kidneys in a short time period.
 During the primary assessment, a minimum of two large-bore (14–16 gauge)
intravenous catheters should be placed peripherally if fluid resuscitation is
required.
 At the time of placement of an intravenous catheter, blood should be drawn
from the catheter to allow for typing, cross-matching, and baseline hematologic
and chemical studies.
 If there is any doubt of adequate ventilation, arterial blood should be obtained
for blood gas analysis
Circulation

 Tissue perfusion and oxygenation are dependent on cardiac output and are
best initially evaluated by physical examination of skin perfusion, pulse
rate, and mental status of the patient.
 Blood pressure levels are commonly used as a surrogate for cardiac output
and to suspect hypovolemia, but in the emergency situation, blood pressure
measurement may be an unreliable indicator of developing shock.
 The response of the blood pressure level to intravascular loss is nonlinear.
 Compensatory mechanisms of increased cardiac rate and contractility,
along with venous and arteriolar vasoconstriction, maintain the blood
pressure in the young healthy adult during the first 15% to 20% of
intravascular blood loss.
 Circulation
 After a blood loss of 20%, the blood pressure level may drop significantly.
 In the elderly patient with less efficient compensating mechanisms, the decline
in blood pressure levels may begin to develop after a 10% to 15% blood loss.
 The patient may arrest at an intravascular blood loss of 40%.
 Blood pressure level may be insensitive to the early signs of shock.
 The usual baseline blood pressure level of the patient is often unknown
 A patient who has a systolic pressure of 120 mmHg but is normally
hypertensive may have a significant loss, whereas a healthy young athlete may
have a normal systolic pressure of 90 mmHg and the blood loss might be
assumed to be greater than it is.
 Circulation
 Skin perfusion is the most reliable indicator of poor tissue perfusion during the
initial evaluation of the patient.
 The early physiologic compensation for volume loss is vasoconstriction of the
vessels to the skin and muscles.
 The cutaneous capillary beds are one of the first areas to shut down in response
to hypovolemia because of stimulus from the sympathetic nervous system and
the adrenal gland through epinephrine and norepinephrine release.
 The release of the catecholamines causes sweating, and during palpation, the
skin may feel cool and damp.
 The lower extremities are usually first to be affected, and the first indication of
intravascular loss may be paleness and coolness of the skin over the feet and
kneecaps.
 Circulation
 Check of the capillary filling time by performing a blanch test gives an estimate
of the amount of blood flowing to the capillary beds.
 Capillary Refill Time; The time required for the blood to return to the capillary
beds, represented by the restoration of normal tissue color.
 Normally less than 2 seconds; capillary beds are receiving adequate circulation.
 A CRT of less than 1 second is suggestive of a hyperdynamic state and
vasodilation
 A CRT longer than 2 seconds suggests poor perfusion due to peripheral
vasoconstriction
 Circulation
 The pulse rate is a more sensitive measure of hypovolemia than is the blood
pressure, but it is affected by other factors commonly associated with the
trauma situation, such as:
 The patient’s pain,
 Excitement, and emotional response
 Resulting in tachycardia without underlying hypovolemia.
 Adults with tachycardia greater than 120 beats per minute (bpm), hypovolemia
should be expected and investigated further.
 Patients who have pacemakers, are taking heart blocking medications such as
propranolol or digoxin, or have conduction abnormalities within the heart,
hypovolemia may not cause tachycardia.
 Circulation
 The most distal palpable pulse may give some indication of the blood pressure
and cardiac output.
 If the radial pulse is palpable, the patient’s systolic blood pressure is greater
than 80 mmHg
 If the femoral pulse is palpable, the patient’s systolic blood pressure is 70
mmHg or higher
 If the carotid pulse is noted, the systolic blood pressure is greater than 60
mmHg.
 Cardiac dysrhythmias such as premature ventricular contractions or arterial
fibrillation produce an irregular rate and rhythm, signaling the potential loss of
compensating mechanisms maintaining myocardial oxygenation.
 Decreased intravascular volume is immediately reflected in decreased urinary
output
 Circulation
 Any patient with significant trauma should always have an indwelling urinary
catheter inserted to monitor urine volume every 15 minutes.
 A minimally adequate urine output is 0.5 mL/kg/hr
 Fluid therapy should be initiated to maintain at least this level of urinary output.
 If the patient’s injuries include pelvic fractures or blunt trauma to the groin, a
urinary catheter should not be placed until the urethra has been evaluated for
injury.
 If urethral injury is unlikely, the urinary catheter may be placed with minimal
concern after a rectal examination.
 Classic signs of urethral injury include blood at the meatus, scrotal hematoma, or
a high-riding boggy prostate on rectal examination.
 Compensatory mechanisms maintain blood flow to the brain, and hypoperfusion
to the brain does not develop until the systolic blood pressure falls below 60
mmHg.
 Circulation
 Hypovolemia caused by hemorrhage may commonly cause flat neck veins.
 Distended neck veins, suggest either tension pneumothorax or cardiac
dysfunction.
 Cardiac tamponade presents a clinical picture similar to that of tension
pneumothorax
 Distended neck veins,
 Decreased cardiac output
 Hypotension.
 Blunt or penetrating trauma may cause blood to accumulate in the pericardial
sac.
 The blood in the pericardial sac results in inadequate cardiac filling during
diastole, diminished cardiac output, and circulatory failure.
 Circulation
 Cardiac tamponade usually is associated with penetrating wounds to the chest
that have injured the tissues of the heart.
 The classic Beck’s triad of decreased systolic blood pressure levels, distended
neck veins, and muffled heart sounds may be observed, although all three are
rarely seen together.
 The expected distended neck veins caused by increased central venous
pressure may be absent because of hypovolemia.
 The neck veins, if distended, may become distended further during inspiration
(Kussmaul’s sign)
 Pulsus paradoxus (lowering of the systolic pressure by > 10 mmHg on normal
inspiration) may be accentuated or absent
 Circulation
 Cardiac tamponade is initially managed by prompt pericardial aspiration
through the subxiphoid route.
 Radiographs and physical examination may be not helpful in the diagnosis of a
cardiac tamponade.
 A fast scan ultrasound may provide evidence of pericardial fluid, but a high
index of suspicion may be the best asset in the diagnosis of a developing
cardiac tamponade.
 A positive pericardial aspiration along with a history of chest trauma is
frequently the only method of making a correct diagnosis.
 Because of the self-sealing qualities of the myocardium, aspiration of pericardial
blood alone may temporarily relieve symptoms.
Circulation

 All trauma patients with a positive pericardial aspiration require open

thoracotomy and inspection of the heart.
 Pericardial aspiration may not be diagnostic or therapeutic if the blood in
the pericardial sac has clotted, as occurs in 10% of patients with cardiac
tamponade.
 If aspiration does not lead to improvement of the patient’s condition, only
emergent thoracotomy can solve the problem unless another injury to the
patient has been overlooked
Pericardiocentesis
 Control of Bleeding
 Hemorrhage is defined as an acute loss of circulating blood.
 Normally, the blood volume is approximately 7% of the adult ideal body weight.
 A 70-kg male has approximately 5 L of circulating blood.
 The blood volume does not increase significantly in obese patients, and in
children, the blood volume is usually between 8% and 9% of body weight (80–
90 mL/kg).
 Bleeding may be external or internal into body cavities.
 Most external hemorrhage can be controlled with direct pressure to the wound.
 If an extremity is involved, it should be elevated.
 Control of Bleeding
 Scalp or skin wounds may best be managed with immediate closure with large
monofilament sutures (without cosmetic closure considerations) and direct
pressure until the hemorrhage is controlled.
 the scalp may lose a large amount of blood, which oozes from the galea and
loose connective tissue layers.
 2-0 Nylon
 Internal Carotid Arteries or Maxillary artery system; facial bleeding
 Most hemorrhages from facial injuries can be controlled with direct pressure or
packing.
 Control of Bleeding
 The potential internal sites of hemorrhage are the thoracic cavity, abdomen,
retroperitoneum, and extremities.
 A complete physical examination with radiography and computed tomography
(CT) is useful to identify hemorrhages into these areas.
 When there is no evidence of external or intrathoracic bleeding, continued
severe hypovolemia is usually the result of bleeding into the abdomen or at
fracture sites.
 Blood loss with fractures should be considered to be at least 1000 to 2000 mL
for pelvic fractures
 500 to 1000 mL for femur fractures
 250 to 500 mL for tibia or humerus fractures
 125 to 250 mL for fractures of smaller bones.
Control of Bleeding

 A hematoma the size of an apple usually contains at least 500 mL of blood.

 Control of hemorrhage into internal spaces is not done in the primary
survey unless the hemorrhage may have damaging effects on the
cardiovascular or pulmonary system.
 Slow internal hemorrhage may be controlled by:
 Splinting, casting, or fixation of fractures
 The defense mechanisms of vascular occlusion, retraction, and clot
formation
 By open exploratory surgery.
Pelvic
Fracture
 Femur Fracture

Fat embolism syndrome is

usually associated with major
fractures of long bones,
especially of the femur.
The patient typically does well for 24
to 48 hours and then develops
progressive respiratory and central
nervous system deterioration.

Hypoxemia, thrombocytopenia, fat in

the urine, and a slight drop in
hemoglobin.
 Hypovolemic Shock in multisystem trauma patient

The guidelines in the table are based on the “3-for-1” rule. This rule is
derived from the empiric observation that most patients in hemorrhagic
shock require as much as 300 mL of electrolyte solution for each 100 mL of
Management of Hypovolemic Shock

 The speed with which resuscitation is initiated and the time required to
reverse shock are the factors crucial to the patient’s outcome.
 The focus should again always be on controlling the hemorrhage.
 Aggressive and continued volume resuscitation is not a substitute for
definitive control of hemorrhage.
 Two large-bore (≥16 gauge) short angiocatheters are a minimum for
beginning fluid therapy.
 Initial attempts should be made to percutaneously place the catheters in
the basilic or cephalic veins in the antecubital fossa of both arms.
 Percutaneous placement of femoral, jugular, or subclavian vein catheters
may also be used if there are no abdominal injuries or pelvic or femur
fractures.
Management of Hypovolemic Shock

 When the patient is in an extreme hypovolemic state, placement of

percutaneous catheters may be difficult; venous cut-down procedures to
expose the saphenous vein provide venous access for fluid resuscitation.
 Flow is directly dependent on the catheter’s internal diameter and is
inversely dependent on its length.
 Two catheters of the same length and diameter, whether inserted
peripherally or centrally, give the identical flow rate, but a longer central
catheter delivers a lower possible maximum flow rate than does a shorter
peripherally placed catheter.
 Management of Hypovolemic Shock
 A central line through the subclavian or internal jugular vein routes usually
takes longer to place than does a peripheral line and may require disruption of
other resuscitation measures such as chest compressions during placement.
 A central line may complicate resuscitation of the trauma victim by causing or
aggravating a developing pneumothorax or hemothorax or other potential
complications associated with its placement.
 Peripheral intravenous lines are the access of choice in the primary
management of the trauma patient.
When to place Foley’s Catheter?

 A Foley catheter should be placed in the bladder as soon as possible to

measure urinary flow.
 There are three contraindications for the insertion are:
 The presence of blood at the urethral meatus
 Hemorrhage into the scrotum
 High-riding prostate
 May convert a small incomplete Laceration into a complete Laceration and
can introduce infection into the perineal and retropubic hematoma
Which Fluid should be initiated for Resuscitation?

 The initial intravenous resuscitation fluid used in most hospitals is a

balanced electrolyte solution such as lactated Ringer’s solution or 0.9%
normal saline.
 During prolonged shock, isotonic fluid is lost from the intravascular and
interstitial spaces to the extracellular space.
 Initially, the patient should be given 2 L of intravenous fluid (20 mL/kg for a
pediatric patient) rapidly over 10 to 15 minutes and then observed.
 If this maneuver does not raise the systolic blood pressure to at least 80 to
100 mmHg, the patient requires additional fluid, blood, and control of blood
loss.
Which Fluid should be initiated for Resuscitation?

 There is still controversy about the use of colloids (albumin, plasma protein
fractions) and artificial plasma expanders (dextran, hetastarch) to treat
hypovolemia secondary to trauma; cost of these materials does not appear
to be justified by clinical data.
 Extensive meta-analysis shows increased mortality with the use of colloids
over Crystalloid; there is still support for their use particularly if blood
replacement is delayed or inadequate or in patients with severe head
injuries that require fluid restriction therapy to control rising intracranial
pressure (ICP) levels.
 When to transfuse Blood?

 Most patients respond to initial fluid administration, but this improvement may
be transient; especially in patients who have lost greater than 20% of their
blood volume.
 With excess hemorrhage, red blood cells must be replaced in the intravascular
circulation to maintain an optimum oxygen- carrying capacity.
 The safest type of blood to administer is blood that has been fully cross-
matched.
 Obtaining fully cross-matched blood may require 30 minutes or more and is
usually not immediately possible in the trauma situation.
 Type-specific blood is a safe alternative and can usually be ready within 5 to 15
minutes
When to transfuse Blood

 With whole blood loss and requirements for early blood replacement, O-
negative blood may also be given in patients with excessive hemorrhage.
 The O blood group is the most common and contains no cellular antigens.
 Theoretically, O-negative blood can be given to persons regardless of the
individual’s blood group with minimal risk of antigen-antibody hemolytic
reaction.
 No more that 4 U of O-negative blood should be given
 When to transfuse Blood

 Fresh frozen plasma (FFP) is frequently used as a volume expander and

provides all of the clotting factors except platelets.
 It also provides opsonins and some complement factors, which may be deficient
in patients with severe trauma or shock.
 During massive transfusions, FFP is often given after an elevation of
International Normalized Ratio (INR), especially if packed red blood cells are
administered in an attempt to prevent coagulation abnormalities.
 Platelet levels below 100,000/mm3 may be an indication for a platelet
transfusion.
When to transfuse Blood?

 Ideally, the amount of blood given should be equal to the amount lost by
the patient, but this is difficult to assess in the trauma patient.
 In critically ill or injured patients, the ideal hemoglobin is 10 g/dL
(hematocrit ≥ 30%).
 If the patient does not respond to initial attempts; either surgical
intervention is required to control continued hemorrhage or the initial
diagnosis of hypovolemia is incorrect
When to transfuse Blood?

 A patient being treated for hypovolemic shock is usually placed in a head-

down or Trendelenburg position to empty the venous side of the peripheral
circulation back to the heart.
 The patient with multisystem trauma has injuries to the abdomen or chest
that may interfere with the respiratory capacity if the patient is in the
Trendelenburg position.
 Both of the patient’s legs can be elevated while the patient’s trunk is
maintained in a supine position.
 Neurological Examination
 Brief neurologic examination quickly identifies any severe CNS problems that
require immediate intervention or additional diagnostic evaluation.
 A lack of consciousness with altered pupillary reaction to light requires an
immediate CT scan of the head and possible management with mannitol or fluid
restriction.
 Be aware of any medications that the patient may have received or drugs she
or he may have taken that may affect the pupils.
 Some individuals will have anisocoria; an unequal size of the pupils.
Neurological Examination

 The Committee on Trauma of the American College of Surgeons

recommends the use of the mnemonic AVPU.
 Each letter describes a level of consciousness in relation to the patient’s
response to external stimuli:
 Alert
 Responds to vocal stimuli
 Responds to painful stimuli
 Unresponsive
Neurological Examination

 The reactivity of the pupils to light provides a quick assessment of cerebral

function.
 The pupils should react equally.
 Changes represent cerebral or optic nerve damage or changes in ICP.
 The most common causes of coma or depressed levels of consciousness are
hypoxia, hypercarbia, and hypoperfusion of the brain.
 Depressed levels of consciousness and narrow pinpoint pupils may result
after an opiate overdose
 Neurological Examination

 Treatment requires the narcotic antagonist naloxone hydrochloride, 0.4 mg

initially.
 Care should be taken to avoid a quick violent withdrawal phase in the opiate
abuser; this is accompanied by profound distress, nausea, agitation, and muscle
cramps.
 Both hypoglycemia and hyperglycemia can cause depressed levels of
consciousness.
 If a quick blood glucose level cannot be obtained, the patient can be given an
immediate bolus of 25 g of glucose to manage critical hypoglycemia.
 A benefit of the glucose load is the hyperosmolar status that may, for a short
time, reduce cerebral edema, if present.
EXPOSURE
Question

 A 21-year-old female is an unrestrained driver involved in an RTA, She

suffers a scalp laceration with multiple facial lacerations and is noted to
have lost 1000mL of blood at the scene. You would expect her vital signs to
be consistent with:
A. Pulse rate >100, normal systolic blood pressure, decreased pulse pressure,
respiratory rate of 20-30, urinary output of 20-30mL/hr.
B. Pulse rate <100, normal systolic blood pressure, normal or increased pulse
pressure, respiratory rate of 14-20, urinary output of >30mL/hr.
C. Pulse rate >120, decreased systolic blood pressure, decreased pulse
pressure, respiratory rate of 30-40, urinary output of 5-15mL/hr.
D. Pulse rate >140, decreased systolic blood pressure, decreased pulse
pressure, respiratory rate of >35, urinary output that’s negligible.
Question 2

 Which of the following is a contraindication for Chest tube placement?

A. Pleural Effusion
B. Pneumothorax
C. Pulmonary adhesions from previous surgery
D. Hemothorax
E. Chylothorax

Question 3: Chest Tube should be placed in the 2nd intercostal space in the mid-
axillary line or the 5th intercostal space in the mid-clavicular line
The above statement is
A. True
B. False
SECONDARY ASSESSMENT
 Secondary Assessment
 The secondary assessment does not begin until the primary assessment has
been completed and management of life-threatening conditions has begun.
 The patient’s vital signs and condition should be constantly monitored.
 Changes in the patient’s vital signs, respiratory and circulatory status, and
neurologic functions are expected in the first 12 hours.
 If at any time during the secondary survey the patient has a significant change
in status, a return to the primary survey and management is indicated.
Secondary Assessment

Secondary
Subjective Objective Assessme
nt
 Head and Skull
 Primary injuries to the head and skull may involve:
 Lacerations, abrasions, avulsions, and contusions of the scalp
 Fractures of the cranium and cerebral contusions
 Intracranial bleeding from lacerations or shearing injuries.
 The brain may also suffer secondary insults from intracranial bleeding, hypoxia,
and ischemia.
 Hypoxia is due to an impaired delivery of oxygen to the brain
 Ischemia can result from arterial hypotension, elevated ICP, or pressure on
intracranial vessels from expanding hematomas.
 Increased ICP can result in herniation of the brain from the cranial vault
A subdural hematoma is usually
caused by venous bleeding with
progressive loss of neurologic
function.
The epidural hematoma is
usually associated with skull
fractures near the
temporoparietal region, with
tearing of the middle meningeal
artery
 Head and Skull
 The secondary insults of hypoxia and various forms of ischemia are usually
preventable.
 About one half of patients with head injuries have some degree of reversible
injury caused by increased ICP that can be controlled with aggressive
management.
 Failure to prevent increased ICP is the most frequent cause of death in
hospitalized patients with a severe head injury.
 Hypertension with concomitant bradycardia may indicate increasing ICP
(Cushing’s phenomenon).
 Hypotension with tachycardia usually indicates blood loss.
 Shock is rarely associated with the primary neurologic injury, and systemic
sources of blood loss should be investigated.
Head and Skull

 The classic findings of Cushing’s phenomenon are usually present less than
25% of the time, even when the ICP is found to be greater than 30 mmHg.
 A value greater than 15 mmHg is considered abnormal.
 When an intracranial injury is suspected, CT scans can quickly and easily be
used to diagnose localized intracranial hemorrhage, contusion, foreign
bodies, and skull fractures.
Head and Skull

 As ICP increases above normal, a fairly standard progression of neurologic

abnormalities ensues, involving sections of the brain sequentially:
 The cerebral cortex; producing an altered state of consciousness
 The midbrain, producing dilation and then fixation of the pupils, initially on
the side of the lesion, with varying degrees of bilateral hemiparesis
 Pons, resulting in a loss of the corneal reflex and the occurrence of the
doll’s eye reflex
 The medulla, producing, in sequence, apnea, hypotension, and death.
 Head and Skull
 The head should be examined for signs of a basilar skull fracture:
 Hematoma over the mastoid process behind the ears (Battle’s sign)
 Hemotympanum; cerebrospinal fluid (CSF) rhinorrhea, or otorrhea
 Subscleral hemorrhage.
 Whenever a basilar skull fracture is suspected, a nasogastric tube should not be
used because the tube may inadvertently pass into the cranial vault
 Two regions of the brain, if injured, can produce unconsciousness:
 The cerebral cortices bilaterally
 Brainstem reticular activation system
 A sluggish reactive or a dilated nonreactive (blown) pupil on one side indicates
compression of the third cranial nerve by brain herniation in the unconscious
patient
Rhinorrhea
Otorrhea
Responses that test the third, sixth, and eighth cranial nerves, as well as ascending brainstem
pathways from the pontomedullary junction to the mesencephalon. A, The caloric response
(oculovestibular maneuver) involves the placement of cold water into the ear. In a comatose patient,
the eyes should tonically deviate toward the irrigated ear. B, Patient at rest.
C, In the oculocephalic response (doll’s eye reflex) in comatose patients, the head is turned from the
midline and there is a reflex movement of the eyes in the opposite direction of head rotation.
 Head and Skull

 In normal activity, when light is shone in one eye, both pupils constrict equally.
 The pupillary fibers are relayed bilaterally to the Edinger-Westphal nucleus of
the oculomotor or third cranial nerve.
 If a light is shone into the right eye and the left eye does not respond, there
may be a disruption of the right optic or left oculomotor nerves.
 If the light is then shone into the left eye and it does not respond, a disruption
of the third cranial nerve should be suspected.
 Pinpoint pupils after head trauma may indicate drug overdose or loss of
sympathetic tone as seen in Horner’s syndrome
Head and Skull

 Clear or red-tinged fluid that drains from the nose or ear should be
considered to be CSF.
 There is no reliable method available in the emergency department for
distinguishing CSF from nasal mucous drainage.
 The use of glucose indicator sticks is associated with a high incidence of
false-positive results.
 A useful aid may be a “ring sign; A drop of the fluid from the nose or ear is
placed on a piece of filter paper.
 If the fluid is CSF, the blood components of the fluid remain in the center
and rings of clear fluid form around them
Head and Skull

 Secondary effects of trauma such as edema, ischemia, infarction, brain

shift, and hydrocephalus can be seen on CT scans.
 In the acutely traumatized patient, CT scans can be used to diagnose
intracerebral and extra-cerebral blood collections with nearly 100%
accuracy.
 A significant mass lesion can cause cerebral ischemia by elevating ICP or by
compressing vascular structures.
 A CT scan should be done immediately after stabilization of the injured
patient.
CT scan Indications

 Seizure activity
 Unconsciousness lasting for more than a few minutes
 Abnormal mental status
 Abnormal neurologic Evaluation
 Evidence of a skull fracture found on physical Examination
 History of head trauma.
 A CT of the head may be obtained in all patients with blunt head trauma
who have experienced a loss of consciousness or mild amnesia, even those
with normal neurologic findings
Subarachnoid hemorrhage; blood within the cerebral spinal fluid
and meningeal intima and probably results from tears of small
subarachnoid vessels.

Blood is spread diffusely through the

arachnoid matter and usually does
not cause mass effect, but may
predispose a patient to cerebral
vasospasm
  Intracerebral hemorrhage; formed deep within the brain
tissue.

usually caused by shearing or

tensile forces that
mechanically stretch and tear
deep small-caliber arterioles
as the brain is propelled
against irregular surfaces in
the cranial vault.
 Subdural hematomas are
blood clots that form
between the dura and the
brain
They are usually caused by the
movement of the brain relative
to the skull, as is seen in
acceleration-deceleration
injuries.
e considerable shift of midline to the right.
 Chest
 It is estimated that chest injuries are responsible for 20% to 25% of all trauma
deaths per year in the United States.
 The secondary assessment of chest trauma involves the
 Evaluation of an upright chest radiograph for the presence of air in the
mediastinum or under the diaphragm
 Widening of the mediastinum or a shift from the midline
 Thoracic injuries and fractures that alter lung expansion
 The presence of fluid
 Chest
 Pulmonary contusions are treated in the same manner regardless of whether
there is an accompanying flail chest injury.
 Pulmonary contusions are common in blunt chest trauma because the capillary
damage within the lungs results in interstitial and intra-alveolar edema and
shunting.
 Pulmonary contusions and acute respiratory distress syndrome (ARDS) are the
most common potentially lethal chest injuries seen in the United States.
 The resulting respiratory failure does not occur instantaneously but develops in
24 to 72 hours
 Chest
 The patient may complain of pain and dyspnea, and blood gas levels tend to
deteriorate progressively over the initial 48 to 72 hours as increasing edema
develops in the alveoli.
 Chest radiographs reveal a developing opacification of the involved areas.
 Treatment involves adequate ventilation of the lungs, including chest
physiotherapy, supplemental oxygen, coughing with deep breathing, and naso-
tracheal suction.
 The use of steroids is controversial
 Injury to large intrathoracic arteries or veins may develop with blunt or
penetrating trauma; this is the most common cause of sudden death after an
automobile accident or a fall from a great height.
 Common sites of injury are the aortic root and the descending aorta at the origin
of the ductus arteriosus and at the diaphragm.
 These injuries are fatal within a few minutes—only 15% of patients with thoracic
aortic injuries are still alive on arrival at a hospital.
Chest

 Adjunctive signs on chest radiographs that are suggestive of thoracic

vascular injury include
 Widened mediastinum
 Fractures of the first and second ribs
 Obliteration of the aortic knob
 Deviation of the trachea to the right
 The presence of a pleural cap
 Deviation of the esophagus to the right
 Downward displacement of the left mainstream bronchus.
 Maxillofacial Area and Neck
 Soft tissue injuries; Facial Nerve or Parotid duct
 The eyelids.
 The face should be symmetrical without discolorations or swelling suggestive of
bony or soft tissue injury.
 The bony landmarks should be palpated; Any step-off or irregularities along the
bony margin are suggestive of a fracture.
 Numbness over the area of distribution of the trigeminal nerve is usually noted
with fractures of the facial skeleton.
 The oral cavity should be inspected.
 Any teeth lost at the time of injury must be accounted for because the tooth
may have been aspirated or swallowed.
Maxillofacial Area and Neck

 The neck should also be examined for injury.

 Subcutaneous air may be visualized if massive injury is present; if subtle, it
may be detected only by palpation.
 The presence of air in the soft tissues may be the result of tracheal damage
or pneumothorax.
 Any externally expanding edema or hematoma of the neck must be
observed closely for continued expansion and airway compromise.
 Carotid pulses should be assessed.
 Palpation for abnormalities in the contour of the thyroid cartilage and for
the midline position of the trachea in the suprasternal notch should be
performed
Comminuted ZMC Fracture
Sublingual Hematoma
What do you suspect in such case?
Maxillary Mobility Examination
 Spinal Cord
 There are more than 10,000 spinal cord injuries per year in the United States,
usually caused by motor vehicle accidents.
 Multiple studies have reported a 10% to 20% association of cervical spine
injuries with maxillofacial injuries in the multiply traumatized patient
 Data suggest no increase in cervical spine injury when facial trauma is present.
 Approximately 55% of spinal injuries occur in the cervical region
 15% in the thoracic region
 15% in the thoracolumbar junction
 15% in the lumbosacral area.
 Spinal Cord
 Up to 50% of cervical spine injuries seen on CT radiographs are missed on plain
neck radiographic cervical spine series owing to the difficulty in obtaining a
clear view of the cervical spine with plain films.
 Visualization of all seven cervical vertebrae is important.
 The shoulders must be distracted inferiorly by pulling down on the arms to
provide a clear view of the spinal anatomy from C6 through T1.
 If visualization of C6 and T1 cannot be obtained, the radiographic view may be
improved by placing the arms in a “swimmer’s position,” with downward
traction on one arm and upward traction on the other and the radiograph beam
aimed through the axilla of the upward arm.
Spinal Cord – Radiographic Assessment

 Fractures and fracture dislocations of the spine by evaluation of the

anteroposterior diameter of the spinal canal
 The contour and alignment of the vertebral bodies
 Displacement of bony fractures of the laminae, pedicles, or neural fascicles;
and soft tissue swelling.
 Three-way cervical views (anteroposterior, oblique cervical, and lateral
cervical) plus an open-mouth odontoid view or a CT scan of the neck
coupled with adequate cervical spine immobilization during evaluation and
resuscitation should allow the cervical spine to be viewed safely.
Spinal cord

 On a lateral cervical spine radiograph, the soft tissue thickness between the
pharynx and osseous C3 should be less than 5 mm.
 An increase in this area suggests a fracture.
 The distance may vary with inspiration or expiration.
 On the lateral view, the features to be examined are the general contour of
the spine, the vertical alignment of the anterior and posterior margins of
the vertebral bodies, the mid-laminar line, the width of the spinal column,
and evidence of compression or fracture of individual vertebrae.
 On anteroposterior views, the height and alignment of the spinous
processes and the inter-spinous distances are examined.
 Normal Cervical
Normal cervical
Radiographs;
radiographs: lateral
anteroposterior
Flexion – Teardrop Fracture
 Abdomen
 Penetrating wounds must be identified
 Many surgeons believe that the safest management of penetrating wounds is a
laparotomy, although surgical management of penetrating wounds continues to
evolve.
 The abdominal girth should be measured at the umbilicus soon after admission
to establish a baseline against which to evaluate possible intra-abdominal
bleeding.
 Abdominal rigidity and tenderness are important signs of peritoneal irritation by
blood or internal contents, and they may be the main indications for a
laparotomy of a patient injured by blunt trauma.
Abdomen

 Plain films have limited value in abdominal trauma.

 They can be useful in localizing foreign bodies, bony structures, and free air
with the use of anteroposterior and cross-table views.
 The use of diagnostic peritoneal lavage (DPL), once a standard diagnostic
test used in blunt and occasionally penetrating abdominal traumas, has
decreased significantly with the advancement in CT and ultrasonography.
 DPL is indicated in patients with a history of blunt abdominal trauma and
increasing pain, with unexplained hypovolemia after multiple trauma, who
are candidates for laparotomy but who have questionable findings, and who
have experienced severe trauma and may require an extended period
under general anesthesia.
 Abdomen

 Absolute contraindications to DPL are a history of multiple abdominal operations

and obvious indications for an exploratory laparotomy—free air, evisceration,
and/or penetrating trauma.
 A DPL is usually performed with a sterile intravenous catheter inserted
percutaneously through a small midline incision approximately 2.5 to 4 cm below
the umbilicus.
 The catheter is advanced into the pelvis after the bladder has been emptied.
 If no blood, bile, or intestinal fluid is aspirated, the abdominal cavity is irrigated
with 1 L of saline.
 The fluid is then drained from the abdomen through the intravenous tubing.
It is generally felt that the presence of 100,000
red blood cells/mm3 or 500 white blood
cells/mm3 after blunt trauma is sufficient to
make a laparotomy mandatory
Abdomen

 CT scanning of the abdomen is also acceptable if the patient is stable and

emergent laparotomy is not indicated.
 The advantages to CT include that it is:
 Noninvasive
 Capable of discerning the presence, source, and approximate quantity of
intraperitoneal hemorrhage
 Occasionally can demonstrate active bleeding.
 It is helpful in the evaluation of hematuria and, if used early enough, in
determining renal artery injury
 Abdomen
 Disadvantages include suboptimal sensitivity for injuries of the pancreas,
diaphragm, small bowel, and mesentery.
 Injuries of the small bowel and mesentery can have profound morbidity and
even mortality if not diagnosed early.
 In the absence of hepatic or splenic injuries, the presence of free fluid in the
abdominal cavity suggests an injury to the gastrointestinal tract and/or its
mesentery and mandates early surgical evaluation and possible intervention.
 Complications also can result from intravenous contrast administration.
 The cost can also be significant, especially if established indications are not
followed
Abdomen

 Ultrasonography or focused assessment with sonography for trauma is

rapidly becoming an integral diagnostic component in trauma centers.
 Its primary role is detecting free intraperitoneal blood after blunt trauma.
 This is accomplished by a focused examination of specific anatomic areas
where blood or fluid is most likely to accumulate.
 Ultrasonography can also evaluate the pericardial space and intraperitoneal
spaces.
 Ultrasonography carries a host of advantages:
Advantages of F.A.S.T

ultrasonography can serve as

an accurate and rapid test and
is a less expensive diagnostic
screening tool than are DPL and
CT.
Disadvantages of
F.A.S.T
 Genitourinary Tract
 The perineum should be examined for contusions, hematomas, lacerations, and
urethral bleeding.
 A rectal examination should assess for the presence of blood within the bowel
lumen, a high-riding prostate, presence of blood or pelvic fractures, and quality of
sphincter tone.
 Pregnancy tests should be performed on all females of childbearing age.
 The major cause of urethral ruptures is blunt trauma.
 Approximately 10% of patients with a pelvic fracture have an associated posterior
urethral rupture.
 The major cause of urethral ruptures is blunt trauma.
 Approximately 10% of patients with a pelvic fracture have an associated posterior
urethral rupture.
 Anterior urethral ruptures are also commonly associated with blunt trauma. (Mostly
men)
 Genitourinary Tract
 Blood at the urethral meatus is the single best indicator of urethral trauma.
 A rectal examination must be performed on all patients with a suspected pelvic
injury.
 If the prostate is not palpable, a genitourinary injury should be suspected.
 Urine should be obtained and evaluated for the presence of blood.
 A urinalysis with 10 or more red blood cells on a high-power field is suggestive of a
urinary system injury.
 Hematuria is the best indicator of renal injury, and the degree of hematuria may not
correlate with the degree of injury.
 If the patient with a blunt injury is stable but has hematuria, a CT scan can be used
to accurately visualize the genitourinary system and abdominal and retroperitoneal
contents.
 Approximately 40% of rape victims report having sustained physical injury; of those,
54% receive medical care in a hospital emergency department.
 Extremities
 Pelvic fractures, fractures of the femur, and multiple fractures of other long
bones may cause hypovolemic shock and life-threatening blood loss, the
primary site of which may be difficult to determine.
 Typical closed fractures of the pelvis may lose 1 to 5 L of blood; Femur fractures
1 to 4 L; Arm fractures 0.5 to 1 L from the vasculature.
 Physical examination should consist of inspection and palpation of the chest,
abdomen, pelvis, and all four extremities.
 All peripheral pulses should be examined for evidence of vascular injury.
 Pulse rates should be equal; any abnormality of distal pulse rate suggests a
vascular injury and must be explained.
 Doppler examination of the extremity is useful, but angiography is the best test
for definitively evaluating a suspected vascular injury when the diagnosis is in
doubt
 Extremities
 Direct pressure should be used to control hemorrhage, and fractures should be
splinted as quickly as possible.
 Splints should generally include joints above and below the site of injury.
 Prompt orthopedic consultation should be obtained.
 Fat embolism syndrome is usually associated with major fractures of long
bones, especially of the femur.
 The patient typically does well for 24 to 48 hours and then develops progressive
respiratory and CNS deterioration.
 Concomitant laboratory value changes include hypoxemia, tachypenia,
tachycardia, thrombocytopenia, fat in the urine, and a slight drop in
hemoglobin.
 A petechial patch may be present.
 Question 1

 Which of the following is a sign of Basilar Skull Fracture?

A) Sublingual Hematoma
B) Otorrhea
C) Rhinorrhea
D) Raccoon Eyes
E) B, C and D are correct

Question 2: Presence of blood at meatus is an indication for Foley’s Catheter

placement.
Regarding the above statement, the statement is
A) True
B) False
Question 3

 CT scan is indicated in which of the following scenarios

1- GCS of 15
2- Any signs of Basilar Skull fracture
3- Falling down of 3 m height
4- More than 1 episode of vomiting
A) 1,2,3 and 4 are indications
B) 1,2 and 4 are indications
C) 2 and 4 only are indications
D) 2,3 and 4 are indications
 References
 Peterson’s Principles of Maxillofacial Surgery: Chapter 14: Initial Management of
the Trauma Patient
 Fonseca Oral and Maxillofacial Surgery; Chapter 1: Initial and Postoperative
Management of the Craniomaxillofacial Trauma Patient
THANK YOU!