Principles of Trauma Symphony of Surgery Dr. Hassan Bukhari Depart of Surgery 4-1435

Objectives By the end of this discussion, the doctors will be able to*: Recognize the impaction of trauma Understand the trimodal death distribution understand the general principles of Primary and Secondary Survey and management Establish the ability to recognize the critical scenarios in trauma patients *ATLS-Student Course

Contents MCQ / Scenarios – based lecture Why trauma is important? What is the Trimodal death distribution and the golden hours? Mechanisms of Injury Primary Survey Secondary Survey References

Why Trauma is Important? Around 5 million deaths worldwide Motor vehicle crash (MVC) 1 million deaths annually The leading cause of death between the age of 1 and 44 in developing country Almost 5000 deaths in KSA in one year (1429)* 1 death every one and half hour!!! *www.saher.gov.sa

Trimodal death phases Immediate death ( --- ) Early death ( --- ) Brain, spine, CV Early death ( --- ) Brain bleed, rupture organ Late death ( --- ) Infection, organ failure

Mechanisms of Injury Blunt Trauma Penetrating Trauma MVC Fall PHBC Stabbing Gunshot

MCQ #1 20 year old male pt, involved in MVC, came to ER unconscious and low blood pressure with bleeding wound in the leg. What is the most important initial step? 1. Control airway 2. Control blood pressure 3. Control bleeding wound 4. Order chest x-ray ✓

Initial assessment and management Prehospital Phase Paramedics Hospital Phase Triage Primary Survey + Resuscitation Adjuncts to primary survey Secondary Survey Adjuncts to secondary survey Definitive treatment

Primary Survey

A Primary Survey Airway control with cervical spine Alignment Quickest way to assess airway? Types of airways? A

Primary Survey Breathing Look, feel and listen Pulse oximetry B

C Primary Survey Circulation + Control the bleeding wound Pulse, BP, bleeding wound Hemorrhagic shock C

D Primary Survey Disability Glascow coma scale (GCS): 15 GCS Pupils Lateralization Glascow coma scale (GCS): 15 Eye: 4 Verbal: 5 Motor: 6 Most important predictor of outcome D

Primary Survey Exposure Avoid hypothermia E

MCQ #2 38 YO Female was hit by a car when crossing the street. She is screaming of pain in her leg. Her HR 98, BP 90/50, good breath sound bilateral, deformed left leg. What is the most appropriate intervention: 1 – Intubate 2 – Insert chest tube 3 – Establish intravenous access and give fluid 4 – Send her home because she is not nice with you ✓

Resuscitation For each step in Primary survey, you should fix it before you move to the next step Airway – intubate or not Breathing – give O2 , insert chest tube Circulation – give fluid, stop the bleeding

Adjunct to Primary Survey ECG Foley catheter + NGT Blood tests X-rays FAST (focused assessment with sonography for trauma)

MCQ # 3 48 YO Male, fell down a 5 meter ladder. He is talking to you, C/O difficulty in breathing. HR 88, BP 110/90, O2 Sat 92 and he has no breath sound in the right chest. What would be the appropriate initial assessment and management? 1- Breathing, airway, circulation 2-Airway, circulation, breathing 3-Circulation, breathing, airway 4-Insert chest tube immediately after checking the airway ✓

Secondary Survey History (AMPLE) Physical examination A – Allergies M – Medications P – Past Medical / Pregnancy L – Last meal E – Event / Environment Physical examination Head – to - Toe

MCQ # 4 79 YO female. She slipped then fell down the stairs. She is talking to you, comfortable, HR 60, BP 110/70, O2 sat 95. the rest of primary survey is within normal. She told you that she has HTN. What part of AMPLE is very important in this particular patient: 1- Allergy 2- Medication 3- Past Surgical history 4-Pregnancy ✓

Adjuncts to Secondary Survey Additional X-ray CT scan Definitive U/S Diagnostic peritoneal lavage (DPL)

Transfer to Trauma center when needed Definitive Treatment Transfer to Trauma center when needed

MCQ # 5 33 YO male was stabbed to left abdomen. Is very drowsy and pale. C/O sever, generalized abdominal pain. You are the only family doctor in a small rural hospital in Al-Hafof. What would be the appropriate management? 1- Rapid assessment followed by admission 2- Rapid assessment then take him to the OR 3- Refuse to see him and transfer him immediately 4- Rapid assessment and initiate the transfer simultaneously ✓

Any Questions

MCQ # 6 A 23 YO man has a stab wound just below the left nipple. He is alert and breathing normally. HR 94, BP 111/73. His Chest x-ray is normal. All of the following is correct EXCEPT 1- Repeat CXR in 4-6 hrs 2- FAST (Focused assessment with sonography for trauma) 3- Chest CT scan 4- DPL (diagnostic peritoneal lavage) ✓

In Summary Importance of trauma Trimodal death distribution Mechanisms of trauma ABCDE of Trauma + Resuscitation Adjuncts Components of secondary survey When to transfer

References American College of Surgeons. Advance Trauma Life Support for Doctors (ATLS), Student Course Manual, 8th edition 2008. www.saher.gov.sa American College of Surgeons. Surgical Education and Self-Assessment Program (SESAP) 13