By M. Ashraf Balbaa, M.D. Associate Professor of Surgery

USA has labeled injury as the " neglected disease of modern society ".

 In the United States, trauma is the leading cause of death in children and adults up to age 44 years

 The 150,000 annual deaths in the United States caused by trauma.  The total cost of injury in the United States is estimated at approximately $200 billion per year

 Blunt trauma:  Motor vehicle accidents.  Motorcycle accidents.  Falls.

 Penetrating wounds:  Gunshot wound:  It has a high frequency of organ injury.  Stab wound:  Carry a significantly lower risk when compared with gunshot wound

Within minutes:  Approximately 1/2 of trauma deaths occur within seconds or minutes after injury.  They are caused by lacerations to the aorta, heart, brain stem, and spinal cord.

Within minutes:  Few of these patients can be saved by trauma systems.  These deaths must be addressed by prevention strategies that limit high-risk behavior and prevent injury and by active legislation.

Within Hours:  Accounts for approximately 30% of deaths.  Half of these deaths are caused by hemorrhage and the other half by central nervous system injury.  Most of these deaths can be averted by treatment during the "golden hour.“

After 24 hours:  Incidence is close to 10%.  They include death resulting from infection, multiple organ failure and pulmonary emboli

 TRIAGE  PRE-HOSPITAL CARE  TRANSPORTATION  HOSPITAL CARE  PRIMARY SURVEY  SECONDARY SURVEY  TERTIARY SURVEY

 TRIAGE  PRE-HOSPITAL CARE  TRANSPORTATION  HOSPITAL CARE  PRIMARY SURVEY  SECONDARY SURVEY  TERTIARY SURVEY

The term triage, derived from the French word "to sort" victims into categories based on severity of injury and urgency of care.

 Category 1: Critical:  It cannot wait. As airway obstruction and catastrophic hemorrhage.  Category 2: Urgent:  Serious injury but can wait a short time (30) min.  Category 3: Emergent:  Less serious injuries. Not endangered by delay.  Category 4: Expectant  Severe multisystem injury (survival is not likely).

 TRIAGE  PRE-HOSPITAL CARE  TRANSPORTATION  HOSPITAL CARE  PRIMARY SURVEY  SECONDARY SURVEY  TERTIARY SURVEY

 Determining the need for emergency treatment.  Initiating treatment according to protocols for medical direction.  Communicating with medical control.  Rapid transfer of the patient to a trauma center.

 The goal in prehospital care of the trauma patient is:  To deliver the trauma patient to the hospital for definitive care as rapidly as possible.

 The role of advanced life support interventions is either:  Scoop and run, or,  Stay and play.

 TRIAGE  PRE-HOSPITAL CARE  TRANSPORTATION  HOSPITAL CARE  PRIMARY SURVEY  SECONDARY SURVEY  TERTIARY SURVEY

 The best method for transportation depends on:  The patient's condition.  Distance to the regional trauma center.  Accessibility of the scene.

 The ground ambulances serve the majority of the needs.  Helicopter use is more appropriate at times with traffic congestion and natural barriers.

 TRIAGE  PRE-HOSPITAL CARE  TRANSPORTATION  HOSPITAL CARE  PRIMARY SURVEY  SECONDARY SURVEY  TERTIARY SURVEY

 Trauma center care consists of:  Care provided in the emergency department.  The operating room.  The intensive care unit.

 PRIMARY SURVEY  SECONDARY SURVEY  TERTIARY SURVEY

 PRIMARY SURVEY  Air way  Breathing  Circulation  Disability  Exposure  SECONDARY SURVEY  TERTIARY SURVEY

Air way  Secure an adequate airway:  Mechanical removal of debris.  Chin lift or jaw thrust maneuver to pull the tongue and oral musculature forward from the pharynx.

Air way  Endotracheal intubation:  Indications:  If there is any question about airway adequacy.  If there is evidence of severe head injury.  If the patient is in profound shock.  Precautions:  Must be done rapidly, under the assumption of cervical spine instability.

Air way  Surgical airway:  Cricothyroidotomy is the preferred emergency procedure.  Indications:  Massive maxillofacial trauma.  Inability to visualize the vocal cords because of the presence of blood, secretions, or airway edema.

Breathing:  Chest examination:  Inspection, palpation, and auscultation of the chest:  Will demonstrate the presence of normal, symmetric ventilation.

Breathing:  Chest x-ray:  A supine anteroposterior (AP): is the primary diagnostic adjunct, demonstrating:  Chest wall.  Pulmonary parenchyma.  Pleural abnormalities.

Breathing:  Assisted ventilation:  Indications:  Severe chest wall injury.  Pulmonary parenchymal injury.  Serial measurement of arterial blood gases.

Circulation:  Identification and control of the hemorrhage:  External hemorrhage:  It is controlled by direct pressure on the wound.  Hemorrhage into the chest, abdomen or pelvis:  The possibility is raised by clinical examination.

Circulation:  Intravenous line:  At least two large-bore intravenous lines should be placed to allow fluid resuscitation, placed percutaneously in the vessels of the arm.

Circulation:  Intravenous line:  If peripheral upper extremity access is inadequate:  A large-bore venous line in the femoral vein at the groin.  Cutdown on the greater saphenous vein at the ankle.  The subclavian vein is a poor site for emergency access in the hypovolemic patient and should be used only when other sites are not available.

Circulation:  Fluid resuscitation:  Begins with a 1000-ml bolus of lactated Ringer solution for an adult, or 20 ml per kilogram for a child.  Response to therapy is monitored by clinical indicators:  Blood pressure.  Skin perfusion.  Urinary output.  Mental status.

Circulation:  Fluid resuscitation:  If there is no response or only transient response to the initial bolus, a second bolus should be given.  If ongoing resuscitation is required after two boluses, it is likely that transfusion will be required, and blood products should be initiated early.

Diability:  Rapid examination to determine the presence and severity of neurologic injury measured by the The Glasgow Coma Scale (GCS) score:  Eye opening  Verbal response  Motor response.

Eye openingNo response To painful stimulus To verbal stimulus Spontaneous Best verbal responseNo response Incomprehensible sounds Inappropriate words Disorientate, inappropriate content Orientated and appropriate Best motor responseNo response Abnormal extension (decerebrate posturing) Abnormal Flexion (decorticate posturing) Withdrawal Purposeful movement Obeys commands Total3-15

Exposure:  The final step in the primary survey is to:  Completely undress the patient.  Rapid head-to-toe examination to identify:  Any injuries to the back, perineum, or other areas that are not easily seen in the supine, clothed position.

 PRIMARY SURVEY  Air way  Breathing  Circulation  Disability  Exposure  SECONDARY SURVEY  TERTIARY SURVEY

 It is often done in a head-to-toe manner.  Order & collect data from appropriate laboratory and radiologic tests.

 Placement of additional lines as catheters (such as nasogastric tube or Foley) & monitoring devices.  A number of minor injuries may not become apparent until the patient has been under medical care for 12 to 24 hours as pain from other major injuries has often subsided.

 PRIMARY SURVEY  Air way  Breathing  Circulation  Disability  Exposure  SECONDARY SURVEY  TERTIARY SURVEY

Another complete head to toe physical examination aimed at identifying injuries that may have escaped notice in the first several hours.