1. Initial management of multiple trauma patient
DR. MUDDATHER ABDUL-AZIZ MOHAMMED

2. DIFINITIONS Trauma Injury Multiple injured patient
pathological vs clinical
overt and covert injuries

3. ATLS PRIMARY SERVEY AMPLE HISTORY SECONDARY SERVEY
DEFINITIVE MANAGEMENT
CONT. RE-EVALUATION
PATIENT REFFERAL & DISPOSITION

4. Primary survey
ABC’s - Identified and simultaneous management of the life-threatening conditions
A – Airway management with C-spine control
B – Breathing
C – Circulation & hemorrhage control
D – Disability: neurologic status
E – Exposure & environmental control

5. A -Airway way (with cervical spine protection)
Stabilization of cervical spine- neck collar +head blocks
Inspection for foreign bodies – remove ---BUT NO BLIND FINGER SWEEP IN CHILDREN
Suction – remove blood & secretions
Jaw-thrust maneuver; +
Oropharangeal airway, LMA etc –KEEP UPPER AIRWAY PATENT.

8. Rapid sequence intubation (RSI) DIFINITIVE AIRWAY
Head trauma
GCS < 8
Facial trauma
Laryngeal trauma
Neck trauma
Burn or inhalational injury
Patient in extremis
Cricothyroidostomy --- NEEDLE OR SURGICAL
Alternative Airway

10. C-spine protection Suspicion of C-spine injury
Initial trauma management
C-spine protection
Suspicion of C-spine injury
Multiple trauma history?
Severe face & head trauma
Injuries above the clavicle
➣ Neurologic examination does not exclude
C-spine injury
NECK COLLAR- HEAD BLOCKS----

12. B- Breathing
* Listen for breath sounds and palpate the chest
No breathing start ventilation (BVM OR Pocket mask)
*Breathing with equal breath sounds bilaterally
STAT Chest x-ray & continue with primary survey
*Breathing with unequal breath sounds pneumothorax
Unstable patient----- needle decompression------chest tube
Stable patient wait chest x-ray if immediately available
Flail chest immobilization + PPV.
Open pneumothorax THREE SIDED AIR TIGHT dressing

14. Assess for Breathing Is the patient breathing?
Look, listen, & feel for 10 seconds
If not breathing proceed

15. C – Circulation with Hemorrhage control
Initial trauma management
C – Circulation with Hemorrhage control
Blood volume & Cardiac output
Pulse
Capillary refill > 2 sec
Skin color
Level of consciousness
BLOOD PRESSURE

16. TO STOP OR MINIMIZE FURTHER BLOOD LOSS
VOLUME REPLACEMENT

17. Resuscitation - IV Fluid therapy
Initial trauma management
Resuscitation - IV Fluid therapy
Balanced salt solution: Ringer’s Lactate or normal saline
In hypovolemic patient - 2 L rapidly
Rapid response
Transient response
Unresponsive
Blood
Type specific cross-matched
Type specific unmatched
O – negative
O - positive

18. Bleeding ASSESS FOR CARDIAC TEMPONADE ---- Drain
Initial trauma management
Bleeding
Hemorrhage should be identified & controlled in the primary survey
Direct pressure
Pneumatic splints
Tourniquets ?????
Operative repair of the major intra-thoracic or intra-abdominal bleeding (DAMAGE CONTROL SURGERY)
ASSESS FOR CARDIAC TEMPONADE ---- Drain
CARDIAC ARREST START---- CPR

19. D- NEUROLOGIC DISABILITY
IN HOSPITAL GCS.
PUPILE SIZE

20. E – Exposure / Environmental control
Initial trauma management
E – Exposure / Environmental control
Undressing
Protection from hypothermia

21. Urinary catheter Indicator of volume status Urethral injury suspected
Initial trauma management
Urinary catheter
Indicator of volume status
Urethral injury suspected
blood at the meatus
perineal hematoma
high-riding prostate by rectal examination
cystogram

22. Naso-gastric tube Remove gastric content Decompression
Initial trauma management
Naso-gastric tube
Remove gastric content
Decompression
Help to prevent aspiration
Help to rule out upper GI bleeding
➣Precautions:
Suspected # of cribriform palate
Maxillo-fascial trauma

23. Roentgenograms Should not delay resuscitation Chest AP Pelvis AP
Initial trauma management
Roentgenograms
Should not delay resuscitation
Chest AP
Pelvis AP
Lateral C-spine ???

24. History AMPLE A Allergies M Medications P Past illness L Last meal
Initial trauma management
History
AMPLE
A Allergies
M Medications
P Past illness
L Last meal
E Events/ environment related to the injury

25. Secondary survey Vital signs assessment
Initial trauma management
Secondary survey
Vital signs assessment
Head to toe examination (DCABTS)
Role of FAST in abdominal trauma
Rectal exam .
Complete neurologic examination
Log roll for back exam
X-rays and imaging as needed
Laboratory tests

27. Alcohol/ toxicology/Pharmacology Pregnancy test for childbearing women
blood analyses:
Type & Crossmatch
CBC
Chemistry
PT/ PTT
Alcohol/ toxicology/Pharmacology
Pregnancy test for childbearing women

28. Re-evaluation New findings Discover deterioration of previous signs
Initial trauma management
Re-evaluation
New findings
Discover deterioration of previous signs

29. DIFINITIVE TREATMENT PRINCIPLE OF DAMAGE CONTROL
DIFINITVE TRAETMENT AND CARE
PROPER PATIENT DISPOSITION
REHABILITATION AND RETURN TO UASUAL LIVE

31. Thank you