THORACIC TRAUMA Life threatening condition that need to be identified and treated immediately on Primary Survey Airway Laryngeal

Injury Sign of upper airway obstruction ( stridor) Hoarseness/emphysema subcutaneous emphysema/palpable fracture of the larynx Humidified Oxygen/IV access/Prepare for early intubation or surgical airway/ ENT consult If edema larynx : Dexamethasone, adult 4 mg IV, ped: 0.25 mg 0.5 mg/kg IV Fracture /Dislocation of Sternoclavicular joint Obvious sign of trauma on the base of the neck with palpable defect on the sternoclav. Joint Closed reduction of the sternoclavicular joint in supine position Breathing Tension Pneumothorax Clinical diagnosis : Chest pain / respiratory distress/tachycardia/ hypotension/ tracheal deviation/unilateral absence of breath/JVD/cyanosis Needle thoracocentesis ( large bore needle , 14-16 G, 2nd intercostal space, midclav) followed by insertion of chest tube Open Pneumothorax Large defects of chest wall which remain open or sucking chest wound Close the defect with sterile occlusive dressing, large enough to overlap the wound, tapes securely on 3 sides Flail chest Multiple ribs fractures ie, two or more ribs fractured in two or more places Paradoxical movement of the chest wall ( inspiration/expiration) Main problem is the underlying lung disease : Pulmonary contusion Humidified oxygen/fluid resuscitation/analgesic Asses adequate ventilation for the need for assisted ventilation /intubation Circulation Massive Hemothorax > 1500 ml blood in the chest cavity or blood loss > 200 ml/hour for 2 to 4 hours shock associated with the absence of breath sound and or dullness on percussion on one side of the chest

Management : Fluid resuscitation/blood transfusion simultaneously with decompression of chest cavity ( chest tube)

Cardiac Tamponade Commonly associated with penetrating injury Becks triad : JVD/hypotension/muffled heart sounds, not always present PEA in the absence of hypovolemia/tension pneumothorax Pericardiocentesis Secondary Survey Further physical examination CXR P ox /Blood Gas Analysis ECG Simple Pneumothorax Decreased breath sounds / hyperresonance /CXR If pneumothorax < 15 %, no cardiovascular or respiratory compromise : observe for 4 to 6 hours and repeat CXR , if no change : discharge otherwise chest tube insertion Hemothorax Shown in CXR , needed to be evacuated with chest tube Pulmonary contusion Cause respiratory failure Intubation Blunt Cardiac Injury Traumatic Aortic Disruption Persistent hypotension CXR: widened mediastinum Subcutaneous emphysema Not require treatment Underlying injury If needed to assist ventilation with positive pressure, anticipate possible pneumothorax Rib fractures Upper ribs : 1-3 : severe injury , associated with other serious injury ( major blood vessels) Lower ribs : 10 -12 : considered hepatosplenic injury Common associated injury : pneumohemato thorax Treatment : adequate pain management to improve ventilation. Risk of infection esp. in elderly

Traumatic Diaphragmatic injury More common in the left side Sternum/scapular fractures Generally results of direct pressure Sternum fracture can accompanied by lung contusion/blunt cardiac injury

ABDOMINAL TRAUMA Primary survey : ABCDE , Hypotension? Obvious sign of trauma on the abdomen : blunt/penetrating injury Internal organ injury : Liver/spleen/pancreas/hollow viscus/kidney Sign of peritonitis ( distension /tenderness/muscle guarding/ rebound) Serial Hb/urinalysis/pregnancy test Abdominal series /USG Pelvic Injury , associated with major blood vessel Genito-urinary trauma : blood OUE/scrotal-perineal hematoma/high riding prostate or blood on the rectal exam , precaution for urinary catheter. Penetrating injury : closed wound with gauze soaked with NS

MUSCULOSKELETAL TRAUMA AB C DE IV/O2 /Monitor Hipovolemic shock Femur fr. Pain management . Narcotic pain relief ( Pethidine/Morphine) Asses N V D ( Neurovascular distal) . Always check colour/pulsation/capillary refill / sensation, compare bilaterally, and documented prior and after every manipulation /splint Open wound Open fractures ? , cover with sterile dressing Splint , immobilized one joint above and one joint below the injury site Mal-aligned/ compromise NVD : attempt to realign by gentle traction. If after traction NVD compromise worsened back to position before and splint in that position Do not forced re-alignment if difficult splint in that position Tetanus prophylaxis : vaccine/Ig Antibiotic : Cefazolin ( gr I ) , + gentamycine ( gr II / III ) , dose check on 5MEC Orthopedic consult Compartment syndrome o Pain is the earliest symptoms esp. with passive stretching of the involved groups of muscle o Other ischemic sign: 5 P :pain /pressure/paresis/paresthesia/pulse o Unconscious patient is at increased risk

NEAR DROWNING Near Drowning : survival at least a day after submersion Secondary drowning : Complication of near drowning after initially successful resuscitation ( may be delayed by up to 12 hours in otherwise normal appearing patient) In near drowning, aspiration as little as 2 cc/kg may cause lung damage/hypoxia : Surfactant loss/alveolar dysfunction Direct tissue toxicity , pulmonary edema V/Q mismatch , vasoconstriction Even without aspiration, life threatening pulmonary edema may occur due to cerebral hypoxia or cardiac failure ( dry drowning) Management Prehospital ABCDE with neck/spinal injury and hypothermia ( especially in children) precaution Begin CPR immediately with max Oxygen IV/ Monitor No role for trying to evacuate water by Heimlich or other maneuvers Asymptomatic patient still need to be observe for possible secondary drowning Patient with Cardio pulmonary arrest /.P ox < 90 % with max Oxygen, should be transported to hospital with facility of Intubation Emergency Department Consider other associated injuries ( spine/head/other trauma) and medical condition ( AMI/Disrythmia/ stroke) Patient who arrived awake but with respiratory distress or hypoxia IV /O2 max with NRB/Monitor CXR PA/Lat and other X-ray if needed ECG / ABG / electrolyte/BUN /Creatinin/CBC/ Glucose If unable to maintain P ox > 90 % with max O2, need to intubate Antibiotic : Levofloxacine 500 mg QD Observation for 12-24 hours Repeat CXR/lab test every 6 to 12 hours Patient who arrived without any symptoms If physical exam/CXR and Pox normal , patient may be discharged after 6 hours of observation ( repeat CXR/lab test)

High risk patient Loss of consciousness Cardiopulmonary arrest Cyanotic /tachypnoe / respiratory distress Seizures Prolonged time under water /water ingestion Preexisting medical condition /elderly/young children