TRAUMA

Dr. Yasser Alshomrani

 To

understand the essential information and skills to

identify and treat trauma cases based on Advanced
Trauma Life Support protocol.

To

know the different types of Open Fractures and

the way of management.

To

be able to understand the Compartment

Syndrome, clinical presentation and treatment.

To

be able to read bone x-rays in a systematic

approach.

Introduction

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Road traffic fatality of all

mortalities:
KSA= 4.7%
USA & UK = do not exceed
1.7%
Accident to death ratio:
USA = 283:1
KSA = 32:1
RTA considered to be the
countrys main cause of death
for 16-30-year-old males

TheCooperationCouncilfortheArabStatesoftheGulf(GCC) 2012. Statistics Department. [cited 2014 Feb]

Available from: http://www.gcc-sg.org/eng/
World Health Organization. Global Status Report on Road Safety 2009. Geneva (CH): World Health
Organization; 2009. Available from: http://www.who.int/violence_injury_ prevention/road_safety_status/
2009/en/

ATLS scenario 1
Scenario

in RTA ..

1: 27 years old, male patient, involved

ATLS scenario 1
brought

to you in ER by ambulance

ATLS scenario 1
What are you going to do ?

ATLS scenario 1
ATLS language ..
-

1ry survey. A, B, C, D, E + Adjunct to 1ry survey.

2ndry survey.

Reevaluation.

Definitive care.

ATLS scenario 1
-

Connect to
monitor.

IV lines.

Send trauma
panel.

ATLS scenario 1

Ac
Air way + C spine
protection

ATLS scenario 1

Ac
-

Assess.

Action.

ATLS scenario 1

Ac

Intubation !!

ATLS scenario 1

Ac

Neck collar !!

Every trauma patient

has cervical spine injury
until proven otherwise

ATLS scenario 1

B
Breathing

ATLS scenario 1

- Assess.
Inspection, palpation,
percussion and
auscultation.

- Action!!
Pneu/hemothorax!!

ATLS scenario 1

C
Circulation

ATLS scenario 1

- Assess.

Check pulse!
Identify source of
hemorrhage!
Look to the monitor !!
Skin color
Capillary filling

- Action!!

Ext vs Int

ATLS scenario 1
Is

SHOCK !!

the pt in SHOCK?! How to recognize shock?!

Any injured pt who is cool and has tachycardia is

considered to be in shock until proven otherwise.
Hemoglobin and Hematocrit not used to exclude
presence of shock!!
What

is the most common cause of shock in

injured pt?

ATLS scenario 1
- Classes of Hemorrhage:

SHOCK !!

ATLS scenario 1
Initial
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-
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SHOCK !!

management: Stop bleeding + Replace volume

loss
Vascular access lines.
Draw blood for investigation.
Give 1-2 L of isotonic fluid.
Control obvious hemorrhage.
Pelvic binder!!

Check for source of bleeding !!

Blood on the floor and four more ( Chest, Abd, Pelvis
and thigh).

ATLS scenario 1

SHOCK !!

- Responses to initial fluid resuscitation:

ATLS scenario 1

SHOCK !!

- Blood Replacement:
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-

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Type and cross match: requires 1 hour to prepare.

Type specific: ready within 10 minutes (ABO and
RH ).
Emergency blood (Type O ve).
Warming fluids !?
Balanced Resuscitation !?

ATLS scenario 1

D
Disability (Neurologic
evaluation)

ATLS scenario 1
- Disability, to evaluate :
- Level of consciousness.
- Pupil size and reaction.
- Lateralization signs.

ATLS scenario 1

E
Expose/Cover

ATLS scenario 1

Adjunct
to primary survey

ATLS scenario 1
- Adjuncts to 1ry survey:
- ECG.
- Urinary catheter.
- NGT.
-

X-ray: AP chest & AP pelvis. Wt if she is

pregnant ?!

FAST vs DPL !?

ATLS scenario 1
Re-evaluate your patient.
Dont start 2ndry Survey until the
1ry Survey is completed and vital
functions are normalized.

ATLS scenario 1

ndry
2

Survey

ATLS scenario 1
-

2ndry survey:
AMPLE history. Allergy, Medication, Past med/
Pregnancy, Last meal, Event.

Head to toe examination.

Adjunct to 2ndry Survey: CT, other diagnostic

procedure, or transportation.

Open
Fractures

Open Fractures
Introduction:
-

a fracture with direct communication to

the external environment.

Fracture management begins after initial

trauma survey and resuscitation is
complete.

Open Fractures
Classification:

Open Fractures
Classification:

12

Open Fractures
Classification:

3A

Open Fractures
Classification:

3B

Open Fractures
Classification:

3C

Open Fractures
Management
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in ER:
begins after initial trauma survey and
resuscitation.
initiate early IV antibiotics and update tetanus
prophylaxis.
direct pressure will control active bleeding.
remove gross debris from wound.
place sterile saline-soaked dressing on the
wound.
splint fracture for temporary stabilization.

Open Fractures

Antibiotic coverage: Start as soon as possible.

Type 1 and 2:
1st generation cephalosporinfor 24 hours after
closure.

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Type 3:
gram positive coverage = 1st generation
cephalosporin.
Gram negative coverage = Aminoglycoside(such
as gentamicin).
the cephalosporin/aminoglycoside should be
continued for 24-72 hours after the last debridement
procedure.
Anearobic coverage= Penicillin. (farm injury).

Open Fractures
Management
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-

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in OR:
Aggressive debridement and
irrigation(Saline).
debridement is critical.
on average, 3L of saline are used for each
successive Gustilo type (Type I: 3L, Type II: 6L
and Type III: 9L).
bony fragments without soft tissue
attachment can be removed.
Fracture stabilization.
Staged debridement and irrigation

Compartment
syndrome

Compartment Syndrome
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-

compartment pressure rises to a level that

decreases perfusion.
may lead to irreversible muscle and nerve
damage.
Occurs any where but commonly legand
forearm.

local

trauma > soft tissue destruction >bleeding

and edema> increased interstitial
pressure>vascular occlusion> myoneural
ischemia.

Compartment Syndrome
Etiology:
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fractures (most common).

crush injuries.
tight casts, dressings, or external
wrappings.
extravasation of IV infusion
Burns
bleeding disorders

Compartment Syndrome
Symptoms
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pain out of proportion to clinical

children !! comatosed pt !!

Physical
-

exam
pain w/ passive stretch

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is most sensitive finding.

Paralysis
Paresthesia
palpable swelling
peripheral pulses absent

Compartment Syndrome
Treatment:
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bi-valving the cast and loosening

circumferential dressings.
emergent fasciotomy of all compartments
medial-lateral incision (leg).

Compartment Syndrome
Random

questions !!!

Elevate the limb or not?

Any relation to kidney?

Will you do fasciotomy if diagnosed late?

How to read
x-rays ?

Ordering X rays
Rule
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of Two:
Two views.
Joints above and below.
Before and after reduction.

How to read an x ray

1- history and examination.
2- check patient ID.
3- What type of Image?
4- What is the view?
5- What area of the body?
6- identify each bone.
7- Describe any fracture, dislocation,
deformity

How to describe a fracture?

In relation to the joint:
- intra or extra articular.
Anatomical location:
- Epiphysis
- metaphysis
- diaphysis.
Characteristics of the fracture:
- Oblique
- transverse
- spiral
- comminuted
Shortening , rotation. Displacement, angulation ..

What are the goals from

treating fractures ?
To

obtain and maintain reduction = healing.

To

avoid complications.

To

regain the function of the limb.

Principles of fracture
management
- Ensure ATLS is done.
- Neurovascular examination.
- Splinting.
- Pain control.
- X rays.
- Reduction.
- NV re-assessment.
- X ray

Closed vs Open Reduction

Closed vs Open Reduction

How to maintain reduction?

Splint,

Cast.

Internal

fixation.

External

fixation,

^_^ Take home message ^_^

-

ATLS .. be systematic, 1ry survey, 2ry survey,

reevaluate.

In open fracture, It is critical to follow Advanced

Trauma Life Support (ATLS) protocol.
Initiate early IV antibiotics
Good irrigation and debridement.

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In Compartment syndrome, severe pain with

Passive stretch is the most specific finding.
bi-valve any or dressings.
Release compartment (fasciotomy)..