TRAUMA

Dr Anuj Raj
Bijukchhe
 Introduction

Trauma is a severe physical injury

resulting from dissipation of energy to
and within the victim, caused by a
penetrating or blunt mechanism

Trauma can be defined in terms of bodily
injury severe enough to pose a threat to
life or limb


Anatomic injury


Physical derangement
Classifications of
trauma
 
 

 
 
 
Closed injury Open injury
 
Motor vehicle crashes

Falls

Burns and fire-related injuries

Intentional trauma: homicides, nonfatal
assaults, and suicides
Three peaks of death
Immediate: head injury, brainstem injury,
cardiovascular system

Early: within the first few hours, major torso
trauma, closed head injury


Late
Physiological response to
trauma
Involves both local and systemic
reactions
Extent of response proportional to
severity of insult
An appropriate response maintains
homeostasis and allows wound
healing
An excessive response can produce a
systemic response
 Systemic inflammatory response syndrome (SIRS)
 Multiple organs dysfunction syndrome (MODS) can
result from SIRS
SIRS
systemic inflammatory response syndrome
(SIRS) is an inflammatory state of the
whole body (the "system").
It is characterized by tachycardia, >90/min,
low blood pressure (systolic <90 or MAP
<65), low or high body temperature (38
C), high respiratory rate (>20/min), and
low or high white blood cell count (12
billion/liter). It can be caused by severe
trauma, burns, hyperglycemia (high blood
sugar) or acute pancreatitis.
Initiation of response
Multiple simultaneous factors can have a
synergistic effect
Important factors are:
Tissue injury
Infection
Hypovolaemia
Hypoxia or hypercarbia

Acute phase response
Tissue injury results in cytokine
release

Cytokines have mainly paracrine
actions
Important in regulating the
inflammatory response
Cytokines stimulate the production of
acute phase proteins such as:
C-reactive protein
Fibrinogen
Complement C3
Haptoglobin
Endocrine response
The hypothalamus, pituitary, adrenal axis is
important
Trauma increases ACTH and cortisol
production
Steroids have a permissive action in many
metabolic responses
Catabolic action increases protein breakdown
Insulin antagonism increases blood sugar
levels
Anti-inflammatory actions reduce vascular
permeability
Aldosterone increases sodium reabsorption
Vasopressin increases water reabsorption
and produces vasoconstriction
Histamine increases vascular permeability
Limitation of response
Reducing degree of trauma with
appropriate and careful surgery
Reducing infection with wound care
and antibiotics
Maintaining enteral nutrition
Controlling pain
Correcting hypovolaemia
Correcting acid-base disturbance
Correcting hypoxia

TRIAGE



Triage means the

allocation of injured
patients into certain
categories for action by
emergency team.




 FOUR
CATEGORIES


 1. Critical – with in seconds
 2. Immediate - with in minutes
 3. Urgent - with in the golden hour
 4. Deferred - as soon as practical
Advanced Trauma Life Support

ATLS component step
 Primary survey- identify what is killing pt.
 Resuscitation - treat what is killing the pt.
 Secondary survey – proceed to find all other
injuries
 Definitive care – develop a definitive Mx
plan
Pre hospital mini –
neurological examination

 A – Alert
 V - responds to Voice
 P - responds to Pain
 U - Unresponsive
 pupils - Size and reaction
TRAUMA SEVERITY
SCORES
Glasgow Coma Scale
This widely used scale relates specifically
to the head injury component of the
injured patient.

 The three aspects of the coma
which are specifically assessed are --
GCS

1. EYE OPENING

2. BEST VERBRAL RESPONSE

3. BEST MOTOR RESPONSE
EYE OPENING
Spontaneous 4
To Voice 3
To Pain 2
None 1

VERBAL RESPONSE
5
Orientated
4
Confused
3
Inappropriate words
2
Incomprehensible sound
1
None
MOTOR RESPONSE 6
Obeys command 5
Localises pain 4
Withdraws(pain) 3
Flexion(pain) 2
Extension (pain) 1
None
Immediately life –threatening
thoracic condition

Airway obstruction
Tension pneumothorax
Massive haemothorax
Open Pneumothorax
Flail chest
Cardiac tamponade
REVISED TRAUMA
SCORE(RTS)
Glasgow Coma Systolic blood Respiratory rate Points
Scale pressure (breath/min)
13-15 >89
(mmhg) 10-19 4

9-12 76-89 >29 3

6-8 50-75 6-9 2

4-5 1-49 1-5 1

3 0 0 0
FLUID , ELECTROLYTE &
ACID BASE
BALANCE
COMPOSITION OF BODY FLUIDS
TOTAL BODY WATER.


Total body water (TBW) as a percentage of

body weight varies with age.
The fetus has very high TBW, which
gradually decreases to approximately 75%
of birth weight for a term infant. Premature
infants have higher TBW than term infants.
During the 1st yr of life, TBW decreases to
approximately 60% of body weight and
basically remains at this level until puberty.
Because fat has very low water content and
muscle has high water content. The
percentage of body weight comprised by
body water decreases as the fat content
increases.
At puberty, the fat content of females
increases more than that of males, who
acquire more muscle mass than females.
So by the end of puberty, TBW in males
remains at 60%, but TBW in females
decreases to approximately 50% of body
weight.
 Fluid Compartments.
TBW is divided between two main
compartments:
 Intra cellular fluid (ICF). (all the liquids inside the
cell )
 Extra cellular fluid (ECF). ( present in the space outside
the cell )

ECF volume is about 20% of body weight ICF

volume is about 40% of body weight, close to
twice the ECF volume .
The ECF is further divided into


Plasma
Interstitial fluid (including lymph)
Transcellular fluid .
PLASMA


( Intravascular fluid)
It is the fluid that is
confined to the
cardiovascular
system.
Plasma + blood
cells fill the
vascular system.
The plasma
accounts for 5% of
body weight.
INTERSTITIAL FLUID


It accounts for about 15% of the body weight.

It is present outside the vascular system.
It consists of the fluid bathing all the cells of
the body except the blood cells ( cells of
vascular system).
Reduction in the interstitial fluid manifests as
dehydration while an increase results in
edema.
TRANSCELLULAR FLUID
It is the fluid present in the number of
cavities called the “Third space”
 *CSF fluid
 *Intraoccular fluid , cochlear fluid.
 *Digestive secretions, gut fluid and
bile.
 *Pleural & pericardial fluid , peritoneal
fluid.
 *Sweat.
 *Synovial fluid.
These fluids are predominantly the products of
epithelial cell secretion which are separated
not only from the blood by the capillary
endothelium but also from the interstitial fluid
by epithelium. Thus they are called
transcellular fluids.
The interstitial fluid and transcellular fluid is
about 15% of body weight .



All the cells live in extracellular fluid that
contains ions and nutrients needed by the
cells for the maintenance of the normal
cell functions.
Hence Claude Bernard call ECF the “
Internal environment of the body ”.
Essentially all the organs & tissues of the
body perform functions to maintain the
constant conditions in the internal
environment ( ECF) , and this maintenance
of constant conditions in the internal
environment is called ‘ homeostasis’.
BODY FLUID
COMPOSITION
The distribution of the body fluids is
determined by the composition of the
electrolytes and proteins in the different
compartments.
ELECTROLYTE

CATIONS AND ANIONS.

The total number of the cations in the body is
equal to the number of anions
Electrolyte composition
INTRACELLULAR FLUID (ICF)


Potassium ( K) is the most abundant cation in the

ICF. Other cation is Mg.
Proteins, organic anions, and phosphate are the
most plentiful anions in the ICF.
Sodium and chloride concentrations in the ICF are
much lower.


EXTRACELLULAR FLUID (ECF) – BOTH PLASMA &



INTERSTITIAL FLUID
Sodium and chloride, bicarbonate are the dominant
cation and anion, respectively, in the ECF.
K , Ca , Mg and monohydrogen phosphate are
present in low conc. In ICF.
Fluid intake is derived from 2
sources.

 1. Exogenous

 2. Endogenous

 Distribution of body
water
In normal persons, the total body water
constitutes 50-60 % of lean body weight in
men and 45-50 % in women.

 A healthy ( 70 kg) - approximately 40 liters(
average 57% of total body wt)

Contain in two major compartment.
AVERAGE DAILY WATER BALANCE OF A
HEALTHY ADULT IN TEMP CLIMATE
INTAKE OUTPUT

Water from beverage= 1200 ml Urine = 1500 ml

Water from solid food = 1000 Insensible loss from skin &
ml lungs = 900 ml
Water from oxidation = 300 ml Faeces = 100 ml
2500 ml 2500 ml
QUANTITIES OF DAILY SECRETION

Bile = approx 1000 ml/ 24 hour
Gastric juice = approx 2000 ml / 24 hr
Pancreatic juice = approx 600 ml / 24 hr
Small intestine = approx 3000 ml / 24 hr
Saliva = approx 1500 ml/ 24 hr

PRINCIPLE OF FLUID & ELECTROLYTE
REPLACEMENT

1. Replace the deficits

2. Fulfill daily maintenance requirement
3. Replace ongoing lossses.

 FLUID REQUIREMENTS IN EVERY 24 HOUR

 water = 30-35 ml/kg
 sodium & potassium= 1mEq/ kg
 Chloride = 1.5 mEq/ kg
How to differentiate function
and non-function interstitial
fluids
Function:Taking part in modulating the
 balance of body fluids.
Non-function: Fluids in cavityin
 normal status.
 Including: cerebrospinal , joint, pericardium and
abdominal cavity fluids



THIRD SPACE

Definition:
 Pathophysiologiclly, relatively nonfunctional extra
cellular fluid.
 Mainly for the change of quantity of functional and
nonfunctional ECF.

 Third Space
Distribution: (not normal)
 exudates in burns; ascites;
 soft tissue injuries; bowel wall;
 peritoneum; infected lesions .
Attention: Don’t confusewith the nonfunctioning
components from interstitial fluid.

 ELECTROLYTE
BALANCE
 TWO KINDS OF IONS


CATIONS ANIONS

Sodium Chloride
Potassium Phosphate
Calcium Bicarbonate
Magnesium Sulphate
Classification of body
fluid change ( Four Types )
 1. Volume Changes ( ECF )
 Volume Deficit
 Volume Excess
ü
2. Concentration Changes

 Hyponatremia
 Hypernatremia
 Classification of body
fluid change( Four Types )
 3. Mixed volume and Concentration Abnormalities


 ECF Deficit and Excess with Hyponatremia

ü
 ECF Deficit and Excess with Hypernatremia
ü

Classification of body
fluid change( Four Types )
 4. Composition Changes


 Acid-base disturbances


 Potassium , Calcium, Magnesium

 abnormalities



 SODIUM BALANCE

 Total body Na - 5000 mmol
 ECF=44%
 ICF= 9%
 Bone = 47%
Daily intake - 80 --100 mmol

Total serum Na+ 132 – 144 mmol / L

 Hyponatraemia
Causes
 Excessive water intake

 Excessive water retention- inappropriate ADH

secretion
Inadequate Na intake ( rare)

Inadequate Na retention
 - vomiting, diarrhoea,exessive sweating,burns
C/F
Thirst
Muscle cramps
Nausea
Vomiting
Dizziness
Neurological symptoms
 drowsiness
 confusion

Rx


Restriction of water intake
3% Nacl solution i/v
Monitoring of plasma sodium and fluid
balance
treatment of underlying cause.
 Hypernatraemia
Characteristic of primary water deplication


 Causes
Inadequate water intake- lack of water,
inability to drink.
Inadequate water retention (excess water loss)

Excessive sodium intake

Excessive sodium retention -

Hyperaldosteronism
C/F
Non specific symptom
 nausea
 vomiting
 fever
 confusion

 Convulsion in severe case
Rx
Replacement of water
In severe ( >170 mmol/L)
 0.9% saline should be used
initially
Les severe (>150 mmol/L)
 5% Dextrose or 0.45% saline.
Treatment of underlying cause.
 THANK YOU