TRAUMA 1

MAJOR TRAUMA
AND MULTIPLE INJURIES

⁕ Incidence :

• Trauma is a common cause of mortality in civilian life and during

war time.

• It is the commonest cause of death at age of 1-44 year.

• It is the 3rd. common cause of death in all ages .

⁕ Aetiology :There 2 types of injuries

A) Penetrating injury :

1-Low velocity injuries:

• These are caused by stab by sharp instrument or bullets from

pistols.

• The injury is suspected over a small area.

2- High velocity injuries:

•These are caused by firearm injury from rifles.

• Shock waves spread from the missile tract and affect areas far
from this tract .

B) Blunt injuries :

• These are caused by direct blow

, fall from height or

• Road traffic accidents :

▪ When a pedestrian is struck by a moving vehicle , there is

acceleration injury in addition to the direct trauma at the

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site of impact .

▪ The person inside the moving car acquires the same

velocity of the car :

 If he is not wearing the seat belt , his body strike the car .

 If he is wearing the seat belt → seat belt injuries ( skin

mark, fracture clavicle , thoracic or abdominal injuries ).

⁕ Causes of mortality after major trauma :

I) Immediate death :( within few minutes )

▪Airway obstruction or major injuries of airway .

▪Rupture heart or major blood vessels .

▪Major injury of brain or upper spinal cord.

II)Early death : ( within few hours )

▪ Intracranial haemorrhage .

▪ Intra-thoracic or intra-abdominal haemorrhage .

▪ Major fracture ( femur, pelvis & spine )

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III)Late death : ( within few weeks )

▪ Sepsis.

▪ Multiple organ failure.

⁕ Management of major trauma :

• Intoduction :

▪ Victims of major trauma should be treated well trained trauma

team.

▪ In mass casualty , triage or sorting of the patients according to

their clinical diagnosis and the available resources .It may take 2
forms :

 If the number of victims does not exceed the facilities , all injured
are treated .

 If the number of victims exceed the facilities , the critically

injured most likely to survive are treated first .

• Methods : Advanced Trauma Life Support (ATLS) protocol

I) Primary survey and resuscitation :(ABCDE)

❖ This should start at the site of accident by well trained

ambulance team and continue as the victim reaches the
emergency department .

A) Airway and cervical control :

▪The patient’s airway is evaluated and protected with concomitant

control of movement of the cervical spine .

▪In general, if the patient is capable of unstrained speech , his

airway is patent .

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▪ Clear airway :
1- Remove any blood , vomit , secretions or foreign body by
finger sweep or with a rigid sucker .
2- Chin lift or jaw thrust to avoid falling back of tongue .

Main causes of upper airway obstruction are : falling of the

tongue , blood , vomitus , secretions , teeth or dentature and soft
tissue oedema .

▪ Protect the airway :

1- Oropharyngeal or nasopharyngeal tube prevent falling
back of tongue and occlude the airway ( prevent inhalation),
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in unconscious patient .

2- Tracheal intubation :
➢ Indications : Apnea , maxillofacial trauma , inhalation ,
injury of airway , close head injury ( allow hyperventilation
to decrease intracranial pressure ) , mechanical ventilation
is essential or unconscious patient .
➢ Methods :
 Orotracheal intubation allows the use of a large tube.
 Nasotracheal intubation is safer if cervical spine
fracture is suspected .

3- Cricothyroidotomy :
➢ Indications : This a temporary measure done for urgent
upper airway obstruction with inability to ventilate and
inability of tacheal intubation .
➢ Contraindications : Children below 12 years or tracheal
transection .

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➢ Methods:This done either by surgical cricothyroidotomy

(make incision in the middle line in the skin and cricothyroid
membrane and insertion of a tube ) or pecutaneous
needle cricothyroidotomy ( insertion of wide bore needle) .

⁕ N.B:
• Tracheostomy is rare needed nowadays as emergency.
• Please see the following excellent videos:
• https://www.youtube.com/watch?v=n5DUC1Lit08
• https://www.youtube.com/watch?v=PzyTXXQp2j8
• https://www.youtube.com/watch?v=XpcrsVNGoM4
• https://www.youtube.com/watch?v=fNRDWN2OdpY

Rigid Collar

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• Cervical spine control :

➢ Immediate manual immobilization of the head and cervical spine

until a rigid collar , bags and adhesive tape across the forehead
are applied .

➢ Cervical spines are suspected to be unstable in the following

situations :

 Clinical examination reveals deformity or cervical tenderness

 Maxillofacial or head trauma or trauma above the clavicle .

 Multisystem trauma or unconsciousness .

➢ Radiological evaluation is done later after stabilization of vital

signs , by at least 3 views of cervical spine ( AP, lateral and
odontoid).
B) Breathing :
•Assessment :
1-Inspection: air movement , respiratory rate , cyanosis , tracheal
shift , jugular venous distension , open chest wound , asymmetric
chest expansion and use of accessory muscles of respiration .
2- Palpation : for subcutaneous emphysema and flail segment
3- Percussion : for hyper-resonance or dullness over lung fields
4- Auscultation : for upper & lower airway sounds .
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⁕ N.B : 5 main features of respiratory distress :Tachyponea or

dyspnea , use accessory respiratory muscles , difficult speaking ,
agitation or confusion and low O2 saturation at bed side oximetry .

• Methods :

▪ All patients receive oxygen by mask .

▪ Urgent treatment of 4 threatening thoracic conditions :

1- Open pneumothorax :
 Intial treatment is occlusive dressing fixed at 3 sides only.
 Once available, definitive treatment is insertion of chest tube
connected to under water seal.
2-Tension pneumothorax:
 Immediate decompression by insert a needle in 2nd
intercostal space in the mid-clavicular line. It is temporary
measure until the definitive treatment is available .
 Once available, definitive treatment is insertion of chest tube
connected to under water seal .
3-Haemothorax:
 A chest tube connected to under water seal .
 Later thoracotomy may be needed if bleeding continues .
4-Flail chest : Immediate stabilization of flail segment by cotton

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gauze and adhesive bandage.

Intial treatment for Open pneumothorax

Site of insertion of intercostals tube

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⁕ N.B:

• Nowadays , intercostal tube is inserted in the 5 th. intercostals

space in the midaxillary line .

• The nipple is a landmark for the 5th. intercostals space .

• Intercostal tube is inserted in the 5 th. intercostals space, at the

upper border of 6th. rib to avoid injury of intercostals
vessels and nerves at the lower border of 5th. rib.

Old & Recent Under Water Seal

C) Circulation :
a) Cardiac arrest : Immediate CPR
b) Shock is one of main causes of death in major trauma patient and
it may be one of the followings :
1) Haemorrhagic shock: Commonest.
2) Cardiogenic shock : due to cardiac tamponade or myocardial
trauma .
3) Neurogenic shock : due to spinal cord injury .

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▪ Assessment : pulse , B.P, color of skin and level of consciousness

▪Methods :
1)Control of external bleeding: ( Compression )
 Packing of wound and local pressure bandage. (The most efficient
method).
 Direct Pressure.
 Proximal pressure over the feeding vessels.
 Elevate the part.
 Tourniquet is used only if other measures fail to stop life
threatening bleeding .
➢ Complications : acute ischaemia and injury of soft tissues .

⁕ N.B:
➢ ABC for bleeding ( Alert ambulance center , find the
Bleeding & Compression )
➢ Sites of occult severe internal bleeding are intra-
thoracic ,intra-abdominal , fracture pelvis or femur .

2- 2 large caliber ( 16 gauge) peripheral IV lines are inserted .A

central IV line ( in the IJV) may be needed .
3-Blood samples are sent for typing , cross matching ,HB% ,
haematocrite and blood chemistry .
4- Ringer’s lactate solution is infused.
 Crystaloid needed = 3 times the estimated blood loss .
5- Once available , infusion of cross matched blood.
 IV fluid and blood transfusion at a rate that ensures normal
urine output of o.5 -1 ml/kg/hour for adults.Therefore ,
urinary catheter is applied for any patient for major tauma .

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Packing & local pressure bandage

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Direct Pressure Proximal pressure

IV lines and fluids Urinary catheter

c)Cardiac tamponade :
▪ Urgent decompression by needle pericardiocentesis followed later
by operative pericardiotomy and control source of bleeding .

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D) Disability :
▪ Common causes of neurological deficit related to trauma are :
1. Head injury .
2. Shock .
3. Hypoxia .
4. Alcohol & drugs abuse .
▪ Neurological assessment :
 AVPU evaluation : Base on patient’s best response .
A. Alert and responsive .
V. Response to Vocal stimuli .
P. Response to painful stimuli .
U. Unresponsive .
E) Exposure and Environments :
▪ Clothes : All clothes of the trauma victim are removed using sharp
large scissors .
▪ Warmth: Keep the ER warm and use blanket to prevent hypothermia

⁕ N.B : Triad of death in trauma :

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⁕ Additional important points :

a) Pain control .
b) Prolapsed viscera or bones are never reduced but covered only
by sterile dressing.
c) Insert:
1- Urethral catheter: to monitor urine output. It is contraindicated if
there is urethral bleeding suggesting urethral injury as cathererization
compound the condition.
2- Nasogastric ( Ryle’s ) tube : to prevent vomiting & aspiration .
d)Monitoring of trauma patient :
1- ECG,B.P, temperature , Pulse & oxygen oximetry
2- Capnography( CO 2) and ventilatory rate
3- Urine output

Oximetry Capnography
d) Radiological assessment :
1- AP chest and pelvis X-rays
2- EFAST exam. : ( Extended Focused Assessment with Sonography
in Trauma). Nowadays , this included in the primary survey to
identify pneumothorax , haemothorax , pericardial tamponade, and
free fluid in the abdomen.
e) History : SAMPLE
 Symptoms , if the patient is conscious .
 Allergy .
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 Medications
 Past medical history and pregnancy in females.
 time of Last meal.
 Events of injury .

⁕ N.B :At the end of survey for trauma patient early detection or
exclusion of the following 5 serious fatal conditions :
1-Airway obstruction .
2-Pneumothorax ( open or tension ).
3-Massive haemothorax .
4-Flail chest .
5. Cardiac tamponade .

II) Secondary survey :

⁕ Secondary survey is started once resuscitation , stabilization of vital
signs and preliminary radiological evaluation are completed .
⁕ Objectives & methods :
A) Complete history :in addition to SAMPLE
▪ Trauma : site , type & effects .
B) Examination of the patient from head to toe and front to back .

NB: Meticulous exam. of all systems of the body putting in

mind that associated multiple injuries are very common.

1- Head : ( see exam. of the head in management of head injury )

2- Face :
3- Neck :exam. of front of neck & cervical spine ( tenderness or
deformity ) .
4- Chest : ( see exam. of the chest in management of chest injury )

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5-Abdomen : ( see exam. of the abdomen in management of

abdominal injury )
6- Perineum with PR & PV exam.: to exclude evidence of rupture
urethra .
7- Limbs : for deformity , swelling , fracture or evidence of vascular ,
nerve or tendon injuries .
8- Spine : To exam. the back turn the patient in one piece by 4
persons to avoid spinal cord injury if there is unstable spine fracture

9- Nervous system :
 Glasgow coma scale ( see head injury)
 Pupils for size , equality and reaction to light .
 Exam. cranial nerves .
 Sensory & motor exam. in the limbs .
C) Urgent investigations: (See investigations for head. chest &
abdominal injuries).

• If the patient on clinical grounds, is in urgent need for

surgery, no time should be lost in doing investigation.

D) Final diagnosis after integration of all clinical , laboratory and

radiological information.

 Some cases require transfer to another department in the same

hospital or transfer to another hospital .

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 The level of medical care should not drop during transfer.

 Repeated evaluation of the patient because some injuries may

present after a lucid interval e.g. rupture spleen ,
retroperitoneal duodenal injury or extra-dural haemorrhage .

III) Antibiotics & tetanus Prophylaxis

IV) Definitive treatment of individual injuries :

• This will be discussed in the related chapters .

•N.B:

▪ The severity of the injuries determine the priority in the

treatment .

▪ Treatment of respiratory obstruction , cardiac arrest &

blood volume replacement have the first priority followed
by s e v e r e i n t e r n a l abdominal bleeding , head injuries
then chest injury and finally injuries in the limbs (unless
there is vascular injury with threatened ischaemia of the
limb).

▪ In the operating theatre many teams of surgeons are working

simultaneously for urgent control of these injuries.

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