• Trauma: leading cause of death <40yo
• 3 patients permanently disabled per death
• Every doctor should know basics of trauma care
• Eg. Penetrating injury (stab/ chop wound) vs. blunt injury (no external wound)

• 50% at scene (prevention of trauma: safety belt, drink-driving laws)
• 30% in next 1-2 hours (golden hours) (this lecture)
• 20% after op/ multi-organ failure/ irreversible brain(stem) damage/ sepsis

• Normal Pt: Hx + P/E
• Trauma Pt: ID and deal with life-threatening problems immediately

• American College of Surgeons Committee on Trauma
• For all disciplines

• Multiple injuries might coexist
• Life threatening injuries might be occult
• Missed injuries might cause death or permanent disability
• Time is critical

• Rapid primary survey
• Resuscitation and monitoring
• Detailed secondary survey
• Re-evaluation
• Definitive care: OT, ICU, CT scan

Adults/paediatrics/pregnant women ® priorities are the same

• A = Airway with C-spine protection (neck collar)
• B = Breathing (rapid/ slow, regular, equal breath sounds on both sides)
• C = Circulation with haemorrhage control
• D = Disability
• E = Exposure/ Environment

• Mask
• Gown
• Gloves
• Goggles/face shield

Sorting of patients according to severity

1. ABCDE's
2. Available resources
3. Multiple casualties
4. Mass casualties/disaster

• Save those with severe injuries
• Will not save those who are almost dead (do not have the resources)

• Is the airway adequate?
• When does airway compromise occur?
• How do you determine it? (Ask Pt to speak; open mouth to see if anything blocking)
• What can you do about it? (jaw thrust + chin lift; suck out blood/ saliva, intubation)
• What is a definitive airway? (Patient if Pt can speak)

• Distinguish airway vs. ventilation problem (eg. Chest wall)
• Oxygen is the universal drug
• Eg. Life threatening chest injuries

1. Haemothorax: cyanosis, neck veins flat, resp difficulty as late symptom, shock - skin cold and clammy, breath sounds absent, percussion note full/ flat)
2. Traumatic pneumothorax: decreased breath sounds on one side, percussion: hyperresonance
3. Tension pneumothorax: HT, trachea deviates to one side (use needle to allow fluid to exit, insert chest tube), engorged neck veins
4. Heart: cardiac tamponade - blood in pericardial sac, impedes heart filling, no CO, develop cardiac arrest (most life threatening). Signs: hypotensive (low CO), pulsus paradoxus (decreased pulse during inspiration), engorged neck veins

• Note: always think of mediastinal injury

• Assessment of organ perfusion: BP, pulse, urine output (Foley)
• Identify the cause of shock (1) Haemorrhagic: flat neck vein, hypotensive (2) Non-haemorrhagic: cardiac tamponade, tension pneumothorax, cardiogenic problem, neurogenic problem (spine - spinal shock)
• Note: trauma Pt - assume haemorrhagic shock until proven otherwise
• Circulatory management

1. STOP THE BLEEDING
2. Restore volume
3. Reassess

• Venous access: insert large bore needle to increase BP (not too high, or else will bleed out)

Disability

• Baseline neurological evaluation (1) GCS: max 15 (2) Pupillary response

Observe for neurological deterioration: ask questions (any neuro deficit)

Exposure/ Environment

• Prevent HYPOTHERMIA
• Eg. Cold IV fluid, rural areas (NT), left overnight

• Vital signs: BP, P, RR, SaO2
• Pulse oximeter
• Urinary/ gastric catheters if indicated

• If Pt not OK, go back to ABC
• Eg. Establish definite aw, but after time, SaO2 drops and one side has more sounds than other -> inserted endotracheal tube too far? Pneumothorax? (do not rush to put into chest tube)

• X-rays (trauma series): chest, lateral C-spine, pelvis (for blunt trauma Pt; not needed for penetrating Pt b/c know where inj is)
• If only one X-ray = CHEST (small abn may not be seen clinical - eg. Small pneumothorax)
• Cervical = immobilise neck, assume it has problems, no need to determine problem in immediate setting
• Pelvis = clues on clinical exam (eg. Unstable pelvis when pressing on pelvis, Pt hypovolaemic, male Pt urethral bleeding, scrotal haematoma, female more difficult - bruises in lower ab). Bind pelvis to immobilise
• If limb injuries, X-ray limbs later; X-ray vital areas (trauma series) first
• FAST (Focused Abdominal Ultrasound for Trauma); look for blunt injury
• DPL (diagnostic peritoneal lavage); put small catheter in ab cavity and insert fluid (see if any blood coming out); used less b/c of good US availability
• Spiral CT scan: once Pt stable (if suspect ab or chest injury)
• Do NOT delay resuscitation

After Pt stabilised

• A = Allergies
• M = Medications
• P = Past health
• L = Last meal
• E = Event (most important; cause/ mechanism of injury). Eg. MVA = how fast car travelling, seat belt, air bag?

• Head-to-toe examination (don't forget the BACK)
• Missed injuries
• "Tubes and fingers in all orifices": for unstable Pt ® nasogastric tube, endotracheal tube, PR (eg. pelvic injury - if can feel prostate, urethra not that damaged), Foley in UB

• Must document everything (potential ML cases). Anything not documented has NOT happened.
• Usu nurse records vital signs according to time scales

• Relief of pain/anxiety as appropriate
• Careful monitoring is essential

• ABCDE-approach to trauma care
• Treat greatest threat to life first: do not treat screaming Pt's; treat Pt's that are unconscious
• Time is critical: do not wait until Pt deteriorates
• Team approach
• DO NO FURTHER HARM