ABSTRACTS
The initial assessment and management of seriously injured patients is a challenging task and requires a rapid and systematic approach. This systematic approach can be practised
to increase speed and accuracy of the process but good clinical judgement is also required. Although described in sequence, some of the steps will be taken simultaneously. The aim of
good trauma care is to prevent early trauma mortality. Early trauma deaths may occur because of failure of oxygenation of vital organs or central nervous system injury, or both.
Injuries causing this mortality occur in predictable patterns and recognition of these patterns led to the development of advanced trauma life support ATLS by the American College of
Surgeons. A standardised protocol for trauma patient evaluation has been developed. The protocol celebrated its 25th anniversary in 2005.
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Good teaching and application of this protocol are held to be important factors in improving the survival of trauma victims
worldwide.
Initial assessment
Resuscitation and primary survey.
Secondary survey.
Definitive treatment or transfer for definitive care.
1. Resuscitation and primary survey
For speed and efficacy a logical sequence of assessment to establish treatment priorities must be gone through sequentially although, with good teamwork, some things will be done
simultaneously resuscitation procedures will begin simultaneously with the assessment involved in the primary survey, ie lifesaving measures are initiated when the problem is
identified. Special account should be taken of children, pregnant women and the elderly as their response to injury is modified.
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The primary survey is according to:
A = Airway maintenance cervical spine protection
The key = Look, Listen, Feel. Ensure the airway is open obstructions, airway is clear, Trachea is midline and Mandibular or maxillofacial fracture.
Assume a cervical spine injury with any multisystemtrauma, especially with an altered level of consciousness or blunt injury above the clavicle.
Recognition of: Stridor, change of voice quality, obvious trauma
Major problems: 1. obstructions,
2. Laryngeal injury, 3. Posterior dislocation fracture dislocation of the sternoclavicular joint.
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Management: Establishing a patent airway ET intubation; closed reduction.
B = Breathing and ventilation
Potentially Disabling and Life Threatening Condition:
Recognition of: Neck vein distention, respiratory effort and quality changes, cyanosis
Major problems: 1. Tension pneumothorax:
Clinical diagnosis
Chest pain, air hunger, respiratory distress, tachycardia, hypotension,
tracheal deviation, unilateral absence of breath sounds, neck vein distention, cyanosis. V.S. cardiac tamponade
Hyperresonant percussion.
Immediate decompression: Needle decompression chest tube.
2. Open pneumothorax:
23 of the diameter of the trachea – impaired effective ventilation
Sterile occlusive dressing, taped securely on 3 sides.
Chest tube remote 3. Flail chest:
2 ribs fractured in two or more places.
Severe disruption of normal chest wall movement.
Paradoxical movement of the chest wall.
Crepitus of ribs.
The major difficulty is underlying lung injury pulmonary
contusion
Pain.
Adequate ventilation, humidified oxygen, fluid resuscitation.
The injured lung is sensitive to both underresuscitation of shock and fluid overload.
4. Massive hemothorax:
Compromise respiratory efforts by compression, prevent adequate ventilation.
C = Circulation with haemorrhage control Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly
observe:
Assessment: Pulse quality, rate and regularity. BP, pulse pressure, observing and palpating the skin for color and temperature. Neck veins.
Important notes: Neck veins may not be distented in the hypovolemic patient
with cardiac tamponade, tension pneumothorax,or traumatic diaphragmatic injury.
Monitor with: Cardiac monitorpulse oximeter.
Major problems: 1. Massive hemothorax:
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Rapid accumulation of 1500 mL o blood in the chest cavity.
Hypoxia
Neck veins may be flat secondary to hypovolemia
Absence of breath sounds andor dullness to percussion on one side of the chest
Management: Restoration of blood volume and decompression of the chest
cavity.
Indication of thoracotomy: a. Immediately 1500 mLof blood evacuated. b. 200mLhr for 2-4 hrs. c. Patient’s physiology status. d. Persistent blood
transfusion requirements.
2. Cardiac Tamponade
