Basics of Trauma Care😊

Basics of Trauma Care

Pre-Hospital Information

• From Responders (MIST):
• Mechanism of Injury
• Injuries observed
• Signs & Symptoms
• Treatment given

• From Patient (AMPLE):
• Allergies
• Medications
• Past medical history
• Last meal
• Events of trauma

Patient Transfer

• Manual In-Line Stabilization

Mortality in Trauma (Trimodal Distribution)

Triage (Sorting by Priority)

Advanced Trauma Life Support (ATLS)

• Approach:
• Primary Survey (1° Survey): 
• Address life-threatening injuries (ABCD).
• CXR, Pelvic Xray, eFAST

• Secondary Survey (2° Survey): 
• Detailed head-to-toe assessment.
• CT Scan

Primary Survey (C → ABCD)

Cervical Spine (C-Spine)

• Assessment (NEXUS Criteria - if any positive, assume C-spine injury → ):
• Neurological deficit
• Unable to provide history (altered sensorium)
• EtOH (intoxication)
• eXtreme distracting injuries
• Spinal midline tenderness

• Imaging: C-spine X-ray

• SPINE/SHINE
• Spinal midline tenderness
• Provide history
• Injury → extreme
• Neurological deficit
• Ethanol

Airway (A)

• Secure Airway if:
• Unable to speak
• GCS ≤ 8
• Coma
• Severe maxillofacial injury

• Emergency Airway:
• Needle Cricothyroidotomy:
• Through cricothyroid membrane.
• Provides 20-30 min of oxygenation.
• Contraindicated: 
• Patients < 12 years.

• Definitive Airway: 
• Tracheostomy (if needle fails).

Permanent tracheostomy

Indications of Tracheostomy

Mnemonic: Occupy Most Seats in Medical Association

• O → Obstruction: Above T₂–T₄

• M → prolonged Mechanical ventilation:
• Most common indication for elective tracheostomy

• S → Secretion removal / pulmonary toilet (coma, chest injury)

• M → Maxillofacial, head & neck surgeries

• A → Aspiration prevention (bilateral complete vocal cord palsy)

Tracheostomy Tube :

 

• High volume, low pressure.

• For air tight seal.

Position :

• Rose’s position :
• Extension at cervico-thoracic and atlanto-occipital joint.
• Rose has extension everywhere

Tracheal incision :

• 2, 3, 4 tracheal rings.

• Emergency
• Vertical incision :
• From lower border of cricoid to suprasternal notch

• Elective
• Horizontal incision/Skin crease incision :
• 2.5 cm above suprasternal notch

• High tracheostomy :
• Incision at T1
• Indication : Ca larynx.
• Complication : Laryngeal stenosis

• Low tracheostomy :
• Infections like Papillamatosis

Tube block :

• C/f of complete block : Stridor.

• Prevention : Saline/sodium bicarbonate suction.

• Management : Change tracheostomy tube.

Structures Injured During Tracheostomy

• Isthumus and below vessels
• Isthmus of thyroid gland
• Arteria thyroidea (Thyroid Ima artery)
• Inferior thyroid vein

• Surgical emphysema
• D/t tight sutures → injure nearby structures

Notes:

• Nasotracheal intubation: 
• Contraindicated in head injury
  (due to anterior cranial fossa fracture risk).

• Laryngeal mask airway (LMA) is easier to insert.

Breathing (B)

• Assessment: Chest examination (AP)

• Adjuncts: Pulse oximetry, Chest X-ray (AP), eFAST scan.

• Intervention: Chest tubes (if indicated).

Circulation (C)

• IV Access:
• Minimum 2 large-bore 18 G (green) or larger IV cannulas.

• Fluid Administration: 1 liter IV fluids (ATLS 10th ed.).

• Alternative IV Access:



• Emergency: 
• Intraosseous (just below tibial tuberosity),
• Venous cutdown (great saphenous vein).
• Definitive: 
• Central line (IJV most common).

• Tranexamic Acid (CRASH-2 trial):
• Indication: 
• SBP < 90 mmHg
• HR > 110 bpm.
• Dose: 
• Give within 3 hrs of injury
• 1g IV over 10 min
• - then 1g over 8 hrs.
• Effect: Decreases mortality.

• Pelvic Binder:



• Use: Trauma with hypovolemic shock.
• Mechanism: Stops bleeding by tamponade effect until fracture ruled out.

• Damage Control Resuscitation (DCR):
• Permissive hypotension.
• Minimal crystalloid use.
• 1:1:1 blood product ratio (RBC:Platelet:FFP).
• Early hemorrhage control.

Disability (D)

• Glasgow Coma Scale (GCS):

• Head Injury (Based on GCS)
• Mild: 13–15
• Moderate: 9–12
• Severe: ≤ 8

• GCS-P Score: 
• GCS (-) Pupillary Reactivity Score (PRS).
• Min: 1

Pupils unreactive to light	Pupils Reactivity Score (PRS)
Both pupils	2
One pupil	1
Neither pupil	0

• Log Roll:
• Purpose: Examine patient's back.
• Personnel: Requires 4 people (5 if limb fracture).

Whole-Body CT (Trauma CT) in RTA

• Part of ATLS protocol to assess life-threatening injuries.

• NOT PRIMARY SURVEY

Components

1. CT Brain
• Detect intracranial hemorrhage
• Skull fractures

2. CT Spine
• Evaluate spinal injuries (common in high-energy trauma)

3. CT Abdomen & Pelvis
• Identify internal organ injury
• Detect bleeding or fractures

Note:

• CT within 1 hour if
• GCS < 13 at any point of time
• GCS < 15 after 2 hours of the injury.
• Focal neurological deficit
• Suspected skull fracture
• Open
• Depressed
• Basal
• > 1 episode of vomiting
• Post-traumatic seizure

• CT within 8 hours if
• Age > 65 years
• Bleeding or clotting disorder
• Dangerous mechanism of injury
• Fall > 1 m
• Fall > 5 stairs
• Road traffic accident
• Retrograde amnesia > 30 minutes

Trauma Scores

Mangled Extremity Severity Score (MESS): 

• Used for limb salvageability
• Messi = 7, Visa Kitti → But ponel kaalu vettanam
• Score ≤ 6 = salvageable
• Score ≥ 7 = Amputation (Not salvagable)
• Mnemonic: VISA.
• V: Velocity of injury or soft tissue coverage.
• I: Ischemia time (most important).
• S: Shock.
• A: Age of patient.
• Messed up leg → 6 thavayil kuravu tyre kalil kude keri irangiyal rakshapedutham else amputate

Damage Control Surgery (DCS) and
Early Total Care (ETC)

Criteria

• DCS:
• Terrible Triad of Trauma
• Serum Lactate > 5 mmol/L
• Transfusion approaching 15 units
• Injury Severity Score > 36
• BP < 70 mmHg
• Mnemonic: CAT + 5, 15, 36, 70

• ETC:
• Stable hemodynamics
• Normal serum lactate
• Normal coagulation
• Normothermia
• No need for vasoactive/inotropic stimulation

ETC Approach

• Definitive Management: 
• Within 36 hours (after resuscitation)

• If patient deteriorates: 
• Convert to DCS approach

DCS (Abbreviated Laparotomy)

• In terrible triad of trauma
• Mnemonic: CAT (Coagulopathy, Acidosis, Temp ↓↓) makes Terrible trauma
1. Hypothermia (< 34°C)
2. Acidosis (pH < 7.2)
3. Coagulopathy

• Phases (ATLS):

Phase	Location	Action
Phase 0	ER	Patient identification
Phase 1	Emergency OT	Stop bleeding, prevent contamination
Temporary Abdominal Closure	OT/Post-op area	- Abdominal swab/cotton drape - Suction drains - Urobag/Bogota bag
Phase 2	ICU	Correct physiology (Terrible Triad)
Phase 3	After 24–48 hrs: Re-exploration OT	Correct anatomy

• Stages of DCS:
1. Patient selection
2. Control of hemorrhage and contamination
3. ICU care
4. Definitive Surgery
5. Abdominal closure

Abdominal Compartment Syndrome (ACS)

• Intra-abdominal Pressure (IAP): 
• Measured by bladder pressure

• Causes:
• Bowel obstruction
• Massive burns
• Massive ascites

• Definitions:
• Intra-abdominal Hypertension (IAH):
• Sustained/repeated pathological ↑↑ in IAP > 12 mmHg
• ACS: 
• Sustained increased IAP ≥ 20 mmHg + new organ dysfunction

• Clinical Features:
• Renal:
• Renal vessels compressed
• Decreased GFR
• Decreased urine output
• Cardiac:
• Decreased BP
• Increased HR (due to decreased venous return)
• Respiratory:
• Increased Respiratory Rate (RR)
• Decreased lung volumes
• Intracranial: Increase in intracranial tension

• Mx:
• Decompressive Laparotomy

Blast Injury

• Tympanic membrane (TM) rupture is the most common primary blast injury.

• F/b Lungs and GIT

Decerebrate vs Decorticate

Decorticate Rigidity

• Mnemonic: Decor → Red ribbon from up, Brown ribbon from down

• Mnemonic: Corticate → Kuuttipidich irikkunnu → Red blood kandapo → hemorrhage → Rubral nucleus/Red nucleus → In midbrain → (Red → Mid) → Midbrain affected

• Cut: Upper midbrain (above red nucleus).

• Lower limb extension

• Pathophysiology:
• Decortication (Cortex removed) → Cortical inhibition lost
• Pontine reticulospinal tract.
• Head Extension
• LL Extension
• Rubrospinal tract is intact (and unopposed)(lesion above red nucleus)
• Upper limb flexion → Decorticate rigidity

• Cause:
• Thrombosis or hemorrhage of internal capsule → Decorticate rigidity

Decerebrate Rigidity / Extensor rigidity / γ rigidity

• Cerebrum prevents all extensor muscle always.

• When it is lost → causes
1. Extensor plantar → Babinsky
2. Extension of UL, Head, LL → Extensor rigidity / γ rigidity

• It is characterized by rigid extension of the limbs and trunk, not all muscles of body

• Pathophysiology:
• Cut: Upper pons (between superior/inferior colliculi).
• Mechanism:
Cortical inhibition lost
↓
Dorsal sensory roots activated
↓
Pontine Reticulospinal tract overactive (++)
↓
Gamma (γ)-motor neurons overactive (++)
↓
Increased extensor muscle tone
↓
Decerebrate rigidity / γ rigidity

• Cause:
• Uncal herniation (due to space occupying lesion)

 

Decerebellate rigidity / α rigidity

• Mechanism:
• Anterior cerebellum removed (++)
• → α Motor neurons overactive
• → Exaggeration of extensor activity

Uncal Herniation & Kernohan’s Notch & Hutchinson pupil

• Uncal herniation:
• Herniation of uncus (medial temporal lobe)

• Progression:
• Affect Parasympathetic fibers of ipsilateral cranial nerve III
• Called "ipsilateral blown pupil" or "false localizing sign"
• C/L corticospinal tract/crus cerebri compressed
• I/L UMN palsy

• Kernohan’s notch phenomenon:
• False localizing sign
• Hemiparesis appears ipsilateral to lesion
• instead of expected contralateral

Key signs:

• Ipsilateral pupil dilatation → Hutchinson pupil

• Ipsilateral UMN palsy