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TRAUMA
Presenter:
- Wisnu Adiputra (07120080072)
- Nofilia Citra Candra (07120090066)
Definition of Trauma
A term derived from the Greek for
WOUND
It refers to any bodily injury.
It defined as tissue injury due to direct
effects of externally applied energy.
Energy may be mechanical, thermal,
electrical, electromagnatic or nuclear.
Included:burns, drowning, smoke,
inhalation,
slip & fall.
Excluded: poisoning/toxic ingestion.
Initial Assessment
SURVEY
Survey
Safe?
What
happen?
Count the
victim
How many
helper?
Help
TRIAGE
Black or white: Dead
Red:patient with heavy trauma, combusio with
high BSA
Yellow : extremity fracture without heavy
hypovolemic shock
Green: minimal trauma
PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment
(temp control)
Eye
opening
Motor
response
Verbal
response
Spontaneous 4 Move to
command
6 Converse
To speech
3 Localizes to
pain
5 Confused
To pain
2 Withdraw
from pain
4 Gibberish
none
1 flexes
3 grunts
2 none
1
Extends
none
Airway
LOOK
LISTEN
FEEL
Airway
Is there any obstruction?
Protection of the spine & spinal cord is the
1/00
11
BREATHING
Breathing dan Ventilasi
Chest expansion
Auskultasi (if possible)
Percussion : hyporesonance(fluid) dan
Hyperesonance(air)
8 lethal Injury
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheo-bronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Mediastinal traversing wounds.
Breathing Interventions
Ventilate with 100% oxygen
Needle decompression if tension
pneumothorax suspected
Chest tubes for pneumothorax / hemothorax
Occlusive dressing to sucking chest wound
If intubated, evaluate ETT position
CIRCULATION
Circulation
Hemorrhagic shock should be assumed in any hypotensive trauma patient
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin color and capillary refill
c. Pulse.: Normal ( 60-100x/min)
Tachycardi ( >100x/min
Bradycardi ( <50x/min)
2. Bleeding
*external bleeding is identified & controlled in the
primary survey.
*Tourniquets should not be use.
Hemorrhage Classification :
Class I Hemorrhage :
up to 15% loss
Class II Hemorrhage :
15-30% loss
1/00
17
Circulation Interventions
Cardiac monitor
Apply pressure to sites of external
hemorrhage
Establish IV access
indicated
Volume resuscitation
3 for 1 Rule
a rough guideline for the total
amount of crystalloid volume acutely
is to replace each ML of blood loss
with 3 ML of crystalloid fluid, thus
allowing for restitution of plasma
volume lost into the interstitial &
intracellular space
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20
21
Disability
Disability ( Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Not forget to use also Glascow Coma Scale.
Disability Interventions
Spinal cord injury
High dose steroids if within 8 hours
ICP monitor- Neurosurgical consultation
Elevated ICP
Head of bed elevated
Mannitol
Hyperventilation
Emergent decompression
EXPOSURE
Exposure / Environmental Control
-It is the pts body temp that is most important, not he
comfort of the health care provider.
-Intravenous fluid should be warm.
-Warm environment (room tem) should be maintained.
-early control of hemorrhage.
-Complete disrobing of patient
-Logroll to inspect back
E- Exposure
Complete disrobing of patient
Logroll to inspect back
Rectal temperature
Warm blankets/external warming device to
prevent hypothermia
RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts ability to
Secondary survey
Although maxillofacial injuries is part of
the secondary survey, OMFS might be
involved at early stage if the airway is
compromised by direct facial trauma
Head Injury
Facial injury
Chest Injury
Abdominal injury
Injury to extremities
29
Facial numbness
Trigeminal branch nerve injury
Malocclusion
Fracture or dislocation
Palpation
Physical Exam
Orbital examination
Done early before swelling
Pupil reactivity
Tear drop pupil associated with globe rupture
Marcus Gunn pupil
Hyphema
Visual acuity
EOM
Ocular muscle entrapment
Ocular nerve injury
Pain can be a clue to associated orbit fractures
Proptosis - consider retrobulbar hematoma
Upper
Eyelid
Droop
Disruption of levator
palpebral muscle
Grays Anatomy (Wikipedia
)
Physical Exam
Nose
Septal
CSF
hematoma
Rhinorrhea
Deformity
Ears
CSF
leak
Hemotympanum
Battles sign - indicates basilar skull fracture
Mandible/Dentition
Malocclusion
Flail mandible - two separate fracture site
TMJ dislocation - typically anterior
Tongue blade test
Patient bites down on tongue blade and it is
twisted until it breaks:
Unable to break tongue blade indicates
mandibular fracture
95% sensitive; 65% specific for mandibular
fracture
Loose/chipped teeth
Secondary Survey
Neurologic
Skin fold symmetry at rest
Motor: each division of CN-VII
Sensation: 3 divisions of CN-V
Sensation on tongue
Gag reflex
Challenging to read
Approach
Asymmetry
Bony
integrity
Subcutaneous air
Sinus opacity
Teardrop sign - orbital fat herniation
Waters
Jug Handle
RadiologyInfo.o
rg
Head injury
Many of facial injury patients sustain
head injury in particular the mid face
injuries
Open
Closed
it is ranged from Mild concussion to brain
death
42
OR
History of loss of conscious
History of vomiting
Change in pulse rate, blood pressure and
pupil reaction to light in association with
increased intracranial pressure
Assessment of head injury (behavioral
Skull fracture
Skull base fracture (battles sign)
Temporal/ frontal bone fracture
Naso-orbital ethmoidal fracture
43
Chest injuries:
Pneumothorax, haemopneumothorax, flail
segments, reputure daiphram, cardiac
tamponade
signs
Clinical
Deviated trachea
Absence of breath
sounds
Dullness to percussion
Paradoxical movements
Hyper-response with
a large pneumothorax
Muffled heart sounds
Radiographical
Loss of lung marking
Deviation of trachea
Raised hemi-diaphragm
Fluid levels
Fracture of ribs
45
chest
46
Hemorrhage
Acute bleeding may lead to hemorrhagic
shock and circulatory collapse
47
Abdominal Trauma
Look for distension, tenderness, seatbelt
Extremity trauma
Fracture of extremities in particular
the femur can be a significant cause
of occult blood loss. Straightening
and reduction of gross deformity is
part of circulation control
Cardinal features of extremities injury
Impaired distal perfusion (risk of ischemia)
Compartment syndrome (limb loss)
Traumatic amputation
50
Ocular damage
Reduction in visual acuity
Eyelid injury
52
Prevention of infection
Fractures of jaw involving teeth bearing areas
are compound in nature and midface fracture
may go high, leading to CSF leaks (rhinorrhoea,
otorrhoea) and risk of meningitis,
and in case of perforation of cartilaginous
auditory canal
Diagnosis:
(Eljamal, 1993)
53
Control of pain
Displaced fracture may cause severe pain but
strong analgesic ( Morphine and its derivatives)
must be avoided as they depress cough reflex,
constrict pupils as they may mask the signs of
increasing intracranial pressure
Management:
Non-steroidal anti-inflammatory drugs can
be prescribed (Diclofenac acid)
Reduction of fracture
sedation
54
SECONDARY SURVEY
Does not begin until the primary survey
SECONDARY SURVEY
History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.
Fracture Classification
Major
Lefort I, II, III
Mandibular
Minor
Nasal
Sinus wall
Zygomatic
Supraorbital
Orbital floor
Lefort Fractures
Lefort fractures can coexist with additional
facial fractures
Patient may have different Lefort type fracture
on each side of the face
Differentiating Leforts
Pull forward on maxillary teeth
Lefort I: maxilla only moves
Lefort II: maxilla & base of nose move:
Lefort III: whole face moves:
Lefort I: Nasomaxillary
Horizontal fracture extending through maxilla
Lefort I: Nasomaxillary
Closed reduction
Intermaxillary fixation: secures maxilla to
mandible
May need wiring or plating of maxillary wall
and / or zygomatic arch
Antibiotics: anti-staphylococcal
Lefort III
Craniofacial dissociation
Bilateral suprazygomatic fracture resulting in
Lefort III
Signs and Symptoms
Face lengthening: caved-in or donkey face
Malocclusion: open bite
Lateral orbital rim defect
Ecchymoses: periorbital, subconjunctival
Lefort III
Signs and Symptoms
Bilateral epistaxis
Infraorbital paresthesia
Often medial canthal deformity
Often unequal pupil height
Lefort III
Usually associated with major soft tissue
Lefort III
Transosseous wiring or plating
Frontozygomatic suture
Nasofrontal suture
May need extracranial fixation if concurrent
mandibular fracture
Antibiotics
Mandible Fractures
Airway obstruction from loss of attachment at
base of tongue
>50 % are multiple
Condylar fractures associated with ear canal
lacerations & high cervical fractures
High infection potential if any violation of oral
mucosa
Mandible Fractures
Signs and symptoms
Malocclusion
Decreased jaw range of motion
Trismus
Chin numbness
Ecchymosis in floor of mouth
Palpable step deformity
Mandible Fractures
Tongue blade test: have patient bite down
TMJ Dislocation
Can occur from direct blow to mandible
Can occur spontaneously from yawning or
laughing
Mandible dislocates forward & superiorly
Concurrent masseter & pterygoid spasm
TMJ Dislocation
Symptoms
Patient presents with mouth open, cannot
close mouth or talk well
Can be misdiagnosed as psychiatric or
dystonic reaction
TMJ Dislocation
Treatment
Manual reduction: place wrapped thumbs on
molars & push downward, then backward
Be careful not to get bitten
Usually does not require procedural sedation
or muscle relaxants
control epistaxis
Usually do not need antibiotics
Early reduction under local anesthesia useful
if nares obstructed
Zygomatic Fractures
Tripod (tri-malar) fracture
Depression of malar eminence
Fractures at temporal, frontal, and maxillary
suture lines
Zygomatic Fractures
Isolated arch fracture
Less common
Shows best on submental-vertex x-ray view
Painful mandible movement
Usually treat with fixation wire if arch
depressed
Zygomatic Fractures
Tripod S & S
Unilateral
epistaxis
Depressed malar
prominence
Subcutaneous
emphysema
Orbital rim stepoff
Altered relative
pupil position
Periorbital
ecchymosis
Subconjunctival
hemorrhage
Infraorbital
hypoesthesia
Supraorbital Fractures
Frontal sinus fracture
Often associated with intracranial injury
Often show depressed glabellar area
If posterior wall fracture, then dura is torn
Supraorbital Fractures
Ethmoid fracture
Blow to bridge of nose
Often associated with cribiform plate fracture,
CSF leak
Medial canthus ligament injury needs
transnasal wiring repair to prevent
telecanthus
Orbital Fractures
Blow out fracture of floor
Rule out globe injury
Visual acuity
Visual fields
Extraocular movement
Anterior chamber
Fundus
Fluorescein & slit lamp
Orbital Fractures
Symptoms and signs
Diplopia: double vision
Enophthalmos: sunken eyeball
Impaired EOMs
Infraorbital hypesthesia
Maxillary sinus opacification
Hanging drop in maxillary sinus
Orbital Fractures
Diplopia with upward gaze: 90%
Suggests inferior blowout
Entrapment of inferior rectus & inferior oblique
Diplopia with lateral gaze: 10%
Suggests medial fracture
Restriction of medial rectus muscle
Orbital Fracture:
Treatment
Sometimes extraocular muscle dysfunction
Bottom to top
Top To Bottom
vermillion border
Never shave an eyebrow: may not grow back
If debridement of eyebrow laceration needed,
debride parallel to angle of hairs rather than
vertically
primarily
Clean facial wounds can be repaired up to 24
hours after injury
Place incisions or debridement lines parallel
to the lines of least skin tension (Lines of
Langer)
SUMMARY
Assess ABC's first
Do complete exam as part of secondary
survey
Obtain standard X-rays and / or CT scan as
indicated
Decide if specialist referral and / or operative
repair indicated
Arrange followup after repair to assess for
delayed complications or cosmetic problems
THANK YOU