ACCIDENT AND EMERGENCY SURGERY Dr Tamara Kaileh

ACCIDENT AND EMERGENCY SURGERY Dr. Tamara Kaileh

TYPES OF INJURY Penetrating Non penetrating blunt Blast overpressure Thermal Chemical Other, including crush and barotrauma

Impact + Severity of Injury • Impact between the body and an external object may result in Tissue Compression, Stretching, Tearing And Other Deformation ranging in severity from trivial to tissue injury beyond recoverable limits. • The Severity Of Damage is related to many factors, the most important of which are The Amount Of Energy Transferred And The Nature And Extent Of The Tissues Over Which It Is Applied. • In Penetrating Injury of low velocity and low available energy, tissue damage is focused over a small area. • In Blunt Injuries mechanisms may be multiple and tissue damage of complex aetiology.

Mechanisms of Blunt Injuries • • Acceleration Deceleration Rotational Stretch and shear

Death Categories • Deaths Following Injury Fall Broadly Into 3 Groups: • 1 IMMEDIATE DEATHS (50%) — those occurring imme diately or within the first few minutes of injury and usually due to widespread damage to the brain or upper spinal cord, the heart or major vessels, or multiple injuries. • 2 -EARLY DEATHS (30%) — those occurring within the first few hours after injury [called by some the ‘Golden Hour(S)’ of trauma]. These deaths are deemed preventable and are due to facial injuries with developing airway obstruction, lethal disruption of the breathing mechanism, massive blood loss into body cavities or from multiple long bone fractures leading to collapse of the circulation, and dysfunction of the central nervous system due to space occupying collections of blood within the skull. • 3 LATE DEATHS (20 PER CENT) — those occurring days or weeks after injury, generally due to sepsis and multiple organ failure. Organ failure may involve the heart, kidney, liver, lung, brain and haemopoietic systems.

The Advanced Trauma life Support Approach • ATLS management is based on a ‘treat lethal injury first, then reassess and treat again’ strategy. • ATLS component steps: • Primary Survey — identify what is killing the patient • Resuscitation — treat what is killing the patient • Secondary Survey — proceed to identify all other injuries • Definitive Care — develop a definitive management plan • NB. Primary survey and resuscitation must be concurrent.

ABCDE Approach • • • ABCDE approach : Elements of the primary survey: Airway with cervical spine control Breathing and ventilation Circulation with control of haemorrhage Dysfunction of the central nervous system Exposure in a controlled environment

Mini Neurological Exam • • • Prehospital Mini-Neurological Examination A Alert V — Responds to Voice P — Responds to Pain U — Unresponsive Pupils — Size and reaction

The mobilisation of the trauma team: • penetrating injury to the chest, abdomen, head, neck or groin; • two or more proximal long bone fractures; • flail chest and pulmonary contusion; • evidence of high energy impact: • falls of 2 m (6 feet) or more; • changes in velocity in an road traffic accident of 32 km/hour (20 miles/hour) or more estimated from outward • deformity of car • rearward displacement of front axle; • sideward intrusion of 35 cm or more on the patient’s side of the car; • • ejection of the patient; rollover; death of another person in the same car; pedestrian hit at more than 32 km/hour.

Immediately life-threatening thoracic conditions • • • Airway obstruction (dealt with under ‘A) Tension pneumothorax Massive hemothorax (> 1500 ml blood in a hemithorax) Open pneumothorax (sucking wound’) Flail segment with pulmonary contusion Cardiac tamponade (almost always penetrating injury)

Fluid Challenge • In adults, 1— 2 litres of warmed Hartmann’s (Ringer’s) solution is recommended as an initial fluid challenge. The initial volume in children is calculated according to weight &is by convention 20 m. I /kg body weight. This bolus may be repeated once. • Responses to initial fluid challenge • Immediate and sustained return to normal vital signs • Transient response with later deterioration • No improvement

SECONDARY SURVEY • This phase comprises a head to toe examination of the undressed and stable patient. It is lengthy and includes a detailed history if this is feasible. The examination may be conducted in any order.

Damage Control — Staged Or Abbreviated Laparotomy • The earliest uses of the approach concerned perihepatic packing for extensive liver injury. While the commonest indication remains catastrophic intra abdominal haemorrhage. The technique should usually be considered as part of the primary survey and resuscitation phases in patients who fail to respond to nonoperative resuscitation methods. • Correct coagulopathy, acidosis, hypothermia

Objectives Of Staged Or Abbreviated Laparotomy • • • Objectives Of Staged Or Abbreviated Laparotomy: Arrest haemorrhage Control or limit coagulopathy Limit cavity contamination Protect viscera and limit fluid/protein loss

Focused Abdominal Sonogram For Trauma (Fast) • Portable, hand-held ultrasound used by trauma surgeons for evaluation of patients with blunt thoracoabdominal trauma, and is the preferred initial technological assessment of the patient. • It belongs early on in the secondary survey, although some centres advocate its use during the ‘C’ component of the primary survey to localise intra-abdominal haemorrhage and to rule out cardiac tamponade in overtly shocked patients where no haemorrhage source is evident. • The technique is rapid, with only four areas being scanned at the initial investigation (pericardium, pelvis, two lower quadrants)

TRIAGE • (from the French ‘trier’) means to sift or to sort and refers to the allocation of injured patients into certain categories for action by emergency teams. • • Triage sieve — a quick survey is made to separate the dead and the walking from the injured. • • Triage sort — remaining casualties are now assessed and allocated to three or four groups according to local protocols: category 1: critical and cannot wait. Airway obstruction and catastrophic haemorrhage are examples; category 2 : urgent. Serious injury but can wait a short time, 30 minutes in most systems; category 3 : less serious injuries. Not endangered by delay; category 4 : expectant. Severe multisystem injury. Survival not likely;