Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1348 - файл.pdf
inevitable within minutes. The former group (about 80%) requires
careful assessment and observation and may need minimal attention to
soft tissue injuries. And usually if they remain stable, they could be
discharged from hospital within several hours.
In between these two extremes, which account respectively for 80%
and 5% of all trauma admissions, are a group of potentially salvageable
unstable victims whose injuries could be life-threatening if not managed
urgently.
These trauma patients benefit most from rapid transportation to a
hospital to deal properly with a spectrum of injuries.
III. MECHANISMS OF INJURIES.
An impact between the body and an external object may result in
tissue compression, stretching, tearing and other deformation ranging
in severity from trivial and soft injury to tissue injury beyond recoverable
limits.
The severity of damage is related to many factors, the most important
of these are the amount of energy transferred and the nature and
extent of the tissues over which it is applied.
The understanding of the basic mechanisms of injury could help at all
levels of trauma care. Knowing the time and how the patient was
injured can guide the assessment and provision of care in both the
prehospital and in-hospital phases. An understanding of the
mechanism of injury could also help in triage decisions because of the
association with severity of injury.
INJURIES ARE CLASSIFIED INTO SEVERAL CATEGORIES:
1- Penetrating injury.
2- Non-penetrating blunt trauma.
3- Blast overpressure trauma.
10
4- Thermal injury.
BLUNT TRAUMA.
5- Chemical injury.
6- Other, including crush and barotraumas.
1. PENETRATING INJURY.
This is usually a result of stab wounds, low- and high-velocity missile
injuries. In penetrating injury of low velocity and low available
energy, tissue damage is focused over a small area, for example
injuries caused by low energy handguns, knives, sharp instruments,
spikes of glass, wood or metal. Injury severity and outcome is related
to the tissues involved.
In high velocity injury, associated with the potential for high energy
transfer, damage to structures may extend over a wide area remote
from the wound track.
2-
It results from road traffic accidents, industrial injuries and sporting
accidents etc. The extent of the injury will depend on the body region
involved, degree of restraint and severity of the impact.
Deformation and intrusion may result in blunt, penetrating or crush
injury. In an adult, injury is commonly due to bumper impact to the
limbs, in children, such an impact is over a wider area often involving
the chest and abdomen, and is associated with multiple injuries and
high mortality.
IV. DEATH FOLLOWING TRAUMA.
Deaths as complications following injuries are divided into three
groups. (Trimodal distribution).
A. IMMEDIATE DEATHS.
These are happening immediately or within the first few minutes after
11
injury and usually due to extremely widespread and huge damage to
the brain or upper spinal cord, the heart or major vessels, or
polytrauma with lethal injuries. This group of immediate deaths makes
about 50 percent of the deaths following injuries.
This high peak is due to severely damaging injuries, where little could
be done in their management.
Preventive measures may help to achieve possible reduction of this
high peak of deaths, such as seat belts in automobiles, head protection
in motorcycles and bicycles, road safety legislation and education of
pedestrians.
The prevention and reduction of complications and mortality in the
industrial centers and factories are achieved by following restrict
rules and orders of occupational medicine.
B. EARLY DEATHS.
These make about 30 per cent and occur in the first few hours after
injury (the golden hours of trauma). These deaths 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 in the skull.
C. LATE DEATHS.
About 20 per cent of deaths following injuries, happen days or weeks
after trauma, usually because of sepsis and multiple organ failure. For
example, failure of the heart, kidney, liver, lung, brain and haemopoietic
systems.
12
V. MODERN MANAGEMENT OF INJURED PATIENT.
Fundamental changes in the care and management of the injured have
taken place in recent decades. These changes have contributed and
improved the way of management in which the injured patient is
perceived and managed throughout the chain of care from point of
injury onwards.
The management of trauma patient is facilitated by having qualified
personnel and the necessary equipment in a state of readiness. There
must be an organized trauma team, a cohesive group, where every
member should have a defined role.
It is very important for any hospital with an emergency unit to be
prepared to provide immediate assessment and resuscitation of trauma
patient.
The initial assessment of the injured patient provides the basis for all
subsequent management, whether the patient is observed, subjected to
extensive diagnostic studies or rushed to operation theatre for direct
operative treatment.
Many training courses were introduced e.g. the Advanced Trauma
Life Support Course (ATLS), the Advanced Trauma Nursing Course
(ATNC) and the Pre-Hospital Trauma Life Support Course (PHTLS).
ATLS and its derived variants such as ATNC and PHTLS provide a
framework and a common way throughout the chain of management
of the injured.
VI. THE ADVANCED TRAUMA LIFE SUPPORT APPROACH (ATLS).
The ATLS educational package is the standard way in early trauma
initial assessment and resuscitation. ATLS management is based on:
Treat lethal injury first, then reassess and treat again - strategy.
13
ATLS component steps:
1- Primary survey - identify what is killing the patient.
2- Resuscitation - treat what is killing the patient.
3- Secondary survey - proceed to identify all other injuries.
4- Definitive care - develop a definitive management plan.
The main idea is based on the urgency and crisis surrounding early
management of a multiply injured patient (polytrauma case) whose
life is in danger.
The ATLS approach focuses on the second or early death group where
death is preventable. Early and effective treatment during the period
when the second group of deaths occurs, also reduces the number of
deaths during the third phase of the trimodal distribution.
The elements of the primary survey and resuscitation
management (ABCDE):
1- Airway with cervical spine control.
2- Breathing and ventilation.
3- Circulation with control of haemorrhage.
4- Dysfunction of the central nervous system.
5- Exposure in a controlled environment.
VII. PREHOSPITAL MANAGEMENT.
The main strategy must be for accurate retrieval and rapid and smooth
transfer of trauma patients from the site of the accident to a hospital
that is well equipped and adequately staffed, with properly trained
personnel to deal quickly and efficiently with all of the injuries
encountered.
In all cases, attention is first paid to securing and establishes an adequate
airways, stop bleeding and restore the circulation.
14
Different ways of pre-hospital management are practiced:
a: A scoop and run - policy is the quick and usual way, where transfer
time to hospital is short.
b: A stay and play - policy may be required and is practiced where the
site of trauma is far and transport to the hospital is relatively long
(PHTLS).
Prehospital treatment protocols follow the same sequence as the
clinical assessment protocols ABCDEs.
At first a quick, complete and closed inspection of the injured and
start soon with resuscitation steps, such as securing and establishing
respiration and oxygenation, controlling obvious external bleeding by
direct pressure and covering and sealing open sucking chest wounds
and so on.
Very important is the control and monitoring of the circulation and the
neurological status of the injured. Attention is paid to the positioning
of the injured to protect the spine and the extremities to avoid and
prevent any further complications during transport, by the use of all
modern spine boards, well-fitting semirigid neck brace, sandbags and
forehead strapping and to achieve strict immobilization during
transport.
If there is any obvious long bone fracture of any extremity with gross
deformity the limb should be gently drawn into alignment and a
traction splint applied.
The AVPU method is recommended in the prehospital setting.
Prehospital mini-neurological examination:
1- A – Alert.
2- V– Responds to Voice.
15
3. P – Responds to Pain.
4. U – Unresponsive.
5. Pupils – Size and reaction.
If there are signs of shock or severe hypotension, vascular access is
then performed and intravenous fluid infusions are given. And especially
if the transport time could be prolonged.
The transportation of an injured patient is very important and vital for
the injured, so that here well trained and oriented people are required.
VIII. HOSPITAL MANAGEMENT.
The management of the trauma patient in the hospital is very
important and vital. Trauma department must be well equipped and
have properly and ideally trained medical staff. ATLS courses are
ideal framework to train the medical staff to deal with trauma patients.
There must be a trauma team that can successfully assess and
resuscitate an injured patient, then it is obvious that a team approach is
more efficient, systematic and quicker. In the working trauma team
the roles should be paired and tasks allocated on a pre-agreed basis.
Chaos should be avoided during resuscitation and management.
IX. THE PRIMARY SURVEY
This is the initial assessment and resuscitation of the injured patient.
The main achievement in this phase is to seek and manage
immediately life-threatening conditions.
According ATLS language it is the primary survey and resuscitation,
following an ABCDE sequence in every circumstance.
A- AIRWAY MANAGEMENT AND CERVICAL SPINE CONTROL.
The first and most vital resuscitative step in the management of the
16
injured is securing and establishing adequate airways and restore
respiration.
There should be no doubt about the integrity of the airways.
Injury to the cervical spine is assumed in the presence of injury above
the clavicle, loss or alteration of conscious level, involvement in high
speed collisions or where there is a history of neck pain.
During assessment and management of the airways, the cervical spine
of the injured is immobilized and put in a neutral position by manual
in-line immobilization or by a well fitting neck brace or sand bags and
so on. Usually all patients require supplemental oxygen via a masque
with a rebreathing bag.
B- BREATHING AND VENTILATION.
The treating doctor should examine properly the neck and the chest of
the injured. The examination starts in the neck with inspection for
wounds, condition of neck veins, wounds and evidence of tracheal
injury.
The vital signs such as pulse and respiratory rate are counted and
recorded.
Chest symmetry, respiratory activity and present wounds and bruising
are assessed and evaluated. Palpation, percussion and auscultation of
chest and abdomen are gently performed without spinal movement if
possible.
The main objective is to diagnose and treat properly the six lifethreatening Thoracic traumatic conditions are listed below.
Immediately life-threatening traumatic conditions of the thoracic:
1- Airway obstruction.
2- Tension pneumothorax.
3- Massive pneumothorax (> 1500 ml blood in a hemithorax).
17
4- Open pneumothorax (sucking wound of the chest wall).
just anterior to the midaxillary line.
5- Flail segment with pulmonary contusion.
6- Cardiac tamponade (almost due to penetrating injury).
Tension pneumothorax requires immediate needle thoracocentesis in
the second intercostal space in the midclavicular line on the affected
side, followed by tube thoracostomy through the fifth intercostal space
Massive haemothorax is a combined breathing and circulation
problem with lethal complications due to hypovolemic shock and
impaired ventilation.
The rapid effective management is therefore by vigorous support of
the circulation followed by tube thoracostomy.
Open pneumothorax is managed by sealing the wound with dressing
and tube thoracostomy.
Flail segment with underlying contusion may require endotracheal
intubation and mechanical ventilation to maintain adequate arterial
oxygen saturation.
Cardiac tamponade is a life-threatening condition and could be a result
of a penetrating wound medial to the nipples anteriorly or medial to
the scapulae posteriorly.
It may require quick life-saving needle pericardiocentesis.
C. CIRCULATION AND HEMORRHAGE CONTROL.
The assessment of the injured should include the degree of any blood
loss and the signs of shock. Tachycardia in a cold patient with pallor
Indicates hypovolemic hemorrhagic shock.
Causes of shock following trauma are:
1- Hypovolemic hemorrhagic shock (the most common).
18
2- Cardiogenic shock (cardiac tamponade, tension pneumothorax or
myocardial contusion).
3- Neurogenic shock (often combined with hypovolemic shock).
4- Septic shock (a late event after 24 hours and associated with
missed faecal spillage).
The assessment and evaluation of any blood loss and degree of shock
must start as early as possible at the beginning of the management of
the injured.
Blood loss may be external and obvious, or internal and covert, or
combination of both. External bleeding sites are dealt with by direct
pressure at this stage. One should look for any signs of covert bleeding.
The chest, abdomen and pelvis should be rapidly assessed for signs of
injury.
A good aide-memoire is: Blood on the floor and four more:
1. Blood on floor or environment, including clothing.
2. Blood in the chest (dull percussion note).
3. Abdomen (wounds, abrasions, tenderness but may be silent).
4. Pelvis (usually associated with obvious pelvic disruption).
5. Limbs (should be obvious).
The treatment of shock must be conducted by well trained physicians.
The emphasis must be on stopping the bleeding and administration of
intravenous fluids. Once a cannula is in position, blood must be taken
for blood grouping and hemoglobin or full cross-matching depending
on the degree of urgency.
There are three responses to initial fluid administration.
1- Immediate and sustained return to normal vital signs.
2- Transient response with later deterioration.
3- No improvement.
19