Dr Anuj Raj Bijukchhe

TRAUMA Dr Anuj Raj Bijukchhe

Introduction Trauma is a severe physical injury

resulting from dissipation of energy to and within the victim, caused by a penetrating or blunt mechanism  Trauma can be defined in terms of bodily

injury severe enough to pose a threat to life or limb  

Anatomic injury   Physical derangement

Classifications of trauma

     Closed injury 

 

   Open injury 

Motor vehicle crashes  Falls  Burns and fire-related injuries  Intentional trauma: homicides, nonfatal

assaults, and suicides

Three peaks of death Immediate: head injury, brainstem injury,

cardiovascular system  Early: within the first few hours, major torso

trauma, closed head injury   Late

Physiological response to trauma Involves both local and systemic

reactions Extent of response proportional to severity of insult An appropriate response maintains homeostasis and allows wound healing An excessive response can produce a systemic response  Systemic inflammatory response syndrome (SIRS)  Multiple organs dysfunction syndrome (MODS) can

result from SIRS

SIRS systemic inflammatory response syndrome

(SIRS) is an inflammatory state of the whole body (the "system"). It is characterized by tachycardia, >90/min, low blood pressure (systolic <90 or MAP <65), low or high body temperature (38 C), high respiratory rate (>20/min), and low or high white blood cell count (12 billion/liter). It can be caused by severe trauma, burns, hyperglycemia (high blood sugar) or acute pancreatitis.

Initiation of response Multiple simultaneous factors can have a

synergistic effect Important factors are: Tissue injury

Infection Hypovolaemia Hypoxia or hypercarbia 

Acute phase response Tissue injury results in cytokine

release

 Cytokines have mainly paracrine

actions Important in regulating the inflammatory response Cytokines stimulate the production of acute phase proteins such as: C-reactive protein Fibrinogen Complement C3 Haptoglobin

Endocrine response The hypothalamus, pituitary, adrenal axis is

important Trauma increases ACTH and cortisol production Steroids have a permissive action in many metabolic responses Catabolic action increases protein breakdown Insulin antagonism increases blood sugar levels Anti-inflammatory actions reduce vascular permeability Aldosterone increases sodium reabsorption Vasopressin increases water reabsorption and produces vasoconstriction Histamine increases vascular permeability

Limitation of response Reducing degree of trauma with

appropriate and careful surgery Reducing infection with wound care and antibiotics Maintaining enteral nutrition Controlling pain Correcting hypovolaemia Correcting acid-base disturbance Correcting hypoxia 

TRIAGE

 

Triage

means the allocation of injured patients into certain categories for action by emergency team.

 

  

FOUR CATEGORIES

     

1. Critical – with in seconds 2. Immediate - with in minutes 3. Urgent - with in the golden hour 4. Deferred - as soon as practical

Advanced Trauma Life Support 

ATLS component step

 Primary survey- identify what is killing pt.  Resuscitation - treat what is killing the pt.  Secondary survey – proceed to find all other

injuries  Definitive care – develop a definitive Mx plan

Pre hospital mini – neurological examination      

A – Alert V - responds to Voice P - responds to Pain U - Unresponsive pupils - Size and reaction

TRAUMA SEVERITY SCORES

Glasgow Coma Scale This

widely used scale relates specifically to the head injury component of the injured patient.

 

The three aspects of the coma which are specifically assessed are --

GCS  1.  2.  3.

EYE OPENING BEST VERBRAL RESPONSE BEST MOTOR RESPONSE

EYE OPENING Spontaneous To Voice To Pain None

4 3 2 1

VERBAL RESPONSE Orientated Confused Inappropriate words Incomprehensible sound None

5 4 3 2 1

MOTOR RESPONSE Obeys command Localises pain Withdraws(pain) Flexion(pain) Extension (pain) None

6 5 4 3 2 1

Immediately life –threatening thoracic condition  Airway obstruction Tension pneumothorax Massive haemothorax Open Pneumothorax Flail chest Cardiac tamponade

REVISED TRAUMA SCORE(RTS) Glasgow Coma Systolic blood Respiratory rate Points Scale pressure (breath/min) 13-15 >89 10-19 4 (mmhg) 9-12

76-89

>29

3

6-8

50-75

6-9

2

4-5

1-49

1-5

1

3

0

0

0

FLUID , ELECTROLYTE & ACID BASE BALANCE

COMPOSITION OF BODY FLUIDS TOTAL BODY WATER. Total body water (TBW) as a percentage of body weight varies with age. The fetus has very high TBW, which gradually decreases to approximately 75% of birth weight for a term infant. Premature infants have higher TBW than term infants. During the 1st yr of life, TBW decreases to approximately 60% of body weight and basically remains at this level until puberty. 

Because fat has very low water content and

muscle has high water content. The percentage of body weight comprised by body water decreases as the fat content increases. At puberty, the fat content of females increases more than that of males, who acquire more muscle mass than females. So by the end of puberty, TBW in males remains at 60%, but TBW in females decreases to approximately 50% of body weight.

Fluid Compartments. TBW is divided between two main compartments:  Intra cellular fluid (ICF). (all the liquids inside the 

cell ) 

Extra cellular fluid (ECF).

( present in the space outside

the cell )

ECF volume is about 20% of body weight ICF

volume is about 40% of body weight, close to twice the ECF volume .

The ECF is further divided into Plasma Interstitial fluid (including lymph) Transcellular fluid . 

PLASMA ( Intravascular fluid) It is the fluid that is confined to the cardiovascular system. Plasma + blood cells fill the vascular system. The plasma accounts for 5% of body weight. 

INTERSTITIAL FLUID It accounts for about 15% of the body weight. It is present outside the vascular system. It consists of the fluid bathing all the cells of the body except the blood cells ( cells of vascular system). Reduction in the interstitial fluid manifests as dehydration while an increase results in edema. 

TRANSCELLULAR FLUID It is the fluid present in the number of cavities called the “Third space”  *CSF fluid  *Intraoccular fluid , cochlear fluid.  *Digestive secretions, gut fluid and bile.  *Pleural & pericardial fluid , peritoneal fluid.  *Sweat.  *Synovial fluid. 

These fluids are predominantly the products of

epithelial cell secretion which are separated not only from the blood by the capillary endothelium but also from the interstitial fluid by epithelium. Thus they are called transcellular fluids. The interstitial fluid and transcellular fluid is about 15% of body weight . 



All the cells live in extracellular fluid that

contains ions and nutrients needed by the cells for the maintenance of the normal cell functions. Hence Claude Bernard call ECF the “ Internal environment of the body ”. Essentially all the organs & tissues of the body perform functions to maintain the constant conditions in the internal environment ( ECF) , and this maintenance of constant conditions in the internal environment is called ‘ homeostasis’.

BODY FLUID COMPOSITION The distribution of the body fluids is

determined by the composition of the electrolytes and proteins in the different compartments. ELECTROLYTE CATIONS AND ANIONS. The total number of the cations in the body is equal to the number of anions

Electrolyte composition INTRACELLULAR FLUID (ICF) 

Potassium ( K) is the most abundant cation in the

ICF. Other cation is Mg. Proteins, organic anions, and phosphate are the most plentiful anions in the ICF. Sodium and chloride concentrations in the ICF are much lower. 

EXTRACELLULAR FLUID (ECF) – BOTH PLASMA &



INTERSTITIAL FLUID

Sodium and chloride, bicarbonate are the dominant

cation and anion, respectively, in the ECF. K , Ca , Mg and monohydrogen phosphate are present in low conc. In ICF.

Fluid intake is derived from 2

sources.  

1.

Exogenous

2.

Endogenous

  

Distribution of body water In normal persons, the total body water

constitutes 50-60 % of lean body weight in men and 45-50 % in women.   A

healthy ( 70 kg) - approximately 40 liters( average 57% of total body wt)

 Contain in two major compartment.

AVERAGE DAILY WATER BALANCE OF A HEALTHY ADULT IN TEMP CLIMATE INTAKE

OUTPUT

Water from beverage= 1200 ml Urine = 1500 ml Water from solid food = 1000 Insensible loss from skin & ml lungs = 900 ml Water from oxidation = 300 ml Faeces = 100 ml 2500 ml

2500 ml

QUANTITIES OF DAILY SECRETION  Bile = approx 1000 ml/ 24 hour Gastric juice = approx 2000 ml / 24 hr Pancreatic juice = approx 600 ml / 24 hr Small intestine = approx 3000 ml / 24 hr Saliva = approx 1500 ml/ 24 hr 

PRINCIPLE OF FLUID & ELECTROLYTE REPLACEMENT 1. 2. 3.  

Replace the deficits Fulfill daily maintenance requirement Replace ongoing lossses.

FLUID REQUIREMENTS IN EVERY 24 HOUR

   

water = 30-35 ml/kg sodium & potassium= 1mEq/ kg Chloride = 1.5 mEq/ kg

How to differentiate function and non-function interstitial fluids Function:Taking part in modulating the

balance of body fluids. Non-function: Fluids in cavityin  normal status.  Including: cerebrospinal , joint, pericardium and abdominal cavity fluids 

  

THIRD SPACE  Definition: 



Pathophysiologiclly, relatively nonfunctional extra cellular fluid. Mainly for the change of quantity of functional and nonfunctional ECF.



Third Space Distribution:

(not normal)  exudates in burns; ascites;  soft tissue injuries; bowel wall;  peritoneum; infected lesions . Attention: Don’t confusewith the nonfunctioning components from interstitial fluid. 

ELECTROLYTE BALANCE   

TWO KINDS OF IONS

CATIONS

ANIONS

Sodium Potassium Calcium Magnesium

Chloride Phosphate Bicarbonate Sulphate

Classification of body fluid change ( Four Types ) 1. Volume Changes ( ECF )  Volume Deficit  Volume Excess ü 2. Concentration Changes  Hyponatremia  Hypernatremia 

Classification of body fluid change( Four Types ) 

3. Mixed volume and Concentration Abnormalities

 

ECF Deficit and Excess with Hyponatremia

ü 

ECF Deficit and Excess with Hypernatremia

ü 

Classification of body fluid change( Four Types ) 

4. Composition Changes

 

Acid-base disturbances

   



Potassium , Calcium, Magnesium abnormalities

SODIUM BALANCE 

Total body Na - 5000 mmol  ECF=44%  ICF= 9%  Bone = 47% Daily intake - 80 --100 mmol Total serum Na+ 132 – 144 mmol / L 

Hyponatraemia Causes  Excessive water intake  Excessive water retention- inappropriate ADH secretion Inadequate Na intake ( rare) Inadequate Na retention  - vomiting, diarrhoea,exessive sweating,burns 

C/F Thirst Muscle cramps Nausea Vomiting Dizziness Neurological symptoms  



drowsiness confusion

Rx   Restriction of water intake 3% Nacl solution i/v Monitoring of plasma sodium and fluid

balance treatment of underlying cause.

Hypernatraemia Characteristic

of primary water deplication



Causes Inadequate water intake- lack of water, inability to drink. Inadequate water retention (excess water loss) Excessive sodium intake Excessive sodium retention Hyperaldosteronism 

C/F Non specific symptom

nausea vomiting fever confusion

   

 

Convulsion in severe

case

Rx Replacement of water In severe ( >170 mmol/L) 

0.9% saline should be used

initially Les severe (>150 mmol/L)  5% Dextrose or 0.45% saline. Treatment of underlying cause.



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