MODUL II

MODUL II C Course number 15- Trauma Duration of course – two weeks Definition of educational goals : Contents of course number 15 is basic trauma overview for pregradual education with dividing on individual phases in problems of trauma and trauma care : 1.Pathophysiology, 2.Pharmacology, 3. Epidemiology, 4. Imunology, 5. Radiologic diagnostic and therapetic modalities in trauma, 6. Medicolegal and legislative issues in trauma. 6. Basic diagnostic and therapeutic procedures in specific injuries. Goal of student education is reached qualified kwoledge and skills directed to injuried patient. MODUL II C Course number 15- Trauma Duration of course : two weeks Trauma is a wound or injury characterized by a structural alteration or physiologic imbalance resulting from acute exposure to mechanical, thermal, electrical , or chemical energy, or from the absence of such essentials as heat or oxygen. This definition encompasses a wide variety of injuries, many of which require urgent diagnosis and treatment. Problems of trauma and trauma care included besides kwouledges of pathophysiology, pathological anatomy and pharmacology others included diagnostic and therapeutic approach / epidemiology, prevention of trauma, pre-hospital care and transport, evaluation and resuscitation in the emergency department, operative and nonoperative care for specific injuries, critical care after trauma, posttraumatic rehabilitation /. Further special chapters like pediatric and geriatric trauma, thermal, chemical and radiation injuries, organ transplanation, reconstrictive surgery, management of complications after trauma nad medicolegal and legislative issues in trauma. Injuries account for approximately 25 % of all emergency department visits and the leading cause of death among aged 45 years and is the third leading cause of death for all ages. Death from trauma occur in a trimodal distribution. Immediate deaths occur at the accident scene and represent nearly half of all traumatic deaths. Brain, high spinal cord, cardiac, major vascular injuries represent the usual cause. Approximately 30 % comprise „ early „ deaths, occuring within a few hours of sustaining injury. Hemorrhage, airway and breathing problems, and brain injuries are most common causes . Late deaths peak at 3 to 4 weeks, are now unusual, and are attributable to 2 multisystem organ dysfuction. Trauma care systems Definition. A trauma care system represents a comprehensive, well-organized, regional approach to the management of injured patients. Optimal trauma management includes prehospital care, hospital care, and subsequent rehabilitation. Trauma care systems have been shown to be effective in reducing transport times, leasing to a decrease in these „ early „ deaths. Among resources for optimal care of the injured patients belongs: 1.Trauma care system 2.Injury prevention and control 3.Principles of prehospital care 4.Field triage 5.Traumatological Centre 6.Qualifications of trauma care personnel 7.Hospital criteria 8.Resuscitation 9.Specialized care for trauma patients: neurotrauma care, musculoskeletal management, care of maxillofacial injuries, burns, spinal injuries, reconsturtive surgery, pediatric trauma care 10.Trauma registry INDIVIDUAL CHAPTERS OF COURSE : 1.TRAUMA – definition, cause of injury, field triage, PATTERNS OF INJURY: - factors affecting patterns of injury / age of victim, anatomy, alcohol, mechanism of injury / blunt x penetrating trauma / 3 TRAUMA SCORING : - types of severity scores – Glasgow Coma Scale, Revised Trauma Score, Acute Physiology and Chronic Health Evaluation ( APACCHE ) , Injury Severity Score / TRAUMA CARE SYSTEM / trauma center / - identification of trauma center, organization, personnel, device, instruments and equipment 2. PATHOPHYSIOLOGY OF TRAUMA - hypovolemic, traumatic shock, postinjury reaction / hemodynamic response- ischemia / reperfusion , metabolic and endocrine response/ , SIRS, MOF 3. EPIDEMIOLOGY AND TRAUMA PREVENTON 4. IMMUNOLOGIC RESPONSE TO INJURY - nonspecific inflammatory response, specific imunity, post-injury immunodysfunction 5. PHARMACOLOGY OF TRAUMA – analgetics, anesthetic drugs, antiinfective drugs / antibiotics, chemotherapeutics, antimycotic /, volume therapy, nutrients for parenteral and enteral nutritions 6. RADIOLOGY – diagnostic modalities and rationale for their selection, radiologic assessment of blunt and penetrating trauma 7. NUCLEAR MEDICINE – radionuclid diagnostic modalities and rationale for their selection, radionuclid assessment of blunt and penetrating trauma 8.GENERAL APPROACHES TO THE TRAUMATIZED PATIENT PREHOSPITAL CARE / Phase of prehospital care, emergency medical personnel, eqiupment / - INITIAL ASSESSMENT OF TRAUMA PATIENT 1.Primary survey – is performed to identify immediately treatable life-threatening injuries: A. Airway maintenance with cervical spine control B. Breathing and ventilation C. Circulation with hemorrhagie control D. Disability : Neurologic status E. Exposure / environmental control. Completely undress the patient, but prevent hypothermia. 2.Resuscitation – as life-therating injuries found during primary survey resuscitation efforts are instituted . 3. Secondary survey – is not performed until the primary survey is completed, resuscitation has been initiated and reevaluation of vital 4 functions has been performed : Physical examination / head, neck, chest, abdomen, musculoskeletal and peripheral vascular assessment , neurologic assesment / 4.Stabilization and transfer MANAGEMENT OF SHOCK – specific cause of shock, pathophysiology of shock, diagnosis and treatment / hemorrhagic shock, compressive shock, cardiogenic shock, septic shock , burns shock / PREVENTION AND MANAGEMENT OF INFECTIONS – risk of infection following injury, prevention, management of selected wounds and injuries, prevention and management of nosocomial infections - 9. MANAGEMENT OF SPECIFIC INJURIES – INJURY TO THE CRANIUM Epidemiology.Classification of injuries , Blunt injuries – fracture of the cranium, intracranial hemorrhagie / epidural, subdural, subarachnoid and intraventricular hemorrhagie / , brain contusions , difuse axonal injury. Posttraumatic intracranial hypertension Penetrating injuries. Emergency room management / evaluation and stabilization, neurologic assessment - Glasgow Coma Scale, fluid resuscitation in haed – injuried patients , radiological modalities, surgical and medical management. INJURY TO THE VERTEBRAE AND SPINAL CORD – Epidemiology.Classification of injuries : Spinal cord injuries, Vertebral column injury . Penetrating spine injuries. Pre-hospital and emergency room management – diagnostic / physical examination, radiological modalities / and therapeutic procedures . MAXILLOFACIAL AND MANDIBULAR INJURIES Epidemiology, Classification of injuries,: Maxillary fractures Nasal fractures Mandibula fractures Penetrating injuries Evaluation and management : diagnostic modalities, therapeutic procedures - - 5 - THORACIC TRAUMA Epidemiology. Classification of injuries : Blunt thoracic trauma : Injury to the chest wall - ribs fracture, flait chest, fracture of the sternum Injury to the trachea and bronchus Injury to the lung Injury to the esophagus Injury to he heart Injury to the thoracic great vessels Injury to the diaphragma Penetrating thoracic trauma Initial evaluation and management :diagnostic modalities/ physical examination ,radiological, endoscopy ( thoracoscopy, bronchoskopy, esophagoscopy) / , therapeutic procedures/ tube thoracostomy, indication for emergency department and acute thoracotomy, videothoracoscopy/. ABDOMINAL TRAUMA Epidemiology. Classification of injuries : Blunt abdominal injuries: Hemoperitoneum, Perforating peritonitis Liver and biliary trauma Injury to the spleen Injury to the gastrointestinal tract Injury to the duodenum and pancreas Abdominal vascular injury Penetrating abdominal trauma Initial evaluation and management : diagnostic modalities /radiological, laparoscopy, diagnostic peritoneal lavage / therapeutic procedures / nonoperative management of solid organs injury – spleen, liver, pancreas, indication for acute laparotomy , laparoscopy/ GENITOURINARY TRAUMA Epidemiology. Classification of injuries : Blunt injuries : Renal trauma Injury of ureter , bladder and urethra Genitoperineal injuries Penetrating injuries Initial evaluation and management : diagnostic modalities / physical examination, radiological, endoscopy , radionuclide imaging /, therapeutic procedures / indication for acute operation , endoscopic procedures / - - 6 - MUSCULOSKELETAL INJURIES Epidemiology. Classification of injuries : Contusion Dislocations Fractures Fractures of the pelvis and associated injuries Upper extremity fractures and dislocations Hand injury Lower extremity fractures and dislocations Initial evaluation and management : diagnostic modalities / physical examination, radiologic, endoscopy /, therapeutic procedures / nonoperative management of the fractures dislocations , open stabilization, fixation, rehabilitation / - PERIPHERAL VASCULAR INJURY Classification of injuries : Blunt x penetrating Evaluation and management : diagnostic modalities / physical examination, radiologic,ultrasonic flow detection / therapeutic procedures / nonoperative, operative management : indications and general principles / - INJURY TO THE PERIPHERAL NERVES Classification of nerve injuries . Evaluation and management : diagnostic modalities / physical examination, EMG / therapeutic procedures / operation : indication and general principles/ THERMAL INJURIES Epidemiology, Pathophysiology, Classification of burns Initial evaluation and management of burns : Burn estimate , formulas for estitation of fluid reqiurements in burn patients, therapeutic procedures : - shock therapy - arway and breathing- inhalation injury - circulation –fluid management - surgical management – escharotomy, fasciotomy, care of burns wound Hypothermia 7 10. MANAGEMENT OF POSTINJURY COMPLICATIONS Bleeding and coagulation problems / pathophysiologic response , aquired disorders of hemostasis, management of post-injury coagulopathy / Cardiovascular failure / pathophysiology, causes of failure, diagnosis, management / Respiratory insufficiency / pathophysiology, diagnosis of ARDS, management / Renal failure / pathophysiology of acute renal failure , clinical manifestation, management / Metabolic changes / post-injury hypermetabolism, management- nutritional support / - 11. REHABILITATION OF THE TRAUMA PATIENT – classification of rehabilitation needs, rehabilitation facilities 12. MEDICOLEGAL AND LEGISLATIVE ISSUE IN TRAUMA CARE