introduction to trauma lsu medical student clerkship, new orleans, la

Introduction to Trauma

LSU Medical Student Clerkship, New Orleans, LA

Trauma

Goals

Review the components of the primary and secondary survey for a trauma patient

Identify injuries requiring immediate intervention during primary survey

Review the initial steps of resuscitation of a trauma patient in the ED

Review the advantages and uses of diagnostic modalities in the trauma patient

Discuss the appropriate disposition of the trauma patient from the ED.

Trauma

Epidemiology

Trauma is a disease. Trauma is predictable, preventable, and treatable. Trauma is the 4th leading cause of death in the US. Trauma is the leading cause of death in people

below the age of 45 in the US. 3.8 M deaths/ year/ worldwide 312 M injured

Trauma

Epidemiology

•Trimodal distribution of mortality•Prehospital (Major head injuries, rapid exsanguination)•Early Hospital (Head, chest, abdominal trauma)•ICU (End result of prolonged hypoperfusion)

Trauma

History of Trauma Systems

1991: Congress passed the Trauma Care Systems Planning and Development Act requiring the development of a Model Trauma Care System Plan to be used as a reference document for each state to develop its system

Based on the severity of injury, patients are triaged to trauma centers

The American College of Surgeons has developed requirements for trauma center certification of commitment of personnel and resources needed to maintain a state of readiness to receive critically injured patients.

The Golden Hour

Trauma

History of Trauma Systems

Trauma

Initial Approach

The initial approach to trauma care in the ED is a process that consists of an initial primary assessment, rapid resuscitation, and a more thorough secondary survey followed by diagnostic tests and ultimate disposition.

Subsequent mortality and morbidity tied directly to the initial assessment and resuscitation

Trauma

Trauma

Primary Survey

Rapid examination to identify and treat life threatening conditions. Ideally is performed in a few minutes.

A - Airway (with C-spine precautions) B - Breathing C - Circulation D - Disability E – Exposure

When derangements in any of the components of the primary survey are identified, treatment is undertaken immediately.

Trauma

Primary Survey - Airway

Maintain C-spine precautions Clear any obstructions Jaw thrust instead of head tilt chin lift Endotracheal intubation for airway protection or

expected clinical course (ie,obstruction from blood or vomitus, neck hematoma, facial burns or trauma, GCS 8 or less, combative patient, potential for airway compromise while out of department.)

Trauma

Primary Survey - Breathing

Auscultation for bilateral breath sounds Palpation for subcutaneous emphysema

-needle decompression followed by chest tube for pneumothorax

Inspection for flail chest Observation of respiratory rate, oxygen

saturation, and overall work of breathing-mechanical ventilation for inadequate ventilation or to decrease work of breathing

Trauma

Trauma

Primary Survey - Circulation

Check peripheral pulses, heart rate, BP, pulse pressure, capillary refill, cyanosis

All hypotensive trauma patients are assumed to be in hemorrhagic shock

2 large bore peripheral IV’s (at least 18 gauge) Control external bleeding

Trauma

Trauma

Primary Survey - CirculationTable 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial Presentation Class I Class

I I Class I I I

Class I V

Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000

Blood loss (percent blood volume)

Up to 15 15–30 30–40 40

Pulse rate <100 100–120 120–140 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure (mm Hg) Normal or increased

Decreased Decreased Decreased

*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.

Trauma

Primary Survey - Circulation

Begin volume resuscitation with liter boluses of crystalloid for class I or II hemorrhage.

Begin crystalloid and blood for class III or IV hemorrhage.

O- blood until type specific is available Constant reevaluation is paramount If class I or II is patient still showing signs of shock after

3L of crystalloid, begin blood “3:1 rule” 3cc crystalloid for every 1cc of blood loss

Trauma

Primary Survey - Circulation

5 Places life threatening hemorrhage can occur

-Chest

-Abdomen

-Pelvis

-Thighs

-Externally

Trauma

Primary Survey - Circulation

Cardiac Tamponade can cause hypotension with little blood loss.

Becks triad: hypotension, distended neck veins, muffled heart sounds

Easily confirmed with ultrasound Pericardiocentesis

Trauma

Trauma

Trauma

Primary Survey - Disability Quick assessment of ability to move all extremities Glascow Coma Scale

Trauma

Primary Survey – Exposure

Completely undress the patient and inspect the entire patient from head to toe both front and back.

Maintain spinal precautions during logrolling Inspect both axillae and peritoneum Warm blankets!!!

Trauma

Secondary Survey

Head to toe evaluation once any derangements in primary survey have been addressed.

AMPLE History-Allergies-Medications-Past medical history (LMP, Td, transfusions) -Last meal-Events leading up to trauma

Trauma

Imaging

Choice of imaging modality depends on nature of injuries and stability of patient.

Knowledge of injury mechanism and index of suspicion most important

Trauma

Imaging – Plain Films

Quick Can be performed at bedside Useful for rapid identification of pneumothorax,

hemothorax, fractures and locating ballistics

Trauma

Trauma

Imaging – Ultrasound

Quick Can be performed at bedside FAST: Focused Assessment with Sonography

for Trauma Rapid examination to identify free

intraperitoneal fluid and/or pericardial fluid

Trauma

Trauma

Imaging – CT

•Detailed•Requires patient to leave the department•Necessary for head trauma

Trauma

Trauma

Disposition

To the OR-Unstable patients with blunt or penetrating abdominal trauma or chest trauma. Hemothorax with >1500 cc of blood out initially. Surgical injuries identified with imaging.

Admission -Nonsurgical, high-risk injuries

Discharge-Stable patients, minor or no injuries identified.