APPROACH TO TRAUMAResident Rounds July 17th, 2003Rob Hall PGY4What is your approach?

Ouch.

Key Points Systematic approach to trauma is a mustTriage toolsPrehospital trauma managementHow to manage the trauma roomPriorities in the multitrauma patientPEARLs of the primary surveyPEARLs of adjuncts and investigations

Case Presentation: you know youre having a bad day when.50ish yo femaleGets up in am, lights a smokeGas leak overnight ->EXPLOSIONShe is blown out the second story patio door and is found lying on a driveway ON THE OTHER SIDE OF THE STREETHusband is dead inside burning building

Who needs transport to a trauma center?Case: does this patient need a trauma center? Why?What criteria do you use?Triage decision scheme from ACS (see ATLS)Revised Trauma Score (RTS)Injury Severity Score (ISS)

How to prepare for a trauma patient?How would you prepare for this case?PersonelRN, RT, DI, Notify trauma surgeon if nastyEquipmentThink of what you will need in primary surveyAnticipate what you will useGSW to abdomen, BP 50 ->get some blood hanging in the level I infuserDraw RSI drugs in advanceMake sure you have all of the equipment you will need if you are working in a smaller center

The Paramedic ReportWhat do you want to hear in the report?Mechanism of injuryKey point of historyPay close attensionPredicts certain injuriesSuspected injuriesStability of vital signsTreatments they have givenPMHx/med/all if known and relevant

Example of importance of MOI:Side impact VERSUS Front impactDriver side impactCspineLeft h/pthrxSplenic lacLateral compression pelvic fractureLeft femur fractureFront end collisionCspineMediastinal injuryAny intraadbo injuryAnterior compression pelvic fracturePosterior hip dislocationsBilateral femur/tib/fib fracturesCalcaneal fractures, pilon fractures

Prehospital Trauma ManagementCase: what do you want the medics to do? BLS C spine, spine board, basic airway maneuvers, oxygen and BVM, control of external hemorrhage, scoop and runALS Some controversy re advanced airway mx Iv fluids: no evidence for prehospital fluidsBLS care and RAPID TRANSPORT are the most important

Case: the trauma arrivesMOI: 70% burn + traumaUnable to intubate X 2; BVMAgonal resps, BP 60 palp, HR 140No sat obtainable, No iv access? Head injury: GCS 3, external signs of head traumaWhat is your approach?

ATLS approach: good but not perfectPRIMARY SURVEYAirwayBreathingCirculationDisabilityExposureFull VitalsADJUNCTSCXR, PXR, CspineNG, foley, ECGMonitors, trauma panelDPL, FAST if neededSECONDARYAMPLE hxFull head-to-toe ADJUNCTSCT, FAST, DPLExtremity XraysAngiographyEndoscopyContrast studies

Case: how do you actually do the primary survey? The Airway

Breathing

Circulation

Disability, Exposure, Full Vitals

PEARLS of the ABCsConsider yourself stuck until you have dealt with an issueFrequent reassessmentStart from A whenever there is a problemSecondary survey is truly secondary

PEARLS of ABCs25 yo maleMotorbike into pole at 80 km/hrHelmet damagedIntubated by EMSHR 75 BP 60 palp Sats 97% GCS 6What is the differential dx of shock in a trauma patient?

Ddx of shock in the trauma patientHypovolemic/Hemorrhagic shockChest (note: not likely aortic injury)BellyPelvisFemursExternal hemorrhage (esp scalp)NeurogenicBrainstem herniation (preterminal)Other: example -> MI then crashed car

PEARLS of managing shockHow much initial fluid?

Which fluid?When to give blood?When to give blood products?

What tests will help you?2-3L (20-60ml/kg)

CrystalloidAfter 2-3L or 20-60ml/kg crystalloid> 4 units prbc.s: order 4 units FFP and 10 units plateletsEARLY CXR/PXR and FAST will help you identify the etiology of shock

PEARLS of the ABCs50 yo maleSmall plane crashTransported by STARSIntubated by STARSHR 120 BP 100 Sats 75% on 100% oxygenWhat is the differential dx of hypoxemia in a trauma patient?

Differential Dx of Hypoxemia in traumaAirway obstructionPneumothoraxHemothoraxPulmonary contusionTrachobronchial transectionAspirationAtelectasisARDSPulmonary hemorrhageFat EmbolismIntubated patient: GDOPE

PEARLS of diagnositic imagingOral Contrast and CT abdomenTheoretic increase in pick up of small bowel perforation and pancreatic injuriesIncreases risk of vomiting and aspirationEvidence doesnt support that it increases sensitivity of CT for bowel injuries?Why: doesnt get past stomachOral contrast OK but do NOT delay the CT in a patient that needs it sooner than later

Head injured, drunk, combative: what sedative would you use?Midazolam: risk of hypotension and respiratory depressionHaldol: theoretical risk of lowering seizure threshold, longer durationHaldol probably preferred

What comes first: head or belly?CASE: Hypotensive trauma patient that needs laparotomy and has blown left pupil and signs of head traumaWhat comes first?To OR for laparotomy: pack off bleedingBurr hole in OR (blind) or go back to CT for CT head In general, belly comes first

The TRAUMA ARRESTWhat type of rhythm is usually present? What is your approach to the PENETRATING trauma arrest?Thoracotomy if ever had vitalsWhat is your approach to the BLUNT trauma arrest?

The TRAUMA ARRESTIntubate: crash intubation, no drugsVentilate: hyperventilateVolume: blood through berthaNeedle the chestCPR/Epi/atropineRun for 5 10 minutesNO thoracotomy

How to MANAGE the trauma roomShould be ONE leader: only leader should be talking and giving ordersToo many cooks in the kitchen is badRTs and RNs need to stick to their rolesBe decisiveErr on the side of being aggressiveMove rapidly if the patient is sickCXR and pelvic Xray BEFORE trauma labs, ABG, foley, NG, Cspine Xray

The Trauma question on the examSame approachBe methodologicalStick Man

Key PointsHave a systematic approach to traumaHave a systematic approach to the hypotensive and hypoxemic trauma patientBe ready for the trauma arrestManage the trauma room