ED Approach to the Trauma Patient

University of Utah Medical Center

Division of Emergency Medicine

Medical Student Orientation

Why?

• Trimodal Death Distribution– 1. seconds to minutes

• Often CNS or severe vascular injuries• Little can be done• Prevention is key

– 2. minutes to hours• Golden Hour• Rapid assessment and resuscitation

– 3. days to weeks• Sepsis• Multisystem organ failure

Assessment:Primary Survey

–Evaluate for immediate life threats–Management of issues immediately–ABC’s (and D &E)

Airway

• Assessment– First priority in ANY

patient– If they can speak

clearly = good airway– Hoarse/sonorous/

gurgling = further evaluation and intervention

– Are they protecting their airway?

• Intervention– Jaw Thrust (c-spine)– Suction– NPA– OPA– Intubation– Have a back-up plan!– Maintain in-line

cervical stabilization

Breathing

• Assessment– Yes or No?– Adequate?– Evaluate breath

sounds– Evaluate chest wall

symmetry and stability

• Intervention– O2 for all (won’t hurt)– BVM– Intubation– Needle

decompression– Chest tube

Circulation

• Assessment– Pulse?– Rate/Rhythm/Strength– Skin CTM– Bleeding?

• External• Internal

• Intervention– CPR– 2 large bore IVs

• (14-16G)

– IO (even easier now)– Central line– Fluid replacement– Control bleeding– FAST Scan (now

maybe ABC’s & F?)

Primary Survey

• Disability– AVPU

• Awake• Verbal• Painful• Unresponsive

– Posturing?– Seizing?

Assessment Area Score

Eye Opening (E)•Spontaneous•To speech•To pain•None

•4•3•2•1

Best Motor Response (M)•Obeys Commands•Localizes Pain•Normal flexion (withdrawal)•Abnormal flexion (decorticate)•Extension (decerebrate)•None (flaccid)

•6•5•4•3•2•1

Verbal Response (V)•Oriented•Confused conversation•Inappropriate words•Incomprehensible sounds•None

•5•4•3•2•1

• Mild– GCS 14-15

• Moderate – GCS 9-13

• Severe– GCS =/<8

Primary Survey

• Expose/Environment– Undress– Protect from becoming

hypothermic• Warm room• Warm blankets• Warm fluid

Assessment:Secondary Survey

•A thorough once-over

•Fingers & Tubes

•AMPLE history

Secondary Survey• Thorough physical exam

– HEENT (look in nose, ears, mouth)

– Neck (undo collar and palpate)

– Chest/Abdomen/Pelvis (FAST Scan if not done)

– Back – GU/rectal if indicated– Extremities– Detailed neuro exam

Secondary Survey

• Fingers and Tubes/Td– Rectal? If indicated

only – Foley? If indicated– Re-assess IV access– Td Booster

Secondary Survey

• AMPLE History– Allergies– Meds– PMHx/PSHx– Last meal– Events leading up to

accident

Secondary Survey

• Reassess vitals– Better or worse?– Further intervention needed?– Transfer patient?

Imaging

• Plain films in trauma bay– CXR– Pelvis

Imaging

• CT scan? (the “Grand Slam” if all done)– Head– Neck– Face– Chest– Abdomen– Pelvis

Labs

• Type and screen or cross

• CBC• CMP• Coags• UA-visually inspect

for gross hematuria• UPT

IV Fluids

• Crystalloids– Normal Saline– Lactated Ringers

• Colloids– PRBC– FFP– Factors in hemophiliacs

3:1 Rule

• Rough estimate

• Crystalloid volume : blood loss

• 3 mL: 1mL

• Caveat: – More and more, we are moving toward early

transfusion– Massive transfusion = 1:1:1

PRBC:FFP:Platelets (admittedly strong data lacking)

Hypovolemic Shock

• Blood volume– Adults: 7% of weight– Peds: 8-9% of weight

• Replacement – http://www.trauma.org/resus/massive.htm

Class Blood Loss %

Vol. Blood Loss (cc)

HR PP sBP Urine Output

AMS Rx

I < 15% <750cc <100 Norm Norm Norm No Crystalloids (3:1 rule); no PRBC

II 15-30% 750-1500

↑ ↓ ↓ ↓ No Crystalloids; +/- PRBC

III 30-40% 1500-2000

↑↑ ↓↓ ↓↓ ↓↓ Yes Crystalloids + type=spec PRBC

IV >40% >2000 ↑↑↑ ↓↓↓ ↓↓↓ ↓↓↓ Yes 2L crystalloid bolus + uncross’d PRBC

Classes of Hemorrhagic Shock

Where Can you Lose Blood?

• Environment

• Chest– Hemothorax: 40-50% volume each side– Aortic rupture– Cardiac rupture

• Abdomen

• Pelvis: 3-4L retroperitoneal

• Femur : 1-1.5L

Summary

• Preparation

• ABCDE’s

• Secondary Survey

• Imaging

• Lab

• Hemorrhagic Shock

• The Basics