Emergency Trauma Care

A Course on the Early Management A Course on the Early Management of Victims of Traumaof Victims of Trauma

Introduction:Goals of the Emergency Trauma Care Course Provide medicale personnel with a Provide medicale personnel with a

standardized systematic approach to caring standardized systematic approach to caring for trauma victimsfor trauma victims

Encompass the care needed for both major Encompass the care needed for both major and minor traumaand minor trauma

Improve morbidity and mortality rates in Improve morbidity and mortality rates in trauma victimstrauma victims

Basic Sequence of Trauma Care

Rapid primary assessment of the patientRapid primary assessment of the patient Start resuscitative measuresStart resuscitative measures Complete a secondary assessmentComplete a secondary assessment Determine if the patient needs emergent Determine if the patient needs emergent

surgery or transfer to another medical surgery or transfer to another medical facility for specialized or advanced carefacility for specialized or advanced care

Definitive careDefinitive care RehabilitationRehabilitation

Why is Trauma Care Important

U.S.A. statistics(per year):U.S.A. statistics(per year): 60 million injuries total60 million injuries total 30 million injuries need medical care30 million injuries need medical care 3,6 million injuries need hospitalization3,6 million injuries need hospitalization 300.000 injuries cause permanent disability300.000 injuries cause permanent disability 145.000 deaths145.000 deaths Trauma is the leading cause of death in the first Trauma is the leading cause of death in the first

four decades of lifefour decades of life

Death Due to Injury Occur in Three Time-related Peaks after Injury First peak-seconds to a few minutes after First peak-seconds to a few minutes after

injury due to:injury due to: -lacerations of the brain or high spinal cord-lacerations of the brain or high spinal cord -laceration of the heart or great vessels-laceration of the heart or great vessels Very few of these patients can be salvaged Very few of these patients can be salvaged

in any systemin any system Best “ treatment” is preventionBest “ treatment” is prevention

Deaths due to injury occur in three time-related peaks after injury Second peak- minutes to a few hours after the Second peak- minutes to a few hours after the

injury due to:injury due to: -Subdural and epidural hematomas -Subdural and epidural hematomas -hemo-pneumotorax-hemo-pneumotorax -ruptured spleen or liver-ruptured spleen or liver Pelvic fracturesPelvic fractures Blood loss from other multiple fracturesBlood loss from other multiple fractures These patients can often be saved by proper These patients can often be saved by proper

emergency care emergency care

Deaths due to injury occur in three time-related peaks after injury Third peak –days to weeks after the injury Third peak –days to weeks after the injury

due to:due to: -severe head injury-severe head injury -sepsis-sepsis -multiple organ failure syndrome-multiple organ failure syndrome Proper early emergency care can prevent Proper early emergency care can prevent

some of these deathssome of these deaths

The care sequence for major trauma patients is different than stable medical patients For stable medical patients the standard care For stable medical patients the standard care

sequence is:sequence is: -history of present illness and past medical history-history of present illness and past medical history -phisical exam from head to toe-phisical exam from head to toe -develop a differential diagnosis-develop a differential diagnosis -utilize accessory diagnostic tests(lab, x-ray,etc.)-utilize accessory diagnostic tests(lab, x-ray,etc.) -arrive at a final diagnosis-arrive at a final diagnosis This approach has to be greatly modified for care This approach has to be greatly modified for care

of the trauma patient to prevent deathof the trauma patient to prevent death

Three principles of Emergency Trauma Care If a patient has multiple problems or injuries, treat If a patient has multiple problems or injuries, treat

first the one that is the greatest threat to lifefirst the one that is the greatest threat to life Indicated treatments should not be delayed simply Indicated treatments should not be delayed simply

because the diagnosis is not yet certainbecause the diagnosis is not yet certain A detailed history is not essential to start A detailed history is not essential to start

evaluation and treatment of an injuried patientevaluation and treatment of an injuried patient

Identifying the greatest threats to life in the trauma patient Life threats from trauma are (in order of Life threats from trauma are (in order of

decreasing severity):decreasing severity): - loss of airway -kills most quickly( head position, - loss of airway -kills most quickly( head position,

blood, vomitus, foreing body, external blood, vomitus, foreing body, external compression)compression)

- loss of breathing- kills next most - loss of breathing- kills next most quickly(pneumotorax, hemotorax, lung injury)quickly(pneumotorax, hemotorax, lung injury)

Loss of circulation: bleeding(internal or external), Loss of circulation: bleeding(internal or external), heart injury, arrythmiasheart injury, arrythmias

Expanding intracranial massExpanding intracranial mass

The “ABCDE” system for trauma care Always follow this sequence:Always follow this sequence: -Airway ( with cervical spine control)-Airway ( with cervical spine control) -Breathing-Breathing -Circulation( and haemorrage control)-Circulation( and haemorrage control) -Disability( neurologic status)-Disability( neurologic status) -Expose and environment-Expose and environment Completely undress the patient for exam, but take Completely undress the patient for exam, but take

measures to avoid hypothermiameasures to avoid hypothermia

Initial assessment

Objectives:Objectives: -identify and treat immediately life-threatening -identify and treat immediately life-threatening

injuries in the correct priority sequenceinjuries in the correct priority sequence Establish needed resuscitative measures to then Establish needed resuscitative measures to then

allow a complete secondary survey to be allow a complete secondary survey to be conductedconducted

-allow triage decisions to be made when there are -allow triage decisions to be made when there are multiple simultaneous patientsmultiple simultaneous patients

Proper Trauma Care Sequence

Initial Assessement-Rapid Primary SurveyInitial Assessement-Rapid Primary Survey Start resuscitation measuresStart resuscitation measures Detailed secondary surveyDetailed secondary survey Diagnostic studiesDiagnostic studies Reevaluate the patient at frequent intervalsReevaluate the patient at frequent intervals Decide on patient disposition and definitive Decide on patient disposition and definitive

carecare

Basic Principle of Initial Assessment Correction of life-threatening emergenciesCorrection of life-threatening emergencies

(resuscitation) must be done simultaneously (resuscitation) must be done simultaneously with the primary surveywith the primary survey

Treatment takes precedence over diagnosisTreatment takes precedence over diagnosis

Good communication from prehospital Good communication from prehospital personnel to the ED-radio or phone reports personnel to the ED-radio or phone reports on trauma patient shoul be brief< 45 sec on trauma patient shoul be brief< 45 sec

Communication between prehospital personnel and the ED Number of victims and their age and genderNumber of victims and their age and gender Mechanism of injuryMechanism of injury Suspected injuriesSuspected injuries Vital signsVital signs Treatment measures startedTreatment measures started Estimated time of arrivalEstimated time of arrival Any special precautions for the E.D.: hazardous Any special precautions for the E.D.: hazardous

materals contamination, combative patient or materals contamination, combative patient or accompanying personsaccompanying persons

Preparation of the ED to receive a major trauma victim Collect adequate ED personnelCollect adequate ED personnel Clear a bed or room for the victimClear a bed or room for the victim Obtain and arrange:Obtain and arrange:

-airway equipment,iv fluid bags and lines,bandages, -airway equipment,iv fluid bags and lines,bandages, chest tubes and waterseal bottles,blood bank (0-chest tubes and waterseal bottles,blood bank (0-negative)negative)

Alert ancillary personnel:-X-ray, laboratory, Alert ancillary personnel:-X-ray, laboratory, respiratory therapy, special nursing unit, securityrespiratory therapy, special nursing unit, security

The Primary Survey

A-airway and C-spine controlA-airway and C-spine control B-breathingB-breathing C-circulation(hemorrhage control)C-circulation(hemorrhage control) D-disability( mini-neurologic exam)D-disability( mini-neurologic exam) E-expose/environmentE-expose/environment

(to some extent D and E are really part of the (to some extent D and E are really part of the secondary survey)secondary survey)

How to do the primary survey

Look at the patient from across the room:Look at the patient from across the room:- is he breathing?- is he breathing?- is he speaking?is he speaking?- What is the skin color?What is the skin color?- Is he bleeding?Is he bleeding?- Is he immobilized properly?Is he immobilized properly? Obtain a quick history of what happened:Obtain a quick history of what happened:- mechanism of injurymechanism of injury- Time of injuryTime of injury

How to do the primary survey Assess the airway:Assess the airway:

Do airway- opening maneuvers if neccesary (c-spine precaution)Do airway- opening maneuvers if neccesary (c-spine precaution) Place oral airway if unconsciousPlace oral airway if unconscious

Assess breathing:Assess breathing: Listen with stethoscope to the chestListen with stethoscope to the chest Obtain pulsoximetry if availableObtain pulsoximetry if available Bag-valve-mask assisted ventilation if neededBag-valve-mask assisted ventilation if needed Start oxygen by high flow face maskStart oxygen by high flow face mask

Early cervical spine injury precautions:Early cervical spine injury precautions: Immobilize the neck if any possibility of neck injuryImmobilize the neck if any possibility of neck injury ““hard” collar hard” collar Blocks on either side of head and tape across foreheadBlocks on either side of head and tape across forehead

Patients who might have a neck injury and need early c-spine immobilization Appropiate mechanism of injuryAppropiate mechanism of injury

Fall Fall Vehicle accidentVehicle accidentStruck by object on neck or headStruck by object on neck or head

Unconscious Unconscious Complaining of neck painComplaining of neck pain Crepitus or deformity of posterior neckCrepitus or deformity of posterior neck Altered mental status (alcohol)Altered mental status (alcohol)

How to do the primary survey

Assess circulationAssess circulation Check pulse, blood pressure, respiratory Check pulse, blood pressure, respiratory

raterate Check temperature quicklyCheck temperature quickly Check for external bleeding and apply Check for external bleeding and apply

direct pressure with gauze dressingsdirect pressure with gauze dressings Place cardiac monitor leads and Place cardiac monitor leads and

determine the patient’s cardiac rhytm determine the patient’s cardiac rhytm

Emergency resucitation procedures that should be done immediately with the primary survey

If inadequate airway:If inadequate airway: Airway opening maneuvers Airway opening maneuvers Oral airway if unconsciousOral airway if unconscious

If inadequate breathing:If inadequate breathing: Attempt BVM ventilation Attempt BVM ventilation Endotracheal intubation if BVM Endotracheal intubation if BVM

inadequate or unsuccessfulinadequate or unsuccessful

Emergency endotracheal intubation Oral intubation with assistant holding head Oral intubation with assistant holding head

and neck steady ussualy best and neck steady ussualy best May attempt nazal intubation if:May attempt nazal intubation if:

No possible nazal or mid-facial fracturesNo possible nazal or mid-facial fractures Not known coagulopathy Not known coagulopathy

Surgical airway (cricothyroidotomy) if Surgical airway (cricothyroidotomy) if endotracheal attempt unsuccessful endotracheal attempt unsuccessful

Emergency resucitation procedures that should be done immediately with the primary survey

If inadequate circulation or suspected major blood If inadequate circulation or suspected major blood loss:loss: Start at least one large bore iv (16-14 gauge)Start at least one large bore iv (16-14 gauge) Run lactated Ringer or normal salineRun lactated Ringer or normal saline

• Run very slow if only isolated closed head injuryRun very slow if only isolated closed head injury

• Run wide open (very fast) if patient hypotensiveRun wide open (very fast) if patient hypotensive

• Rapidly infuse 0-negative bloode 2 or more units Rapidly infuse 0-negative bloode 2 or more units if obvious ongoing blood loss and severely if obvious ongoing blood loss and severely hypotensivehypotensive

Initial Blood Draw

With the I.v. stick,draw tubes of blood:With the I.v. stick,draw tubes of blood: -Type and cross-most important-Type and cross-most important -CBC,amylase,glucose,electrolytes,BUN, -CBC,amylase,glucose,electrolytes,BUN,

platelet count, PT, PTT,creatinine,CPK, platelet count, PT, PTT,creatinine,CPK, medication levels,pregnancy testmedication levels,pregnancy test

-drug(especially alcohol)or toxin levels may -drug(especially alcohol)or toxin levels may also be neededalso be needed

Emergency resucitation procedures that should be done immediately with the primary survey

If major external bleeding:If major external bleeding: Apply direct pressure with gauze dressing Apply direct pressure with gauze dressing Rarely direct clamping of visible pumping Rarely direct clamping of visible pumping

lacerated arteries may be needed (clamps can lacerated arteries may be needed (clamps can damage adiacent nerves however)damage adiacent nerves however)

Apply steril dressings to cover any open Apply steril dressings to cover any open fractures or exposed viscera fractures or exposed viscera

Tourniquets are almost never indicated Tourniquets are almost never indicated

Emergency resucitation procedures that should be done immediately with the primary survey

After assessment of the patient chest:After assessment of the patient chest: Suspected tension pneumothorax- immediate needle Suspected tension pneumothorax- immediate needle

thoracostomy, then follow with tube thoracostomythoracostomy, then follow with tube thoracostomy Flail chest- stabilisation with broad taping or overlying Flail chest- stabilisation with broad taping or overlying

heavy flat dressing heavy flat dressing Open “sucking” pneumotorax- seal defect with gauze Open “sucking” pneumotorax- seal defect with gauze

and dressing, insert thorocostomy tube and dressing, insert thorocostomy tube Suspected pericardial tamponade with imminent Suspected pericardial tamponade with imminent

cardiac arrest- pericardiocentesiscardiac arrest- pericardiocentesis Consider checking an arterial blood gas Consider checking an arterial blood gas

Sequential Priorities of the secondary Survey Completely undress patient to allow complete exam-clothing Completely undress patient to allow complete exam-clothing

may need to be cut off if movement may hurt the patientmay need to be cut off if movement may hurt the patient Use room warming, heat lamps, and/or heating blaket to help Use room warming, heat lamps, and/or heating blaket to help

protect against hypothermiaprotect against hypothermia Recheck the vital signs-obtain temperature if not done yetRecheck the vital signs-obtain temperature if not done yet Complete head to toe examComplete head to toe exam Consider nasogastric and urinary bladder tube Consider nasogastric and urinary bladder tube

placement (if no contraindications are found on placement (if no contraindications are found on exam)exam)

Decide what X-rayDecide what X-ray

Secondary Survey

First, clarify the history of injuryFirst, clarify the history of injury One simple mnemonic is AMPLE:One simple mnemonic is AMPLE:-Allergies-Allergies-Medications-Medications-Past illnesses-Past illnesses-Last meal(time)-Last meal(time)-events( preceding injury) -events( preceding injury) Clarify mechanism of injuryClarify mechanism of injury Assess for other conditions:-hypoglicemia, toxic Assess for other conditions:-hypoglicemia, toxic

exposure, smoke/CO exposureexposure, smoke/CO exposure

Secondary Survey:how to start the head to toe exam Assess mental status:assign Glasgow Coma ScoreAssess mental status:assign Glasgow Coma Score Palpate scalp( use gloves)Palpate scalp( use gloves) Look at tympanic membranesLook at tympanic membranes Look at nasal passagesLook at nasal passages Look in mouthLook in mouth Palpate face and mandiblePalpate face and mandible Assess pulpilary light reaction and extraocular Assess pulpilary light reaction and extraocular

movementsmovements Fundoscopy can be done, but not usually helpfullFundoscopy can be done, but not usually helpfull

Secondary Survey: neck and Chest Hold patient’s head and neck stableHold patient’s head and neck stable Open the c-collar and observe anterior neck – Open the c-collar and observe anterior neck –

check traheal positioncheck traheal position Palpate posterior neck, reapply collarPalpate posterior neck, reapply collar Percuss and palpate chest wall and claviclesPercuss and palpate chest wall and clavicles Auscultate lungsAuscultate lungs Auscultate heartAuscultate heart Palpate upper backPalpate upper back

Secondary Survey: abdomen , perineum and back Auscultate and palpate and percuss abdomenAuscultate and palpate and percuss abdomen Palpate and rock pelvisPalpate and rock pelvis Logroll patient to look at back(maintain spine and Logroll patient to look at back(maintain spine and

limb stability with the logroll)limb stability with the logroll) Palpate genitaliaPalpate genitalia Vaginal examVaginal exam Rectal exam:-check for high prostateRectal exam:-check for high prostate

– Check stool guiacCheck stool guiac

Secondary Survey: exam of extremities: Palpate along all four limbsPalpate along all four limbs Assess active joint range of motionAssess active joint range of motion Palpate pulse and capilary refillPalpate pulse and capilary refill Assess tendon functionAssess tendon function

Secondary Survey: neurologic exam Assign GCSAssign GCS Mental status / orientation( to person, place, Mental status / orientation( to person, place,

time, events)time, events) Cranial nerves II thru XIICranial nerves II thru XII Motor,Sensory,Reflexes –all four limbsMotor,Sensory,Reflexes –all four limbs CoordinationCoordination

Secondary Survey:addional Considerations Splin and bandage injuries as these are Splin and bandage injuries as these are

discovereddiscovered Cleanse dirty wounds to allow better Cleanse dirty wounds to allow better

assessment of their depth and extentassessment of their depth and extent Leave deeply imbedded objects in place for Leave deeply imbedded objects in place for

removal in the operating room( premature removal in the operating room( premature removal could result in exanguination if the removal could result in exanguination if the object is tamponading a major vessel)object is tamponading a major vessel)

Secondary Survey: Final Considerations Consider 12 lead ECG( if major chest trauma or Consider 12 lead ECG( if major chest trauma or

chest pain)chest pain) Usually minimum X-rays needed are( for major Usually minimum X-rays needed are( for major

truncal trauma): lateral C-spine, CXR,AP truncal trauma): lateral C-spine, CXR,AP pelvis(order these while doing secondary survey)pelvis(order these while doing secondary survey)

X-ray all sites of potential fractures ( order these all X-ray all sites of potential fractures ( order these all at one time)at one time)

Decide if special studies needed: peritoneal lavage, Decide if special studies needed: peritoneal lavage, computed tomography, angiography, ultrasoundcomputed tomography, angiography, ultrasound

Place Foley and or NG tube if no contraindicationsPlace Foley and or NG tube if no contraindications

Contraindication

Nasogastric tube:nasal fractures, midfacial Nasogastric tube:nasal fractures, midfacial fractures, severe coagulopathyfractures, severe coagulopathy

Insert via mouth if any of these are presentInsert via mouth if any of these are present Foley: suspected anterior urethral injury-Foley: suspected anterior urethral injury-

blood at meatus,”high-riding” or nonpalpate blood at meatus,”high-riding” or nonpalpate prostate, “butterfly” perineal hematomaprostate, “butterfly” perineal hematoma

Revised trauma score

Parameter Finding Points

Respiratory rate 10-29 per minute 4

> 29 per minute 3

6-9 per minute 2

1-5 per minute 1

Nil 0

Systolic blood pressure >89 mm Hg 4

76-89 mm Hg 3

50-75 mm Hg 2

1-49 mm Hg 1

Nil 0

Glasgow Coma Score 13-15 4

9-12 3

6-8 2

4-5 1

2 0