Introduction to TraumaUCSF Osher Mini Medical School

Jillian Mongelluzzo, MDLauren Chalwell, MD

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Objectives• Trauma center designation and criteria

• ATLS protocol

• Demonstrate teamwork in the care of critically injured patients

• Discuss common interventions and diagnostics for trauma patients

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Who is affected by traumatic injuries?

• A leading cause of death globally (WHO) and nationally (CDC)

• In US, accounts for 10% of all deaths

• #1 cause of death in young adults in US

• >50 million patients receive some form of trauma-related medical care each year

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

ZSFG• Only Level I Trauma Center in

City and County of SF and Northern San Mateo County

• Established as Level I Trauma Center in 1968

• Serve 1.5 million people

• In 2014, the Trauma Center treated over 4,200 trauma patients

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

What is a Trauma Center?• 24-hour in-house coverage by

general surgeons and prompt availability of other specialists

• Referral resource

• Community prevention, public education

• Continuing education of the trauma team

• Substance abuse program

• Teaching and research

• Meets minimum annual volume of severely injured patients

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Why does it matter?

• Decreased mortality for severely injured patients cared for at trauma centers compared to non-trauma center hospitals

• 2006 New England Journal of Medicine article by MacKenzie et al.

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Distribution of deathsPrevention

Trauma CareCritical care

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Advanced Trauma Life Support (ATLS)

• Treat the greatest threat to life first (primary survey)

• Definitive diagnosis is not immediately important

• Time matters

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Spectrum of Trauma Care• Prehospital

• Emergency Department

• Radiology - imaging, interventional

• OR

• ICU

• Surgical ward

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Prehospital Trauma Care• Obtain history

• Assess ABCs

• Immobilize spine

• Oxygen

• Splint fractures

• Control bleeding wounds

• IV, fluids

• Triage, rapid transport to and communication with trauma center

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Trauma Center Activation Criteria

• Gunshot wounds

• Stab wounds to neck or torso

• Low blood pressure

• Need for breathing tube

• Paralysis

• More than 4 months pregnant

900

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Trauma Center Activation Criteria

• Falls >12 feet/stairs

• Children who fall > 2x height of child or ten feet

• Motorcycle/bicycle > 20 mph

• Serious motor vehicle collisions

• Pedestrian hit by vehicle

911

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Arrival to Emergency Department

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter Modified from http://trauma.reach.vic.gov.au/

Trauma Team

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Good Teamwork = Better Patient

Outcomes

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Ottawa Crisis Resource Management Global Rating Scale

Good Team Work• Stays calm

• Makes prompt and firm decisions

• Maintains a global perspective

• Thorough yet quick Airway, Breathing, Circulation assessment

• Avoids fixation errors

• Anticipates future events

• Sets clear tasks

• Clearly communicates in a direct fashion

Primary Survey

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Primary Survey

rrapid.leeds.ac.uk/ebook/assets/images/01-intro-01-diagram-NEW.gif

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Bicyclist hit by car

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

GCS = Glasgow Coma Score

Verbal Response1 - No response 2 - Incomprehensible sounds 3 - Incomprehensible words 4 - Confused 5 - Oriented Eye Response1 - Eyes closed 2 - Eyes open to pain 3 - Eyes open to voice 4 - Eyes open spontaneously

Motor Response1 - No response 2 - Extension to pain 3 - Flexion to pain 4 - Withdraws to pain 5 - Localizes to pain 6 - Follows command

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Causes of Low Blood Pressure in Trauma Patients

• Bleeding - internally - liver or spleen

• Bleeding - externally

• Bleeding - from long bone fractures

• Spine injury

• Blood around the heart (tamponade)

• Air or blood around the lung (pneumothorax, hemothorax)

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

FAST

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Pelvic BinderDevice that

compresses the pelvic bones to

attempt to decrease major internal bleeding

from pelvic fractures

emsworld.com

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Destination from ED

• Unstable: To Operating Room with trauma surgeons

• Stable: To CT scanner for detailed eval of injuries

ZuckerbergSanFranciscoGeneralHospitalandTraumaCenter

Questions?