Management of Trauma

1
Management of Trauma

• Christopher B. Colwell, MD
• Department of Emergency Medicine
• Denver Health Medical Center

2
Denver Health
3
Trauma

• Penetrating
• Gunshot wounds
• Stabbings
• Blunt
• MVAs
• Falls
• Assaults

4
Trauma

• Leading cause of death
• 1-44 years
• 4th leading cause of death
• Overall
• 90,000 deaths annually
• For every injury-related death, 19 are
  hospitalized
• 1 in 4 Americans affected every year
• 50 million injuries
• 10 million (20) disabling

5
Trauma Management

• Where do we begin?

6
Trauma Management

• Rapid primary evaluation
• Resuscitation of vital functions
• Detailed secondary assessment
• Initiation of definitive care

7
Trauma Management

• Primary survey
• ABCDE
• A Airway
• B Breathing
• C Circulation and hemorrhage control
• D Disability and brief neurologic assessment
• E Exposure

8
Trauma Management

• Primary survey
• Airway
• Rapid assessment
• Brain damage in apneic patient in 4-6 minutes
• Simple maneuvers
• Jaw thrust
• Oropharyngeal airway
• Endotracheal intubation
• Bag-valve-mask
• Protect the cervical spine!

9
Airway

• Think about it early
• Penetrating neck trauma
• Expanding hematoma
• Burns
• It wont get easier
• Head trauma
• Dont hyperventilate

10
Trauma Management

• Breathing
• Adequate airway DOES NOT assure adequate
  ventilation or oxygenation
• 100 oxygen
• Positive pressure ventilation
• If inadequate air exchange
• If still inadequate, consider
• Tension pneumo
• Open pneumo
• Pulmonary contusion
• Massive hemothorax

11
Tension Pneumothorax

• Decreased
• Ventilation
• Venous return
• Findings
• Distended neck veins
• Tracheal deviation
• Hyperresonance
• Treatment
• Needle decompression
• Tube thorocostomy

12
Breathing

• Pulmonary contusion
• Pain from rib fractures
• Disrupts ventilation
• Will get worse
• Massive hemothorax
• Shock
• Absent breath sounds
• Neck veins flat
• To the OR
• gt1500 cc
• gt200 cc/hr for 2-4 hrs
• Continued transfusion

13
Circulation

• 3 components
• Pump
• Pipes
• Blood
• Check pulse, blood pressure, mental status
• Radial pulse SBP gt 80 mm Hg
• Femoral pulse SBP gt 70 mm Hg
• Carotid pulse SBP gt 60 mm Hg

14
Circulation

• External hemorrhage best controlled with direct
  pressure
• Rarely are clamps or tourniquets necessary
• Places that hide enough blood to cause
  hypovolemic shock are
• Chest
• Pelvis
• Intraperitoneal cavity
• Retroperitoneum
• Muscle body surrounding large fractures

15
Disability Exam

• Tests gross neurologic function
• Level of consciousness
• Alert
• Responds to voice
• Responds to pain
• Responds to nothing (unresponsive)
• Pupillary size and reaction
• Movement of extremities

16
Exposure

• Cut off patients clothing
• Look everywhere for signs of trauma
• Often missed areas
• Scalp
• Posterior neck
• Back
• Axilla
• Buttocks/perineum

17
Resuscitation

• Oxygen
• Maximize P02
• Buys valuable time if patient decompensates
• Intravenous access
• 2 large bore peripheral lines
• 14-16G in adult
• Crystalloid (NS or lactated ringers)

18
Resuscitation

• Consider central line
• Tachycardia or hypotension
• Good access AND CVP
• IO?
• Be prepared to transfuse early
• O Negative
• Women of reproductive age
• O positive for others
• Type specific available in 5 minutes
• Crossmatched blood in 20 minutes

19
Resuscitation

• Transfusion
• Rough guideline
• Switch to PRBCs after 3 liters of crystalloid
• Must replace clotting factors and platelets after
  3-5 units
• Hypovolemic shock related to trauma is NOT
  treated with pressors, steroids, or sodium
  bicarbonate

20
Resuscitation

• Ultrasound (FAST)
• Focused
• Abdominal
• Sonography of
• Trauma

21
Ultrasound
22
Ultrasound

• Pericardium
• Tamponade

23
Pericardiocentesis
24
Resuscitation

• Labs (draw through I.V. stick)
• Hct. (baseline)
• Creatinine
• Glucose
• Particularly if altered mental status
• Type and cross
• Early in critical patients

25
Resuscitation

• Portable X-Rays
• Big 3
• C-Spine
• CXR
• Pelvis
• Foley
• If no blood at the meatus or high-riding prostate
  on rectal exam

26
Secondary Survey

• Re-assess vital signs and primary survey
• Comprehensive head to toe physical exam
• Complete neurolgic exam
• Burns
• Remember to remove everything
• Cool the skin

27
Definitive Care

• Consultants
• CT scans
• OR
• Admission
• Ward
• ICU
• Observation

28
Remember

• Always address immediately life-threatening
  problems first
• Most obvious and dramatic not always highest
  priority
• Trauma captain
• Decision maker
• No procedures