ED Approach to the Trauma Patient

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ED Approach to the Trauma Patient

• University of Utah Medical Center
• Division of Emergency Medicine
• Medical Student Orientation

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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

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AssessmentPrimary Survey

• Evaluate for immediate life threats
• Management of issues immediately
• ABCs (and D E)

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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

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Breathing

• Assessment
• Yes or No?
• Adequate?
• Evaluate breath sounds
• Evaluate chest wall symmetry and stability

• Intervention
• O2 for all (wont hurt)
• BVM
• Intubation
• Needle decompression
• Chest tube

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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 ABCs F?)

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Primary Survey

• Disability
• AVPU
• Awake
• Verbal
• Painful
• Unresponsive
• Posturing?
• Seizing?

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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 /lt8

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Primary Survey

• Expose/Environment
• Undress
• Protect from becoming hypothermic
• Warm room
• Warm blankets
• Warm fluid

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AssessmentSecondary Survey

• A thorough once-over
• Fingers Tubes
• AMPLE history

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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

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Secondary Survey

• Fingers and Tubes/Td
• Rectal? If indicated only
• Foley? If indicated
• Re-assess IV access
• Td Booster

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Secondary Survey

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

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Secondary Survey

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

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Imaging

• Plain films in trauma bay
• CXR
• Pelvis

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Imaging

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

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Labs

• Type and screen or cross
• CBC
• CMP
• Coags
• UA-visually inspect for gross hematuria
• UPT

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IV Fluids

• Crystalloids
• Normal Saline
• Lactated Ringers
• Colloids
• PRBC
• FFP
• Factors in hemophiliacs

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31 Rule

• Rough estimate
• Crystalloid volume blood loss
• 3 mL 1mL
• Caveat
• More and more, we are moving toward early
  transfusion
• Massive transfusion 111 PRBCFFPPlatelets
  (admittedly strong data lacking)

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Hypovolemic Shock

• Blood volume
• Adults 7 of weight
• Peds 8-9 of weight
• Replacement
• http//www.trauma.org/resus/massive.htm

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Classes of Hemorrhagic Shock
Class Blood Loss Vol. Blood Loss (cc) HR PP sBP Urine Output AMS Rx
I lt 15 lt750cc lt100 Norm Norm Norm No Crystalloids (31 rule) no PRBC
II 15-30 750-1500 ? ? ? ? No Crystalloids /- PRBC
III 30-40 1500-2000 ?? ?? ?? ?? Yes Crystalloids typespec PRBC
IV gt40 gt2000 ??? ??? ??? ??? Yes 2L crystalloid bolus uncrossd PRBC
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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

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Summary

• Preparation
• ABCDEs
• Secondary Survey
• Imaging
• Lab
• Hemorrhagic Shock
• The Basics