Introduction to Trauma LSU Medical Student Clerkship, New Orleans, LA
Goals • Review the components of the primary and secondary survey for a trauma patient • Identify injuries requiring immediate intervention during primary survey • Review the initial steps of resuscitation of a trauma patient in the ED • Review the advantages and uses of diagnostic modalities in the trauma patient • Discuss the appropriate disposition of the trauma patient from the ED.
Epidemiology • Trauma is a disease. • Trauma is predictable, preventable, and treatable. • Trauma is the 4th leading cause of death in the US. • Trauma is the leading cause of death in people below the age of 45 in the US. • 3.8 M deaths/ year/ worldwide • 312 M injured
Epidemiology Trimodal distribution of mortality Prehospital (Major head injuries, rapid exsanguination) Early Hospital (Head, chest, abdominal trauma) ICU (End result of prolonged hypoperfusion)
History of Trauma Systems • 1991: Congress passed the Trauma Care Systems Planning and Development Act requiring the development of a Model Trauma Care System Plan to be used as a reference document for each state to develop its system • Based on the severity of injury, patients are triaged to trauma centers • The American College of Surgeons has developed requirements for trauma center certification of commitment of personnel and resources needed to maintain a state of readiness to receive critically injured patients. • The Golden Hour
Initial Approach • The initial approach to trauma care in the ED is a process that consists of an initial primary assessment, rapid resuscitation, and a more thorough secondary survey followed by diagnostic tests and ultimate disposition. • Subsequent mortality and morbidity tied directly to the initial assessment and resuscitation
Primary Survey • Rapid examination to identify and treat life threatening conditions. Ideally is performed in a few minutes. • A - Airway (with C-spine precautions) • B - Breathing • C - Circulation • D - Disability • E – Exposure When derangements in any of the components of the primary survey are identified, treatment is undertaken immediately.
Primary Survey - Airway • Maintain C-spine precautions • Clear any obstructions • Jaw thrust instead of head tilt chin lift • Endotracheal intubation for airway protection or expected clinical course (ie,obstruction from blood or vomitus, neck hematoma, facial burns or trauma, GCS 8 or less, combative patient, potential for airway compromise while out of department.)
Primary Survey - Breathing • Auscultation for bilateral breath sounds • Palpation for subcutaneous emphysema -needle decompression followed by chest tube for pneumothorax • Inspection for flail chest • Observation of respiratory rate, oxygen saturation, and overall work of breathing -mechanical ventilation for inadequate ventilation or to decrease work of breathing
Primary Survey - Circulation • Check peripheral pulses, heart rate, BP, pulse pressure, capillary refill, cyanosis • All hypotensive trauma patients are assumed to be in hemorrhagic shock • 2 large bore peripheral IV’s (at least 18 gauge) • Control external bleeding
Primary Survey - Circulation • Begin volume resuscitation with liter boluses of crystalloid for class I or II hemorrhage. • Begin crystalloid and blood for class III or IV hemorrhage. • O- blood until type specific is available • Constant reevaluation is paramount • If class I or II is patient still showing signs of shock after 3L of crystalloid, begin blood • “3:1 rule” 3cc crystalloid for every 1cc of blood loss
Primary Survey - Circulation • 5 Places life threatening hemorrhage can occur -Chest -Abdomen -Pelvis -Thighs -Externally
Primary Survey - Circulation • Cardiac Tamponade can cause hypotension with little blood loss. • Becks triad: hypotension, distended neck veins, muffled heart sounds • Easily confirmed with ultrasound • Pericardiocentesis
Primary Survey - Disability • Quick assessment of ability to move all extremities • Glascow Coma Scale
Primary Survey – Exposure • Completely undress the patient and inspect the entire patient from head to toe both front and back. • Maintain spinal precautions during logrolling • Inspect both axillae and peritoneum • Warm blankets!!!
Secondary Survey • Head to toe evaluation once any derangements in primary survey have been addressed. • AMPLE History -Allergies -Medications -Past medical history (LMP, Td, transfusions) -Last meal -Events leading up to trauma
Imaging • Choice of imaging modality depends on nature of injuries and stability of patient. • Knowledge of injury mechanism and index of suspicion most important
Imaging – Plain Films • Quick • Can be performed at bedside • Useful for rapid identification of pneumothorax, hemothorax, fractures and locating ballistics
Imaging – Ultrasound • Quick • Can be performed at bedside • FAST: Focused Assessment with Sonography for Trauma • Rapid examination to identify free intraperitoneal fluid and/or pericardial fluid
Imaging – CT Detailed Requires patient to leave the department Necessary for head trauma
Disposition • To the OR -Unstable patients with blunt or penetrating abdominal trauma or chest trauma. Hemothorax with >1500 cc of blood out initially. Surgical injuries identified with imaging. • Admission -Nonsurgical, high-risk injuries • Discharge -Stable patients, minor or no injuries identified.