Approach to Trauma Patients Joseph Turner, MD Indiana University School of Medicine
Objectives • Describe the initial approach to the injured patient, including the primary and secondary surveys. • Describe the clinical presentation and initial treatment measures for life threatening injuries. • Identify the types and clinical presentations of shock. Identify the classes (I, II, III, IV) of hemorrhagic shock. • Understand the benefits and downsides of imaging trauma patients • Describe approach to assessing cervical spine trauma
Case 1 • 32 yo female restrained driver in a rollover MVA • 25 minute extrication • complaining of chest pain and difficulty breathing • EMS reports that the windshield is starred and the steering column was bent
Mechanism of Injury • Gives information about the forces potentially involved in the traumatic mechanism • Guides diagnostic testing • More force more likely to have injury • Determines Trauma center activation • Shorter time to arrive at definitive care • Determined by mechanism and vitals
Case 1 • Vitals • HR 94 BP 88/56 RR 26 Biox 93% • Where do you take the patient? • Would you be more or less concerned if this were a 83 yo female?
Susceptibility to Injury • Some populations more vulnerable to injuries • Elderly • More likely to have injuries from given force • Lower bone density, brain atrophy, co-morbities • Alcoholics • Brain atrophy leads to more subdural hematomas • Coagulolopathic • warfarin, cirrhotic
Primary Survey • Goal is to identify and treat any life threatening injuries • Some components are evaluated simultaneously in large trauma centers • All resources are directed toward stabilizing that injury until it is corrected
Airway • Evaluate for patency and secure it if it is not adequate • Usually endotracheal intubation • Keep cervical spine immobilized inline if any concern for spine fracture • Identify injuries that if not treated will threaten the airway • Intervene before it becomes too difficult
What are some signs or symptoms that might indicate that the patient needs an airway intervention? • Airway obstruction • Severe respiratory distress • Altered mental status (GCS < 8 --> Intubate) • Critically ill • If something changes – start over at the top
Breathing • Listen to breath sounds • Look, feel, trachea position • Oxygenation • Skin color, pulse ox
Circulation • Heart rate and blood pressure • Look for signs of shock • Cap refill, mental status • Feel pulses • Check above and below waist and on both sides • Looking for vascular injury • Listen for muffled heart tones • Ultrasound helpful
Disability • Rapid neurologic assessment • Formal Glasgow Coma Score • Eye opening, verbal and motor • Gross motor exam for quadro/paraplegia • Heighten suspicion for spinal cord injury • Palpate spinal cord • Rectal tone?
Exposure/Environmental Control • Remove clothing to evaluate for external evidence of injury • Keep patient warm • hypothermia will complicate many injuries
Secondary Survey • Starts once the primary survey is complete and all injuries identified there have been stabilized • Head to toe examination of the patient to evaluate for additional injuries • Evaluate need for imaging studies to identify injuries
Case 2 • 24 yo male patient involved in a drive by shooting • Suffered with multiple gunshot wounds to the chest and abdomen. There were 2 fatalities at the scene • Vs HR 124 BP 76/p RR 36
Primary Survey • Airway • Breathing • Breath sounds diminished on right side, trachea deviated to left • What is going on and what are you going to do about it?
Tension Pneumothorax • Diminished breath sounds and hypotension • Hyper-resonance, JVD; deviated trachea late sign • Treatment is needle thoracostomy, followed by tube thoracostomy • large gauge angio in 2nd intercoatal space in mid clavicular line • get rush of air and improvement in vs • needs immediate tube thoracostomy
Primary Survey • Airway • Breathing • Circulation • Low blood pressure and elevated heart rate • HR 124 BP 76/p SHOCK
Top 10 Types of Shock in Trauma Patients • Hemorrhagic • Hemorrhagic • Hemorrhagic • Hemorrhagic • Hemorrhagic • Hemorrhagic • Hemorrhagic • Hemorrhagic • Cardiogenic • Neurogenic
Hemorrhagic Shock • Class I- <15% blood loss • Minimal symptoms and normal vitals • Class II- >15% blood loss (800-1500 cc) • Tachycardia, decreased pulse pressure, delayed cap refill • Class III- >30 % blood loss (1500-2000 cc) • Tachycardia, tachypnea, hypotension • Usually requires transfusion
Hemorrhagic Shock • Class IV- > 40% blood loss (>2000 cc) • Immediately life threatening • Marked abnormalities in vitals • Skin cool, diaphoretic • Negligible urinary output • Depressed mental status
Stop the bleeding Locate and control bleeding sites Body sites an adult can bleed and develop shock Chest Abdomen Retroperitoneal Pelvis Femur External losses Volume Resuscitation Isotonic fluid Start with 1-2 liters Blood Switch to quickly if not stable with crystalloid If hypotensive start early with O-neg Send type and cross to get type specific ASAP Treatment of Hemorrhagic Shock
Assure that the patient has adequate IV access in order to deliver large amounts of volume quickly • Two 18 G or larger Ivs • Or Central Access • Key is short and fat catheters deliver fluids and blood faster • Flow directly proportional to diameter of catheter and inversely proportional to length of catheter
Tranexamic Acid? • Antifibrinolytic agent • Decreases bleeding and need for transfusion • Reduced mortality in CRASH-2 trial
Primary Survey • Airway • Breathing • Circulation • Low blood pressure and elevated heart rate • shock • No palpable pulse in right leg with gsw to thigh
Assess neurovascular status • Vascular Exam • Hard Signs • No palpable or dopplerable pulse, visible pulsatile bleeding, bruit or thrill over artery, expanding hematoma • Soft Signs • Decreased pulse compared to extremities, neurologic abnormality, fracture or penetrating injury in proximity to artery • Neuro exam • Assess motor and sensory nerve function • distal to injury
Ankle-Brachial Index • Useful adjunct in vascular assesment • SPB in leg/SBP in arm while patient laying down • Normal is >0.9 • Less than 0.9 is indication for further diagnostic testing • Angiogram (CT or fluoroscopic) • Exploration
Case 2:Outcome • GSW to right chest with tension pneumothorax • Chest tube placed and 300 cc blood removed • >1000 cc (20cc/kg) initally or 150cc/hr continuing • indications for exploration in the OR • Pulse in right leg dopplerable, but ABI 0.4 • Get angiogram to evaluate when stable
Case 3 • 38 yo female fell from a 3rd story window • She complains about a headache and abdominal pain • Very brief loss of consciousness • Vitals • P 94 BP 110/60 RR 20 Biox 97% on RA
Primary Survey • Airway • Intact, patient speaking • Breathing • No distress, normal biox • Circulation • No evidence of shock or pulse deficit • Disability • GCS 15, non focal neuro
Secondary Survey • HEENT - PERLA, EOMI, no scalp lac, hematoma over left temple • Chest - TTP in right lower chest, equal bs • Abdomen - soft tender in right upper quadrant, no peritonitis • Pelvis - stable to rock and compression, pain on palpation of right hip • Neurologic exam - GCS 15, 5/5 strength throughout, no sensory deficits
What tests do you order at the bedside? • Chest X-ray • To look for pneumothroax, pulmonary contusion or wide mediastinum • Pelvis X-ray • To look for pelvic fractures • FAST Scan • Bedside ultrasound to evaluate for abdominal fluid
FAST Scan • Portable • Non-invasive • Evaluates for intraperitoneal and pericardial fluid • as little as 300 cc detected • Reliably predicts need for laporotomy in hypotensive trauma patients • Not sensitive for solid organ injury and retroperitoneal injuries • E-FAST (extended-FAST) • Looks for pneumo/hemothorax
Case 3 • CXR, FAST negative • Now what? • PanScan? • Routine CT imaging of head, cervical spine, chest, abdomen for trauma patients • Probably beneficial for critically injured patients
Downsides to Imaging • Radiation exposure • Contrast nephropathy • Cost/charge • Resource utilization • Incidental findings
What tests do you order? • Head CT • Identifies intercranial hemorrhage • Subdural, epidural, subarachnoid or interparyenchymal • Will identify patients who need evacuation of blood prior to clinical deterioration • Many patients with severe brain injury have normal head CTs • From diffuse axonal injury • Don’t let a normal head CT fool you into thinking that the patient doesn’t have a head injury
Who needs a head CT? • Decision Rules • Nexus 2, Canadian Head CT, CHIP Rule, New Orleans Criteria • Fairly sensitive though not 100% and specificity may not be enough to reduce CT use that much compared to clinical judgment • Work better for ‘clinically important injuries’ • Requiring observation or neurosurgical intervention
Who needs a head CT? • Generally accepted indications: • Persistent altered mental status • Focal neurologic deficits • Signs of basilar skulls fracture • Coagulopathic • Other factors • Loss of consciousness, vomiting, age >60, severity of headache, scalp hematoma/contusion • Important to take mechanism of injury into account when deciding to order head CT
ACEP Guidelines • Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy. • Level B recommendations. A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.*
Abdominal CT • Used to evaluate for intra-abdominal, retroperitoneal and pelvic injuries • Excellent detail of solid organ injuries • Spleen and Liver Laceration classification
Abdominal CT • Bone windows allow visualization of spine and pelvic fractures • Equivalent or better than plain films • Hollow viscous injury • Historically a weakness of CT • New generation multi-slice spiral scanners much higher sensitivity
Chest CT • Evaluates for aortic injury • High risk patients – rapid deceleration • Abnormal mediastinum on plain chest xray • More sensitive than chest x-ray for small pneumothorax or pulmonary contusion • Some are so small they don’t need treatment
Case 4 • Two patients on backboards and c-collars after being in a motor vehicle accident • Patient A is complaining of neck pain and Patient B is screaming in pain from his left shoulder. They are yelling that the collar and backboard are making things worse. • They want the collars off and to be taken off the board. What do you want to do?
Patient A • 24 yo female complaining of neck pain, unrestrained passenger who has also been drinking alcohol and her speech is slightly slurred. No other injuries noted • Neck seems non-tender • Neuro exam reveals no focal deficits Can you clinically clear this patients c-spine?
Patient B • Restrained driver and is complaining of left shoulder pain and left ankle pain. He denies alcohol use and doesn’t seem intoxicated clinically. • States that his left shoulder commonly dislocates and that he needs out of the collar so he can turn his head to pop it back in.
Physical Exam • Patient B’s neck is non-tender on exam • Left shoulder with obvious anterior dislocation • Neurovascular exam is intact • Left ankle with swelling and deformity, tender on palpation • Can you clinically clear this patient’s c-spine?
Clinical C-spine Clearance • Based on NEXUS Criteria (NEJM, 343(2), 2000) • Study involved 34,000 patients who had imaging of the cervical spine after blunt trauma • All criteria must be met in order to clear pt. • Absence of tenderness in the posterior midline over the cervical spine • Absence of a focal neurologic deficit • Normal level of alertness • No evidence of intoxication • Absence of clinically apparent pain that might distract the patient from the pain of a cervical spine injury
Clinical Spine Clearance • If patient meets all five NEXUS criteria they can be taken out of c-collar without x-rays • Study had 99% sensitivity for clinically significant injuries • Palpate thoracic and lumbar spine in midline to determine need for imaging • Take off backboard and leave flat if imaging indicated