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ED Approach to the Trauma Patient

ED Approach to the Trauma Patient. University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation. 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

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ED Approach to the Trauma Patient

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  1. ED Approach to the Trauma Patient University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation

  2. 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

  3. Assessment:Primary Survey Evaluate for immediate life threats Management of issues immediately ABC’s (and D &E)

  4. 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 Airway

  5. Assessment Yes or No? Adequate? Evaluate breath sounds Evaluate chest wall symmetry and stability Intervention O2 for all (won’t hurt) BVM Intubation Needle decompression Chest tube Breathing

  6. 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 ABC’s & F?) Circulation

  7. Primary Survey • Disability • AVPU • Awake • Verbal • Painful • Unresponsive • Posturing? • Seizing?

  8. Mild • GCS 14-15 • Moderate • GCS 9-13 • Severe • GCS =/<8

  9. Primary Survey • Expose/Environment • Undress • Protect from becoming hypothermic • Warm room • Warm blankets • Warm fluid

  10. Assessment:Secondary Survey A thorough once-over Fingers & Tubes AMPLE history

  11. 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

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

  13. Secondary Survey • AMPLE History • Allergies • Meds • PMHx/PSHx • Last meal • Events leading up to accident

  14. Secondary Survey • Reassess vitals • Better or worse? • Further intervention needed? • Transfer patient?

  15. Imaging • Plain films in trauma bay • CXR • Pelvis

  16. Imaging • CT scan? (the “Grand Slam” if all done) • Head • Neck • Face • Chest • Abdomen • Pelvis

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

  18. IV Fluids • Crystalloids • Normal Saline • Lactated Ringers • Colloids • PRBC • FFP • Factors in hemophiliacs

  19. 3:1 Rule • Rough estimate • Crystalloid volume : blood loss • 3 mL: 1mL • Caveat: • More and more, we are moving toward early transfusion • Massive transfusion = 1:1:1 PRBC:FFP:Platelets (admittedly strong data lacking)

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

  21. Classes of Hemorrhagic Shock

  22. 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

  23. Summary • Preparation • ABCDE’s • Secondary Survey • Imaging • Lab • Hemorrhagic Shock • The Basics

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