APPROACH TO TRAUMAResident Rounds July 17th, 2003Rob Hall PGY4 What is your approach?
Key Points • Systematic approach to trauma is a must • Triage tools • Prehospital trauma management • How to “manage the trauma room” • Priorities in the multitrauma patient • PEARLs of the primary survey • PEARLs of adjuncts and investigations
Case Presentation: you know you’re having a bad day when…………. • 50ish yo female • Gets up in am, lights a smoke • Gas leak overnight ->EXPLOSION • She is blown out the second story patio door and is found lying on a driveway ON THE OTHER SIDE OF THE STREET • Husband is dead inside burning building
Who needs transport to a trauma center? • Case: does this patient need a trauma center? Why? • What criteria do you use? • Triage decision scheme from ACS (see ATLS) • Revised Trauma Score (RTS) • Injury Severity Score (ISS)
How to prepare for a trauma patient? • How would you prepare for this case? • Personel • RN, RT, DI, Notify trauma surgeon if nasty • Equipment • Think of what you will need in primary survey • Anticipate what you will use • GSW to abdomen, BP 50 ->get some blood hanging in the level I infuser • Draw RSI drugs in advance • Make sure you have all of the equipment you will need if you are working in a smaller center
The Paramedic Report • What do you want to hear in the report? • Mechanism of injury • Key point of history • Pay close attension • Predicts certain injuries • Suspected injuries • Stability of vital signs • Treatments they have given • PMHx/med/all if known and relevant
Driver side impact Cspine Left h/pthrx Splenic lac Lateral compression pelvic fracture Left femur fracture Front end collision Cspine Mediastinal injury Any intraadbo injury Anterior compression pelvic fracture Posterior hip dislocations Bilateral femur/tib/fib fractures Calcaneal fractures, pilon fractures Example of importance of MOI:Side impact VERSUS Front impact
Prehospital Trauma Management • Case: what do you want the medics to do? • BLS • C spine, spine board, basic airway maneuvers, oxygen and BVM, control of external hemorrhage, scoop and run • ALS • Some controversy re advanced airway mx • Iv fluids: no evidence for prehospital fluids • BLS care and RAPID TRANSPORT are the most important
Case: the trauma arrives… MOI: 70% burn + trauma Unable to intubate X 2; BVM Agonal resps, BP 60 palp, HR 140 No sat obtainable, No iv access ? Head injury: GCS 3, external signs of head trauma What is your approach?
PRIMARY SURVEY Airway Breathing Circulation Disability Exposure Full Vitals ADJUNCTS CXR, PXR, Cspine NG, foley, ECG Monitors, trauma panel DPL, FAST if needed SECONDARY AMPLE hx Full head-to-toe ADJUNCTS CT, FAST, DPL Extremity Xrays Angiography Endoscopy Contrast studies ATLS approach: good but not perfect
PEARLS of the ABCs • Consider yourself stuck until you have dealt with an issue • Frequent reassessment • Start from A whenever there is a problem • Secondary survey is truly secondary
PEARLS of ABCs • 25 yo male • Motorbike into pole at 80 km/hr • Helmet damaged • Intubated by EMS • HR 75 BP 60 palp Sats 97% GCS 6 • What is the differential dx of shock in a trauma patient?
Ddx of shock in the trauma patient Hypovolemic/Hemorrhagic shock • Chest (note: not likely aortic injury) • Belly • Pelvis • Femurs • External hemorrhage (esp scalp) • Neurogenic • Brainstem herniation (preterminal) • Other: example -> MI then crashed car
How much initial fluid? Which fluid? When to give blood? When to give blood products? What tests will help you? 2-3L (20-60ml/kg) Crystalloid After 2-3L or 20-60ml/kg crystalloid > 4 units prbc.s: order 4 units FFP and 10 units platelets EARLY CXR/PXR and FAST will help you identify the etiology of shock PEARLS of managing shock
PEARLS of the ABCs • 50 yo male • Small plane crash • Transported by STARS • Intubated by STARS • HR 120 BP 100 Sats 75% on 100% oxygen • What is the differential dx of hypoxemia in a trauma patient?
Differential Dx of Hypoxemia in trauma • Airway obstruction • Pneumothorax • Hemothorax • Pulmonary contusion • Trachobronchial transection • Aspiration • Atelectasis • ARDS • Pulmonary hemorrhage • Fat Embolism • Intubated patient: GDOPE
PEARLS of diagnositic imaging • Oral Contrast and CT abdomen • Theoretic increase in pick up of small bowel perforation and pancreatic injuries • Increases risk of vomiting and aspiration • Evidence doesn’t support that it increases sensitivity of CT for bowel injuries • ?Why: doesn’t get past stomach • Oral contrast OK but do NOT delay the CT in a patient that needs it sooner than later
Head injured, drunk, combative: what sedative would you use? • Midazolam: risk of hypotension and respiratory depression • Haldol: theoretical risk of lowering seizure threshold, longer duration • Haldol probably preferred
What comes first: head or belly? • CASE: Hypotensive trauma patient that needs laparotomy and has blown left pupil and signs of head trauma • What comes first? • To OR for laparotomy: pack off bleeding • Burr hole in OR (“blind”) or go back to CT for CT head • In general, belly comes first
The TRAUMA ARREST • What type of rhythm is usually present? • What is your approach to the PENETRATING trauma arrest? • Thoracotomy if ever had vitals • What is your approach to the BLUNT trauma arrest?
The TRAUMA ARREST • Intubate: crash intubation, no drugs • Ventilate: hyperventilate • Volume: blood through bertha • Needle the chest • CPR/Epi/atropine • Run for 5 – 10 minutes • NO thoracotomy
How to MANAGE the trauma room • Should be ONE leader: only leader should be talking and giving orders • Too many “cooks in the kitchen” is bad • RTs and RNs need to stick to their roles • Be decisive • Err on the side of being aggressive • Move rapidly if the patient is sick • CXR and pelvic Xray BEFORE trauma labs, ABG, foley, NG, Cspine Xray
The Trauma question on the exam • Same approach • Be methodological • Stick Man
Key Points • Have a systematic approach to trauma • Have a systematic approach to the hypotensive and hypoxemic trauma patient • Be ready for the trauma arrest • Manage the trauma room