APPROACH TO TRAUMA Resident Rounds July 17 th, 2003 Rob Hall PGY4 What is your approach? Ouch . 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 Example of importance of MOI: Side impact VERSUS Front impact 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 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? ATLS approach: good but not perfect 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 Case: how do you actually do the primary survey? The Airway LOOKLISTENFEELMANAGE AIRWAYAIRWAY LOC Facial trauma UAW burn Cyanosis Retractions Stridor Gurgling Hoarseness Crepitus Tendernes Edema Trach midline Cervical Collar Suction Jaw Thrust OP/NP airways Remove FB Identify need for ETT: draw meds, start iv, get BP Breathing LOOKLIST EN FEELMANAGE BREATHINGBREATHING Resp effort Resp rate Cyanosis Chest wall movements Flail segment AE =Crepitus Tendernes Chest mvmt 100% oxygen BVM Pulsox Decompress chest Seal open chest wounds Circulation LOOKLISTE N FEELMANAGE CIRCULATIONCIRCULATION Pale Sweaty LOC External Bleeding JVD Heart Sounds Murmur Pulse rate, Quality Quick feel of abdomen, pelvis, femurs Obtain HR, BP Cardiac and BP monitors Two large iv.s Pressure to external bleeding Bolus crystalloid Blood FIND SOURCE OF BLEEDING: exam, CXR, PXR, FAST, DPL Disability, Exposure, Full Vitals ASSESSMENTMANAGMENT Disability GCS Pupils Hyperventilate Mannitol Elevate HOB Exposure Clothes off Log roll As per findings Full Vitals Don t forget temp and chemstrip As per findings 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 PEARLS of managing shock 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 ml/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 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