The First 15 Minutes of Trauma Care

Jake Breeding MD FACS

June 24, 2011

Nothing to disclose

ATLS Approach to Trauma

• Brief patient history• Primary Survey• Secondary Survey• Adjuncts to care

– Tubes and lines– X-rays

• Definitive Care

The Cajun Man

First 15 minutes of Trauma Care

• Anticipation• Preparation• Evaluation• Recognition• Intervention• Disposition

The Golden Hour• Trauma patient deaths recognized as

having three peaks:– Immediate (at the scene)– First 2 hours

• Where we can make a difference!– Delayed (days to weeks)

– The first 15 minutes of trauma care is important!

Anticipation

Anticipation• In a rural area, trauma is somewhat

infrequent• Fewer opportunities to develop skills and

experience• Military drills: “Always ready to go to war.”• Mental exercises• “What if?.........”• Continually reassess yourself, your team,

and your facility: what are you ready for?

Preparation• Ready your team

– Who will help me?

• Ready your supplies– What do I need?

• Ready yourself– Education– Know your resources– Know your limitations

Preparation• Ready your team

– Nurse (ICU, ER, Floor), X-ray tech (at a minimum)– OR staff, RT/Anesthesia, Lab, Scribe

• TNCC (Trauma Nurse Core Course)• RTTDC (Rural Trauma Team Development

Course)

• Everyone has a defined role• Important to discuss roles and rehearse• You are the “team leader”• Evaluation and Interventions performed

simultaneously by team members

Preparation• Ready your supplies

– Standard Precautions (Protect Yourself!)– Warm blankets– Warm IV fluids– Blood / Blood products– Oxygen– Airway management– Critical procedures supplies/equipment

Preparation• Prepare your livesaving equipment

– Airway cart / Intubation supplies– 14 gauge Angiocath– #11 blade– Chest tube insertion tray– Central line kit

Preparation• Ready yourself

– ATLS (Advanced Trauma Life Support)– RTTDC (Rural Trauma Team Development

Course)– Procedures

• Intubation• Central line placement• Chest tube placement• Cricothyrotomy

Preparation• Know your resources

– OR– ICU– Rehab– Ambulance / Helicopter– Blood bank– Subspecialty support / availability

Preparation• Know your limitations

– Blood bank– ICU / Hospital beds– Ventilators (# and availability)– Transportation resources (Air vs. Ground)– Staff experience / comfort level– Your experience / comfort level

Preparation• “I don’t remember what to do with this…”• “I haven’t seen one of these in a while….”• “I haven’t EVER seen one of these……”• “This sucks, I want to go home……”

• It is NEVER a sign of weakness to ask for help!

Recognition

Recognition• Begins when the ambulance/ER doors

open• Gather information

– Patient– Family / Witnesses– EMS – Law enforcement– Telemetry data (OnStar)

• Can gather a lot of information as the patient is brought into the room

Recognition• Mechanism

– Blunt or penetrating

• Blunt– Speed, restraint use, damage to vehicle,

windshield starring, airbag deployment

• Penetrating– Caliber, Distance, number of shots fired– Length

Evaluation (Primary Survey)• A – Airway and C-spine immobilization• B – Breathing• C – Circulation• D – Disability and Deformity• E – Environment

Evaluation (Airway)• What is a quick and easy way to assess a

trauma patient in 10 seconds?– Identify yourself– Ask the patient his/her name– Ask the patient what happened

• A: Patent airway• B: Sufficient air reserve to permit speech• C: Sufficient perfusion to permit

cerebration• D: Clear sensorium

Evaluation (Airway)• Obtain a secure airway

– Nasal airway– Oral airway– LMA– Combitube– Endotracheal tube– Cricothyrotomy

• Assess placement of endotracheal tube:– Bulb, EtCO2, Fogging of tube, CO2

detector, bilateral breath sounds, chest rise

Evaluation (Breathing)• Assess and ensure adequate oxygenation

and ventilation– Respiratory rate– Chest movement– Air Entry– Oxygen saturation

• Pneumothorax• Hemothorax• Flail chest

Evaluation (Circulation)• Assess for organ perfusion

– Level of consciousness– Skin color and temperature– Pulse rate and character

• Identify external bleeding and apply direct pressure

Evaluation (Disability and Deformity)

• Assess pupil response• Assess Glascow Coma Scale

– Best eye opening response (4)– Best verbal response (5)– Best motor response (6)

• Comatose patient will have a GCS of 3.• Patients with GCS < 8 should be

intubated.

Evaluation (Environment)• Completely expose / undress the patient

– Avoid missed injuries

• Avoid hypothermia– Warm room, blankets, fluids, Bair Hugger,

etc.

Evaluation• AMPLE history:

– Allergies– Medication– Past Medical / Surgical History– Last Meal– Events of accident

• Loss of consciousness• Where does it hurt?

Evaluation• X-Ray• FAST Exam• Foley Catheter• NG/OG tube• ABG

Evaluation (X-ray)• Chest x-ray

– Pneumothorax– Hemothorax– Assess position of endotracheal tube

• Pelvis x-ray– Pelvic fractures– Pelvic ring disruption

Evaluation (FAST Exam)• Rapid bedside ultrasound test to evaluate

for free fluid in the abdomen– Pericardial space– Morrison’s pouch (RUQ)– Splenorenal recess (LUQ)– Pouch of Douglass (pelvis)

Intervention• Lifesaving procedures that can be

performed at the bedside in the trauma bay:– Endotracheal intubation– Central venous access– Needle thoracostomy– Tube thoracostomy– Cricothyrotomy– External pelvic fixation

Intervention: Endotracheal Intubation

• Maintain C-spine precautions• Make sure equipment is functioning and

ready• Have suction available• Have a backup plan• Verify tube placement

– CO2 colorimeter/detector– Tube fogs with respiration– Bilateral chest rise– Bilateral breath sounds

Intervention: Central Venous Access

• Have central line kit available– 7 fr. 20cm central line (double or triple

lumen)– 8.5 fr. Introducer– 12 fr resuscitation line

• Internal Jugular• Subclavian• Femoral

Intervention Central Venous Access

• Try to avoid major injury between line site and heart (femoral approach)

• Use ultrasound if available• Maintain C-spine precautions• Place line on side of chest tube (if

possible)• Suture line securely in place

Intervention: Needle Thoracostomy

• Emergently treat tension pneumothorax• Clinical diagnosis

– Decreased breath sounds on one side– Hypotension (decreased preload)– Tracheal deviation (late)

• 14 gauge Angiocath needle• 2ndintercostal space, midclavicular line• Leave Angiocath in place

Intervention: Tube Thoracostomy

• Treat pneumothorax/hemothorax

• Follows placement of needle thoracostomy

• Use large caliber chest tube (36 or 40 FR)

• 5thintercostal space in mid to anterior axillary line.

• Be generous with local anesthesia

• Penetrate just superior to edge of rib

• Palpate opening with finger

• Direct chest tube posteriorly and superiorly

Intervention: Tube Thoracostomy

• Verify placement of tube– Fogging of tube– Blood return

• Suture tube securely in place• Vasoline and gauze dressing• Tape tube securely to patient• Chest X-ray to verify resolution of problem

Intervention: Cricothyrotomy

Intervention: Cricothyrotomy• Emergent surgical airway• #11 scalpel, ET tube (6 or 7)• Palpate trachea and cricothyroid

membrane with non-dominant hand. • Vertical/horizontal incision• Incise cricothyroid membrane with scalpel• Dilate opening with handle of scalpel• Insert ET tube

Intervention (Pelvic Fixation)• “Open book” pelvic fractures• Increased volume of true pelvis

– More room for bleeding

• Decrease volume of pelvis• Commercial device• Bedsheet

Disposition• “Get therightpatient to the right facility in

the right amount of time.”• Identify patient’s that need to be

transferred to higher level of care EARLY.– Time critical injuries– Improved outcomes– Frees up local resources

Disposition• Call trauma center, ask to speak with

trauma surgeon on call• Give patient details, events of accident,

work-up performed, and injuries identified• Discuss transportation• ASK QUESTIONS!

Disposition (Air)PROS

• Fast (mph)

• Can go anywhere

• Highly trained flight team (nurse, paramedic)

CONS

• Limited in poor visibility, wind, precipitation

• Limited room for patient interventions

• Risk to flight crew and patient

• Cost

Disposition (Ground)PROS• Readily available• Familiar team to provider and patient• Fast (mph)

CONS• Weather• Traffic• Loss of local resource

Improving the Process• Discuss the event with your team

– What went right– What went wrong– What can we do better next time

• Opportunity to debrief– Stressful situation– Bad outcomes– Lend support

Summary• Anticipation• Preparation• Evaluation• Recognition• Intervention• Disposition

Questions