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

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• Golden Hour• Rapid assessment and resuscitation

– 3. days to weeks• Sepsis• Multisystem organ failure

Assessment:Primary Survey

–Evaluate for immediate life threats–Management of issues immediately–ABC’s (and D &E)

Airway

• 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

Breathing

• 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

Circulation

• 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?)

Primary Survey

• Disability– AVPU

• Awake• Verbal• Painful• Unresponsive

– Posturing?– Seizing?

Assessment Area Score

Eye Opening (E)•Spontaneous•To speech•To pain•None

•4•3•2•1

Best Motor Response (M)•Obeys Commands•Localizes Pain•Normal flexion (withdrawal)•Abnormal flexion (decorticate)•Extension (decerebrate)•None (flaccid)

•6•5•4•3•2•1

Verbal Response (V)•Oriented•Confused conversation•Inappropriate words•Incomprehensible sounds•None

•5•4•3•2•1

• Mild– GCS 14-15

• Moderate – GCS 9-13

• Severe– GCS =/<8

Primary Survey

• Expose/Environment– Undress– Protect from becoming

hypothermic• Warm room• Warm blankets• Warm fluid

Assessment:Secondary Survey

•A thorough once-over

•Fingers & Tubes

•AMPLE history

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

Secondary Survey

• Fingers and Tubes/Td– Rectal? If indicated

only – Foley? If indicated– Re-assess IV access– Td Booster

Secondary Survey

• AMPLE History– Allergies– Meds– PMHx/PSHx– Last meal– Events leading up to

accident

Secondary Survey

• Reassess vitals– Better or worse?– Further intervention needed?– Transfer patient?

Imaging

• Plain films in trauma bay– CXR– Pelvis

Imaging

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

Labs

• Type and screen or cross

• CBC• CMP• Coags• UA-visually inspect

for gross hematuria• UPT

IV Fluids

• Crystalloids– Normal Saline– Lactated Ringers

• Colloids– PRBC– FFP– Factors in hemophiliacs

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)

Hypovolemic Shock

• Blood volume– Adults: 7% of weight– Peds: 8-9% of weight

• Replacement – http://www.trauma.org/resus/massive.htm

Class Blood Loss %

Vol. Blood Loss (cc)

HR PP sBP Urine Output

AMS Rx

I < 15% <750cc <100 Norm Norm Norm No Crystalloids (3:1 rule); no PRBC

II 15-30% 750-1500

↑ ↓ ↓ ↓ No Crystalloids; +/- PRBC

III 30-40% 1500-2000

↑↑ ↓↓ ↓↓ ↓↓ Yes Crystalloids + type=spec PRBC

IV >40% >2000 ↑↑↑ ↓↓↓ ↓↓↓ ↓↓↓ Yes 2L crystalloid bolus + uncross’d PRBC

Classes of Hemorrhagic Shock

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

Summary

• Preparation

• ABCDE’s

• Secondary Survey

• Imaging

• Lab

• Hemorrhagic Shock

• The Basics