TRAUMA OVERVIEW Mark E. Armstrong, M.D.

Overview

1. Preparation 2. Triage 3. Primary Survey 4. Resuscitation 5. Secondary Survey 6. Continued postresuscitation monitoring and re-evaluation 7. Definitive care

Preparation

 Prehospital    Notify receiving hospital Closest appropriate facility Report pertinent information  Inhospital    Warmed IV solutions Ancillary departments notified Equipment made readily available  Hospital personnel protection

Primary Survey

 A irway  B reathing  C irculation  D isability: Neurologic Evaluation  E xposure/Environmental Control

Primary Survey Airway

 Patency  Foreign bodies  Facial Fractures  Protect C-spine

Primary Survey Breathing

 Patency does not equal adequate ventilation  Expose chest  Auscultate  Conditions that may acutely impair ventilation  Tension pneumothorax  Massive hemothorax  Flail chest  Rib fractures  Open pneumo  Pulmonary contusion

Primary Survey Circulation

 Hemorrhage control  Two Key Elements 1. Level of Consciousness -AVPU -Glasgow Coma Score 2. Pulse

Bleeding

 Control  No hemostats  Consider occult sources

Primary Survey Disability

 AVPU

Glasgow Coma

Verbal Response Motor response Oriented 5 Obeys 6 Confused 4 Localizes 5 Inappropriate words 3 Withdraws 4 Incomprehensible sounds 2 Decortication 3 None 1 Decerebration 2 None 1 Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1

Primary Survey Exposure

 Remove all clothes  Cover to prevent hypothermia

Resuscitation

 Airway   Nasal- do not put in someone with facial trauma  Oral Endotracheal  Surgical  Breathing   Supply O2 Ventilate alveoli

Resuscitation

 Circulation        Establish 2 large bore IVs Draw blood Vigorous IV therapy ECG monitoring Avoid hypothermia Evaluate PEA Other dysrhythmias

I Class II III IV Hemorrhage classification % blood loss 10 – 19 (750 cc) 20 – 29 (1250) Heart rate >100 Blood pressure Slightly Pulse pressure Resp rate Capillary refill Normal Urine output Delayed 30 – 39 (2000) >40 >120 >140 (>30) Very Delayed Oliguria Anuria Other Mortality Acidosis 25% 60%

Resuscitation

 Catheters   Urinary Rectal first  Check for other signs of urethral injury   Gastric Oral v.s. nasal placement

NGT Intracranial

Resuscitation

 Monitoring     ABG ’ s Pulse oximetery Blood pressure ECG

Roentgenograms

 Should not delay resuscitation  AP pelvis  AP chest  Lateral C-spine  Odontoid, AP C-spine

Other Imaging

 FAST scan Focused Assessment Sonography in Trauma  Ultrasound 1.

Pericardial sac (epigastric area) 2.

3.

4.

Hepatorenal fossa Splenorenal fossa Pelvis or Pouch of Douglas (bladder)

Secondary Survey

 Head-to toe evaluation   Detailed neuro exam if not done in primary survey  Vital sign evaluation Special procedures  “ Tubes and fingers in every orifice ”

Secondary Survey History

 A  M Allergies Medications  P  L Past illnesses Last meal  E Events related to injury 1.Blunt

2.Penetrating

3.Burns

4.Hazardous Environment

Secondary Survey History

 A  M  P  L  E Allergies Medications Past illnesses Last meal Events related to injury 1.Blunt

2.Penetrating

3.Burns

4.Hazardous Environment

Secondary Survey (PE) Head

 Scalp  Eyes  Nose  Mouth  Bite occlusion

Secondary Survey (PE) Head

PITFALLS  Hyphema  Optic nerve injury  Lens dislocation  Head injury  Posterior scalp laceration

Secondary Survey (PE) Maxillofacial

 Midline facial fractures  Bite occlusion  Bleeding  Fracture repair can wait

Midface Fractures LaFort

 I: Maxilla only transversely above the alveolar ridge Most common isolated  II (pyramidal): Through nasal bone or nasal bone disarticulation with frontal bone Most common when associated with other fractures  III (dislocated face): Through nasal bone, across floor of orbit, through lateral wall of orbit, zygomatic arch Rare

Secondary Survey (PE) Maxillofacial

PITFALLS  Pending airway obstruction  Changes in airway status  Cervical spine injury  Exsanguinating midface fracture  Lacrimal duct lacerations  Facial nerve injuries

Secondary Survey (PE) C-spine and neck

 Must be immobilized  Inspection  Palpation  Auscultation (carotids)

Secondary Survey (PE) C-spine and neck

PITFALLS  C-spine injury  Esophageal injury  Tracheal or laryngeal injury  Carotid injury (blunt or penetrating)

Secondary Survey (PE) Chest

 Visual evaluation (ant & post)  Palpate rib cage  Sternal pressure  Auscultation (heart & lungs)  Chest xray

Secondary Survey (PE) Chest

PITFALLS  Tension pneumothorax  Open chest wound  Flail chest  Cardiac tamponade  Aortic rupture (widened mediastinum)

Pneumothorax

Tension Pneumothorax

Secondary Survey (PE) Abdomen

 Frequently repeated exams  Inspection  Palpation  Normal initial exam does not rule out injury  Peritoneal lavage v.s. CT scan v.s. U/S (FAST)

Secondary Survey (PE) Abdomen

PITFALLS  Liver or splenic flexure  Deceleration injuries Hollow viscus, Lumbar spine  Pancreatic injury  Major intraabdominal vascular injury  Renal injury  Pelvic fractures

Secondary Survey (PE) Perineum/Rectum/Vagina

 Contusions,Hematomas, Lacerations  Urethral bleeding  Rectal blood  High riding prostate  Sphincter tone  Vaginal vault injuries (pelvic fractures)

Secondary Survey (PE) Perineum/Rectum/Vagina

PITFALLS  Urethral injury  Rectal injury  Bladder injury  Vaginal injury

Retrograde urethrogram

Secondary Survey (PE) Musculoskeletal

 Contusion  Deformity  Palpation  Pelvic pressure and compression  Vascular exam  Neurologic exam

Secondary Survey (PE) Musculoskeletal

PITFALLS  SPINE FRACTURES  Fractures with vascular compromise  Pelvic fractures  Digital fractures

Secondary Survey (PE) Neurologic

 Immobilization of entire patient  Reevaluate GCS  Cranial nerve exam  Motor exam  Sensory exam  Monitor frequently for changes in neuro status  Assess O2 delivery if changes noted  Early neurosurgical consultation

Secondary Survey (PE) Neurologic

PITFALLS  Increased intracranial pressure  Subdural hematoma  Epidural hematoma  Depressed skull fracture  Spine injury  Beware of unconscious patient

Subdural Hematoma

Epidural Hematoma

Aftercare

 Continuous reevaluation  Definitive care