Transcript Approach to Trauma - Indiana University

Approach to Trauma
Dan O’Donnell
Indiana University Emergency
Medicine
11/14/06
Goals
• Review the basic approach to a
trauma patient as a first
responder.
• Review current Marion County
protocols regarding trauma
management
Case 1
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Dispatched to the scene
48 year old male MVA versus tree
Driver
Head on vs pole
Unrestrained
No airbag
Basics
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Scene Safety
Mechanism of Injury
C-spine precautions
ABCDE’s, Oxygen, IV access
Hemorrhage control
Rapid transport
Scene Safety
• Hazards to rescuer’s/patient’s safety
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On - coming traffic
Wet or icy ground
Leaking fuel
Downed power lines
Hostile bystanders (crimes)
Fire
Hazardous Materials
Weather
Cervical Spine Precautions
• Assume c-spine injury
• Mechanism
• Head or neck trauma
• Severe blunt trauma to the torso
• Immobilization
• Manual stabilization
• C-collar
• Long backboard
Airway
• Assess level of consciousness
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A - alert, oriented x 3
V- responds to verbal stimuli
P - responds to painful stimuli (sternal rub)
U – unresponsive
• Glasgow Coma Scale
• 4 - eye opening
• 6 – motor
• 5 - verbal
Airway
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Protect C-spine
Jaw thrust
OP or NP airway
Provide high flow oxygen
Suction
Assist ventilation with bag-valve
mask
Airway Intervention
• Nasotracheal Intubation
• Contraindicated in patients facial injuries
• Attempt twice if pt is breathing.
• Endotracheal Intubation
• In patients who are unconscious and
without gag
• Verify placement and secure
• Combitube
• If endotracheal intubation fails
• Circothyrotomy
• >8 y/o- surgical; <8 y/o needle
Breathing
• Look, listen, feel
• Is there spontaneous effort?
• Check for presence and equality of
breath sounds
• Oxygen always a good idea
• Check the neck
– Neck vein distention
– Tracheal deviation
• Tension pneumothorax
– Needle chest decompression
Circulation
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Assess carotid and peripheral pulses
Check capillary refill
CPR if needed
Control massive/life threatening
bleeding with direct pressure
• Baseline vital signs and repeat every 5
min.
• 2 large bore IVs and isotonic fluids
• Don’t delay transport to start IVs
On Scene
• Goal is less than 10 minutes
• C-collar and Backboard
• GOLDEN HOUR
– Get to definitive care is less than 1
hour
Secondary Survey
• En route to the receiving facility
• Purpose: identify potential life
threats
• Head to toe exam
Secondary Survey
• Reassess AVPU, GCS, Vitals
• Pulse, monitor
– regularity, strength
• Blood pressure
– auscultation, palpation, appropriate size
cuff
• Respirations, Biox
– visualization, auscultation, length of time
• Temp
– maintain body temp during transport
Inspect and Palpate for
Injuries
• Deformities
• Burns
• Contusions
• Tenderness
• Abrasions
• Lacerations
• Punctures
• Swelling
Enroute
• Complete secondary survey
• Head, neck, chest, abdomen, back,
extremities
• SAMPLE history if possible
• Maintain body temperature
• Contact the receiving facility early
for notification of patients meeting
Trauma Alert criteria
Trauma Alert Criteria
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SBP 90 mmHg or less
GCS 12 or less
RR <10 or >29
Penetrating trauma
to head, neck, chest,
back, abdomen
• Burns > 15% of BSA
• Neuro
deficit/paralysis
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Ejection
Roll-over
Extrication
Fall from > 20 ft
Pedestrian vs
vehicle traveling
> 20 mph
• EMT/paramedic
judgement
Case 2
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Dispatched to scene
26 y/o male
MCC t-bone vs truck
Helmeted
Awake and alert
Noticeable deformity
Musculoskeletal Trauma
• Assess distal circulation, movement,
and sensation initially
• Cover open wounds
• Splint the extremity and reassess
neurovascular status
• Apply cold packs
• Only straighten an injured extremity if
pulses are absent, but don’t force it!
• Never straighten an injured joint
• Pain control
Fentanyl
• Indications
• Significant orthopedic injuries with pain > 3/10
• Burns > 10% of BSA
• Contraindications
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Allergy to fentanyl
Burns with evidence of inhalation injury
Closed head injury
Evidence of intra-abdominal or pelvic injury
Altered LOC; GCS <15
Hypotension (SBP < 110 mmHg)
Administration of Fentanyl
• Must have IV access
• Adults (>50 kg)
• 50 mcg IVP every 5 minutes up to max of
150 mcg prn pain >3/10
• Children (or pts <50 kg)
• 1 mcg/kg slow IVP q 5 min up to
3mcg/kg prn
• Have Narcan immediately nearby
Case 3
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Dispatched to scene
42 y/o male construction worker
Fell off ladder onto his tool box
Respiratory distress
Chest pain
Chest Trauma
• C-spine precautions
• ABCDE’s
• Assess chest wall for flail segment or rib
fractures
• Needle decompression for suspected
PTX
• Occlusive dressing for open chest
wounds
• Stabilize impaled objects
• Assess breath sounds and vitals every 5
min
• Transport by ALS crew if pt is unstable
A Word about Needle
Decompression
• Indication=tension pneumothorax
• Tension PTX=absent breath
sounds + hypotension
• Tention PTX does not equal absent
breath sounds
• You could create a ptx that is not
there
Case 4
• Dispatched to scene
• 57 y/o male
• Pedestrian stuck by car traveling
30 mph
• Awake but confused
• Complaining of belly pain
Abdominal Trauma
• C-spine precautions
• If patient is eviscerated, cover the
exposed organs with sterile gauze
soked in normal saline
• Do not attempt to replace the
exposed organs
• Transport by ALS
Case 5
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Dispatched to scene
36 y/o male
Hit in head with sledgehammer
Awake, alert, breathing
spontaneously
• Complains of loss of vision
Eye Trauma
• Assess for:
• Globe rupture (do not touch the globe)
• Hemorrhage, lacerations, contusions
• Conjugate gaze
• Fluid leakage from globe
• Visual acuity (finger count, shapes,
light/shadow)
• Foreign body
Eye Trauma
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Cover an avulsed eye with a paper cup
Stabilize impaled foreign bodies
Cover both eyes when bandaging
Irrigate eyes for 20 minutes if patient is
exposed to chemical irritants
• Do not delay transport to irrigate eyes
Case 6
• Dispatched to scene
• 22 y/o female
• Driver of stopped car rear-ended at
15 mph
• No complaints
• 32 weeks pregnant
• Desires transport to hospital
Trauma in Pregnancy
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C-spine precautions
ABCDE’s
Vital signs
For patients in the third trimester,
transport in the left lateral recumbent
position
• Secure pt to the backboard
• If pt is hypotensive, roll on left side and
recheck vitals
C-spine Clearance
• Requirements for c-spine clearance
• Pt must be awake, alert, and oriented
• Not under the influence of drugs or alcohol
• Pt and medic can converse well enough to
perform the evaluation
• Pt must have no neck pain
• No tenderness on palpation of posterior midline of
the neck
• No peripheral neurological deficits at any time
following the accident
• No distracting injuries
C-spine Clearance
• Place the patient in full C-spine
immobilization if you have any question
or concern about possible spinal injury
regardless of the patient’s condition or
wishes
• Never remove a C-collar which has
already been placed on a patient.
Immobilize the entire spine and
transport for evaluation
Take Home Points
• Secure the scene and protect
yourself
• ABCDEs
• Oxygen
• 2 large bore IVs
• Always assume C-spine injury
• 10 minutes on scene for major
trauma