1. The Multiple Trauma Patient
Shawn Dowling, PGY-2
Preceptor: Rhonda Ness

2. Objectives Will not go over these topics in great detail Head trauma
C-spine trauma
Chest trauma
Abdo trauma
Pediatric trauma

3. Why it’s important
Leading Cause of Death for those aged 1-44yrs (in developed countries)
MVC’s account for most injuries
Followed by assaults, drownings, falls, burns

4. Distribution of Death

5. What is ATLS?
Structured algorithm designed to prioritize management issues
Designed as a team-based approach
Applicable to both Academic and Rural Settings
It’s useful – take it.

6. What ATLS isn’t?
A substitute for clinical acumen – trust your instinct
Most up-to-date, most evidence based approach (revised q4yrs, most recently 2004)

7. Why is the ATLS protocol so nice?
Overall, the tenets are
Greatest threats to life are identified and treated 1st
Lack of definitive Tx should never impede the application of an indicated Tx
Detailed Hx was not essential to begin the evaluation of the acutely injured patient

8. ATLS overview Preparation Triage Primary Survey (ABCDE’s)
Resuscitation
Adjuncts to primary survey and Resus
Secondary Survey
Adjuncts to Secondary survey
Continued post-resus monitoring and R/A
Definitive Care

9. ATLS Overview Primary Survey Adjuncts Secondary Survey CANNOT MOVE ON
UNTIL YOU ADDRESS
THE PROBLEM!!!
Primary Survey
Reassess
Adjuncts
Reassess
Secondary Survey

10. ATLS – Primary Survey Airway & C-spine Immobilization Breathing
Circulation
Disability
Exposure/Environmental Control
Full Vital Signs

11. Case 1 60ishM Coming in by STARS, ETA 10 mins MVC – no more details
Facial fractures, unable to intubate
Significant Chest trauma, hypotense
Great...I’ll just go see this LBP patient and wait till I hear the call to the Trauma Bay

12. ATLS overview Preparation Triage Primary Survey (ABCDE’s)
Resuscitation
Adjuncts to primary survey and Resus
Secondary Survey
Adjuncts to Secondary survey
Continued post-resus monitoring and R/A
Definitive Care

13. Organizing the Trauma Bay
What do you want?
Who do you want?

14. What do you want prepare before he arrives?
1° SURVEY
Airway: Intubation equipment incl difficult airway cart, drugs, +/- anasthesia
Breathing: RT, bilateral CT set-up
Circulation: fluids hung, blood ready, level 1 infuser primed, +/- central access
Adjuncts
X-ray, FAST, B.W., U/S

15. What’s the best way to mobilize the right people…
Soil your scrubs and hope someone notices and calls for help
Call Trauma Code
Consult Hospitalist

16. Who do you want? RT, RN’s – 3 ideal, DI techs, U.C. ER res/doc
+/- Level 1 Call-out (trauma, gen surg, ICU)
FAST provider – ER IP or Radiology
Others: Ortho, NA, SW,
Trauma Team Activation
6. ER doc discretion

18. ER #1
FAST
ICU Rez
Muco Man
ER #2/TTL

19. Organizing the Trauma Bay
ONE leader:
only leader should be talking and giving orders
FMC ER doc 1o survey and stabilization THEN trauma junior/ortho/plastics 2o survey
Small rural centers you’re it
Be decisive
Short window of opportunity for sick patients
Rapid decision making important
Err on the side of being aggressive
Thanks Trevor

20. Learn names and use them Be directive Minimize noise/people in room
Close the Loop
Verbalize your findings and thought process.
i.e. I think he has a tension PTX – I’m gonna fix it

21. Now what?
What do you want to know from EMS?

22. Important Historical Features
MVC
Wgt/size vehicle
Speed
Location of pt in veh
?ejected
Mech’m of accident
Amt of damage (esp windshield, steering wheel)
?seatbelt (type)
Airbag
?Other deaths

23. Motorcycle Pedestrian vs MVC Assault GSW’s Same + ?helmet Type of gun
Speed
Damage to windshield
Assault
Weapon used
?trajectory
?sexual assault
GSW’s
Type of gun
Handgun: low velocity
Rifles: high velocity
Type of Ammunition
Distance shot from
Route of Entry

24. Injury Patterns Frontal/Side Impact Side Impact Rear Impact
MVC versus pedestrian
Adult
Peds

25. Frontal/Side Impact
C-spine Injury
Chest: PTX, flail, AoD
Abdo: liver/spleen
PelvisHip/knee #/disloc
Rear Impact
Soft-Tissue Injury Neck

26. Ejection
No specific pattern, but significant risk of severe injury to all systems
MVC versus Pedestrian
Adults triad of
Tib/fib/femur
Truncal injury
Craniofacial injury
Peds: tend to be run over

27. ATLS overview Preparation Triage Primary Survey (ABCDE’s)
Resuscitation
Adjuncts to primary survey and Resus
Secondary Survey
Adjuncts to Secondary survey
Continued post-resus monitoring and R/A
Definitive Care

28. Airway LOOK LISTEN FEEL MANAGE A I R W Y Thanks Trevor/Rob LOC
Facial trauma
UAW burn
Stridor
Gurgling
Hoarseness
Crepitus
Tenderness
Edema
Trachea midline
Cervical Collar
Temporize:
Suction
Jaw Thrust
OP/NP airways
Remove FB
Prepare and perform ETT: draw meds, start iv, get BP/ tools
Thanks Trevor/Rob

29. Breathing LOOK LISTEN FEEL MANAGE B R E A T H I N G Thanks Trevor/Rob
Resp effort
Resp rate
Cyanosis
Chest wall
movements
Flail segment
AE =
Crepitus
Tenderness
Chest mvmt
100% oxygen
BVM
Pulse ox
Decompress chest
Seal open chest wounds
Thanks Trevor/Rob

30. Circulation LOOK LISTEN FEEL MANAGE Thanks Trevor/Rob C I R U L A T O
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
Consider SOURCE OF BLEEDING
Thanks Trevor/Rob

31. Exposure/Environment/Full VS
Disability
GCS
Pupils
Exposure/Environment/Full VS
Fully Expose patient
Prevent heat loss, warm blankets, warm fluids*

32. *NABISH II (Pre-hospital Enrolment)

33. *NABISH II (ED Enrollment)
3. w/i 2 hrs of injury
Goal is moderate hypothermia (32-33°) for 48 hr

34. ATLS overview Preparation Triage Primary Survey (ABCDE’s)
Resuscitation
Adjuncts to primary survey and Resus
Secondary Survey
Adjuncts to Secondary survey
Continued post-resus monitoring and R/A
Definitive Care

35. Adjuncts X-rays: which ones do you want
Blood Work: which ones do we get routinely
Foley, NG: do we need the NG?
FAST/dpl: Who can do it? More to come in the future.

36. X-rays CXR C-spine(we’ll come back to this) Pelvis
Do we need to this in every trauma patient?
Order others you deem necessary (but if unstable prioritize them until after secondary survey)

37. Routine pelvic radiography in severe blunt trauma: is it necessary?
ALL STUDIES ARE LEVEL II or III, so interpret w/caution…
Civil ID, Ross SE, Botehlo G and Schwab CW. Ann Emerg Med 17(5): (1988)
All patients were classified as unconscious; impaired; awake, alert, and symptomatic; or alert, oriented, and asymptomatic for pelvic fracture on admission. All underwent a plain anterior- posterior radiograph of the pelvis.
N=265, 26 pelvic #. 7/26 were unconscious,11/26 were impaired, 8/36 Sx.
No fractures were identified in 110 awake, alert, oriented, and asymptomatic patients (P less than .0001).
They conclude that pelvic radiographs are required in unconscious or impaired victims of severe blunt trauma and those with signs or symptoms of pelvic fractures but are not required in the awake, alert, and asymptomatic patient.
CONCLUSION: Err on the Side of Caution

38. Preserve clot - minimal movement, gentle handling, minimum of rolling
Preserve clot - minimal movement, gentle handling, minimum of rolling. Punch anyone who tries to 'spring' the pelvis. Fit pelvic belt (elasticated version of the old 'many-tailed-bandage' with velcro fastening) on basis of mechanism of injury. Minimal iv fluid to preserve systolic of 70 (90 mmHg if associated head injury). Take to a hospital that understands the condition!
Timothy J Coats MD FRCS FFAEM Senior Lecturer in Accident and Emergency/Pre-Hospital Care Royal London Hospital, UK.

39. Trauma/B.W. What blood work do we get when this is ordered?
If you had only one blood test what would it be Sultana or Heather?

40. Trauma/B.W. What blood work do we get when this is ordered?
If you had only one blood test what would it be Sultana or Heather?
T&S, T&C
What’s the diff?
Unmatched – immediate (F: 0-, M: 0-/+)
T&S – approx 10 min (screens for ABO &Rh)
T&C- approx 30min-1 hr (screens for ABO, Rh, other antibodies)

41. Utility of CBC

42. Utility of CBC Coags Hgb – helpful if low, not helpful if N
Initial hgb fxns more as baseline
WBC- who cares
Plts-helpful if low
Coags
Probably useful, some good evidence for HI, ?elderly

43. Lytes
913 Trauma pts bw – 54 had clinically significant abN, only 6 changed Tx (all hypokalemia)
authors concluded that a history of hypertension, age older than 50, and a Glasgow Coma Scale (GCS) score less than or equal to 10 appeared to be useful criteria
Tortella B, Lavery R, Rekant M. Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med 1995;2:
Cr/BUN
No evidence but likely worthwhile, esp if potential for CT and contrast
EtOH
Allows you to correlate clinical picture with EtOH

44. Amylase LFT’s Lactate/Base Deficit Trop No role
Mure A, Josloff R, Rothberg J, et al. Serum amylase determination and blunt abdominal trauma. Am Surg 1991;57:
LFT’s
No Role in detecting liver injuries
Lactate/Base Deficit
Multiple studies showing that the higher/more –ve these values are the sicker the patients are and more aggr mngmt is needed – DUHH!
Trop
No helpful, unless you think it’s the cause of accident
For cardiac contusion – may be a role, but not likely in the ED

45. ?Trops

46. Case 2 64M, Farmer Brought in by STARS
Bucked off horse, c/o of mild lower abdo/pelvis pain, walked to his house to get help
What do you want to do?
What do you think is going on?

47. Airway/Breathing N
Circulation: BP140/50, HR 80
Disability: GCS- 14, PERLA
Exposure - N
Rest of vitals N
Now what?

48. What films? CXR – Yes Pelvis – Yes (symptomatic)
Can you clear his C-spines clinically?
According to CCR?
According to NEXUS?

49. Canadian C-spine Rule
Stiell. NEJM Dec 2003; 349:

50. S P I N E NEXUS ensorium altered ain the the midline
njury that is distracting N
eurologic deficits E
tOH, Rx
Hoffman et al. NEJM 2000

52. Missed C-spine #’s

53. ATLS overview Preparation Triage Primary Survey (ABCDE’s)
Resuscitation
Adjuncts to primary survey and Resus
Secondary Survey
Adjuncts to Secondary survey
Continued post-resus monitoring and R/A
Definitive Care

54. Secondary Survey Look, listen and feel when possible
Finger (only one)/tubes in every orifice
AMPLE Hx:
Systematic: head to toe
HEENT
Abdomen + GU
Maxillofacial
Pelvis
Neuro (incl CNS/PNS, CN, M/S/R)
Vertebral Column (C/T/L)
Chest
Back
CVS
Extremeties

55. Back to the Case
The trauma jr asks the nurse to put a foley in and she notes
Scrotal hematoma
Blood at meatus
Perineal Ecchymosis
Rectal N (and I’ve got short fingers)
What do you want to do?

56. Retrograde Urethrogram
What is it?
Retrograde injection of contrast urethral integrity and x-ray
How do you do it?
Plain KUB 1st
Sterile, insert foley 1-2cm, inflate baloon w/2-4cc H20 OR
Insert 60cc syringe with x-mas tree adaptor
Slowly inject 60cc of radio-opaque dye (avoid forceful inj)
Ensure not to spill any (spurious results)
Two x-rays, one AP, one lateral/oblique when 10cc left to inject

60. Partial tear Complete tear
+/- talk to urology, attempt to pass 12-14F foley
If resistance/difficulties, speak to urology – may need suprapubic catheter
Complete tear
Talk to urology (actually, page them, wait 6 hours and then talk to them) and they’ll likely need a suprapubic catheter

61. Retrograde Cystogram KUB Foley
Gravity fill bladder with 400cc of contrast (age + 2) x 30 for peds
AP and Oblique/Lateral x-rays
Then AP post-evacuation X-ray

63. Case #
18M, Story from EMS
Brought in from Coventry Hills by STARS who “Scooped and Ran” with him
Hx: MVC (car vs cement abutment), prolonged extrication (>1hr), hwy speeds, couldn’t intubate
P/E: hypotense, pale, concerned about chest/abdo, bilateral femur #, L humerus

64. What do you want to do? Airway: Breathing: Do you want to do anything?
How, ?Rx
Breathing:
Post-intubation -  L
DDx:
Intervention
What if the CXR is N, can they still have a PTX

65. 103 PTX, 57 (55%) were not seen on AP CXR
Likely of little significance in the non-ventilated pt
But for those who are intubated or going to OR- thought that they may progress
One small study, RCT of CT or nothing for oPTX (ventilated and non-ventilated) – NO difference
J Trauma Jun;46(6):987-90

66. Primary Survey
What are six(seven) life-threatening injuries you need to identify and Tx in the primary survey?

67. Primary Survey
What are six(seven) life-threatening injuries you need to identify and Tx in the primary survey?
Airway: Obstruction
Breathing:
Tension PTX
Open PTx
Massive Hemothorax
+/-Flail
Circulation
Cardiac Tamponade (?Beck’s)
Life-Threatening Bleeds

68. Where’s he bleeding from?
Circulation
BP - unable to measure
But palpable radials – what’s his BP?, Only Femorals, Only Carotid?
Where’s he bleeding from?
What are the three big areas you can bleed into?
How about kids?

69. Fluid Resus Crystalloids 2 L then blood Level 1 infuser
Goal is sBP 90ish
What do you want to do know? RA

70. Summarizing What next? Intubated, needle thoracostomy, no CT yet
L humerus, bilateral femurs, VS pelvic #
FAST –ve
Gross blood from Foley
BP still very tenuous
What next?
Let the TTL decide - OR

71. What about the kidneys?
When do you worry enough about renal injuries to image the kidneys?

72. Nicholaisen G, McAninch J, Marshall G, et al
Nicholaisen G, McAninch J, Marshall G, et al. Renal trauma: Re-evaluation of the indications for radiographic assessment. J Urol 1985;133:

73. What Grade of Renal Injury?
CT Renal
What Grade of Renal Injury?

74. Renal Injury Classification
Grade 1: subcapsular hematoma – non-operative
Grade 2: superficial renal laceration with perirenal hemorrhage – non-operative
Grade 3: deep laceration w/o extension into the collecting system of the kidney – serial exams, usu non-op
Grade 4: parenchymal injury: deep laceration that extends into collecting system, – serial exams, usu non-op, +/- embolization/OR
Grade 5: parenchymal injury: multiple deep lacerations that result in a shattered kidney OR Renal Artery Avulsion - OR
Harris A., Zwirewich C CT Findings in Blunt Renal Trauma, Radiographics, 2001

75. CT Chest

76. Case #3 27M Transferred from 8th and 8th –
Single stab wound to the right chest.
Chest had been needle decompressed
Intubated in ED for hypotension
Chest Tube on R side.

77. Move onto your secondary survey? CT scanner?
After chest tube (which is not draining any blood) and intubation, his vitals are…
BP80/40, HR 120, Sats 100% on vent
What do you want to do?
Move onto your secondary survey?
CT scanner?

78. CANNOT MOVE ONTO THE NEXT STEP UNTIL YOU’VE DEALT WITH ALL THE ISSUES.
WHAT ABOUT LOG ROLLING?

81. Case # 4
23F, 28wks pregnant
Brought into trauma bay pt begins to c/o of severe cramping
VS – 70/30,HR-100, RR-12, sats 94%, c/s-N
What do you want to do?

82. Supine Hypotension Syndrome
IVC compression
May have vasovagal bradycardia
90% of term pregnant women have COMPLETE obstruction of IVC when supine
Mx: tilt spine board, towel roll under on hip, manually displace uterus
Thanks Rob

83. PEARL
Pregnant patient may lose up to 40% of blood volume before manifesting typical signs of shock. The fetus is compromised before signs of shock.

84. So you put her into the LLD position and she goes into asystolic arrest.
What do you do?

85. Perimortem C-section Indications
Gestation must be at least wks
- progress if fundal hgt 25wks
?Less if doing for mom
CPR w/no response to other Tx modalities (LLD, fluids, needle chest, ACLS Tx, ) w/i four minutes
Ideal, start by four minutes/finish 5 minutes
Mother hemodynamics improve considerably

86. Procedure Do not stop CPR Don’t prep/drape
Vertical incision from epigastrium to pubis right through peritoneum
Scapel to upper uterus, extend with scissors
Deliver baby
NRP for baby

87. Perimortem C-Section Results
Katz VL. Obstet Gynecol
61 cases b/w that survived
TIME NUMBER NORMAL NEUROSQL
<
>

88. Case #5 69F MVC, restrained driver, hwy speeds PMHx – o
Stable, A & O x 3, ++ agitated

90. When to order CT abdo? Stable: CT abdomen +/- FAST
Abnormal vitals
Abdominal pain/tender
Unreliable physical examination (EtOH, Rx, HI, SCI, sedated).
Inability to do serial examinations
Dangerous mechanism of injury
Gross Hematuria
Stable: CT abdomen +/- FAST
Unstable: FAST or DPL

91. What Injuries does CT abdo miss?
Diaphragmatic
Pancreatic
Bowel
Should we add Telebrex then?

92. Oral Contrast in Trauma CT

93. Case #6 57M, working in the Foothills Industrial Area
Working inside a metal structure welding, when a explosion occurred
Pt was found unresponsive inside
EMS has intubated the patient (for GCS of 3)

94. Blast Injuries What injury patterns are seen in Blasts?
What bodily structures would you expect to be involved?
What do you want to know about accident scene?

95. Incidence
In NA tend to be industry related, accidental (fireworks), bombings/Sept.11

96. 1° blast injury is caused solely by the direct effect of blast overpressure on tissue. Air is easily compressible, unlike water. As a result, a primary blast injury almost always affects air-filled structures
2° blast injury is caused by flying objects that strike people.

97. 3° blast injuries occurs when people fly through the air and strike other objects.
Miscellaneous blast-related injuries encompass all other injuries caused by explosions, i.e. fires

98. Location is important
An explosion that occurs in an enclosed space tends to cause more serious injury.
Intensity of an explosion pressure wave declines increasing distance from the explosion.
Blast waves are reflected by solid surfaces; thus, a person standing next to a wall may suffer increased primary blast injury.

99. Complications Injuries from projectile objects,
Barotrauma
TM’s: perforation, hemotympanum, ossicle #
Lungs: PTX, contusion, ARDS
GI: pneumoperitoneum, hemotoma, solid organ damage
Acute Gas embolism - ?Tx
DIC
Injuries from projectile objects,
Injuries from being thrown (MSK, CNS)
Inhalational, Burns, Toxins (CN, CO)

100. Work-Up Look at their TM’s
B.w. – CO/CN if explosion/fire and entrapped, lytes,
CXR (PA and Lat) preferred)
Urine
Serial Abdo Exams or
AXR/CT abdo if abdo pain
Other tests PRN – CT head as PRN CT head rule

101. Management TM’s – avoid putting stuff in their ears,
Lung – manage PTX as per N
If PTX, probably worth monitoring to ensure no contusion develops
Belly: high index of suspicion for bowel hematoma – may need to be Admitted for serial exams
AGE – LL decubitus, 100% O2, hyperbaric 02, ASA

102. PEA/Asystole 75M MVC, prolonged extrication Lost vitals en route
EMS Unable to intubate
What do you want to do?
What’s you Ddx for PEA/Asystole?
What can we reverse?

103. Intubate
Bilateral CT
2L wide open
FAST
ABG – correct lytes
CXR
Then decide whether to continue

104. Suicide/Jump from a building
Attempted suicide by jumping off a local seven story downtown building, landed feet first.
Brought in by EMS
Combative, hypotense, c/o pain at lower extremeties

105. What injury patterns do you look for in this situation?
What x-rays do you want to order?
What’s the likelihood of dying from a 4 story fall? 7 story fall? If feet first.

106. Now what?
Any other films to order?

107. Where do you usually see spinal #’s
What other films?

109. Why is she hypotense Neurologic shock – but she’s moving here legs
Belly – her abdo FAST is –ve, where else could the blood be
Heart – Autopsy study: 33/61 had cardiac injuries and in 16/33, the heart was felt to be cause of death – pericardial /transmural tears, epicardial tears
SO, WE SHOULD AT THE HEART w/FAST
Blunt Cardiac Trauma Caused by Fatal Falls From Height: An Autopsy-Based Assessment of the Injury Pattern. Journal of Trauma-Injury Infection & Critical Care. 57(2): , August Turk, E E. MD; Tsokos, M MD

110. Missed injuries

111. Important because… Missed cuz… Long-term disability (i.e. scaphoids)
Litigation
Overshadow our heroic measures, “sure they saved my life, but they missed my sprained ankle”
Missed cuz…
Tx life-threatening stuff 1st
Altered sensorium
Distracting injuries
Inadequate p/e
Misinterpretation of investigations

112. MI defined as injury detected >24hrs after A or missed by 3° survey
Intervention: 3° form required to be filled out for ever patient admitted to the TICU or trauma service
Results: significant decrease in MI’s post intervention

113. Results

114. Missed Injuries Unavoidable to some extent To prevent… Think of MOI
3° Exam – no studies in ED, but makes sense
D/c instructions
Interpret your x-rays
If they’re not going to trauma – ENSURE NOTHING ELSE IS GOING ON