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

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Presentation on theme: "ED Approach to the Trauma Patient University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation."— Presentation transcript:

1 ED Approach to the Trauma Patient University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation

2 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

3 Assessment: Primary Survey –Evaluate for immediate life threats –Management of issues immediately –ABCs (and D &E)

4 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

5 Breathing Assessment –Yes or No? –Adequate? –Evaluate breath sounds –Evaluate chest wall symmetry and stability Intervention –O2 for all (wont hurt) –BVM –Intubation –Needle decompression –Chest tube

6 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 ABCs & F?)

7 Primary Survey Disability –AVPU Awake Verbal Painful Unresponsive –Posturing? –Seizing?

8 Assessment AreaScore 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

9 Primary Survey Expose/Environment –Undress –Protect from becoming hypothermic Warm room Warm blankets Warm fluid

10 Assessment: Secondary Survey A thorough once-over Fingers & Tubes AMPLE history

11 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

12 Secondary Survey Fingers and Tubes/Td –Rectal? If indicated only –Foley? If indicated –Re-assess IV access –Td Booster

13 Secondary Survey AMPLE History –Allergies –Meds –PMHx/PSHx –Last meal –Events leading up to accident

14 Secondary Survey Reassess vitals –Better or worse? –Further intervention needed? –Transfer patient?

15 Imaging Plain films in trauma bay –CXR –Pelvis

16 Imaging CT scan? (the Grand Slam if all done) –Head –Neck –Face –Chest –Abdomen –Pelvis

17 Labs Type and screen or cross CBC CMP Coags UA-visually inspect for gross hematuria UPT

18 IV Fluids Crystalloids –Normal Saline –Lactated Ringers Colloids –PRBC –FFP –Factors in hemophiliacs

19 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)

20 Hypovolemic Shock Blood volume –Adults: 7% of weight –Peds: 8-9% of weight Replacement –http://www.trauma.org/resus/massive.htm

21 ClassBlood Loss % Vol. Blood Loss (cc) HRPPsBPUrine Output AMSRx I< 15%<750cc<100Norm NoCrystalloids (3:1 rule); no PRBC II15-30%750- 1500 NoCrystalloids; +/- PRBC III30-40%1500- 2000 YesCrystalloids + type=spec PRBC IV>40%>2000Yes2L crystalloid bolus + uncrossd PRBC Classes of Hemorrhagic Shock

22 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

23 Summary Preparation ABCDEs Secondary Survey Imaging Lab Hemorrhagic Shock The Basics


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