Presentation on theme: "ED Approach to the Trauma Patient"— Presentation transcript:
1 ED Approach to the Trauma Patient University of Utah Medical CenterDivision of Emergency MedicineMedical Student Orientation
2 Why? Trimodal Death Distribution 1. seconds to minutes Often CNS or severe vascular injuriesLittle can be donePrevention is key2. minutes to hoursGolden HourRapid assessment and resuscitation3. days to weeksSepsisMultisystem organ failureThis is where we can make a differenceThe priority of the ED physician is to assess, resuscitate, stabilize on a priority basisATLS Guidelines
3 Assessment: Primary Survey Evaluate for immediate life threatsManagement of issues immediatelyABC’s (and D &E)
4 Airway Assessment Intervention First priority in ANY patient If they can speak clearly = good airwayHoarse/sonorous/ gurgling = further evaluation and interventionAre they protecting their airway?InterventionJaw Thrust (c-spine)SuctionNPAOPAIntubationHave a back-up plan!Maintain in-line cervical stabilizationAlways maintain in-line cervical stabilization!Think c-spine in multiple injured, altered LOC, trauma above clavicleNo NPA/NTI in facial trauma/basilar skull fx = risk direct oxygenation to brain!In children <8rs, uncuffed tubeNeedle cricothyroidotomy preferred to surgical in < 12yo
5 Breathing Assessment Intervention Yes or No? Adequate? Evaluate breath soundsEvaluate chest wall symmetry and stabilityInterventionO2 for all (won’t hurt)BVMIntubationNeedle decompressionChest tubeOxygenation vs actual VENTILATION!
6 Circulation Assessment Intervention Pulse? Rate/Rhythm/Strength Skin CTMBleeding?ExternalInternalInterventionCPR2 large bore IVs(14-16G)IO (even easier now)Central lineFluid replacementControl bleedingFAST Scan (now maybe ABC’s & F?)Length and diameter of catheter (r to the 4th!) The shorter/fatter the catheter, the faster the fluid can go in!
7 Primary Survey Disability AVPU Posturing? Seizing? Awake Verbal PainfulUnresponsivePosturing?Seizing?AVPU is qualitative assessmentGCS is quantitative assessment
8 Mild Moderate Severe GCS 14-15 GCS 9-13 GCS =/<8 Assessment Area ScoreEye Opening (E)SpontaneousTo speechTo painNone4321Best Motor Response (M)Obeys CommandsLocalizes PainNormal flexion (withdrawal)Abnormal flexion (decorticate)Extension (decerebrate)None (flaccid)65Verbal Response (V)OrientedConfused conversationInappropriate wordsIncomprehensible soundsMildGCS 14-15ModerateGCS 9-13SevereGCS =/<8Remember, pt’s BEST response!Intubate for </= to 8 or non-purposeful motor response
10 Assessment: Secondary Survey A thorough once-overFingers & TubesAMPLE 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)BackGU/rectal if indicatedExtremitiesDetailed neuro exam
12 Secondary Survey Fingers and Tubes/Td Rectal? If indicated only Foley? If indicatedRe-assess IV accessTd BoosterNo Foley if blood at urethral meatus, scrotal hematoma, high-riding prostate (retrourethrogram)
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 Typically at least a chestRarely lat C-spine – certain indicationsPelvis if clinically indicatedExtremities as clinically indicated
16 Imaging CT scan? (the “Grand Slam” if all done) Head Neck Face Chest AbdomenPelvisBe selective in your choices vs. the “trauma scan”
17 Labs Type and screen or cross CBC CMP Coags UA-visually inspect for gross hematuriaUPTT&C is most important (as well as UPT in female)Coags handy for those w/liver dz or anticoagulatedRest show baseline…CBC – Hct may be normal until volume replaced and then hemodilution occurs
18 IV Fluids Crystalloids Colloids Normal Saline Lactated Ringers PRBC FFPFactors in hemophiliacs
19 3:1 Rule Rough estimate Crystalloid volume : blood loss 3 mL: 1mL Caveat:More and more, we are moving toward early transfusionMassive transfusion = 1:1:1 PRBC:FFP:Platelets (admittedly strong data lacking)Crystalloid volume needed to replace blood loss 3ml:1ml
20 Hypovolemic Shock Blood volume Replacement Adults: 7% of weight Peds: 8-9% of weightReplacement
21 Classes of Hemorrhagic Shock Blood Loss %Vol. Blood Loss (cc)HRPPsBPUrine OutputAMSRxI< 15%<750cc<100NormNoCrystalloids (3:1 rule); no PRBCII15-30%↑↓Crystalloids; +/- PRBCIII30-40%↑↑↓↓YesCrystalloids + type=spec PRBCIV>40%>2000↑↑↑↓↓↓2L crystalloid bolus + uncross’d PRBC
22 Where Can you Lose Blood? EnvironmentChestHemothorax: % volume each sideAortic ruptureCardiac ruptureAbdomenPelvis: 3-4L retroperitonealFemur : 1-1.5L