1. The Trauma Evaluation Kenneth DeSart, MD
University of Florida Oral Exam Review

2. Primary Survey Airway Breathing Conscious? Talking?
Clear secretions, intubation if needed
Inhalational/Burn injury?
Breathing
Inspect for penetrating injury, tracheal deviation
Auscultate lung sounds
Palpate subcutaneous emphysema
Consider: need for artificial ventilation, tension pneumothorax, cardiac tamponade, flail chest

3. Primary Survey Circulation Disability Exposure Mental status, GCS
Vital signs: BP, HR, pulse, UOP
IV access (2 large bore IV), resuscitation, stat labs
Check abdomen/pelvis for obvious bleeding risk
Stop external bleeding (esp. scalp)
Disability
Mental status, GCS
Exposure
Stabilize neck, remove clothing to check for signs of injury
Maintain body temperature

4. Glasgow Coma Score GCS (max = 15) Motor (max = 6) Verbal (max = 5)
6 follow commands, 5 localizes pain, 4 withdraws from pain, 3 flexion with pain, 2 extension with pain, 1 no response
Verbal (max = 5)
5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 no response
Eye opening (max = 4)
4 spontaneous eye opening, 3 to command, 2 to pain, 1 no response

5. Sources of Massive Hemorrhage
Chest
Abdomen
Pelvis
Long bone (thigh)
Retroperitoneum
Scalp laceration (blood left at the scene)

6. FAST Exam Focused Assessment with Sonography in Trauma
Performed during/after primary survey
Replaced Diagnostic Peritoneal Lavage (DPL)
4 areas: pericardium, perihepatic (Morrison’s pouch), perisplenic, pelvic, & repeat perihepatic
Detects intra-abdominal bleeding
100cc in Morrison’s pouch
most dependent area in peritoneum in supine position
250cc total
Does not detect retroperitoneal bleeding or hollow viscous injury

7. FAST Exam
Sonoguide.com/FAST.html

8. FAST Exam - Perihepatic
Negative
Positive

9. FAST Exam - perisplenic
Negative
Positive

10. FAST Exam - pelvis
Negative
Positive

11. Secondary Survey Performed immediately following primary survey
AMPLE history – allergies, meds, PMH, last meal, events
Head to toe physical examination
Re-assess vital signs, changes in neurologic status
Need for more IV access? Arterial-line?
Imaging: CXR, pelvis XR, +/- extremity XR
Place foley catheter after rectal exam to rule out urethral injury
Blood at meatus, high riding prostate, severe pelvic fx, perineal hematoma
Check spine injury (“tenderness, step-offs”)
Remove back board

12. Decompensation
If the patient’s condition changes during the resuscitation, go back to your ABC’s.
Assess-> Intervene-> Reassess

13. CT Scan Contraindicated in unstable patients
Assess active hemorrhage (“blush”)
Assess degree of organ injury
Various grades affect management in liver, spleen, kidney, etc.
Low sensitivity for hollow viscous injury
Low sensitivity for diffuse axonal injury (brain)

14. Tertiary Survey The infamous “Tert”
Performed within 24 hrs of initial evaluation
Complete history and physical examination
Assess need for further imaging (extremity XR)
Review labs, imaging findings
Summarize diagnoses, treatment plan

15. Special cases - Airway Unable to intubate  surgical cricothyrotomy
Intubation – maintain in-line stabilization of cervical spine
Listen for right main stem intubation
Unable to intubate  surgical cricothyrotomy
Through cricothyroid ligament
Between thyroid and cricoid cartilage

16. Special cases - Breathing
Tension pneumothorax
Large bore needle decompression at mid- clavicular line above 2nd rib
Tube thoracostomy (“chest tube”)
Open pneumothorax (“Sucking chest wound”)
3 sided patch to allow expiration but not inspiration of air through hole
Tube thoracostomy

17. Special cases - Circulation
Scalp laceration
Potential for massive bleeding
Suture lacerations
Apply compressive bandage for 30 minutes and re- assess
Pelvic bleeding
Pelvic binder in ED
Imaging, arterial embolization
Cardiac tamponade (75-100ml)
Pericardial drain
Thoracotomy if in extremis

18. Special cases - Circulation
Positive FAST  Exploratory laparotomy (ex-lap)
Stab abdominal injury  selective lap if fascia violated
GSW abdominal injury  ex-lap
Need for transfusion  O+ blood for males, O- blood for women of child bearing age or younger
No time for results of type and screen or cross
Indication for OR thoracotomy
1500cc blood at initial chest tube insertion
200cc blood for 4 hrs
2500cc in 24hrs
Additional vascular access
Subclavian introducer
Saphenous vein cutdown

19. Special cases - Disability
GCS ≤ 14  head CT
GCS ≤ 10  intubation
GCS ≤ 8  Intra-cranial pressure (ICP) monitoring

20. The Pregnant Patient “To save the fetus, one must save the mother”
Provide all essential diagnostic or therapeutic procedures
CT scans when concern for intra-abdominal injury
Place patient in left lateral decubitus position as possible
Reduces IVC compression
Kleihauer-Betke (K-B) test
Detects fetal blood in maternal circulation
History and ultrasound to estimate fetal age
Cardiotocographic (CTM) monitoring beyond 24 weeks

21. Trauma Pearls Most commonly injured organ in blunt trauma
Liver (spleen is very close 2nd)
Most commonly injured organ in penetrating injury – small bowel (liver is close 2nd)
MCC death
0-60 min: cardiac, aortic, brainstem injuries
1-4 hrs: brain injury, hemorrhage “golden hour”
days to weeks: MSOF, sepsis

22. Trauma Pearls MCC epidural hematoma – middle meningeal artery
MCC subdural hematoma – venous plexus
Femur fractures – up to 2L blood can pool
Open extremity fractures – reduce fracture, reassess pulse
No pulse – angiography or OR