Introduction to Trauma LSU Medical Student Clerkship, New Orleans, LA

Goals Review the components of the primary and secondary survey for a trauma patient Identify injuries requiring immediate intervention during primary survey Review the initial steps of resuscitation of a trauma patient in the ED Review the advantages and uses of diagnostic modalities in the trauma patient Discuss the appropriate disposition of the trauma patient from the ED.

Trauma is predictable, preventable, and treatable. Epidemiology Trauma is a disease. Trauma is predictable, preventable, and treatable. Trauma is the 4th leading cause of death in the US. Trauma is the leading cause of death in people below the age of 45 in the US. 3.8 M deaths/ year/ worldwide 312 M injured

Epidemiology Trimodal distribution of mortality Prehospital (Major head injuries, rapid exsanguination) Early Hospital (Head, chest, abdominal trauma) ICU (End result of prolonged hypoperfusion)

History of Trauma Systems 1991: Congress passed the Trauma Care Systems Planning and Development Act requiring the development of a Model Trauma Care System Plan to be used as a reference document for each state to develop its system Based on the severity of injury, patients are triaged to trauma centers The American College of Surgeons has developed requirements for trauma center certification of commitment of personnel and resources needed to maintain a state of readiness to receive critically injured patients. The Golden Hour

History of Trauma Systems

Initial Approach The initial approach to trauma care in the ED is a process that consists of an initial primary assessment, rapid resuscitation, and a more thorough secondary survey followed by diagnostic tests and ultimate disposition. Subsequent mortality and morbidity tied directly to the initial assessment and resuscitation

Primary Survey Rapid examination to identify and treat life threatening conditions. Ideally is performed in a few minutes. A - Airway (with C-spine precautions) B - Breathing C - Circulation D - Disability E – Exposure When derangements in any of the components of the primary survey are identified, treatment is undertaken immediately.

Primary Survey - Airway Maintain C-spine precautions Clear any obstructions Jaw thrust instead of head tilt chin lift Endotracheal intubation for airway protection or expected clinical course (ie,obstruction from blood or vomitus, neck hematoma, facial burns or trauma, GCS 8 or less, combative patient, potential for airway compromise while out of department.)

Primary Survey - Breathing Auscultation for bilateral breath sounds Palpation for subcutaneous emphysema -needle decompression followed by chest tube for pneumothorax Inspection for flail chest Observation of respiratory rate, oxygen saturation, and overall work of breathing -mechanical ventilation for inadequate ventilation or to decrease work of breathing

Primary Survey - Circulation Check peripheral pulses, heart rate, BP, pulse pressure, capillary refill, cyanosis All hypotensive trauma patients are assumed to be in hemorrhagic shock 2 large bore peripheral IV’s (at least 18 gauge) Control external bleeding

Primary Survey - Circulation

Primary Survey - Circulation Begin volume resuscitation with liter boluses of crystalloid for class I or II hemorrhage. Begin crystalloid and blood for class III or IV hemorrhage. O- blood until type specific is available Constant reevaluation is paramount If class I or II is patient still showing signs of shock after 3L of crystalloid, begin blood “3:1 rule” 3cc crystalloid for every 1cc of blood loss

Primary Survey - Circulation 5 Places life threatening hemorrhage can occur -Chest -Abdomen -Pelvis -Thighs -Externally

Primary Survey - Circulation Cardiac Tamponade can cause hypotension with little blood loss. Becks triad: hypotension, distended neck veins, muffled heart sounds Easily confirmed with ultrasound Pericardiocentesis

Primary Survey - Disability Quick assessment of ability to move all extremities Glascow Coma Scale

Primary Survey – Exposure Completely undress the patient and inspect the entire patient from head to toe both front and back. Maintain spinal precautions during logrolling Inspect both axillae and peritoneum Warm blankets!!!

Secondary Survey Head to toe evaluation once any derangements in primary survey have been addressed. AMPLE History -Allergies -Medications -Past medical history (LMP, Td, transfusions) -Last meal -Events leading up to trauma

Imaging Choice of imaging modality depends on nature of injuries and stability of patient. Knowledge of injury mechanism and index of suspicion most important

Imaging – Plain Films Quick Can be performed at bedside Useful for rapid identification of pneumothorax, hemothorax, fractures and locating ballistics

Imaging – Ultrasound Quick Can be performed at bedside FAST: Focused Assessment with Sonography for Trauma Rapid examination to identify free intraperitoneal fluid and/or pericardial fluid

Imaging – CT Detailed Requires patient to leave the department Necessary for head trauma

Disposition To the OR -Unstable patients with blunt or penetrating abdominal trauma or chest trauma. Hemothorax with >1500 cc of blood out initially. Surgical injuries identified with imaging. Admission -Nonsurgical, high-risk injuries Discharge -Stable patients, minor or no injuries identified.