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

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

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

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

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

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

FAST Exam Sonoguide.com/FAST.html

FAST Exam - Perihepatic Negative Positive

FAST Exam - perisplenic Negative Positive

FAST Exam - pelvis Negative Positive

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

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

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)

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

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

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

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

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

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

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

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

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