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

2. 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.

3. 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

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

5. 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

6. History of Trauma Systems

7. 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

9. 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.

10. 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.)

11. 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

13. 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

15. Primary Survey - Circulation

16. 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

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

18. 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

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

22. 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!!!

23. 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

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

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

27. 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

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

31. 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.