1. Approach to Trauma Patients Joseph Turner, MD Indiana University School of Medicine

2. Objectives Describe the initial approach to the injured patient, including the primary and secondary surveys. Describe the initial approach to the injured patient, including the primary and secondary surveys. Describe the clinical presentation and initial treatment measures for life threatening injuries. Describe the clinical presentation and initial treatment measures for life threatening injuries. Identify the types and clinical presentations of shock. Identify the classes (I, II, III, IV) of hemorrhagic shock. Identify the types and clinical presentations of shock. Identify the classes (I, II, III, IV) of hemorrhagic shock. Understand the benefits and downsides of imaging trauma patients Understand the benefits and downsides of imaging trauma patients Describe approach to assessing cervical spine trauma Describe approach to assessing cervical spine trauma

3. Case 1 32 yo female restrained driver in a rollover MVA 32 yo female restrained driver in a rollover MVA –25 minute extrication –complaining of chest pain and difficulty breathing –EMS reports that the windshield is starred and the steering column was bent

4. Mechanism of Injury Gives information about the forces potentially involved in the traumatic mechanism Gives information about the forces potentially involved in the traumatic mechanism –Guides diagnostic testing  More force more likely to have injury –Determines Trauma center activation  Shorter time to arrive at definitive care  Determined by mechanism and vitals

5. Case 1 Vitals Vitals –HR 94 BP 88/56 RR 26 Biox 93% Where do you take the patient? Where do you take the patient? Would you be more or less concerned if this were a 83 yo female? Would you be more or less concerned if this were a 83 yo female?

6. Susceptibility to Injury Some populations more vulnerable to injuries Some populations more vulnerable to injuries –Elderly  More likely to have injuries from given force –Lower bone density, brain atrophy, co-morbities –Alcoholics  Brain atrophy leads to more subdural hematomas –Coagulolopathic  warfarin, cirrhotic

7. Primary Survey Goal is to identify and treat any life threatening injuries Goal is to identify and treat any life threatening injuries –Some components are evaluated simultaneously in large trauma centers –All resources are directed toward stabilizing that injury until it is corrected

8. Airway Evaluate for patency and secure it if it is not adequate Evaluate for patency and secure it if it is not adequate –Usually endotracheal intubation –Keep cervical spine immobilized inline if any concern for spine fracture Identify injuries that if not treated will threaten the airway Identify injuries that if not treated will threaten the airway –Intervene before it becomes too difficult

9. What are some signs or symptoms that might indicate that the patient needs an airway intervention? What are some signs or symptoms that might indicate that the patient needs an airway intervention? Airway obstruction Airway obstruction Severe respiratory distress Severe respiratory distress Altered mental status (GCS Intubate) Altered mental status (GCS Intubate) Critically ill Critically ill If something changes – start over at the top If something changes – start over at the top

10. Breathing Listen to breath sounds Listen to breath sounds –Look, feel, trachea position Oxygenation Oxygenation –Skin color, pulse ox

11. Circulation Heart rate and blood pressure Heart rate and blood pressure –Look for signs of shock  Cap refill, mental status Feel pulses Feel pulses –Check above and below waist and on both sides  Looking for vascular injury Listen for muffled heart tones Listen for muffled heart tones –Ultrasound helpful

12. Disability Rapid neurologic assessment Rapid neurologic assessment –Formal Glasgow Coma Score –Eye opening, verbal and motor –Gross motor exam for quadro/paraplegia  Heighten suspicion for spinal cord injury –Palpate spinal cord –Rectal tone?

13. Exposure/Environmental Control Remove clothing to evaluate for external evidence of injury Remove clothing to evaluate for external evidence of injury Keep patient warm Keep patient warm –hypothermia will complicate many injuries

14. Secondary Survey Starts once the primary survey is complete and all injuries identified there have been stabilized Starts once the primary survey is complete and all injuries identified there have been stabilized Head to toe examination of the patient to evaluate for additional injuries Head to toe examination of the patient to evaluate for additional injuries –Evaluate need for imaging studies to identify injuries

15. Case 2 24 yo male patient involved in a drive by shooting 24 yo male patient involved in a drive by shooting Suffered with multiple gunshot wounds to the chest and abdomen. There were 2 fatalities at the scene Suffered with multiple gunshot wounds to the chest and abdomen. There were 2 fatalities at the scene Vs HR 124 BP 76/p RR 36 Vs HR 124 BP 76/p RR 36

16. Primary Survey Airway Airway Breathing Breathing –Breath sounds diminished on right side, trachea deviated to left What is going on and what are you going to do about it? What is going on and what are you going to do about it?

17. Tension Pneumothorax Diminished breath sounds and hypotension Diminished breath sounds and hypotension –Hyper-resonance, JVD; deviated trachea late sign Treatment is needle thoracostomy, followed by tube thoracostomy Treatment is needle thoracostomy, followed by tube thoracostomy –large gauge angio in 2nd intercoatal space in mid clavicular line –get rush of air and improvement in vs –needs immediate tube thoracostomy

18. Primary Survey Airway Airway Breathing Breathing Circulation Circulation –Low blood pressure and elevated heart rate  HR 124 BP 76/p SHOCK

19. Top 10 Types of Shock in Trauma Patients 1. Hemorrhagic 2. Hemorrhagic 3. Hemorrhagic 4. Hemorrhagic 5. Hemorrhagic 6. Hemorrhagic 7. Hemorrhagic 8. Hemorrhagic 9. Cardiogenic 10. Neurogenic

20. Hemorrhagic Shock Class I- <15% blood loss Class I- <15% blood loss –Minimal symptoms and normal vitals Class II- >15% blood loss (800-1500 cc) Class II- >15% blood loss (800-1500 cc) –Tachycardia, decreased pulse pressure, delayed cap refill Class III- >30 % blood loss (1500-2000 cc) Class III- >30 % blood loss (1500-2000 cc) –Tachycardia, tachypnea, hypotension –Usually requires transfusion

21. Hemorrhagic Shock Class IV- > 40% blood loss (>2000 cc) Class IV- > 40% blood loss (>2000 cc) –Immediately life threatening –Marked abnormalities in vitals –Skin cool, diaphoretic –Negligible urinary output –Depressed mental status

22. Treatment of Hemorrhagic Shock Stop the bleeding Stop the bleeding –Locate and control bleeding sites –Body sites an adult can bleed and develop shock  Chest  Abdomen  Retroperitoneal  Pelvis  Femur  External losses Volume Resuscitation Volume Resuscitation –Isotonic fluid  Start with 1-2 liters –Blood  Switch to quickly if not stable with crystalloid  If hypotensive start early with O-neg  Send type and cross to get type specific ASAP

23. J Trauma Acute Care Surg. 2013 May;74(5):1215-21

24. Assure that the patient has adequate IV access in order to deliver large amounts of volume quickly Assure that the patient has adequate IV access in order to deliver large amounts of volume quickly –Two 18 G or larger Ivs –Or Central Access Key is short and fat catheters deliver fluids and blood faster Key is short and fat catheters deliver fluids and blood faster –Flow directly proportional to diameter of catheter and inversely proportional to length of catheter

25. Tranexamic Acid? Antifibrinolytic agent Antifibrinolytic agent Decreases bleeding and need for transfusion Decreases bleeding and need for transfusion Reduced mortality in CRASH-2 trial Reduced mortality in CRASH-2 trial

26. Primary Survey Airway Airway Breathing Breathing Circulation Circulation –Low blood pressure and elevated heart rate  shock –No palpable pulse in right leg with gsw to thigh

27. Assess neurovascular status Vascular Exam Vascular Exam –Hard Signs  No palpable or dopplerable pulse, visible pulsatile bleeding, bruit or thrill over artery, expanding hematoma –Soft Signs  Decreased pulse compared to extremities, neurologic abnormality, fracture or penetrating injury in proximity to artery Neuro exam Neuro exam –Assess motor and sensory nerve function  distal to injury

28. Ankle-Brachial Index Useful adjunct in vascular assesment Useful adjunct in vascular assesment –SPB in leg/SBP in arm while patient laying down  Normal is >0.9 –Less than 0.9 is indication for further diagnostic testing  Angiogram (CT or fluoroscopic)  Exploration

29. Case 2:Outcome GSW to right chest with tension pneumothorax GSW to right chest with tension pneumothorax –Chest tube placed and 300 cc blood removed  >1000 cc (20cc/kg) initally or 150cc/hr continuing – indications for exploration in the OR Pulse in right leg dopplerable, but ABI 0.4 Pulse in right leg dopplerable, but ABI 0.4 –Get angiogram to evaluate when stable

30. Case 3 38 yo female fell from a 3 rd story window 38 yo female fell from a 3 rd story window She complains about a headache and abdominal pain She complains about a headache and abdominal pain –Very brief loss of consciousness Vitals Vitals –P 94 BP 110/60 RR 20 Biox 97% on RA

31. Primary Survey Airway Airway –Intact, patient speaking Breathing Breathing –No distress, normal biox Circulation Circulation –No evidence of shock or pulse deficit Disability Disability –GCS 15, non focal neuro

32. Secondary Survey HEENT - PERLA, EOMI, no scalp lac, hematoma over left temple HEENT - PERLA, EOMI, no scalp lac, hematoma over left temple Chest - TTP in right lower chest, equal bs Chest - TTP in right lower chest, equal bs Abdomen - soft tender in right upper quadrant, no peritonitis Abdomen - soft tender in right upper quadrant, no peritonitis Pelvis - stable to rock and compression, pain on palpation of right hip Pelvis - stable to rock and compression, pain on palpation of right hip Neurologic exam - GCS 15, 5/5 strength throughout, no sensory deficits Neurologic exam - GCS 15, 5/5 strength throughout, no sensory deficits

33. What tests do you order at the bedside? Chest X-ray Chest X-ray –To look for pneumothroax, pulmonary contusion or wide mediastinum Pelvis X-ray Pelvis X-ray –To look for pelvic fractures FAST Scan FAST Scan –Bedside ultrasound to evaluate for abdominal fluid

34. Focused Assessment with Sonography for Trauma

35. FAST Scan Portable Portable Non-invasive Non-invasive Evaluates for intraperitoneal and pericardial fluid Evaluates for intraperitoneal and pericardial fluid –as little as 300 cc detected Reliably predicts need for laporotomy in hypotensive trauma patients Reliably predicts need for laporotomy in hypotensive trauma patients Not sensitive for solid organ injury and retroperitoneal injuries Not sensitive for solid organ injury and retroperitoneal injuries E-FAST (extended-FAST) E-FAST (extended-FAST) –Looks for pneumo/hemothorax

36. Case 3 CXR, FAST negative CXR, FAST negative –Now what? PanScan? PanScan? –Routine CT imaging of head, cervical spine, chest, abdomen for trauma patients –Probably beneficial for critically injured patients

37. Downsides to Imaging Radiation exposure Radiation exposure Contrast nephropathy Contrast nephropathy Cost/charge Cost/charge Resource utilization Resource utilization Incidental findings Incidental findings

38. What tests do you order? Head CT Head CT –Identifies intercranial hemorrhage  Subdural, epidural, subarachnoid or interparyenchymal –Will identify patients who need evacuation of blood prior to clinical deterioration –Many patients with severe brain injury have normal head CTs  From diffuse axonal injury  Don’t let a normal head CT fool you into thinking that the patient doesn’t have a head injury

39. Who needs a head CT? Decision Rules Decision Rules –Nexus 2, Canadian Head CT, CHIP Rule, New Orleans Criteria –Fairly sensitive though not 100% and specificity may not be enough to reduce CT use that much compared to clinical judgment  Work better for ‘clinically important injuries’ –Requiring observation or neurosurgical intervention

40. Who needs a head CT? Generally accepted indications: Generally accepted indications: –Persistent altered mental status –Focal neurologic deficits –Signs of basilar skulls fracture –Coagulopathic Other factors Other factors –Loss of consciousness, vomiting, age >60, severity of headache, scalp hematoma/contusion Important to take mechanism of injury into account when deciding to order head CT Important to take mechanism of injury into account when deciding to order head CT

41. ACEP Guidelines Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy. Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy. Level B recommendations. A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.* Level B recommendations. A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.*

42. Abdominal CT Used to evaluate for intra-abdominal, retroperitoneal and pelvic injuries Used to evaluate for intra-abdominal, retroperitoneal and pelvic injuries Excellent detail of solid organ injuries Excellent detail of solid organ injuries –Spleen and Liver Laceration classification

43. Abdominal CT Bone windows allow visualization of spine and pelvic fractures Bone windows allow visualization of spine and pelvic fractures –Equivalent or better than plain films Hollow viscous injury Hollow viscous injury –Historically a weakness of CT –New generation multi-slice spiral scanners much higher sensitivity

44. Chest CT Evaluates for aortic injury Evaluates for aortic injury –High risk patients – rapid deceleration –Abnormal mediastinum on plain chest xray More sensitive than chest x-ray for small pneumothorax or pulmonary contusion More sensitive than chest x-ray for small pneumothorax or pulmonary contusion –Some are so small they don’t need treatment

45. Case 4 Two patients on backboards and c-collars after being in a motor vehicle accident Two patients on backboards and c-collars after being in a motor vehicle accident Patient A is complaining of neck pain and Patient B is screaming in pain from his left shoulder. They are yelling that the collar and backboard are making things worse. Patient A is complaining of neck pain and Patient B is screaming in pain from his left shoulder. They are yelling that the collar and backboard are making things worse. –They want the collars off and to be taken off the board. What do you want to do?

46. Patient A 24 yo female complaining of neck pain, unrestrained passenger who has also been drinking alcohol and her speech is slightly slurred. No other injuries noted 24 yo female complaining of neck pain, unrestrained passenger who has also been drinking alcohol and her speech is slightly slurred. No other injuries noted –Neck seems non-tender –Neuro exam reveals no focal deficits Can you clinically clear this patients c-spine?

47. Restrained driver and is complaining of left shoulder pain and left ankle pain. He denies alcohol use and doesn’t seem intoxicated clinically. Restrained driver and is complaining of left shoulder pain and left ankle pain. He denies alcohol use and doesn’t seem intoxicated clinically. States that his left shoulder commonly dislocates and that he needs out of the collar so he can turn his head to pop it back in. States that his left shoulder commonly dislocates and that he needs out of the collar so he can turn his head to pop it back in. Patient B

48. Physical Exam Patient B’s neck is non-tender on exam Patient B’s neck is non-tender on exam Left shoulder with obvious anterior dislocation Left shoulder with obvious anterior dislocation –Neurovascular exam is intact Left ankle with swelling and deformity, tender on palpation Left ankle with swelling and deformity, tender on palpation Can you clinically clear this patient’s c- spine? Can you clinically clear this patient’s c- spine?

49. Clinical C-spine Clearance Based on NEXUS Criteria (NEJM, 343(2), 2000) Based on NEXUS Criteria (NEJM, 343(2), 2000) –Study involved 34,000 patients who had imaging of the cervical spine after blunt trauma All criteria must be met in order to clear pt. All criteria must be met in order to clear pt. –Absence of tenderness in the posterior midline over the cervical spine –Absence of a focal neurologic deficit –Normal level of alertness –No evidence of intoxication –Absence of clinically apparent pain that might distract the patient from the pain of a cervical spine injury

50. Clinical Spine Clearance If patient meets all five NEXUS criteria they can be taken out of c-collar without x-rays If patient meets all five NEXUS criteria they can be taken out of c-collar without x-rays –Study had 99% sensitivity for clinically significant injuries Palpate thoracic and lumbar spine in midline to determine need for imaging Palpate thoracic and lumbar spine in midline to determine need for imaging –Take off backboard and leave flat if imaging indicated

51. Patient B continued The patient also had an ankle fracture/dislocation as well as obvious anterior shoulder dislocation The patient also had an ankle fracture/dislocation as well as obvious anterior shoulder dislocation The patient undergoes procedural sedation with reduction and stabilization of both injuries The patient undergoes procedural sedation with reduction and stabilization of both injuries After the procedure the patients neck was reexamined and there was tenderness over C5-C6 in the midline. After the procedure the patients neck was reexamined and there was tenderness over C5-C6 in the midline.

52. On CT the patient has a fracture of the articular process and lamina of C5 On CT the patient has a fracture of the articular process and lamina of C5 Patient’s neck kept immobilized Patient’s neck kept immobilized Patient went to surgery for fusion of C5-C6 and has no neurologic deficits after fixation. Patient went to surgery for fusion of C5-C6 and has no neurologic deficits after fixation.

53. Take Home Points Primary Survey for Trauma Primary Survey for Trauma –ABCDE –Systematic approach –Treat life-threatening injuries as you encounter them Mechanism of Injury Mechanism of Injury –More force means more injuries Carefully consider risks/benefits of imaging Carefully consider risks/benefits of imaging