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ED Approach to the Trauma Patient
University of Utah Medical Center
Division of Emergency Medicine
Medical Student Orientation
Why?
• Trimodal Death Distribution– 1. seconds to minutes
• Often CNS or severe vascular injuries• Little can be done• Prevention is key
– 2. minutes to hours• Golden Hour• Rapid assessment and resuscitation
– 3. days to weeks• Sepsis• Multisystem organ failure
Assessment:Primary Survey
–Evaluate for immediate life threats–Management of issues immediately–ABC’s (and D &E)
Airway
• Assessment– First priority in ANY
patient– If they can speak
clearly = good airway– Hoarse/sonorous/
gurgling = further evaluation and intervention
– Are they protecting their airway?
• Intervention– Jaw Thrust (c-spine)– Suction– NPA– OPA– Intubation– Have a back-up plan!– Maintain in-line
cervical stabilization
Breathing
• Assessment– Yes or No?– Adequate?– Evaluate breath
sounds– Evaluate chest wall
symmetry and stability
• Intervention– O2 for all (won’t hurt)– BVM– Intubation– Needle
decompression– Chest tube
Circulation
• Assessment– Pulse?– Rate/Rhythm/Strength– Skin CTM– Bleeding?
• External• Internal
• Intervention– CPR– 2 large bore IVs
• (14-16G)
– IO (even easier now)– Central line– Fluid replacement– Control bleeding– FAST Scan (now
maybe ABC’s & F?)
Primary Survey
• Disability– AVPU
• Awake• Verbal• Painful• Unresponsive
– Posturing?– Seizing?
Assessment Area Score
Eye Opening (E)•Spontaneous•To speech•To pain•None
•4•3•2•1
Best Motor Response (M)•Obeys Commands•Localizes Pain•Normal flexion (withdrawal)•Abnormal flexion (decorticate)•Extension (decerebrate)•None (flaccid)
•6•5•4•3•2•1
Verbal Response (V)•Oriented•Confused conversation•Inappropriate words•Incomprehensible sounds•None
•5•4•3•2•1
• Mild– GCS 14-15
• Moderate – GCS 9-13
• Severe– GCS =/<8
Primary Survey
• Expose/Environment– Undress– Protect from becoming
hypothermic• Warm room• Warm blankets• Warm fluid
Assessment:Secondary Survey
•A thorough once-over
•Fingers & Tubes
•AMPLE history
Secondary Survey• Thorough physical exam
– HEENT (look in nose, ears, mouth)
– Neck (undo collar and palpate)
– Chest/Abdomen/Pelvis (FAST Scan if not done)
– Back – GU/rectal if indicated– Extremities– Detailed neuro exam
Secondary Survey
• Fingers and Tubes/Td– Rectal? If indicated
only – Foley? If indicated– Re-assess IV access– Td Booster
Secondary Survey
• AMPLE History– Allergies– Meds– PMHx/PSHx– Last meal– Events leading up to
accident
Secondary Survey
• Reassess vitals– Better or worse?– Further intervention needed?– Transfer patient?
Imaging
• Plain films in trauma bay– CXR– Pelvis
Imaging
• CT scan? (the “Grand Slam” if all done)– Head– Neck– Face– Chest– Abdomen– Pelvis
Labs
• Type and screen or cross
• CBC• CMP• Coags• UA-visually inspect
for gross hematuria• UPT
IV Fluids
• Crystalloids– Normal Saline– Lactated Ringers
• Colloids– PRBC– FFP– Factors in hemophiliacs
3:1 Rule
• Rough estimate
• Crystalloid volume : blood loss
• 3 mL: 1mL
• Caveat: – More and more, we are moving toward early
transfusion– Massive transfusion = 1:1:1
PRBC:FFP:Platelets (admittedly strong data lacking)
Hypovolemic Shock
• Blood volume– Adults: 7% of weight– Peds: 8-9% of weight
• Replacement – http://www.trauma.org/resus/massive.htm
Class Blood Loss %
Vol. Blood Loss (cc)
HR PP sBP Urine Output
AMS Rx
I < 15% <750cc <100 Norm Norm Norm No Crystalloids (3:1 rule); no PRBC
II 15-30% 750-1500
↑ ↓ ↓ ↓ No Crystalloids; +/- PRBC
III 30-40% 1500-2000
↑↑ ↓↓ ↓↓ ↓↓ Yes Crystalloids + type=spec PRBC
IV >40% >2000 ↑↑↑ ↓↓↓ ↓↓↓ ↓↓↓ Yes 2L crystalloid bolus + uncross’d PRBC
Classes of Hemorrhagic Shock
Where Can you Lose Blood?
• Environment
• Chest– Hemothorax: 40-50% volume each side– Aortic rupture– Cardiac rupture
• Abdomen
• Pelvis: 3-4L retroperitoneal
• Femur : 1-1.5L
Summary
• Preparation
• ABCDE’s
• Secondary Survey
• Imaging
• Lab
• Hemorrhagic Shock
• The Basics