ED Management of Trauma

Department of Emergency Medicine

MGH

Content by Jonathan Adler, MD, MS, Mike Filbin, MD, MS and J. Kimo Takayesu MD, MS

Introduction

• Scope of the problem– ED visits

– Deaths

• Trauma Management

ED Visits, in Millions(2004 total = 110.2 Million)

2004 ED visits

68.8

28.1

2.3

11

Disease/illness

Unintentional injury

Intensional injury

Other injury

Trauma Scope

• Leading cause of death age 1-44• Far greatest loss of productivity (2.2 m years of

life lost, 2nd is CA at 1.9 m)• 3rd overall behind heart dz and cancer, more than

stroke – 167,000 dead in 2004 (All injuries)

• 60 million injuries/y• 37 million ED visits• 3.7 million require admission

Trauma Deaths, by Intent

n = 167,000 (2004)

27%

31%

19%

12%

11%Motor Vehicle Crash

Other UnintentionalInjuriesSuicide

Fall

Homicide

Trauma Deaths

• 50% die at scene– Massive head injury

– High c-spine injury

– Aortic rupture

– Airway obstruction

Trauma Deaths

• 30% die within a few hours– Tension pneumothorax

– Massive hemothorax

– Cardiac tamponade

– Subdural and epidural hematoma

– Massive hemorrhage• Liver, spleen, pelvic fx, aortic rupture

Trauma Deaths

• 20% die in days-weeks– MOF, sepsis

Hospital trauma designations

• Level I– Attending emergency physician and trauma surgeon

immediately available– Operating personnel in hospital– Definitive trauma care– 24/7 OR/Lab/Radiography capability– Surgical subspecialties promptly available

• Neurosurg, ortho, plastics, urology

– Pediatric capability– ICU– Research, administrative and EMS requirements

Hospital trauma designations

• Level II– Attending emergency physician immediately

available

– Trauma surgeon and operatinf personnel available within timely period

– Most surgical subspecialties represented

– Occasional interhospital transfer for certain subspecialties

Hospital trauma designations

• Level III– Attending emergency physician immediately

available

– General surgery and limited subspecialty surgery on-call

– Anesthesiology in hospital

Case

• 50 year old male

• Fell 35 feet from open window

• Somnolent at scene

• Patient arrives pale, with shallow and sonorous respirations, smelling of alcohol

• Vitals: p 118 bp 88/45 resp 22

Prehospital Management

• CMED call• Age• Mechanism of injury• Extrication• Vitals• Exam• Access/Intubation

ED Management

• Primary Survey –ABCde’s (Two minutes)– Airway and C-spine control

– Breathing

– Circulation

– Disability – Neurological exam

– Exposure – Undress and roll

– Finger and Foley

– +/- Nasogastric tube

AirwayObserve

Ask a basic question – How are you? What happened?Immedicate interventions –

Clear airway• chin lift• suction• Finger sweep

Airway

Protect/establish airway

• Oral or nasopharyngeal airway

• naloxone

• tracheal intubation

• crycothyrotomy

• transtracheal needle (jet) ventilation

Breathing

• Evaluate - breath sounds, respiratory rate, pulse ox, chest movement, subcutaneous air

• BVM ventilate with 100% O2

• Check neck for tracheal deviation – look and feel

• Check thorax for asymmetric or paradoxical movements (flail chest) or obvious sucking wound

Breathing

• Listen At Each Lateral Aspect for Breath Sounds

• Interventions– Withdraw ET tube from right mainstem

– Three-sided “occlusive” dressing

– Needle thoracostomy

– Reintubate trachea

– Large bore (38 Fr) tube thoracostomy

– Immediate return of 1500-2000 ml blood is an indication for thoracotomy

Circulation

Apply direct pressure to sites of severe bleeding

Assess blood volume status– Radial pulse ≈ 80 mm Hg

– Femoral pulse ≈ 70 mm Hg

– Carotid pulse ≈ 60 mm Hg

Measure BP including pulse “width”, pulse rate, capillary refill, respiratory rate and rough measure of mental status

Circulation

• Seek Beck’s triad – low BP, distended neck veins and muffled heart tones

• Establish 2 large sites of venous access– Peripheral IV’s

– Central venous access

– IO

– Saphenous cut-down

QuickTime™ and aGIF decompressor

are needed to see this picture.

Circulation

Interventions –– Roll under right hip for advanced pregnancy

– IV crystalloid – controversy• 598 Adults with Penetrating Torso Injuries: 70% vs.

62% survival to d/c with permissive hypotension

– Blood transfusion for obvious massive hemorrhage or for persistent hypovolemia after 2 L crystalloid

Circulation

• Thoracotomy– pericardiotomy

– cross-clamp aorta

– suture wounds

– “vascular” access - repair intrathoracic bleeding

– manual cardiac compressions

– eletrocardioversion

Circulation

• Thoracotomy– Overall survival approx. 7.4%

– Neurologically intact…92% (4-7% of total)

– Overall penetrating survival 8.8%• Stab wounds 16.8%

• GSW 4.3%

Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000 Mar;190(3):288-98

What is the percentage of neurologically intact survivors of ED

thoracotomy?

3.9 % overallNone in blunt trauma without VS in the field

23% thoracic stab wounds with VS in field and none in ED

38% thoracic stab with VS in field and ED

Branney SW, Moore EE, Feldhaus KM, Wolfe RE. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma. 1998 Jul;45(1):87-94

CirculationEstimating Blood Loss and Fluid Requirements:

Crystalloid &

blood

Crystalloid &

blood

CrystalloidCrystalloidFluids

Confused-

Lethargic

Anxious &

Confused

AnxiousSl. AnxiousCNS

DecreasedDecreasedDecreasedNormal or

Increased

Pulse Pressure

DecreasedDecreasedNormalNormalBP

>140120 – 140100 – 120<100Pulse

>40%30-40%15-30%<15%Blood loss (%BV)

>20001500-2000750-1500<750Blood loss (ml)

Class IVClass IIIClass IIClass I

Disability: “AVPU”

• Assess level of consciousness

• Elements of the Glasgow Coma Scale• Eye opening = spontaneous (4), to voice (3),

to pain (2), none (0)

• Verbal = oriented (5), confused (4), inappropriate (3), grunting (2), none (3)

• Motor = follows command (6), localize pain (5), withdraws to pain (4), decorticate posture (3), decerebrate posture (2), none (1)

• Limb movement – moving all of them?

Name five clinical signs of basilar skull fracture

Periorbital ecchymosis (raccoon's eyes) Retroauricular ecchymosis (Battle’s sign) CSF otorrhea or rhinorrhea Hemotympanum or bloody ear discharge 1st, 2nd, 7th, and 8th CN deficits

Where is a subdural hematoma located?

•Beneath the dura and over the brain and arachnoid

•Caused by tears of pial arteries or of bridging veins

•Symptoms immediate, or delayed within 24 h to 2 wk after injury

A 29 y old intoxicated male presents after blunt object vs. head. There was brief LOC, but he was then ambulatory and alert. He is now drowsy with emesis. Diagnosis?

Epidural hematoma20% have “classic” lucid interval

85% have overlying fx

2/3 arterial bleeding - most common is middle meningeal

Secondary Survey

• Head-to-toe

• Roll patient with C-spine stabilization

• More thorough exam looking for coincident, less obvious injuries

Imaging in the Bay

• Ultrasound – FAST (Focused Abdominal Sonography in Trauma)– Morison Pouch, Splenorenal space, heart,

bladder

• Likely includes “Trauma Series,” C-Sp (or not), CXR, Pelvis

• Diagnose and treat immediate life threats that must be dealt with

Do you need to go to the OR?

• Persistent instability despite 2L LR and O-blood in the bay

• Where does massive blood loss go?– Chest, abdomen, retroperitoneum, and femur

(pedi: head)

• Obvious injury requiring immediate operative intervention (usually penetrating injury)

Further Studies/Procedures

• Often includes CT head, neck and abdomen

• Other plain films, special studies (eg., aortography, RUG), interventions

Fundamentals

• Parallel Processing – Team approach allows multiple tasks to be accomplished simultaneously.

• Time is your enemy – Work quickly, quietly and efficiently. A clear and practiced “routine” with well defined roles for team member optimizes outcome.

Fundamentals

• Return to the ABC’s if the patient deteriorates

• Be thorough – Don’t skip steps, avoid distraction.

Fundamentals

• Be skilled – Airway management, team management, vascular access, obtaining history and performing physical exam, procedures!

• Be suspicious – If mechanism or other clues suggest an injury, rule it out.

• Be a team player. Trauma management is a team sport!