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 This is where we can make a difference The priority of the ED physician is to assess, resuscitate, stabilize on a priority basis ATLS Guidelines

Assessment: Primary Survey Evaluate for immediate life threats Management of issues immediately ABC’s (and D &E)

Airway Assessment Intervention 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 Always maintain in-line cervical stabilization! Think c-spine in multiple injured, altered LOC, trauma above clavicle No NPA/NTI in facial trauma/basilar skull fx = risk direct oxygenation to brain! In children <8rs, uncuffed tube Needle cricothyroidotomy preferred to surgical in < 12yo

Breathing Assessment Intervention 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 Oxygenation vs actual VENTILATION!

Circulation Assessment Intervention 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?) Length and diameter of catheter (r to the 4th!) The shorter/fatter the catheter, the faster the fluid can go in!

Primary Survey Disability AVPU Posturing? Seizing? Awake Verbal Painful Unresponsive Posturing? Seizing? AVPU is qualitative assessment GCS is quantitative assessment

Mild Moderate Severe GCS 14-15 GCS 9-13 GCS =/<8 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 Verbal Response (V) Oriented Confused conversation Inappropriate words Incomprehensible sounds Mild GCS 14-15 Moderate GCS 9-13 Severe GCS =/<8 Remember, pt’s BEST response! Intubate for </= to 8 or non-purposeful motor response

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 No Foley if blood at urethral meatus, scrotal hematoma, high-riding prostate (retrourethrogram)

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 Typically at least a chest Rarely lat C-spine – certain indications Pelvis if clinically indicated Extremities as clinically indicated

Imaging CT scan? (the “Grand Slam” if all done) Head Neck Face Chest Abdomen Pelvis Be selective in your choices vs. the “trauma scan”

Labs Type and screen or cross CBC CMP Coags UA-visually inspect for gross hematuria UPT T&C is most important (as well as UPT in female) Coags handy for those w/liver dz or anticoagulated Rest show baseline… CBC – Hct may be normal until volume replaced and then hemodilution occurs

IV Fluids Crystalloids Colloids Normal Saline Lactated Ringers 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) Crystalloid volume needed to replace blood loss 3ml:1ml

Hypovolemic Shock Blood volume Replacement Adults: 7% of weight Peds: 8-9% of weight Replacement http://www.trauma.org/resus/massive.htm

Classes of Hemorrhagic Shock Blood Loss % Vol. Blood Loss (cc) HR PP sBP Urine Output AMS Rx I < 15% <750cc <100 Norm No Crystalloids (3:1 rule); no PRBC II 15-30% 750-1500 ↑ ↓ Crystalloids; +/- PRBC III 30-40% 1500-2000 ↑↑ ↓↓ Yes Crystalloids + type=spec PRBC IV >40% >2000 ↑↑↑ ↓↓↓ 2L crystalloid bolus + uncross’d PRBC

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