1. ED Approach to the Trauma Patient
University of Utah Medical Center
Division of Emergency Medicine
Medical Student Orientation

2. 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

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

4. 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

5. 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!

6. 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!

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

8. 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

9. Primary Survey Expose/Environment Undress
Protect from becoming hypothermic
Warm room
Warm blankets
Warm fluid

10. Assessment: Secondary Survey
A thorough once-over
Fingers & Tubes
AMPLE history

11. 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

12. 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)

13. Secondary Survey AMPLE History Allergies Meds PMHx/PSHx Last meal
Events leading up to accident

14. Secondary Survey Reassess vitals Better or worse?
Further intervention needed?
Transfer patient?

15. 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

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

17. 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

18. IV Fluids Crystalloids Colloids Normal Saline Lactated Ringers PRBC
FFP
Factors in hemophiliacs

19. 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

20. Hypovolemic Shock Blood volume Replacement Adults: 7% of weight
Peds: 8-9% of weight
Replacement

21. 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% ↑ ↓
Crystalloids; +/- PRBC
III
30-40% ↑↑ ↓↓
Yes
Crystalloids + type=spec PRBC IV
>40%
>2000
↑↑↑
↓↓↓
2L crystalloid bolus + uncross’d PRBC

22. Where Can you Lose Blood?
Environment
Chest
Hemothorax: % volume each side
Aortic rupture
Cardiac rupture
Abdomen
Pelvis: 3-4L retroperitoneal
Femur : 1-1.5L

23. Summary Preparation ABCDE’s Secondary Survey Imaging Lab
Hemorrhagic Shock
The Basics