Trauma Management at ACMC

Trauma is all about algorithms, have a step-wise approach to your primary and secondary surveys and do it every time.

Primary Survey: Remember to call out all of your findings to the trauma team, especially the nurse recording the findings

A: Airway- First question you ask the patient- "What's your name?", the answer is not as important as the fact that they can speak, if they can answer clearly they are protecting their airway state "airway patent" and move on to B, if not prepare to intubate

Reasons to Intubate:

       -Airway obstruction

       -GCS <8

       -Cardiac Arrest

       -Persistent hypoxemia or hypoventilation

       -Concern for smoke inhalation

       -Aggressive/combative patient who's behavior is impairing evaluation

B: Breathing and Ventilation: Auscultate breath sounds in chest bilaterally

-If patient is unstable with unequal breath sounds place a chest tube or perform needle decompression immediately,

-If the patient is stable you can shoot a quick portable x-ray

-If breath sounds are equal state "Breath sounds equal bilaterally"

-Err on the side of calling the breath sounds normal on a stable patient, the CXR or ultrasound will tell you if they need a chest tube

Chest tube insertion video: http://www.nejm.org/doi/full/10.1056/NEJMvcm071974

Needle Decompression video: http://www.nejm.org/doi/full/10.1056/NEJMvcm1111468

C: Circulation: 

Palpate carotid, radial, femoral, dorsalis pedis pulses bilaterally and state if they are present or not, example "2+ carotid pulses bilaterally"

-usually the RT or PCA starts getting a BP on their own, if they haven't this should be the step where you stop and ask for it

-If hypotensive start fluid boluses while awaiting blood products if hemorrhage is thought to be the cause

----2u O- blood (uncrossmatched) is available in the trauma fridge for women of child bearing age

----2u O+ blood (uncrossmatched) is available in the trauma fridge for all other patients

-Consider doing FAST if patient is hypotensive 

-Consider placing a central line if nurses are unable to get peripheral access 

-Apply direct pressure to any bleeding wounds

-Consider pelvic binding if pelvic fracture

Reasons to be Hypotensive:

      -Cardiac Tamponade

      -Tension Pneumothorax

      -Hemorrhage

      -Neurogenic shock

      -Overdose (toxicology)

If a patient needs to go to the OR because of something you find in this step, make sure to finish your primary survey and do what you can to stop accessible bleeding sites before they go to the OR

---pack bullet wounds, staple scalp lacs, etc.

Get an ABI on penetrating extremity injuries.

Pericardiocentesis video: http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841

Pelvic Binding video: http://www.nejm.org/doi/full/10.1056/NEJMvcm1200383

IO placement video: http://www.nejm.org/doi/full/10.1056/NEJMvcm1211371

Subclavian central line placement video: http://www.nejm.org/doi/full/10.1056/NEJMvcm074357

D: Disability: Perform GCS and call it out "GCS 15". Eyes, Verbal, Motor - this is difficulty to remember for some reason so many of us save it as our phone background.  Check pupils bilaterally and call it out. Call out the size pre and post shining a light in them " pupils 3 to 2mm bilaterally" Check gross motor function and sensation. Call out any deficits. To assess orientation, ask their name, where they are, what year it is. 

E: Exposure: Make sure the patient is completely exposed, usually this is happening simultaneously during the rest of the assessment. This is also the step where the patient is turned. Call out any injuries seen, "Laceration to left wrist". When the patient is turned palpate their entire spine looking for step-offs or area of pain, call out any findings "Pain to palpation of mid-thoracic spine". If there is pain to their spine the attending will likely want you to order a CT of their spine. After palpating their spine make sure to do a rectal exam, always for penetrating trauma and likely for blunt, when in doubt do it. You are checking for blood and rectal tone. Gross blood on rectal exam=OR. Always call out whether there is blood or not.   You can skip the rectal exam in blunt patients with wimpy mechanisms who can squeeze their buttocks. 

Make sure to take a good look at the back of the head for scalp lacs that can be quickly stapled while the patient is turned.

Attempt to clear the C-spine before turning the patient in patients who it may be reasonable to do so.  Otherwise you'll need someone to hold C-spine for the turns.

Reasons to go to the OR emergently:

      -Gross blood seen on rectal exam

      -Peritonitis

      -Hypotensive with free fluid (presumed to be blood) on FAST or CT

      -Open fracture - after their ancef!

      -Limb ischemia 

      -Compartment syndrome

      -Intracranial hemorrhage with worsening neuro exam

      -Pericardial effusion requiring pericardial window

      -Pelvic fracture requiring IR for embolization

      -Hypotensive with penetrating trauma to abdomen 

      -Hypotensive with penetrating trauma to thorax which is not relieved by chest tube 

Secondary Survey: Head to Toe exam completed on stable patients. Again do not delay a life saving procedure to get an accurate secondary survey. 

Make sure to palpate every bone and get the appropriate corresponding x-ray for any areas that elicit pain.

Determining appropriate imaging:

X-rays

      - X-rays of any part of the limb which elicits pain

      -1 view chest X-ray in any concern for pneumo/hemo thorax or rib fractures

      -1 view pelvis X-ray in concern for pelvic fractures - this is easy to get and pelvic/femur fractures can be subtle when there are distracting injuries.

      - X-ray of the appropriately corresponding body part any time there is a gun shot wound

CT's

Head: Canadian CT head rule-order a CT head if any of the following: 

                              -GSC<15 two hours after injury

                              -suspected open or depressed skull fracture

                              -any sign of basilar skull fracture

                              -two or more episodes of vomiting

                              -65 years of age or older

                              -amnesia before impact of 30 or more minutes

                              -dangerous mechanism (struck by vehicle, ejected, fall > 3 feet or 5 stairs)

                        Other considerations to suggest getting a head CT

                              -neurologic deficit

                              -seizure

                              -oral anticoagulant use

  C-Spine: NEXUS Criteria-do not need radiography if patients satisfy all of the below:

                              -absence of posterior midline cervical tenderness

                              -Normal level of alertness

                              -no evidence of intoxication

                              -no abnormal neurologic findings

                              -no painful distracting findings

   Canadian C-spine rule:  

          Part 1: Perform radiography in patient with any of the following:

                                 -age 65 years or older

                                 -dangerous mechanism of injury

                              (fall from 3 feet or 5 stairs, axial load to the head,

                              MVC at high speed >62mph, ejection from car, bike collison)

                                 -paresthesias in the extremities

          Part 2: In patient's with none of the above, determine if there are any low-risk factors that allow for safe assessment of neck ROM:

                                 -simple rear-end MVC

                                 -sitting position in ED

                                 -ambulatory at any time

                                 -delayed onset of neck pain

                                 -absence of midline cervical spine tenderness

          Part 3: Patients without any low-risk factors need radiographs, if they do have a low risk factor perform ROM testing:  if able to rotate their neck actively 45 degrees both left and right regardless of pain do not need imaging

Chest:   NEXUS Chest Rules: If all of the below are absent, very low risk of intrathoracic injury, chest imaging not recommended

                              -Age >60 years

                              -rapid deceleration mechanism (fall >20 feet, MVC >40 mph)

                              -chest pain

                              -intoxication

                              -abnormal alertness or mental status

                              -tenderness to chest wall palpation

                              -distracting painful injury

Trauma Resources

Landmark Trauma Articles

Blunt C-Spine Trauma

1)Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000; 343:94. http://www.ncbi.nlm.nih.gov/pubmed?term=10891516

2)Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001; 286:1841. http://www.ncbi.nlm.nih.gov/pubmed?term=11597285

Blunt Head Trauma

3)Haydel MJ, Preston CA, Mills TJ, et al.. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000; 343: 100–105. http://www.ncbi.nlm.nih.gov/pubmed/10891517

4)Stiell IG, Wells GA, Vandemheen K, et al.. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001; 357: 1391–1396. http://www.ncbi.nlm.nih.gov/pubmed/11356436

Blunt Abdominal Trauma

5) Holmes JF, McGahan JP, Wisner DH. Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma. Am J Emerg Med 2012; 30:574 http://www.ncbi.nlm.nih.gov/pubmed?term=21641163

6)Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA 2012; 307:1517. http://www.ncbi.nlm.nih.gov/pubmed/22496266

7)Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004; 56:314. http://www.ncbi.nlm.nih.gov/pubmed?term=14960973

8)Livingston DH, Lavery RF, Passannante MR, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial. J Trauma 1998; 44:273. http://www.ncbi.nlm.nih.gov/pubmed/9498497

Penetrating Abdominal Trauma

 9) Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010; 68:721. http://www.ncbi.nlm.nih.gov/pubmed/20220426

Blunt Thoracic Trauma

 10) Rodriguez RM, Anglin D, Langdorf MI, et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013; 148:940. http://www.ncbi.nlm.nih.gov/pubmed?term=23925583

Thoracolumbar Spinal Blunt Trauma

11) Sixta S, Moore FO, Ditillo MF, et al. Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73:S326. http://www.ncbi.nlm.nih.gov/pubmed?term=23114489

Blood Transfusion

12) CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376:23. http://www.ncbi.nlm.nih.gov/pubmed/20554319

13) Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. J Trauma 2009; 67:1439. http://www.ncbi.nlm.nih.gov/pubmed/19773646

Pelvic Fractures

14) Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma 2011; 71:1850. http://www.ncbi.nlm.nih.gov/pubmed?term=22182895