Introduction to
Trauma
LSU Medical Student Clerkship,
New Orleans, LA
Trauma
Goals
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Review the components of the primary and secondary
survey for a trauma patient
Identify injuries requiring immediate intervention during
primary survey
Review the initial steps of resuscitation of a trauma patient
in the ED
Review the advantages and uses of diagnostic modalities in
the trauma patient
Discuss the appropriate disposition of the trauma patient
from the ED.
Trauma
Epidemiology
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Trauma is a disease.
Trauma is predictable, preventable, and treatable.
Trauma is the 4th leading cause of death in the US.
Trauma is the leading cause of death in people
below the age of 45 in the US.
3.8 M deaths/ year/ worldwide
312 M injured
Trauma
Epidemiology
•Trimodal
distribution
of mortality
•Prehospital (Major
head injuries, rapid
exsanguination)
•Early Hospital
(Head, chest,
abdominal trauma)
•ICU (End result of
prolonged
hypoperfusion)
Trauma
History of Trauma Systems
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1991: Congress passed the Trauma Care Systems Planning
and Development Act requiring the development of a Model
Trauma Care System Plan to be used as a reference
document for each state to develop its system
Based on the severity of injury, patients are triaged to
trauma centers
The American College of Surgeons has developed
requirements for trauma center certification of commitment
of personnel and resources needed to maintain a state of
readiness to receive critically injured patients.
The Golden Hour
Trauma
History of Trauma Systems
Trauma
Initial Approach
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The initial approach to trauma care in the ED is
a process that consists of an initial primary
assessment, rapid resuscitation, and a more
thorough secondary survey followed by
diagnostic tests and ultimate disposition.
Subsequent mortality and morbidity tied directly
to the initial assessment and resuscitation
Trauma
Trauma
Primary Survey
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Rapid examination to identify and treat life threatening
conditions. Ideally is performed in a few minutes.
A - Airway (with C-spine precautions)
B - Breathing
C - Circulation
D - Disability
E – Exposure
When derangements in any of the components of the primary
survey are identified, treatment is undertaken immediately.
Trauma
Primary Survey - Airway
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Maintain C-spine precautions
Clear any obstructions
Jaw thrust instead of head tilt chin lift
Endotracheal intubation for airway protection or
expected clinical course (ie,obstruction from blood or vomitus,
neck hematoma, facial burns or trauma, GCS 8 or less, combative patient,
potential for airway compromise while out of department.)
Trauma
Primary Survey - Breathing
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Auscultation for bilateral breath sounds
Palpation for subcutaneous emphysema
-needle decompression followed by chest tube for pneumothorax
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Inspection for flail chest
Observation of respiratory rate, oxygen
saturation, and overall work of breathing
-mechanical ventilation for inadequate ventilation or to decrease work of
breathing
Trauma
Trauma
Primary Survey - Circulation
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Check peripheral pulses, heart rate, BP, pulse
pressure, capillary refill, cyanosis
All hypotensive trauma patients are assumed to
be in hemorrhagic shock
2 large bore peripheral IV’s (at least 18 gauge)
Control external bleeding
Trauma
Trauma
Primary Survey - Circulation
Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial
Presentation
Class I
Class
II
Class
III
Class
IV
Blood loss (mL)*
Up to 750
750–1500
1500–2000
>2000
Blood loss (percent blood
volume)
Up to 15
15–30
30–40
40
Pulse rate
<100
100–120
120–140
>140
Blood pressure
Normal
Normal
Decreased
Decreased
Pulse pressure (mm Hg)
Normal or
increased
Decreased
Decreased
Decreased
*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.
Trauma
Primary Survey - Circulation
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Begin volume resuscitation with liter boluses of
crystalloid for class I or II hemorrhage.
Begin crystalloid and blood for class III or IV
hemorrhage.
O- blood until type specific is available
Constant reevaluation is paramount
If class I or II is patient still showing signs of shock after
3L of crystalloid, begin blood
“3:1 rule” 3cc crystalloid for every 1cc of blood loss
Trauma
Primary Survey - Circulation
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5 Places life threatening hemorrhage can occur
-Chest
-Abdomen
-Pelvis
-Thighs
-Externally
Trauma
Primary Survey - Circulation
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Cardiac Tamponade can cause hypotension
with little blood loss.
Becks triad: hypotension, distended neck veins,
muffled heart sounds
Easily confirmed with ultrasound
Pericardiocentesis
Trauma
Trauma
Trauma
Primary Survey - Disability
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Quick assessment of ability to move all extremities
Glascow Coma Scale
Trauma
Primary Survey – Exposure
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Completely undress the patient and inspect the
entire patient from head to toe both front and back.
Maintain spinal precautions during logrolling
Inspect both axillae and peritoneum
Warm blankets!!!
Trauma
Secondary Survey
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Head to toe evaluation once any derangements in
primary survey have been addressed.
AMPLE History
-Allergies
-Medications
-Past medical history (LMP, Td, transfusions)
-Last meal
-Events leading up to trauma
Trauma
Imaging
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Choice of imaging modality depends on nature
of injuries and stability of patient.
Knowledge of injury mechanism and index of
suspicion most important
Trauma
Imaging – Plain Films
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Quick
Can be performed at bedside
Useful for rapid identification of pneumothorax,
hemothorax, fractures and locating ballistics
Trauma
Trauma
Imaging – Ultrasound
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Quick
Can be performed at bedside
FAST: Focused Assessment with Sonography
for Trauma
Rapid examination to identify free intraperitoneal
fluid and/or pericardial fluid
Trauma
Trauma
Imaging – CT
•Detailed
•Requires
patient
to leave the
department
•Necessary for
head trauma
Trauma
Trauma
Disposition
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To the OR
-Unstable patients with blunt or penetrating abdominal
trauma or chest trauma. Hemothorax with >1500 cc of
blood out initially. Surgical injuries identified with
imaging.
Admission
-Nonsurgical, high-risk injuries
Discharge
-Stable patients, minor or no injuries identified.