Trauma Notes
Preparation
Eye protection
Gown
Gloves
Trauma Team
Handover
M
Mechanism of injury
I
Injuries found
S
Signs (Obs)
T
Treatment
Primary Survey – BEGINS WITH EXPOSURE OF PATIENT, then…
A
Airway (with Cspine control)
B
Breathing with O2
C
Circulation (with control of bleeding)
D
Disability (Neuro status)
E
Exposure (body temp)
Airway
 More important than C-spine
 Can remove collar to intubate with manual in line stabilisation
 Upper Airway – LOOK & FEEL
o Burned Airway
 Do not delay with burned airway – intubate early
 Burns in/around mouth/lips/nose, edema of face/lips
 Resp distress
 Hoarse voice
 Beware CO poisoning – hyperbaric O2 if CO > 30%
o Facial Injury
 Mid face fractures – slide backwards obstruct airway
 May be better to sit up (with collar)
 Fractured jaw
 Bleeding
o Foreign Body
 Dentures/teeth
 Blood
 Other
 Lower Airway
o Examine Neck 6 times when checking airway
 T Trachea – deviation
 Wounds – threatening airway/circulation (lacs/compression)
 Emphysema
 Larynx - ?intact
 Veins - ?distended (tamponade, PTX)
 DON’T FORGET to check under collar

All patients with GCS < 9 need intubation

Cricothyrotomy when all else fails
o For upper airway obstruction
o Beware subcut tracking of O2 – lose landmarks
Pitfalls:
1.
2.
3.
4.
Foreign body in the airway
Mandibular or maxillofacial fracture
Tracheal or laryngeal disruption
Cervical spine injury
Breathing
 Inspect
 Paplpate
 Auscultate
 All trauma patients are hypoxic: Mx = high conc. O2
o Airway compromise
o Chest injury
o Head injury
o Hypovolaemia
o Pain
o Chronic Lung Disease = MORE HYPOXIC
 CO2 kills slowly, no O2 kills quickly
 6 Life threatening chest conditions must be considered
o Airway Obstruction
o Tension Pneumothorax – needle decompression
o Open pneumothorax – 3-sided seal dressing, or IPPV + ICC on suction
o Massive haemothorax – FLUID BEFORE ICC
o Cardiac Tamponade
o Flail Chest
 Treat contusion (ventilatory support prn)
 ICC before ventilation (small PTX may tension)
Pitfalls:
1.
2.
3.
4.
Tension pneumothorax
Flail Chest with pulmonary contusion
Open pneumothorax
Massive Hemothorax
Circulation
 FEEL PULSE, CHECK BP, ATTACH MONITOR & SAT PROBE
 IV – SHORT & THICK (minimum 16G)
 Control Obvious Blood Loss
o Control haemorrhage – pressure dressings
o LOG ROLL to check BACK/BOWEL
 Hidden Blood Loss will CRAMP your style
o C
Chest - CxR
o R
Retroperitoneum – Check Urine
o A
Abdomen – FAST scan, CT, DPL
o M
Missed Long Bone Fracture
o P
Pelvis
 Fluid Resuscitation
o Crystalloid
o Colloid
o O-Negative (NOT > 4 units if Bld Grp unknown)
o X-matched blood
 Burns
o Parkland Formula (crystalloid)
 weight (kg) x %burn x 4 = ml crystalloid in 1st 24hrs
 ½ in first 8 hours
o Muir/Barclay (colloid)
 (weight (kg) x %burn) / 2 = ml colloid/unit time
 Unit Time = 4/4/4/6/6/12 hrs
 Urine Output
o Adult 30-50ml/hr
o Child: 1-2ml/kg/hr
 Head Injury alone does not cause hypotension
o ↑ ICP – HYPERtension & bradycardia (Cushing Response)
o
 Neurogenic shock is hypovolaemic shock until proved otherwise
o ie high spinal injury – lose symp tone
 EMD
o Hypoxia
o Hypovolaemia
o Hypothermia
o Hypo/Hyperkalaemia
o Tamponade
o Tension PTX
o Toxins, drugs/poisons
o Thromboembolism (massive PE)
Pitfalls: Hypovolemia resulting from
1.
2.
3.
4.
Intra-abdominal or intrathoracic injury
Fractures of the femur and/or pelvis
Penetrating injuries with arterial or venous involvement
External hemorrhage from any source.
Disability (Neurologic Status)
 GCS
o Does not measure prognosis
o < 9 = intubation
 Pupils & Plantars
 Lateralising signs
o Unilateral weakness/anaesthesia
 Agitation
o BEWARE: Agitated patients calm down while deteriorating
o Causes:
 Hypoxia
 Cerebral Irritation (cerebral oedema, intracranial haemorrhage)
 Pain
 Anxiety
 Full Bladder
 EtOH/Drugs
o Sedating Pt to control airway is acceptable
o MUST search for causes of agitation
 PAIN
o It’s OK to give analgesia
 Reassurance
 Splints
 N20 – CI in CHEST INJURY/PTX
 Opiates/Ketamine (0.5-1.0mg/kg) – IV
 Local Anaesthetics/Nerve Blocks
Exposure/Environmental
 Temperature
o Hypothermia = core T < 35°
 Mild 32-35
 Mod 30-32
 Severe <30
 Asystole @ 18-20
 VF may not respond to DCR until T > 30
o Management
 Remove wet clothes/sheets, Dry Pt
 Cover – space blanket/warm blankets
 Warm IV fluids
 Bear Hugger
Secondary Survey
Bones
Brain
Back
Bowel/Abdo
Investigations
Bloods
ABG
FAST
Radiology
Transferring Pt to radiology
Tertiary Survey
Penetrating Injury – In extremis:
Number one concern: AIRWAY
 Head
o Pressure on wound
o Fluid
o Cerebral Function
 Yes – CT +/- OR
 No – deceased
 Chest
o Bilateral chest tubes
o Thoracotamy prn
o OR
 Neck/Abdo/Extremity
o Pressure on wound
o OR