Trauma, Multiple Updated 5/2012

Trauma, Multiple Updated 5/2012

This topic is from Rosen and Barkin's 5-Minute Emergency Medicine Consult

Trauma, Multiple Updated 5/2012
Daniel Davis


BASICS
Description
Standardized approach for rapid assessment of the trauma patient
Although presented as a sequential method for gathering information, many of these steps can be performed simultaneously.
Life-threatening injuries must be immediately addressed and treated before going on to the next level of care.
With any change in the patient’s status, the primary survey should be repeated.
Etiology

Variety of causes such as:
Motor vehicle/motorcycle crashes
Falls from heights
Assault
Airplane crashes
Train derailments
Results of mass-casualty weapons
Terrorism

DIAGNOSIS
Triage to a major trauma center is determined by local protocols.
Injured patients with a need for surgical, neurosurgical, or orthopedic intervention should be transported to a major trauma center.
Recent recommendations from the American College of Surgeons suggest that trauma victims with unstable vital signs should be taken to a Level I trauma center, where a larger volume of critically injured patients are seen.
Primary survey should be performed at the scene and en route.
Signs and Symptoms
Primary survey (ABCDE):
Airway, cervical spine:
Look, listen, and palpate from nose/mouth to trachea/bronchial tree.
Assess airway patency.
Evaluate gag reflex.
Cervical spine must be immobilized with significant mechanism of injury and either altered mental status or distracting injuries or with signs and symptoms suggestive of neck injury.
Ability to speak or effective movement of air with respiration indicates patency.
Gurgling, stridor, wheezing, snoring, choking, or absence of air movement requires immediate intervention.
Manage airway compromise before next step in primary survey.
Breathing:
Awake, alert patient with normal speech and good air movement suggests effective breathing.
Symmetric chest wall rise/fall, equal breath sounds, normal respiratory rate, and oxygen saturation at 95% or more suggest effective breathing.
Asymmetric chest movement, unequal breath sounds, abnormal respiratory rate, decreased oxygen saturation, inadequate air movement, or an obtunded patient suggests ineffective breathing.
Decreased unilateral breath sounds, tracheal shift, hyperexpansion, hyperresonance to percussion, subcutaneous air, hypoxia, or hemodynamic compromise raises concerns about tension pneumothorax.
Decreased breath sounds with dullness to percussion suggest hemothorax.
Manage patients immediately with needle thoracostomy followed by tube thoracostomy.
Circulation:
Adequate circulating blood volume must be maintained.
Primary assessment includes BP, heart rate, pulse quality, and end-organ function (eg, mentation, urine output, capillary refill).
Tachycardia and oliguria indicate early shock; hypotension is a late finding.
Disability:
Assess level of consciousness, gross motor function, and pupillary size/reactivity.
Glasgow Coma Scale is most commonly used; score of ≤8 indicates severe head injury/coma.
Spinal cord injuries are grossly assessed by observing movement of all extremities.
Pupillary size and reactivity to light measure brainstem function.
Exposure:
Patient should be undressed completely.
Secondary survey:
After the primary survey has been completed
Patient stabilized at each level
Complete physical exam from head to toe is performed.
“Tubes and fingers in every body cavity”
History

The mechanism of injury, initial clinical presentation, suspected injuries, and treatment rendered should be elicited from EMS personnel.
Physical Exam

Initial stabilization should begin simultaneously with essential workup.
Essential Workup
Primary and secondary survey
Cervical spine and chest radiographs are mandatory for victims of major trauma.
Pelvic radiographs should be performed with clinical suspicion of pelvic trauma or with hemodynamic instability.
Hemoglobin/hematocrit, ABG, blood type
Urine dip for blood
UA if dip shows positive result
Urine-based pregnancy test for any female patient of childbearing age
Tests
Lab

Baseline coagulation and chemistry studies with massive injury or hemorrhage
Imaging
Loss of consciousness, posttraumatic amnesia (anterograde or retrograde), or persistent altered level of consciousness is indication for head CT.
Significant blunt and penetrating chest trauma requires objective evaluation of the heart and great vessels with echocardiography, CT scan, angiography, or direct visualization.
Blunt abdominal trauma requires objective evaluation using US, abdominal CT, or diagnostic peritoneal lavage, depending on patient’s condition:
Hemodynamically stable patients should have an abdominal CT with IV contrast.
Unstable patients should have an abdominal ultrasound (FAST exam) or diagnostic peritoneal lavage.
Many centers now doing “Pan CT scan,” including head, neck, chest, abdomen/pelvis in a single pass with IV contrast
Pan CT lowers missed injury rate but involves significant radiation exposure
Extremity injury:
Radiographs
Suspected vascular damage requires angiography or duplex ultrasound.
Differential Diagnosis
Some level of clinical suspicion should be maintained for other medical conditions leading to trauma (eg, seizures, dysrhythmias).


TREATMENT
Initial Stabilization
The initial treatment should parallel the primary survey with injuries treated before addressing the next assessment level.
Airway with cervical spine control:
Jaw thrust, suctioning, and oropharyngeal or nasopharyngeal airways provide initial airway support.
Rapid sequence intubation is the airway management option of choice for multiple trauma patients:
Insertion of an extraglottic airway (eg, Combitube, laryngeal tube, or laryngeal mask airway) or cricothyroidotomy may be necessary.
Breathing:
100% oxygen and respiratory monitoring
Tension pneumothorax should be diagnosed clinically and decompressed on an emergency basis with a needle thoracostomy below the axilla or above the second rib in the midclavicular line.
Tube thoracostomy should follow.
Open chest wounds should be covered with an adherent dressing and a tube thoracostomy performed.
Respiratory distress from flail segment or pulmonary contusion should prompt early intubation with mechanical ventilation and positive end expiratory pressure.
Hyperventilation should be avoided except with impending herniation or intracranial HTN resistant to other therapies; end-tidal carbon dioxide monitoring should be used.
Circulation:
Two large-bore IV lines with constant hemodynamic and cardiac monitoring should be placed.
Alternatives include central lines, venous cut-downs (eg, saphenous or femoral), or intraosseous lines.
Aggressive fluid replacement with 3 parts fluid for every 1 part circulatory volume loss remains the standard of care; adjust fluids based on ongoing assessment:
2 L initial bolus in adults, 20 mL/kg in children
Whole blood or autotransfused blood for hemorrhagic shock or uncontrolled bleeding
Pericardial tamponade requires emergent pericardiocentesis/pericardial window.
External bleeding should be managed with direct pressure.
Disability:
Head injury with Glasgow Coma Scale score of ≤8 should initiate treatment for elevated intracranial pressure with mannitol or hypertonic saline, rapid-sequence intubation, oxygenation, and controlled ventilation to a Pco2 of 35 mm Hg.
Elevate head 20–30°, maintaining spine immobilization.
ED Treatment
Definitive treatment is often surgical.
Prompt stabilization, early recognition of the need for operative intervention, and appropriate trauma surgical consultation are paramount.
Medication (Drugs)

Dictated by need for specific interventions
ALERT: Pediatric ConsiderationsIntraosseous lines are an alternative to IV lines for fluids and medications.
In-patient Considerations
Admission Criteria
Most major trauma patients should be admitted for observation, monitoring, and further evaluation.
Patients with significant injuries or hemodynamic instability should be admitted to an ICU.
Patients requiring frequent assessments should be admitted to a monitored setting.
Discharge Criteria

Patients with minor trauma and negative objective workup/imaging may be observed in the ED for several hours and then discharged.
Issues for Referral

The main indications for referral concern the availability of subspecialists, such as neurosurgeons, orthopedists/hand surgeons, otolaryngologists, plastic surgeons, or intensivists.


Ongoing Care
Follow-Up Recommendations

Follow-up should be driven by the types of injuries and subspecialty care required.