Download Approach to Trauma Patients

Approach to Trauma
Patients
Joseph Turner, MD
Indiana University School of
Medicine
Objectives

Describe the initial approach to the injured patient,
including the primary and secondary surveys.

Describe the clinical presentation and initial
treatment measures for life threatening injuries.

Identify the types and clinical presentations of
shock. Identify the classes (I, II, III, IV) of
hemorrhagic shock.

Understand the benefits and downsides of imaging
trauma patients

Describe approach to assessing cervical spine
trauma
Case 1

32 yo female restrained driver in a rollover
MVA
– 25 minute extrication
– complaining of chest pain and difficulty
breathing
– EMS reports that the windshield is starred and
the steering column was bent
Mechanism of Injury

Gives information about the forces
potentially involved in the traumatic
mechanism
– Guides diagnostic testing
 More force more likely to have injury
– Determines Trauma center activation
 Shorter time to arrive at definitive care
 Determined by mechanism and vitals
Case 1

Vitals
– HR 94 BP 88/56 RR 26 Biox 93%

Where do you take the patient?

Would you be more or less concerned if
this were a 83 yo female?
Susceptibility to Injury

Some populations more vulnerable to
injuries
– Elderly
 More likely to have injuries from given force
– Lower bone density, brain atrophy, co-morbities
– Alcoholics
 Brain atrophy leads to more subdural hematomas
– Coagulolopathic
 warfarin, cirrhotic
Primary Survey

Goal is to identify and treat any life
threatening injuries
– Some components are evaluated
simultaneously in large trauma centers
– All resources are directed toward stabilizing
that injury until it is corrected
Airway

Evaluate for patency and secure it if it is
not adequate
– Usually endotracheal intubation
– Keep cervical spine immobilized inline if any
concern for spine fracture

Identify injuries that if not treated will
threaten the airway
– Intervene before it becomes too difficult

What are some signs or
symptoms that might indicate
that the patient needs an airway
intervention?
Airway obstruction
 Severe respiratory distress
 Altered mental status (GCS < 8 --> Intubate)
 Critically ill


If something changes – start over
at the top
Breathing

Listen to breath sounds
– Look, feel, trachea position

Oxygenation
– Skin color, pulse ox
Circulation

Heart rate and blood pressure
– Look for signs of shock
 Cap refill, mental status

Feel pulses
– Check above and below waist and on both
sides
 Looking for vascular injury

Listen for muffled heart tones
– Ultrasound helpful
Disability

Rapid neurologic assessment
– Formal Glasgow Coma Score
– Eye opening, verbal and motor
– Gross motor exam for quadro/paraplegia
 Heighten suspicion for spinal cord injury
– Palpate spinal cord
– Rectal tone?
Exposure/Environmental
Control

Remove clothing to
evaluate for external
evidence of injury

Keep patient warm
– hypothermia will
complicate many
injuries
Secondary Survey

Starts once the primary survey is complete
and all injuries identified there have been
stabilized

Head to toe examination of the patient to
evaluate for additional injuries
– Evaluate need for imaging studies to identify
injuries
Case 2

24 yo male patient involved in a drive by
shooting

Suffered with multiple gunshot wounds to
the chest and abdomen. There were 2
fatalities at the scene

Vs HR 124 BP 76/p RR 36
Primary Survey

Airway

Breathing
– Breath sounds diminished on right side,
trachea deviated to left

What is going on and what are you going
to do about it?
Tension Pneumothorax

Diminished breath sounds and
hypotension
– Hyper-resonance, JVD; deviated trachea late sign

Treatment is needle thoracostomy,
followed by tube thoracostomy
– large gauge angio in 2nd intercoatal space in mid
clavicular line
– get rush of air and improvement in vs
– needs immediate tube thoracostomy
Primary Survey
Airway
 Breathing
 Circulation

– Low blood pressure and elevated heart rate
 HR 124 BP 76/p
SHOCK
Hemorrhagic
2. Hemorrhagic
3. Hemorrhagic
4. Hemorrhagic
5. Hemorrhagic
6. Hemorrhagic
7. Hemorrhagic
8. Hemorrhagic
9. Cardiogenic
10. Neurogenic
1.
Top 10 Types
of Shock
in Trauma
Patients
Hemorrhagic Shock

Class I- <15% blood loss
– Minimal symptoms and normal vitals

Class II- >15% blood loss (800-1500 cc)
– Tachycardia, decreased pulse pressure,
delayed cap refill

Class III- >30 % blood loss (1500-2000
cc)
– Tachycardia, tachypnea, hypotension
– Usually requires transfusion
Hemorrhagic Shock

Class IV- > 40% blood loss (>2000 cc)
– Immediately life threatening
– Marked abnormalities in vitals
– Skin cool, diaphoretic
– Negligible urinary output
– Depressed mental status
Treatment of Hemorrhagic
Shock

Stop the bleeding
– Locate and control bleeding
sites
– Body sites an adult can
bleed and develop shock






Chest
Abdomen
Retroperitoneal
Pelvis
Femur
External losses

Volume Resuscitation
– Isotonic fluid
 Start with 1-2 liters
– Blood
 Switch to quickly if not
stable with crystalloid
 If hypotensive start
early with O-neg
 Send type and cross to
get type specific ASAP
J Trauma Acute Care Surg. 2013 May;74(5):1215-21

Assure that the patient has adequate IV
access in order to deliver large amounts of
volume quickly
– Two 18 G or larger Ivs
– Or Central Access

Key is short and fat catheters deliver fluids
and blood faster
– Flow directly proportional to diameter of catheter
and inversely proportional to length of catheter
Tranexamic Acid?

Antifibrinolytic agent

Decreases bleeding and need for
transfusion

Reduced mortality in CRASH-2 trial
Primary Survey

Airway

Breathing

Circulation
– Low blood pressure and elevated heart rate
 shock
– No palpable pulse in right leg with gsw to
thigh
Assess neurovascular status

Vascular Exam
– Hard Signs
 No palpable or dopplerable pulse, visible pulsatile bleeding,
bruit or thrill over artery, expanding hematoma
– Soft Signs
 Decreased pulse compared to extremities, neurologic
abnormality, fracture or penetrating injury in proximity to
artery

Neuro exam
– Assess motor and sensory nerve function
 distal to injury
Ankle-Brachial Index

Useful adjunct in vascular assesment
– SPB in leg/SBP in arm while patient laying
down
 Normal is >0.9
– Less than 0.9 is indication for further
diagnostic testing
 Angiogram (CT or fluoroscopic)
 Exploration
Case 2:Outcome

GSW to right chest with tension
pneumothorax
– Chest tube placed and 300 cc blood removed
 >1000 cc (20cc/kg) initally or 150cc/hr continuing
– indications for exploration in the OR

Pulse in right leg dopplerable, but ABI 0.4
– Get angiogram to evaluate when stable
Case 3

38 yo female fell from a 3rd story window

She complains about a headache and
abdominal pain
– Very brief loss of consciousness

Vitals
– P 94 BP 110/60 RR 20 Biox 97% on RA
Primary Survey

Airway
– Intact, patient speaking

Breathing
– No distress, normal biox

Circulation
– No evidence of shock or pulse deficit

Disability
– GCS 15, non focal neuro
Secondary Survey

HEENT - PERLA, EOMI, no scalp lac, hematoma
over left temple

Chest - TTP in right lower chest, equal bs

Abdomen - soft tender in right upper quadrant,
no peritonitis

Pelvis - stable to rock and compression, pain on
palpation of right hip

Neurologic exam - GCS 15, 5/5 strength
throughout, no sensory deficits
What tests do you order at
the bedside?

Chest X-ray
– To look for pneumothroax, pulmonary
contusion or wide mediastinum

Pelvis X-ray
– To look for pelvic fractures

FAST Scan
– Bedside ultrasound to evaluate for abdominal
fluid
Focused Assessment with Sonography for
Trauma
FAST Scan



Portable
Non-invasive
Evaluates for intraperitoneal
and pericardial fluid
– as little as 300 cc detected



Reliably predicts need for
laporotomy in hypotensive
trauma patients
Not sensitive for solid organ
injury and retroperitoneal
injuries
E-FAST (extended-FAST)
– Looks for pneumo/hemothorax
Case 3

CXR, FAST negative
– Now what?

PanScan?
– Routine CT imaging of head, cervical spine,
chest, abdomen for trauma patients
– Probably beneficial for critically injured
patients
Downsides to Imaging

Radiation exposure

Contrast nephropathy

Cost/charge

Resource utilization

Incidental findings
What tests do you order?

Head CT
– Identifies intercranial hemorrhage
 Subdural, epidural, subarachnoid or interparyenchymal
– Will identify patients who need evacuation of blood
prior to clinical deterioration
– Many patients with severe brain injury have normal
head CTs
 From diffuse axonal injury
 Don’t let a normal head CT fool you into thinking that the
patient doesn’t have a head injury
Who needs a head CT?

Decision Rules
– Nexus 2, Canadian Head CT, CHIP Rule, New
Orleans Criteria
– Fairly sensitive though not 100% and
specificity may not be enough to reduce CT
use that much compared to clinical judgment
 Work better for ‘clinically important injuries’
– Requiring observation or neurosurgical intervention
Who needs a head CT?

Generally accepted indications:
–
–
–
–

Persistent altered mental status
Focal neurologic deficits
Signs of basilar skulls fracture
Coagulopathic
Other factors
– Loss of consciousness, vomiting, age >60, severity of
headache, scalp hematoma/contusion

Important to take mechanism of injury into
account when deciding to order head CT
ACEP Guidelines

Level A recommendations. A noncontrast head CT is indicated in
head trauma patients with loss of consciousness or posttraumatic
amnesia only if one or more of the following is present: headache,
vomiting, age greater than 60 years, drug or alcohol intoxication,
deficits in short-term memory, physical evidence of trauma above
the clavicle, posttraumatic seizure, GCS score less than 15, focal
neurologic deficit, or coagulopathy.

Level B recommendations. A noncontrast head CT should be
considered in head trauma patients with no loss of consciousness or
posttraumatic amnesia if there is a focal neurologic deficit, vomiting,
severe headache, age 65 years or greater, physical signs of a basilar
skull fracture, GCS score less than 15, coagulopathy, or a dangerous
mechanism of injury.*
Abdominal CT

Used to evaluate for intra-abdominal,
retroperitoneal and pelvic injuries

Excellent detail of solid organ injuries
– Spleen and Liver Laceration classification
Abdominal CT

Bone windows allow visualization of spine
and pelvic fractures
– Equivalent or better than plain films

Hollow viscous injury
– Historically a weakness of CT
– New generation multi-slice spiral scanners
much higher sensitivity
Chest CT

Evaluates for aortic injury
– High risk patients – rapid deceleration
– Abnormal mediastinum on plain chest xray

More sensitive than chest x-ray for small
pneumothorax or pulmonary contusion
– Some are so small they don’t need treatment
Case 4

Two patients on backboards and c-collars
after being in a motor vehicle accident

Patient A is complaining of neck pain and
Patient B is screaming in pain from his left
shoulder. They are yelling that the collar
and backboard are making things worse.
– They want the collars off and to be taken off
the board. What do you want to do?
Patient A

24 yo female complaining of neck pain,
unrestrained passenger who has also been
drinking alcohol and her speech is slightly
slurred. No other injuries noted
– Neck seems non-tender
– Neuro exam reveals no focal deficits
Can you clinically clear this patients c-spine?
Patient B

Restrained driver and is complaining of left
shoulder pain and left ankle pain. He denies
alcohol use and doesn’t seem intoxicated
clinically.

States that his left shoulder commonly
dislocates and that he needs out of the collar
so he can turn his head to pop it back in.
Physical Exam

Patient B’s neck is non-tender on exam

Left shoulder with obvious anterior
dislocation
– Neurovascular exam is intact

Left ankle with swelling and deformity,
tender on palpation

Can you clinically clear this patient’s cspine?
Clinical C-spine Clearance

Based on NEXUS Criteria (NEJM, 343(2), 2000)
– Study involved 34,000 patients who had imaging of
the cervical spine after blunt trauma

All criteria must be met in order to clear pt.
– Absence of tenderness in the posterior midline over
the cervical spine
– Absence of a focal neurologic deficit
– Normal level of alertness
– No evidence of intoxication
– Absence of clinically apparent pain that might distract
the patient from the pain of a cervical spine injury
Clinical Spine Clearance

If patient meets all five NEXUS criteria
they can be taken out of c-collar without
x-rays
– Study had 99% sensitivity for clinically
significant injuries

Palpate thoracic and lumbar spine in
midline to determine need for imaging
– Take off backboard and leave flat if imaging
indicated
Patient B continued
The patient also had an ankle
fracture/dislocation as well as obvious
anterior shoulder dislocation
 The patient undergoes procedural
sedation with reduction and stabilization
of both injuries
 After the procedure the patients neck
was reexamined and there was
tenderness over C5-C6 in the midline.


On CT the patient has a
fracture of the articular
process and lamina of C5

Patient’s neck kept
immobilized

Patient went to surgery
for fusion of C5-C6 and
has no neurologic deficits
after fixation.
Take Home Points

Primary Survey for Trauma
– ABCDE
– Systematic approach
– Treat life-threatening injuries as you encounter them

Mechanism of Injury
– More force means more injuries

Carefully consider risks/benefits of
imaging