Trauma

When dealing with trauma patients it is important to have a systematic approach that focuses on concurrent assessment and management. The approach should recognize and treat life threatening injuries first. It is important to suspect medical program as precipitant of trauma (e.g. seizure, drugs, hypoglycemia, attempted suicide, cardiac, etc). In children it is also important to consider abuse as etiology of injuries. Trauma remains the leading cause of death in persons age one to 44 years of age. Following a trauma there is a trimodal morbidity/mortality distribution. The first peak occurs within seconds to minutes of the injury generally secondary to apnea (massive ICH, rupture of heart/great vessels) and only prevention can reduce this burden. The second peak occurs within minutes to hours following an injury (golden hour) where rapid assessment and resus can change outcomes. The third peak occurs several days to weeks after the injury and is often due to sepsis or multiple organ system dysfunction. An important part of family medicine is realizing prevention is key therefore at every opportunity it is important to counsel.

Approach to Trauma

 * Preparation
 * Triage
 * Primary survey (ABCDE's) + adjuncts
 * Consider need for transport
 * Secondary survey (head to toe evaluation and history) + adjuncts
 * Continued re- evaluation and definitive care

Preparation

 * Ensure appropriate personnel available
 * Ensure appropriate equipment
 * Appropriate personal protective equipment
 * +/- call to blood bank

Triage

 * Sorting patients depending on severity, resources available
 * When dealing with mass casualty situation the general approach is sickest viable patients are managed first

Approach

 * Assess patency - is patient able to communicate, inspect for foreign bodies
 * Assess for upper airway sounds - e.g. stridor, gurgling, hoarseness
 * Feel trachea to ensure midline
 * Assess for head and neck trauma

Management

 * Supplemental oxygen
 * Chin-lift/jaw thrust
 * Suction
 * Non-definitive airways: oropharyngeal, nasopharyngeal, extraglottic (LMA)
 * Note: NP airways contraindicated in suspected cribriform plate #
 * Definitive airways: endotracheal tube +/- rapid sequence intubation (RSI)
 * Surgical airway: Emergent cricothyroidotomy
 * Always have back-up plan for failed airway

Indications for intubation

 * 1) Failure to protect or maintain airway
 * 2) Failure to ventilate/oxygenate
 * 3) Anticipated clinical course: neck injury, LOC < 8, burns, overdoses, multi-trauma, risk aspiration (bleed/vomit)

Difficult Airway Evaluation LEMON

 * If difficult airway --> consider obtaining extra personnel and double set up. Avoid neuromuscular paralysis if possible
 * L - look externally (c-spine color, facial trauma)
 * E- evaluate 3-3-2 ( 3 fingers mouth opening, 3 fingers from neck to mentum, 2 fingers from laryngeal prominence
 * M -Mallampati Score
 * O - Obstruction
 * N - neck mobility

Difficult Bag-Mask Ventilation MOANS

 * M - Mask seal (facial anomalies, beard, trauma)
 * O - obstruction or obesity
 * A - age
 * N - no teeth
 * S - stiffness (resistance to ventilation e.g. asthma, COPD)
 * teeth in to ventilate, teeth out to intubate***

Confirmation of Endotracheal Tube Placement

 * ET tube passing through cords
 * End-tital CO2 color change (>after 6 breaths)
 * Wave capnography
 * CXR
 * Auscultate both lung fields and over epigastric region
 * Gold standard: fiberoptic scope + visualize tracheal rings

Rapid Sequence intubation P's
 C-spine precautions
 * 1) Preparation: obtain all equipment
 * 2) Preoxygenate: 100% O2 for 3 minutes
 * 3) Pretreatment: 3 minutes prior to induction (lidocaine, fentanyl
 * 4) Paralysis with induction
 * 5) Induction (rapid IV prior to paralysis): ketamine, etomidate, midazolam, propofol
 * 6) Paralysis: succinylcholine (wait 45 seconds), rocuronium (wait 60 seconds)
 * 7) Positioning: c-spine precautions. +/- sellick maneuver (firm backward pressure over cricoid cartilage
 * 8) Placement of tube + confirmation (as above
 * 9) Post-ET tube management
 * 10) Mechanical ventilation
 * 11) Maintain sedation with opioid/sedative


 * Always assume c-spine trauma with multisystem trauma (c-spine collar)
 * Ensure during helmet removal and intubation that the c-spine is secure
 * See Canadian C-Spine rules under fractures page

Primary Survey B - Breathing and Ventilation

 * Approach: expose patient to assess JVP, trachea position, chest wall expansion, auscultation, O2 saturation, flail chest, subcutaneous emphysema
 * Breathing interventions:
 * As above with management of airway and ventilate with 100% oxygen
 * Recognize thoracic trauma that requires urgent intervention

Thoracic injuries requiring urgent intervention

 * Tension pneumothorax:
 * Classic clinical: tracheal deviation away from affected side, no air entry to affected side, neck vein distention, respiratory distress
 * Management: urgent needle decompression (2nd intercostal space in midclavicular line) followed by chest tube placement in 4-5 intercostal space in anterior axillary line)
 * Open pneumothorax: management - three sided occlusive dressing
 * Flail Chest: multiple rib # that move paradoxically with respiration.
 * Management: supportive, PPV
 * Pulmonary contusion: management: supportive
 * Massive hemothorax: >1500 cc
 * Management: chest tube
 * Cardiac tamponade
 * Beck's triad: elevated neck veins, muffled heart sounds, hypotension
 * Management: surgical intervention. If not possible pericardiocentesis can be diagnostic and therapeutic

Thoracic injuries often recognized during secondary survey

 * simple pneumothorax, hemothorax, pulmonary contusion, tracheobronchial tree injury, blunt cardiac trauma, traumatic aortic disruption, traumatic diaphragmatic injury, blunt esophageal rupture

Primary Survey C - Circulation

 * Approach: Level of consciousness, skin color, pulse, evidence of bleeding, blood pressure
 * Assessment for hemorrhage: long bones, pelvis stability (check once), FAST (focused assessment sonography in trauma) to assess for intraabdominal bleeding
 * Establish IV access - insert 2 large bore IVs (peripheral lines)
 * When administering crystalloid/colloid solutions use fluid warmers and rapid infusion pumps
 * If unable to obtain peripheral vascular access --> Interosseous second line
 * Initial management: Adults 1-2 L NS bolus followed by blood products, Children 20cc/kg NS bolus
 * Massive transfusion protocol (1:1:1): 1 pRBC:1 FFP: 1 platelets
 * Pelvic binder if pelvis instability
 * Direct pressure to external sources of bleeding
 * Consultation to necessary services early

Types of Shock

 * Assumed to be hypovolemic shock in trauma until proven otherwise
 * Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery +/- increased oxygen consumption or inadequate oxygen utilization (definition from uptodate)
 * Type of shock
 * 1) Hemorrhagic or Hypovolemic shock: low circulating volume therefore decrease preload
 * 2) Cardiogenic shock: failure of the pump, therefore decrease cardiac output
 * 3) Obstructive shock: impaired outflow tract, heart pumping okay (PE, tension pneumothorax,
 * 4) Neurogenic shock: brain injury resulting in sympathetic dysfunction and blood vessel dilatation
 * 5) Distributive shock: warm shock, caused by vasodilation and leaky vessels (e.g. sepsis, anaphylaxis)

Primary Survey D - Disability

 * Approach: LOC, pupil size and reactivity, lateralizing signs. GCS
 * Elevated ICP: neurosurgery involvement +/- surgical intervention or monitoring, mannitol, hypertonic saline, hyperventilation, elevation of head of bead

Primary Survey E - Exposure/Environmental Control

 * Approach: complete exposure and evaluation including logroll. Then maintenance of patient's body temperature (prevent hypothermia)

Primary Survey - Adjuncts

 * ECG monitoring: for dysrhythmias
 * Urinary catheters: monitor urine output. Contraindications: blood at meatus, perineal ecchymosis, high riding/non-palpable prostate. Adults urine output 0.5ml/kg/hour, Children urine output 1.0ml/kg/hour
 * Gastric tube: reduce stomach distention and assess for upper GI bleed. Inserted nasogastric unless suspecting cribriform plate #
 * Continuous monitoring of vitals: HR, BP, temp, O2 sat, Respiratory Rate
 * Xray (should not delay patient resus): AP chest and AP pelvis, C-spine
 * FAST (U/S) and deep peritoneal lavage (rare) to r/o occult intraabdominal bleed

Consider Need for Transport

 * This correlates with the patient's injuries, expected clinical course, resources available
 * Discussion with receiving physician
 * Provide documentation
 * Treatment prior to transport -stabilize ABC's, diagnostic imaging (if will not delay definitive mngt), wounds (abx, tetanus), splinting/traction fractures
 * Treatment during transport: monitored vital signs, continued support of ABCs + volume replacement, continue communication with accepting physician, record keeping

Secondary Survey

 * History - AMPLE - (allergies, medications, past medical history, last meal, events surrounding accident
 * Head to toe physical evaluation
 * Note: protection of the spinal cord is required at all times until a spine injury is ruled out
 * Adjuncts: further imaging - added xrays, CT scan