mechanisms of blunt trauma injury
falls MVC assault pedestrian struck MCC bicycle wreck
mechanisms of penetrating injury
stab wounds
GSW
SGW
impalement
special situations that cause traumatic injuries
explosions burns crush injuries drowning hypothermia/exposure
rule #1 of trauma
don’t panic
pre-requisites of initial trauma assessment
wide angled view (don’t get distracted by gory injury)
pattern recognition skills
ability to triage and set priorities
organized structure
overview of primary survey
A- secure airway B- ensure breathing C- is it shock? D- deficit/deformity E- where are all the injuries
overview of secondary survey
more detailed history look them over head to toe reassess FAST adjuncts imaging studies
A is for airway
clear and establish a good airway
-consider intubation for coma, shock, obvious airway compromise, some thoracic injuries
maintain C-spine stabilization
B is for breathing
chest excursion and breath sounds -flail chest (paradoxical movement) pneumothorax -open -tension massive hemothorax
treatment of pneumothorax
needle decompression followed by chest tube
chest tube drains blood from the lungs
C is for circulation
perfusion (mental status, skin, pulse) control bleeding with pressure pericardial tamponade establish 2 large bore IVs resuscitate with blood early, especially for hemorrhagic shock
most common cause of shock in trauma patients
hemorrhagic
Becks triad
JVD
muffled heart sounds
hypotension
massive blood loss
loss of a blood volume within 24 h or acute 50% reduction of total blood volume within minutes of injury
massive transfusion
> 10 units PRBC or equivalent patient’s blood volume in 6-24 h
what class of hemorrhagic shock presents with hypotension
class 3 class 1 and 2 have normal BP, so need to be on the lookout early
triad of hemorrhagic shock
hypothermia
acidosis
coagulopathy
treatment of hemorrhagic shock
balanced resuscitation
1: 1:1
blood: FFP: platelets
D is for disability
neuro status
- glasgow coma scale
- spinal cord injury (neuro shock)
D is for deformity
obvious broken bones
-open vs closed (tetanus status, antibiotics, more urgent OR)
Glasgow coma scale scores
minor brain injury: 13-15
moderate: 9-12
severe: 3-8
neurogenic shock
due to high spinal cord injury which leads to interruption of sympathetic vasomotor input
physical findings in neurogenic shock
hypotension
bradycardia
warm extremities
treatment of neuro shock
volume resuscitation followed by vasopressors if not resolved with volume
E is for exposure
remove clothes temperature (warm blankets and fluid) log roll -maintain spine precautions -palpate for spinal deformities -rectal exam to check tone, blood, prostate
what do you do if a patient decompensates at any point during the primary / secondary survey?
respond and restart survey at ABCDE again
important components of patient history
tetanus
AMPLE (allergy, meds, PMH, last meal, environment)
common imaging in secondary survey
CXR
pelvis Xray
FAST
CT
blood sampling /monitoring in secondary survey
type and cross
ABG
what is the FAST exam
quick ultrasound to scan for blood in the abdomen 4 view: 1. hepatorenal pouch 2. perisplenic space 3. pelvis 4. pericardial black = fluid
pros of FAST exam
fast portable bedside non-invasive may be repeated
cons of FAST exam
not specific for injury
no evaluation of retroperitoneum
will miss bowel injuries
what is the next step in management if your FAST is positive and the pt is hypotensive
go to the OR
management of fractures in trauma scenarios
stabilize
relocate dislocated joints
reassess pulses
what is an effect of long bone/pelvic fractures
increased blood loss
what is a step you can take in the management of a bad pelvic fracture
bring patient to IR for embolization
what are some difficulties with abdominal trauma
high morbidity and mortality if unrecognized (massive hemorrhage, sepsis)
internal injury difficult to assess in the field
often confounding factors present
epidemiology of abdominal trauma
7-15% of all trauma deaths
penetrating injuries account for <10%
blunt injuries are the most difficult to diagnose and have a 10-30% mortality
75% of blunt abdominal trauma is due to MVCs
abdominal vs thoracic injuries
abdominal: found on secondary survey and higher % require surgery
thoracic: found on primary survey and lower % require surgery
define the abdomen on the anterior
between nipples (diaphragm) and pubic symphysis between axillary lines
define the abdomen on the posterior
between scapular tips to crest of iliac wings
solid organs in the peritoneal cavity
liver
spleen
risk of hemorrhage > hypotension
hollow organs in the peritoneal cavity
stomach
intestines
colon
risk of contamination > peritonitis
components of retroperitoneal cavity
solid organs (kidneys, pancreas)
large blood vessels (aorta and vena cava)
potential space for massive hemorrhage
results of deceleration forces
differential movement of fixed and non-fixed structures
tearing occurs leading to bleeding and contamination
organs most commonly injured in blunt trauma
solid organs (spleen, liver kidney
blunt diaphragm injury
can be due to increased abdominal pressure or lacerations from rib fractures
blunt small bowel injuries
“seat belt injury”
can be due to crushing, deceleration, or increased pressure
2 types of blunt bladder injury
- intraperitoneal rupture with full bladder (need surgery)
2. extraperitoneal rupture with pelvic fracture (heal with foley decompression)
assessment of abdominal trauma
look: distension, bruising, seat belt sign
feel: tenderness, guarding, rebound, soft vs rigid
peritoneal signs
= acute abdomen
- guarding
- rebound tenderness
- percussion guarding
what is the response to discovery of an acute abdomen
laparotomy
what are some factors that could make a physical exam unreliable within trauma
if it is normal
associated (distracting) injuries
head injury
intoxication
pitfalls in physical exam in trauma patients
- blood is not initially irritating to the peritoneum
- altered sensorium decreased physical exam
- small bowel injury may not show signs of peritonitis for many hours
treatment of small bowel perf
debridement and primary repair
treatment of transverse colon perf
transverse colectomy