- UNC Emergency Medicine
- Medical Student Lecture Series
Objectives - Demonstrate concepts of primary and secondary patient assessment
- Establish management priorities in trauma situations
- Initiate primary and secondary management as necessary
- Arrange appropriate disposition
Trauma - Epidemiology
- Leading cause of death in the first 4 decades
- 150,000 deaths annually in the US
- Permanent disability 3 times the mortality rate
- Trauma related dollar costs exceed $400 billion annually
Why ATLS? - Trimodal death distribution
- First peak instantly (brain, heart, large vessel injury)
- Second peak minutes to hours
- Third peak days to weeks (sepsis, MSOF)
- ATLS focuses on the second peak…..Deaths from:
- TBI, Epidurals, Subdurals, IPH…
- Basilar skull fractures, orbital fractures, NEO complex injury…
- Penetrating neck injuries…
- Spinal cord syndromes…
- Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …
- Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries
- Bladder rupture, renal contusion, renal laceration, urethral injury…
- Pelvic fractures, femur fractures, humerus fractures…
- You get the point
Concepts of ATLS - Treat the greatest threat to life first
- The lack of a definitive diagnosis should never impede the application of an indicated treatment
- A detailed history is not essential to begin the evaluation
- “ABCDE” approach
Initial Assessment and Management - An effective trauma system needs the teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialists
- Trauma roles
- Trauma captain
- Interventionalists
- Nurses
- Recorder
Trauma Team Primary Survey - Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms
- ABCDEs of trauma care
- A Airway and c-spine protection
- B Breathing and ventilation
- C Circulation with hemorrhage control
- D Disability/Neurologic status
- E Exposure/Environmental control
Airway - How do we evaluate the airway?
A- Airway - Airway should be assessed for patency
- Is the patient able to communicate verbally?
- Inspect for any foreign bodies
- Examine for stridor, hoarseness, gurgling, pooled secrecretions or blood
- Assume c-spine injury in patients with multisystem trauma
- C-spine clearance is both clinical and radiographic
- C-collar should remain in place until patient can cooperate with clinical exam
Airway Interventions - Supplemental oxygen
- Suction
- Chin lift/jaw thrust
- Oral/nasal airways
- Definitive airways
- RSI for agitated patients with c-spine immobilization
- ETI for comatose patients (GCS<8)
Difficult Airway Breathing - What can we look for clinically to assess a patient’s ‘breathing’ status?
B- Breathing - Airway patency alone does not ensure adequate ventilation
- Inspect, palpate, and auscultate
- Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds
- CXR to evaluate lung fields
Flail Chest Subcutaneous Emphysema Breathing Interventions - Ventilate with 100% oxygen
- Needle decompression if tension pneumothorax suspected
- Chest tubes for pneumothorax / hemothorax
- Occlusive dressing to sucking chest wound
- If intubated, evaluate ETT position
Chest Tube for GSW What would we do for this patient who is having difficulty breathing? C- Circulation - Hemorrhagic shock should be assumed in any hypotensive trauma patient
- Rapid assessment of hemodynamic status
- Level of consciousness
- Skin color
- Pulses in four extremities
- Blood pressure and pulse pressure
Circulation Interventions - Cardiac monitor
- Apply pressure to sites of external hemorrhage
- Establish IV access
- Cardiac tamponade decompression if indicated
- Volume resuscitation
- Have blood ready if needed
- Level One infusers available
- Foley catheter to monitor resuscitation
D- Disability - Abbreviated neurological exam
- Level of consciousness
- Pupil size and reactivity
- Motor function
- GCS
- Utilized to determine severity of injury
- Guide for urgency of head CT and ICP monitoring
GCS Disability Interventions - Spinal cord injury
- High dose steroids if within 8 hours
- ICP monitor- Neurosurgical consultation
- Elevated ICP
- Head of bed elevated
- Mannitol
- Hyperventilation
- Emergent decompression
E- Exposure Always Inspect the Back Lets do a Case! Stabilize this patient Case - 28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.
- HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask
- Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle
ABCDE - What are the management priorities at this time?
- What are this patient’s possible injuries?
- What are the interventions that need to happen now?
Secondary Survey - AMPLE history
- Allergies, medications, PMH, last meal, events
- Physical exam from head to toe, including rectal exam
- Frequent reassessment of vitals
- Diagnostic studies at this time simultaneously
- X-rays, lab work, CT orders if indicated
- FAST exam
HEENT - What are the names of these signs?
Seatbelt Sign Diagnostic Aids - Standard trauma labs
- CBC, K, Cr, PTT, Utox, EtOH, ABG
- Standard trauma radiographs
- CXR, pelvis, lateral C-spine (traditionally)
- CT/FAST scans
- Pt must be monitored in radiology
- Pt should only go to radiology if stable
Simple Pneumothorax Tension Pneumothorax Hemothorax - Is this patient lying or upright?
Widened Mediastinum - What disease process does this indicate?
Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption - What should this injury make you worry about?
Epidural Hematoma Subdural Hematoma with SAH Abdominal Trauma - Common source of traumatic injury
- Mechanism is important
- Bike accident over the handlebars
- MVC with steering wheel trauma
- High suspicion with tachycardia, hypotension, and abdominal tenderness
- Can be asymptomatic early on
- FAST exam can be early screening tool
Abdominal Trauma - Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis
- Be suspicious of free fluid without evidence of solid organ injury
Splenic Injury - Most commonly injured organ in blunt trauma
- Often associated with other injuries
- Left lower rib pain may be indicative
- Often can be managed non-operatively
- Spleen with surrounding
- blood
- Blood from spleen
- Tracking around
- liver
Liver injury - Second most common solid organ injury
- Can be difficult to manage surgically
- Often associated with other abdominal injuries
What’s wrong with this picture? - May only see the nasogastric tube appear to be coiled in the lung.
- Left > right due to liver protection of the diaphragm.
- Trace the Diaphragm
- Outline. Where is the
- Diaphragm on the left?
- Abdominal contents
- Up in the chest on the
- left
Hollow Viscous Injury - Injury can involve stomach, bowel, or mesentery
- Symptoms are a result from a combination of blood loss and peritoneal contamination
- Small bowel and colon injuries result most often from penetrating trauma
- Deceleration injuries can result in bucket-handle tears of mesentery
- Free fluid without solid organ injury is a hollow viscus injury until proven otherwise
- Mesenteric and bowel injury from blunt abdominal
- trauma. Notice the bowel and mesenteric disruption.
- Abdominal CT scan visualizes solid organs and vessels well
- CT does NOT see hollow viscus, duodenum, diaphram, or omentum well
- Some recent surgery literature advocates whole body scans on all trauma
- Keep in mind that there is an increase in mortality related to cancer from CT scans
FAST Exam - Focused Abdominal Scanning in Trauma
- 4 views: Cardiac, RUQ, LUQ, suprapubic
- Goal: evaluate for free fluid
- See normal
- Liver and kidney
- Free fluid in Morrison's
- Pouch between liver and
- kidney
Non-accidental Trauma - Key is SUSPICION!!!
- Incongruent stories of mechanism
- Delay in seeking treatment
- Multiple stages of injuries
- Pattern Injuries
- Multiple hospital visits
- Injury mechanism beyond the scope of the age of child (6week old rolled over off the bed)
- Bite marks, submersion injury, cigarette burns
Disposition of Trauma Patients - Dictated by the patient’s condition and available resources i.e. trauma team available
- Transfers should be coordinated efforts
- Stabilization begun prior to transfer
- Decompensation should be anticipated
- Serial examinations
- CHI with regain of consciousness
- Abdominal exams for documented blunt trauma
- Pulmonary contusions with blunt chest trauma
Summary - Trauma is best managed by a team approach (there’s no “I” in trauma)
- A thorough primary and secondary survey is key to identify life threatening injuries
- Once a life threatening injury is discovered, intervention should not be delayed
- Disposition is determined by the patient’s condition as well as available resources.
Sources - ATLS Student Course Manuel, 6th edition.
- Rosen’s Emergency Medicine Concepts and Clinical Practice, 5th edition.
- Emergency Medicine A Comprehensive Study Guide, 5th edition.
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