Trauma (main): Difference between revisions
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**Consider Resuscitative Endovascular Occlusion of the Aorta (REBOA) if readily available and indicated (ie. pelvic hemorrhage) | **Consider Resuscitative Endovascular Occlusion of the Aorta (REBOA) if readily available and indicated (ie. pelvic hemorrhage) | ||
====Disability==== | ====Disability (D)==== | ||
*Clinical Presentation | |||
**Establish the patient’s level of consciousness and assess for neurologic deficits | |||
**The [[Glasgow Coma Scale]] (GCS) is a 15-point scale that determines the patient’s level of consciousness | |||
**GCS of 15 does not exclude the possibility of a traumatic brain injury | |||
**The GCS motor score best correlates with patient outcomes | |||
*Diagnosis and Evaluation | |||
**Altered mental status can occur from traumatic or non-traumatic causes | |||
**If there is a decrease in GCS, always assume there is a central nervous system injury until proven otherwise | |||
**Perform pupillary exam and brief motor exam of extremities as part of disability assessment | |||
**Perform appropriate CTs, generally non-contrast head and c-spine | |||
*Treatment | |||
**If GCS <8, consider intubation to protect airway | |||
**Reverse any obvious cause of altered mental status, i.e., D50 for hypoglycemia, fluid/blood product resuscitation for hypoperfusion, oxygen for hypoxia, ventilation for hypercarbia | |||
**Consult a neurosurgeon when a brain or spinal cord injury is identified | |||
**If elevated intracranial pressure suspected, elevate the head of the bed, infuse mannitol or hypertonic saline, hyperventilate (pCO2 goal 35 mmHg) | |||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Indications for intubation in trauma patient''' | |||
|- | |||
| A GCS equal to or less than 8 in trauma patients (inability to protect airway) | |||
|- | |||
| Failure to oxygenate | |||
|- | |||
| Failure to ventilate | |||
|- | |||
| Expected clinical course | |||
|- | |||
| Impending airway compromise (i.e. expanding hematoma) | |||
|} | |||
====Exposure==== | ====Exposure==== |
Revision as of 00:31, 22 November 2019
Background
- The emergency clinician plays a critical role in coordinating a multi-disciplinary team to stabilize, resuscitate, and manage multiple trauma patients
- A structured assessment, namely the ABCDE method, can be used to systematically assess the trauma patient to quickly identify and prioritize injuries, simplifying the thought process in a chaotic environment
- Multiple trauma is defined as any trauma associated with two or more injuries, of which, one injury is classified as life threatening
- The two most common mechanisms of multiple trauma are blunt and penetrating trauma
- The ABCDE method is used to assess these trauma patients: airway and cervical stabilization, breathing, circulation, disability, and exposure/environmental control
- General Approach to Multiple Trauma Patients
- Pre-hospital and Triage
- Primary Survey
- Secondary Survey
- Laboratory and Radiographic Evaluation
- Disposition
Initial evaluation objectives
- Rapidly identify life-threatening injuries
- Initiate supportive therapy
- Organize definitive therapy
Locations of Possible Life-Threatening Bleeding
- External
- Internal
- Thoracic cavity
- Peritoneal cavity
- Retroperitoneal space (i.e. pelvic fracture)
- Femur fracture (into muscle/subcutaneous tissue)
Lethal Triad of Major Trauma
Clinical Features
Primary Survey
- The goal of the primary survey is to immediately identify and manage life-threatening injuries
- There are five components of ABCDE: airway and cervical stabilization, breathing, circulation, disability, exposure and environmental control
- As critical conditions are encountered, initiate treatment without delay before continuing to the next step of the assessment
- Often multidisciplinary team involved who can address treatment while primary survey can continue
- After the primary survey, evaluate whether the patient needs to be transferred to a facility that can provide definitive treatment not available at the initial hospital
- Specifically if not a level 1 trauma center
- Continually reassess components of the primary survey
Airway and cervical spine stabilization (A)
- Clinical Presentation
- Patients can present with poor respiratory effort, altered mental status, inability to phonate, hypoxia, tachypnea, bradypnea, etc.
- Look for signs of airway obstruction: blood, hematoma, edema, vomitus, facial or neck trauma, foreign bodies
- Diagnosis and Evaluation
- Assess airway patency, phonation, and ability to protect airway
- If a patient can clearly phonate and protect their airway, move to “B” or Breathing, but continually reevaluate
- If airway not patent or patient cannot phonate or protect airway, consider intubation
- If there is any concern for a cervical spine (c-spine) injury base on history or exam, take care to limit c-spine movement and place c-collar
- If intubation is warranted, have a second provider maintain c-spine immobilization during procedure
- If time permits, perform a neurologic examination prior to intubation and sedation
- The need for an emergent airway always takes priority and need not be delayed
- Assess airway patency, phonation, and ability to protect airway
- Treatment
- Although not a definitive airway, a supraglottic airway may be useful when a patient has significant facial trauma or is difficult to intubate or ventilate
- These devices are contraindicated in awake patients and those with inability to open the mouth
- Avoid nasal airway if suspected basilar skull fracture
- Suction the airway of blood or emesis, and remove foreign bodies and dentures before laryngoscopy
- Video laryngoscopy with rapid sequence intubation (RSI) is the recommended first line approach to minimize cervical spine motion and provide superior laryngeal views
- A cricothyrotomy or another surgical airway may be necessary if endotracheal intubation fails or there is significant facial trauma or airway obstruction
- Use capnography, auscultation and post-intubation CXR to confirm tube placement
- Although not a definitive airway, a supraglottic airway may be useful when a patient has significant facial trauma or is difficult to intubate or ventilate
Breathing (B)
- Clinical Presentation
- Awake patients may complain of difficulty breathing
- The mechanisms of injury, such as penetrating chest trauma or blunt force trauma to the chest, may signal impending respiratory failure
- Deviated trachea, flail chest, sucking chest wounds, asymmetric breath sounds, chest wall crepitus, etc.
- If patient is adequately ventilating and oxygenating, then proceed to “C” or circulation
- Diagnosis and Evaluation
- Ventilation
- Assess mental status, chest wall rise, respiratory rate and check end-tidal CO2 or blood gas
- If poor ventilation identified, consider naloxone and check glucose
- If persistent altered mental status, consider head CT, send toxicology workup, and have a second provider obtain collateral history for exposure to toxins and identify co-morbidities
- Intubate if unable to identify or reverse cause of hypoventilation and the patient is retaining significant CO2
- Oxygenation
- If there is respiratory distress or hypoxia, consider flail chest, pulmonary contusion, pneumothorax or massive hemothorax
- If unequal breath sounds, and you identify pneumothorax, hemothorax or hemopneumothorax, perform a tube thoracostomy
- Use the Extended Focused Assessment with Sonography for Trauma (eFAST) to assess for pneumothorax and hemothorax
- Presence of B-lines may be a sign of lung contusion
- Lung sliding for detection of pneumothorax by absence of lung sliding
- Ventilation
- Treatment
- For suspected pneumothorax/hemothorax, perform needle decompression with 14-gauge needle or tube thoracostomy at the fourth or fifth intercostal space along the mid or anterior axillary line
- If asymmetric breath sounds or lung sliding only on one side (generally on the right) immediately following intubation, the endotracheal tube may be positioned in either mainstem bronchus
- Measure depth on chest x-ray and reposition tube above the carina
- Treat toxidromes appropriately when present
Circulation (C)[1]
- Clinical Presentation
- Assess the patient’s level of consciousness, skin perfusion, capillary refill, blood pressure, heart rate, pulse pressure and quality of pulse
- If the patient has good peripheral pulses, normal mental status, and adequate peripheral perfusion without obvious signs of shock, then proceed to “D” or Disability
- Signs of shock include tachycardia, hypotension, altered mental status, rapid and thready pulse, and pale skin
- Do not transport unstable patients to the CT scanner
- Classes of hemorrhagic shock shown in table below
Class | I | II | III | IV |
---|---|---|---|---|
Approximate blood loss | <15% | 15-30% | 30-40% | >40% |
Heart rate | ↔ | ↔/↑ | ↑ | ↑↑ |
Blood pressure | ↔ | ↔ | ↔/↓ | ↓ |
Pulse Pressure (mmHg) | ↔ | ↓ | ↓ | ↓ |
Respiratory Rate (per min) | ↔ | ↔ | ↔/↑ | ↑ |
Urine Output (mL/hr) | ↔ | ↔ | ↓ | ↓↓ |
Glasgow coma scale score | ↔ | ↔ | ↓ | ↓ |
Base deficit^ | 0 to -2 mEq/L | -2 to -6 mEq/L | -6 to -10 mEq/L | -10 or less mEq/L |
Need for blood products | Monitor | Possible | Yes | Massive transfusion protocol |
- ^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.
- Diagnosis and Evaluation
- In penetrating trauma, may use eFAST to assess for pneumothorax, free fluid in the abdomen, and cardiac tamponade
- The FAST exam has a high specificity, but poor sensitivity for identifying clinically important hemorrhage
- Serial FAST exams should be performed if initial FAST was negative in an unstable patient
- Look for hemorrhage before considering other causes of shock (e.g., neurogenic)
- For hemorrhagic shock, locate the hemorrhage using physical exam, x-rays, eFAST, CT imaging
- For non-hemorrhagic shock, consider tension pneumothorax, cardiac tamponade, cardiogenic shock, neurogenic shock, septic shock, or hypovolemic shock from insensible fluid losses
- Treatment
- Identify the culprit source of hemorrhage and if possible, obtain control (may need interventional radiology, embolization, etc).
- Establish a minimum of 2 large bore IVs 16 gauge or larger
- Consider central venous or intraosseous access if peripheral IVs cannot be obtained quickly
- If hemorrhagic or unclear source of shock, infuse blood products as soon as possible
- No more than 1 liter of balanced crystalloid solution is recommended
- More fluid may contribute to dilutional coagulopathy
- Balanced crystalloid over normal saline is recommended to avoid non-anion gap metabolic acidosis and renal insufficiency
- There is no advantage of giving colloids over crystalloid
- If further resuscitation required, consider 2:1:1 or 1:1:1 infusion of packed red blood cells to platelets to plasma
- No more than 1 liter of balanced crystalloid solution is recommended
- Massive transfusion protocol (MTP) can be initiated when a patient is suspected to require more than 10 units of pRBC in the first 24 hours of admission OR more than 4 units of pRBC in one hour
- MTP should follow the 2:1:1 or 1:1:1 ratio discussed above
- If the patient is male or not of childbearing age, and requires emergent blood transfusion, prior to type and screen, O positive blood should be administered.
- For women who might be of childbearing age, administer O negative blood to prevent formation of Rho antibodies
- Consider tranexamic acid (TXA) as a 1g bolus over 10 minutes, ideally administered within 1 hour of injury, although benefit lasts up to 3 hours
- Then infuse 1g over 8 hours if hemorrhage not controlled
- Consider permissive hypotension, with a MAP goal of 50mmHg, unless there is concern for traumatic brain or spinal cord injury, in which the MAP goal is 80mmHg
- Ensure adequate tissue perfusion, identified by mental status, vital signs, physical exam, urine output, lactate, and base excess
- Avoid hypothermia from infusion of fluids
- Use fluid warmers for infusions and external warming measures
- Reverse known coagulopathies
- For example, if there is a history of warfarin use or liver disease, consider PCC, FFP and vitamin K
- Give platelets if thrombocytopenic and patient continues to hemorrhage
- If indicated, consider administration of the reversal agents for thrombin and Xa inhibitors
- PCC can be used for Xa inhibitors if the reversal agent is unavailable
- Dialysis should be considered in patients on direct thrombin inhibitors with severe hemorrhage.
- Consider Resuscitative Endovascular Occlusion of the Aorta (REBOA) if readily available and indicated (ie. pelvic hemorrhage)
Disability (D)
- Clinical Presentation
- Establish the patient’s level of consciousness and assess for neurologic deficits
- The Glasgow Coma Scale (GCS) is a 15-point scale that determines the patient’s level of consciousness
- GCS of 15 does not exclude the possibility of a traumatic brain injury
- The GCS motor score best correlates with patient outcomes
- Diagnosis and Evaluation
- Altered mental status can occur from traumatic or non-traumatic causes
- If there is a decrease in GCS, always assume there is a central nervous system injury until proven otherwise
- Perform pupillary exam and brief motor exam of extremities as part of disability assessment
- Perform appropriate CTs, generally non-contrast head and c-spine
- Treatment
- If GCS <8, consider intubation to protect airway
- Reverse any obvious cause of altered mental status, i.e., D50 for hypoglycemia, fluid/blood product resuscitation for hypoperfusion, oxygen for hypoxia, ventilation for hypercarbia
- Consult a neurosurgeon when a brain or spinal cord injury is identified
- If elevated intracranial pressure suspected, elevate the head of the bed, infuse mannitol or hypertonic saline, hyperventilate (pCO2 goal 35 mmHg)
Indications for intubation in trauma patient |
A GCS equal to or less than 8 in trauma patients (inability to protect airway) |
Failure to oxygenate |
Failure to ventilate |
Expected clinical course |
Impending airway compromise (i.e. expanding hematoma) |
Exposure
Classes of hemorrhagic shock[2]
Class | I | II | III | IV |
---|---|---|---|---|
Approximate blood loss | <15% | 15-30% | 30-40% | >40% |
Heart rate | ↔ | ↔/↑ | ↑ | ↑↑ |
Blood pressure | ↔ | ↔ | ↔/↓ | ↓ |
Pulse Pressure (mmHg) | ↔ | ↓ | ↓ | ↓ |
Respiratory Rate (per min) | ↔ | ↔ | ↔/↑ | ↑ |
Urine Output (mL/hr) | ↔ | ↔ | ↓ | ↓↓ |
Glasgow coma scale score | ↔ | ↔ | ↓ | ↓ |
Base deficit^ | 0 to -2 mEq/L | -2 to -6 mEq/L | -6 to -10 mEq/L | -10 or less mEq/L |
Need for blood products | Monitor | Possible | Yes | Massive transfusion protocol |
^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.
Secondary Survey
- Head to toe evaluation for additional injuries
Differential Diagnosis
Head trauma
- Traumatic brain injury
- Orbital trauma
- Maxillofacial trauma
- Scalp laceration
- Skull fracture
- Pediatric head trauma
Neck Trauma
- Penetrating neck trauma
- Blunt neck trauma
- Cervical injury
- Neurogenic shock
- Spinal cord injury
Torso Trauma
Extremity trauma
Pediatric trauma
Evaluation
- Consider FAST
- Consider CT
Management
- Address dysfunctions in airway, breathing, circulation, disability
- Massive transfusion protocol
Complications
- Hypothermia
- Acidosis
- (Dilutional) coagulopathy
- Hypocalcemia
Disposition
- Depends on underlying injury