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

  1. Rapidly identify life-threatening injuries
  2. Initiate supportive therapy
  3. Organize definitive therapy

Locations of Possible Life-Threatening Bleeding

Lethal Triad of Major Trauma

  1. Hypothermia
  2. Coagulopathy
  3. Acidosis

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
  • 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

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
  • 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
    • 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

Neck Trauma

Torso Trauma

Extremity trauma

Pediatric trauma

Evaluation

  • Consider FAST
  • Consider CT

Management

Complications

Disposition

  • Depends on underlying injury

See Also

External Links

References

  1. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
  2. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81