Trauma (main)

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

• External
• Internal
  • Thoracic cavity
  • Peritoneal cavity
  • Retroperitoneal space (i.e. pelvic fracture)
  • Femur fracture (into muscle/subcutaneous tissue)

^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.

1. Hypothermia
2. Coagulopathy
3. Acidosis

• 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

• 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

• 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
• 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)

• 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)

• Clinical Presentation
  • Completely disrobe patient to assess all anatomical areas for injury
  • Hypothermia can be present on arrival or quickly develop in the emergency department and is a preventable, potentially lethal complication
• Diagnosis and Evaluation
  • Look for signs of penetrating trauma, burns, ecchymosis (Grey-Turner, Cullen’s sign), foreign bodies (do not remove until sure it is not penetrating a vessel), open fractures, etc.
  • Logroll patients with c-spine stabilization and check back, axilla, groin and buttocks as these areas are often overlooked
  • All patients should be removed from long backboards to prevent decubitus ulcers and aspiration pneumonia
  • Continually monitor patient’s temperature
• Treatment
  • Place blankets or external warming devices over patients to prevent hypothermia
  • Use warmed crystalloid fluids and blood products if warming transfuser available
    • Can microwave crystalloid fluids but not blood products
  • Decontaminate patient if exposed to toxic chemicals

• Traumatic brain injury
  • Intracranial hemorrhage
  • Moderate-to-severe traumatic brain injury
    • Elevated intracranial pressure
  • Mild traumatic brain injury
    • Clinical decision rules for head CT in trauma
    • Post-concussive syndrome
• Orbital trauma
• Maxillofacial trauma
• Skull fracture
  • Basilar skull fracture
  • Skull fracture (peds)
• Pediatric head trauma
  • PECARN head trauma rule

• Penetrating neck trauma
• Blunt neck trauma
  • Vertebral and carotid artery dissection
  • Strangulation
  • Whiplash injury
• Cervical injury
  • Cervical spine clearance
  • Cervical spine fractures and dislocations
  • Spinal cord injury
  • Isolated transverse process fractures

• Thoracic trauma
  • Cardiac trauma
  • Thoracic and lumbar spine trauma
• Abdominal trauma
• Genitourinary trauma
• Penile trauma

• Fractures (main)

• Pediatric head trauma
  • PECARN head trauma rule

• Clinical assessment and presentation should guide which diagnostic tests to order
• Lab testing can provide a baseline assessment of metabolic derangements to guide resuscitation (e.g., base deficit and lactate)

• Radiographic evaluation of the multiple trauma patient is crucial in identifying acute injuries that may not be elucidated on physical exam
• Chest X-rays and pelvic X-rays are standard exams for multiple trauma patients
• eFAST should be performed as part of the primary survey
  • eFAST is not appropriate (sensitivity is low) to assess for retroperitoneal fluid
• Ultrasound can help to examine the inferior vena cava during the secondary survey to assess volume status
• Although operator dependent, ultrasound is superior to chest X-ray to screen for hemothorax, pneumothorax and tamponade
• Perform CT scans based on clinical judgment after completion of the primary and secondary survey
• If c-spine injury is suspected, apply decision rules such as National Emergency X-Radiography Utilization Study (NEXUS) criteria or Canadian cervical spine rule (CCR) to help determine if a CT C-spine is indicated