Introduction To Trauma: LSU Medical Student Clerkship, New Orleans, LA

Introduction to
Trauma
LSU Medical Student Clerkship,

New Orleans, LA
Trauma
Goals
 Review the components of the primary and secondary

survey for a trauma patient
 Identify injuries requiring immediate intervention during
primary survey
 Review the initial steps of resuscitation of a trauma patient
in the ED
 Review the advantages and uses of diagnostic modalities in
the trauma patient
 Discuss the appropriate disposition of the trauma patient
from the ED.
Trauma
Epidemiology
 Trauma is a disease.
 Trauma is predictable, preventable, and treatable.
 Trauma is the 4th leading cause of death in the US.
 Trauma is the leading cause of death in people
below the age of 45 in the US.
 3.8 M deaths/ year/ worldwide
 312 M injured
Trauma
Epidemiology
•Trimodal distribution
of mortality
•Prehospital (Major
head injuries, rapid
exsanguination)
•Early Hospital
(Head, chest,
abdominal trauma)
•ICU (End result of
prolonged
hypoperfusion)
Trauma
History of Trauma Systems
 1991: Congress passed the Trauma Care Systems Planning

and Development Act requiring the development of a Model
Trauma Care System Plan to be used as a reference
document for each state to develop its system
 Based on the severity of injury, patients are triaged to
trauma centers
 The American College of Surgeons has developed
requirements for trauma center certification of commitment
of personnel and resources needed to maintain a state of
readiness to receive critically injured patients.
 The Golden Hour
Trauma
History of Trauma Systems

Trauma
Initial Approach
 The initial approach to trauma care in the ED is

a process that consists of an initial primary
assessment, rapid resuscitation, and a more
thorough secondary survey followed by
diagnostic tests and ultimate disposition.
 Subsequent mortality and morbidity tied directly
to the initial assessment and resuscitation
Trauma
Trauma
Primary Survey
 Rapid examination to identify and treat life threatening

conditions. Ideally is performed in a few minutes.
 A - Airway (with C-spine precautions)
 B - Breathing
 C - Circulation
 D - Disability
 E – Exposure
When derangements in any of the components of the primary

survey are identified, treatment is undertaken immediately.
Trauma
Primary Survey - Airway
 Maintain C-spine precautions

 Clear any obstructions
 Jaw thrust instead of head tilt chin lift
 Endotracheal intubation for airway protection or
expected clinical course (ie,obstruction from blood or vomitus,
neck hematoma, facial burns or trauma, GCS 8 or less, combative patient,
potential for airway compromise while out of department.)
Trauma
Primary Survey - Breathing
 Auscultation for bilateral breath sounds

 Palpation for subcutaneous emphysema
-needle decompression followed by chest tube for pneumothorax
 Inspection for flail chest

 Observation of respiratory rate, oxygen
saturation, and overall work of breathing
-mechanical ventilation for inadequate ventilation or to decrease work of
breathing
Trauma
Trauma
Primary Survey - Circulation
 Check peripheral pulses, heart rate, BP, pulse

pressure, capillary refill, cyanosis
 All hypotensive trauma patients are assumed to
be in hemorrhagic shock
 2 large bore peripheral IV’s (at least 18 gauge)
 Control external bleeding
Trauma
Trauma

Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial
Presentation
Class I Class Class Class

II III IV
Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000
Blood loss (percent blood Up to 15 15–30 30–40 40

volume)
Pulse rate <100 100–120 120–140 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg) Normal or Decreased Decreased Decreased

increased
*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.

Trauma
 Begin volume resuscitation with liter boluses of

crystalloid for class I or II hemorrhage.
 Begin crystalloid and blood for class III or IV
hemorrhage.
 O- blood until type specific is available
 Constant reevaluation is paramount
 If class I or II is patient still showing signs of shock after
3L of crystalloid, begin blood
 “3:1 rule” 3cc crystalloid for every 1cc of blood loss
Trauma
 5 Places life threatening hemorrhage can occur

-Chest
-Abdomen
-Pelvis
-Thighs
-Externally
Trauma
 Cardiac Tamponade can cause hypotension

with little blood loss.
 Becks triad: hypotension, distended neck veins,
muffled heart sounds
 Easily confirmed with ultrasound
 Pericardiocentesis
Trauma
Trauma
Trauma
Primary Survey - Disability

 Quick assessment of ability to move all extremities
 Glascow Coma Scale
Trauma
Primary Survey – Exposure
 Completely undress the patient and inspect the

entire patient from head to toe both front and back.
 Maintain spinal precautions during logrolling
 Inspect both axillae and peritoneum
 Warm blankets!!!
Trauma
Secondary Survey
 Head to toe evaluation once any derangements in

primary survey have been addressed.
 AMPLE History
-Allergies
-Medications
-Past medical history (LMP, Td, transfusions)
-Last meal
-Events leading up to trauma
Trauma
Imaging
 Choice of imaging modality depends on nature

of injuries and stability of patient.
 Knowledge of injury mechanism and index of
suspicion most important
Trauma
Imaging – Plain Films
 Quick
 Can be performed at bedside
 Useful for rapid identification of pneumothorax,
hemothorax, fractures and locating ballistics
Trauma
Trauma
Imaging – Ultrasound
 Quick
 Can be performed at bedside
 FAST: Focused Assessment with Sonography
for Trauma
 Rapid examination to identify free intraperitoneal
fluid and/or pericardial fluid
Trauma
Trauma
Imaging – CT
•Detailed
•Requires patient
to leave the
department
•Necessary for
head trauma
Trauma
Trauma
Disposition
 To the OR
-Unstable patients with blunt or penetrating abdominal
trauma or chest trauma. Hemothorax with >1500 cc of
blood out initially. Surgical injuries identified with
imaging.
 Admission
-Nonsurgical, high-risk injuries
 Discharge
-Stable patients, minor or no injuries identified.

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Introduction to

LSU Medical Student Clerkship,

 Review the components of the primary and secondary

History of Trauma Systems

 1991: Congress passed the Trauma Care Systems Planning

History of Trauma Systems

 The initial approach to trauma care in the ED is

 Rapid examination to identify and treat life threatening

When derangements in any of the components of the primary

Primary Survey - Airway

 Maintain C-spine precautions

Primary Survey - Breathing

 Auscultation for bilateral breath sounds

 Inspection for flail chest

Primary Survey - Circulation

 Check peripheral pulses, heart rate, BP, pulse

Primary Survey - Circulation

Class I Class Class Class

Blood loss (percent blood Up to 15 15–30 30–40 40

Pulse rate <100 100–120 120–140 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure (mm Hg) Normal or Decreased Decreased Decreased

*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.

Primary Survey - Circulation

 Begin volume resuscitation with liter boluses of

Primary Survey - Circulation

 5 Places life threatening hemorrhage can occur

Primary Survey - Circulation

 Cardiac Tamponade can cause hypotension

Primary Survey - Disability

Primary Survey – Exposure

 Completely undress the patient and inspect the

 Head to toe evaluation once any derangements in

 Choice of imaging modality depends on nature

Imaging – Plain Films

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