The Trauma Evaluation

1. The Trauma Evaluation Kenneth DeSart, MD University of Florida Oral Exam Review

2. Primary Survey • Airway • Conscious? Talking? • Clear secretions, intubation if needed • Inhalational/Burn injury? • Breathing • Inspect for penetrating injury, tracheal deviation • Auscultate lung sounds • Palpate subcutaneous emphysema • Consider: need for artificial ventilation, tension pneumothorax, cardiac tamponade, flail chest

3. Primary Survey • Circulation • Vital signs: BP, HR, pulse, UOP • IV access (2 large bore IV), resuscitation, stat labs • Check abdomen/pelvis for obvious bleeding risk • Stop external bleeding (esp. scalp) • Disability • Mental status, GCS • Exposure • Stabilize neck, remove clothing to check for signs of injury • Maintain body temperature

4. Glasgow Coma Score • GCS (max = 15) • Motor (max = 6) • 6 follow commands, 5 localizes pain, 4 withdraws from pain, 3 flexion with pain, 2 extension with pain, 1 no response • Verbal (max = 5) • 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 no response • Eye opening (max = 4) • 4 spontaneous eye opening, 3 to command, 2 to pain, 1 no response

5. Sources of Massive Hemorrhage Chest Abdomen Pelvis Long bone (thigh) Retroperitoneum Scalp laceration (blood left at the scene)

6. FAST Exam • Focused Assessment with Sonography in Trauma • Performed during/after primary survey • Replaced Diagnostic Peritoneal Lavage (DPL) • 4 areas: pericardium, perihepatic (Morrison’s pouch), perisplenic, pelvic, & repeat perihepatic • Detects intra-abdominal bleeding • 100cc in Morrison’s pouch • most dependent area in peritoneum in supine position • 250cc total • Does not detect retroperitoneal bleeding or hollow viscous injury

7. FAST Exam Sonoguide.com/FAST.html

8. FAST Exam - Perihepatic Negative Positive

9. FAST Exam - perisplenic Negative Positive

10. FAST Exam - pelvis Negative Positive

11. Secondary Survey • Performed immediately following primary survey • AMPLE history – allergies, meds, PMH, last meal, events • Head to toe physical examination • Re-assess vital signs, changes in neurologic status • Need for more IV access? Arterial-line? • Imaging: CXR, pelvis XR, +/- extremity XR • Place foley catheter after rectal exam to rule out urethral injury • Blood at meatus, high riding prostate, severe pelvic fx, perineal hematoma • Check spine injury (“tenderness, step-offs”) • Remove back board

12. Decompensation If the patient’s condition changes during the resuscitation, go back to your ABC’s. Assess-> Intervene-> Reassess

13. CT Scan • Contraindicated in unstable patients • Assess active hemorrhage (“blush”) • Assess degree of organ injury • Various grades affect management in liver, spleen, kidney, etc. • Low sensitivity for hollow viscous injury • Low sensitivity for diffuse axonal injury (brain)

14. Tertiary Survey The infamous “Tert” Performed within 24 hrs of initial evaluation Complete history and physical examination Assess need for further imaging (extremity XR) Review labs, imaging findings Summarize diagnoses, treatment plan

15. Special cases - Airway • Intubation – maintain in-line stabilization of cervical spine • Listen for right main stem intubation • Unable to intubate  surgical cricothyrotomy • Through cricothyroid ligament • Between thyroid and cricoid cartilage

16. Special cases - Breathing • Tension pneumothorax • Large bore needle decompression at mid-clavicular line above 2nd rib • Tube thoracostomy (“chest tube”) • Open pneumothorax (“Sucking chest wound”) • 3 sided patch to allow expiration but not inspiration of air through hole • Tube thoracostomy

17. Special cases - Circulation • Scalp laceration • Potential for massive bleeding • Suture lacerations • Apply compressive bandage for 30 minutes and re-assess • Pelvic bleeding • Pelvic binder in ED • Imaging, arterial embolization • Cardiac tamponade (75-100ml) • Pericardial drain • Thoracotomy if in extremis

18. Special cases - Circulation • Positive FAST  Exploratory laparotomy (ex-lap) • Stab abdominal injury  selective lap if fascia violated • GSW abdominal injury  ex-lap • Need for transfusion  O+ blood for males, O- blood for women of child bearing age or younger • No time for results of type and screen or cross • Indication for OR thoracotomy • 1500cc blood at initial chest tube insertion • 200cc blood for 4 hrs • 2500cc in 24hrs • Additional vascular access • Subclavian introducer • Saphenous vein cutdown

19. Special cases - Disability GCS ≤ 14  head CT GCS ≤ 10  intubation GCS ≤ 8  Intra-cranial pressure (ICP) monitoring

20. The Pregnant Patient • “To save the fetus, one must save the mother” • Provide all essential diagnostic or therapeutic procedures • CT scans when concern for intra-abdominal injury • Place patient in left lateral decubitus position as possible • Reduces IVC compression • Kleihauer-Betke (K-B) test • Detects fetal blood in maternal circulation • History and ultrasound to estimate fetal age • Cardiotocographic (CTM) monitoring beyond 24 weeks

21. Trauma Pearls • Most commonly injured organ in blunt trauma • Liver (spleen is very close 2nd) • Most commonly injured organ in penetrating injury – small bowel (liver is close 2nd) • MCC death • 0-60 min: cardiac, aortic, brainstem injuries • 1-4 hrs: brain injury, hemorrhage “golden hour” • days to weeks: MSOF, sepsis

22. Trauma Pearls • MCC epidural hematoma – middle meningeal artery • MCC subdural hematoma – venous plexus • Femur fractures – up to 2L blood can pool • Open extremity fractures – reduce fracture, reassess pulse • No pulse – angiography or OR