The Trauma Evaluation

1. The Trauma Evaluation Michael S. Hong, MD University of Florida Oral Exam Review

2. Primary Survey • Airway • Conscious? Talking? • Clear secretions, intubation if needed • 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. 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

6. FAST Exam Sonoguide.com/FAST.html

7. FAST Exam - Perihepatic Negative Positive

8. FAST Exam - perisplenic Negative Positive

9. FAST Exam - pelvis Negative Positive

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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 • within 1st hr: cardiac, aortic, brainstem injuries • 1-4 hrs: brain injury, hemorrhage • days to weeks: MSOF, sepsis

20. 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