Trauma (main)

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

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

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

Classes of hemorrhagic shock

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

• Traumatic brain injury
  • Intracranial hemorrhage
    • Intra-axial
      • Traumatic intracerebral hemorrhage
    • Extra-axial
      • Epidural hemorrhage
      • Subdural hemorrhage
      • Subarachnoid 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
• Scalp laceration
• Skull fracture
  • Basilar skull fracture
  • Skull fracture (peds)
• Pediatric head trauma
  • PECARN head trauma rule

Neck Trauma

• Penetrating neck trauma
• Blunt neck trauma
  • Vertebral and carotid artery dissection
  • Strangulation
  • Whiplash injury
• Cervical injury
  • Cervical fractures and dislocations
  • Cervical injury (peds)
  • Cervical spine clearance
• Neurogenic shock
• Spinal cord injury

Torso Trauma

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

Extremity trauma

• Fractures (main)

Pediatric trauma

• Pediatric head trauma
  • PECARN head trauma rule

Evaluation

• Consider FAST
• Consider CT

Management

• Address dysfunctions in airway, breathing, circulation, disability
• Massive transfusion protocol

Complications

• Hypothermia
• Acidosis
• (Dilutional) coagulopathy
• Hypocalcemia

Disposition

• Depends on underlying injury

See Also

• Trauma Sedation
• Trauma in pregnancy
• Trauma center levels
• Hemorrhagic shock