Trauma (main): Difference between revisions
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{{Adult top}} [[Trauma (peds)]].'' | |||
==Background== | ==Background== | ||
*The emergency clinician plays a critical role in coordinating a multi-disciplinary team to stabilize, resuscitate, and manage multiple trauma patients | *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 | *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 | *Multiple trauma (i.e. polytrauma) 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 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 | *The ABCDE method is used to assess these trauma patients: airway and cervical stabilization, breathing, circulation, disability, and exposure/environmental control | ||
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**Laboratory and Radiographic Evaluation | **Laboratory and Radiographic Evaluation | ||
**Disposition | **Disposition | ||
{{Locations of Possible Life-Threatening Bleeding}} | {{Locations of Possible Life-Threatening Bleeding}} | ||
{{Lethal triad trauma}} | |||
== | ==Primary Survey<ref>Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300</ref><ref>American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81</ref><ref>Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.</ref>== | ||
*The goal of the primary survey is to immediately identify and manage life-threatening injuries | *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 | *There are five components of ABCDE: airway and cervical stabilization, breathing, circulation, disability, exposure and environmental control | ||
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*Continually reassess components of the primary survey | *Continually reassess components of the primary survey | ||
===Airway and cervical spine stabilization (A)=== | |||
*Clinical Presentation | *Clinical Presentation | ||
**Patients can present with poor respiratory effort, altered mental status, inability to phonate, hypoxia, tachypnea, bradypnea, etc. | **Patients can present with poor respiratory effort, altered mental status, inability to phonate, hypoxia, tachypnea, bradypnea, etc. | ||
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***If airway not patent or patient cannot phonate or protect airway, consider intubation | ***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 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 | ***If intubation is warranted, remove the front of the cervical collar and have second person hold manual in-line stabilization | ||
***Front of cervical collar significantly decreases mouth opening<ref>Goutcher CM, Lochhead V. Reduction in mouth opening with semi-rigid cervical collars. Br J Anaesth. 2005;95(3):344-348. doi:10.1093/bja/aei190</ref> | |||
**If time permits, perform a neurologic examination prior to intubation and sedation | **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 | ***The need for an emergent airway always takes priority and need not be delayed | ||
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|} | |} | ||
===Breathing (B)=== | |||
*Clinical Presentation | *Clinical Presentation | ||
**Awake patients may complain of difficulty breathing | **Awake patients may complain of difficulty breathing | ||
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***If there is respiratory distress or hypoxia, consider flail chest, pulmonary contusion, pneumothorax or massive hemothorax | ***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 | ***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 | **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 | ***Presence of B-lines may be a sign of lung contusion | ||
***Lung sliding for detection of pneumothorax by absence of lung sliding | ***Lung sliding for detection of pneumothorax by absence of lung sliding | ||
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**Treat toxidromes appropriately when present | **Treat toxidromes appropriately when present | ||
===Circulation (C)=== | |||
*Clinical Presentation | *Clinical Presentation | ||
**Assess the patient’s level of consciousness, skin perfusion, capillary refill, blood pressure, heart rate, pulse pressure and quality of pulse | **Assess the patient’s level of consciousness, skin perfusion, capillary refill, blood pressure, heart rate, pulse pressure and quality of pulse | ||
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**Do not transport unstable patients to the CT scanner | **Do not transport unstable patients to the CT scanner | ||
**Classes of [[hemorrhagic shock]] shown in table below | **Classes of [[hemorrhagic shock]] shown in table below | ||
*Diagnosis and Evaluation | *Diagnosis and Evaluation | ||
**In penetrating trauma, may use eFAST to assess for pneumothorax, free fluid in the abdomen, and cardiac tamponade | **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 | **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 | **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) | **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 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 | **For non-hemorrhagic shock, consider [[tension pneumothorax]], [[cardiac tamponade]], [[cardiogenic shock]], [[neurogenic shock]], [[septic shock]], or hypovolemic shock from insensible fluid losses | ||
*Treatment | *Treatment | ||
**Identify the culprit source of hemorrhage and if possible, obtain control (may need interventional radiology, embolization, etc). | **Identify the culprit source of hemorrhage and if possible, obtain control (may need interventional radiology, embolization, etc). | ||
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****There is no advantage of giving colloids over crystalloid | ****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 | ***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 | **[[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 | ***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. | **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. | ||
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**Consider Resuscitative Endovascular Occlusion of the Aorta (REBOA) if readily available and indicated (ie. pelvic hemorrhage) | **Consider Resuscitative Endovascular Occlusion of the Aorta (REBOA) if readily available and indicated (ie. pelvic hemorrhage) | ||
===Disability (D)=== | |||
*Clinical Presentation | *Clinical Presentation | ||
**Establish the patient’s level of consciousness and assess for neurologic deficits | **Establish the patient’s level of consciousness and assess for neurologic deficits | ||
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**Perform pupillary exam and brief motor exam of extremities as part of disability assessment | **Perform pupillary exam and brief motor exam of extremities as part of disability assessment | ||
**Perform appropriate CTs, generally non-contrast head and c-spine | **Perform appropriate CTs, generally non-contrast head and c-spine | ||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Traumatic''' | |||
| align="center" style="background:#f0f0f0;"|'''Non-traumatic''' | |||
|- | |||
| Epidural hematoma, subdural hematoma, subarachnoid hemorrhage, cerebral contusion||Intoxication | |||
|- | |||
| Diffuse axonal injury||Hypoglycemia | |||
|- | |||
| Poor cerebral perfusion secondary to shock||Electrolyte disturbances | |||
|- | |||
| ||Mental health conditions | |||
|- | |||
| ||Previous stroke or intracranial injury | |||
|} | |||
*Treatment | *Treatment | ||
**If GCS <8, consider intubation to protect airway | **If GCS <8, consider intubation to protect airway | ||
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**If elevated intracranial pressure suspected, elevate the head of the bed, infuse mannitol or hypertonic saline, hyperventilate (pCO2 goal 35 mmHg) | **If elevated intracranial pressure suspected, elevate the head of the bed, infuse mannitol or hypertonic saline, hyperventilate (pCO2 goal 35 mmHg) | ||
===Exposure and Environmental Control (E)=== | |||
*Clinical Presentation | *Clinical Presentation | ||
**Completely disrobe patient to assess all anatomical areas for injury | **Completely disrobe patient to assess all anatomical areas for injury | ||
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**Decontaminate patient if exposed to toxic chemicals | **Decontaminate patient if exposed to toxic chemicals | ||
{{ | ==Secondary Survey<ref>Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300</ref><ref>American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81</ref><ref>Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.</ref>== | ||
*After the primary survey, the clinician can obtain pertinent medical history and perform a more detailed and complete physical exam to find injuries not observed on the primary survey | |||
*Providers can refer to the AMPLE pneumonic for a pertinent history | |||
*Continually reassess the components of the primary survey | |||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''AMPLE in the Secondary Survey''' | |||
|- | |||
| Allergies | |||
|- | |||
| Medications | |||
|- | |||
| Past Medical History and Pregnancy | |||
|- | |||
| Last meal | |||
|- | |||
| Events and environment surrounding the trauma | |||
|} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Head trauma DDX}} | {{Head trauma DDX}} | ||
{{Blunt neck trauma DDX}} | {{Blunt neck trauma DDX}} | ||
{{Thoracic trauma DDX}} | |||
{{Abdominal trauma DDX}} | |||
{{Lower GU trauma DDX}} | |||
{{Extremity trauma DDX}} | |||
=== | ==Evaluation== | ||
* | ===Laboratory Evaluation=== | ||
* | *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) | |||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Laboratory Test''' | |||
| align="center" style="background:#f0f0f0;"|'''Clinical Importance''' | |||
|- | |||
| Complete blood count||Hemoglobin and hematocrit (but note that value may be falsely reassuring, due to time necessary to equilibrate); thrombocytopenia | |||
|- | |||
| Electrolyte panel||Potassium in CKD, often elevated in crush injuries; sodium in head injury or altered mental status | |||
|- | |||
| Liver function tests and lipase||Determine blunt injury to these organs, underlying liver disease, or shock liver in setting of hypoperfusion | |||
|- | |||
| PT/INR and PTT||Determine developing or underlying coagulopathies; provide clues to anti-coagulation use and need for reversal such as INR and coumadin | |||
|- | |||
| Pregnancy test in women||May change medication management; may need to consult OBGYN | |||
|- | |||
| Blood type and screen or type and cross depending on injury severity||Prevent transfusion reactions; prevent Rho antibody formation in women of childbearing age | |||
|- | |||
| Urine studies||Gross hematuria or microscopic hematuria > 20-50 RBC in urine suggests urinary tract injury; toxicology screen may indentify cause of AMS | |||
|- | |||
| Lactate, arterial blood gas, base excess, anion gap||Assess tissue perfusion and help guide fluid resuscitation; assess pH | |||
|- | |||
| Troponin||Myocardial damage if concern for cardiac contusion | |||
|} | |||
===[[ | ===Radiographic Evaluation=== | ||
*[[ | *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 | |||
{{Hemorrhagic shock classes}} | |||
== | ==Management== | ||
===Initial evaluation objectives=== | |||
#Rapidly identify life-threatening injuries | |||
#Initiate supportive therapy | |||
#Organize definitive therapy | |||
== | ===Specific Treatments=== | ||
*[[Massive transfusion protocol]] | *[[Massive transfusion protocol]] | ||
===Reassessment=== | |||
*Continually reassess all multiple trauma patients as their disposition is fluid and their clinical status can change rapidly | |||
==Disposition== | |||
*Depends on underlying injury | |||
**Decide whether to observe in the emergency department, admit to inpatient, transfer to a tertiary care facility with resources that the current facility does not have, or redline to the OR | |||
==Complications== | ==Complications== | ||
*[[Hypothermia]] | *[[Hypothermia]] | ||
*[[Acidosis]] | *[[Acidosis]] | ||
*(Dilutional) coagulopathy | *(Dilutional) [[coagulopathy]] | ||
*[[Hypocalcemia]] | *[[Hypocalcemia]] | ||
==See Also== | ==See Also== | ||
*[[Trauma | *[[Trauma sedation]] | ||
*[[Trauma in pregnancy]] | *[[Trauma in pregnancy]] | ||
*[[Trauma center levels]] | *[[Trauma center levels]] | ||
*[[Hemorrhagic shock]] | *[[Hemorrhagic shock]] | ||
*[[Gun shot wounds]] | |||
==External Links== | ==External Links== |
Latest revision as of 19:44, 3 August 2022
This page is for adult patients. For pediatric patients, see: Trauma (peds).
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 (i.e. polytrauma) 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
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
Primary Survey[2][3][4]
- 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
Airway and cervical spine stabilization (A)
- 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, remove the front of the cervical collar and have second person hold manual in-line stabilization
- Front of cervical collar significantly decreases mouth opening[5]
- 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
- Assess airway patency, phonation, and ability to protect airway
- 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
- 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
Indications for intubation in trauma patient |
A GCS equal to or less than 8 in trauma patients (inability to protect airway) |
Failure to oxygenate |
Failure to ventilate |
Expected clinical course |
Impending airway compromise (i.e. expanding hematoma) |
Breathing (B)
- 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
- Ventilation
- 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
Circulation (C)
- 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
- No more than 1 liter of balanced crystalloid solution is recommended
- 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)
Disability (D)
- 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
Traumatic | Non-traumatic |
Epidural hematoma, subdural hematoma, subarachnoid hemorrhage, cerebral contusion | Intoxication |
Diffuse axonal injury | Hypoglycemia |
Poor cerebral perfusion secondary to shock | Electrolyte disturbances |
Mental health conditions | |
Previous stroke or intracranial injury |
- 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)
Exposure and Environmental Control (E)
- 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
Secondary Survey[6][7][8]
- After the primary survey, the clinician can obtain pertinent medical history and perform a more detailed and complete physical exam to find injuries not observed on the primary survey
- Providers can refer to the AMPLE pneumonic for a pertinent history
- Continually reassess the components of the primary survey
AMPLE in the Secondary Survey |
Allergies |
Medications |
Past Medical History and Pregnancy |
Last meal |
Events and environment surrounding the trauma |
Differential Diagnosis
Head trauma
- Traumatic brain injury
- Orbital trauma
- Maxillofacial trauma
- Scalp laceration
- Skull fracture
- Pediatric head trauma
Neck Trauma
- Penetrating neck trauma
- Blunt neck trauma
- Cervical injury
- Neurogenic shock
- Spinal cord injury
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Abdominal Trauma
- Abdominal compartment syndrome
- Diaphragmatic trauma
- Duodenal hematoma
- Genitourinary trauma
- Liver trauma
- Pelvic fractures
- Retroperitoneal hemorrhage
- Renal trauma
- Splenic trauma
- Trauma in pregnancy
- Ureter trauma
Genitourinary Trauma
- Urinary system
- Genital
- Other
- Child abuse
- Pelvic fracture (often accompanies)
- Sexual assault
Extremity trauma
- Compartment syndrome
- Contusion
- Crush syndrome
- Degloving injury
- Fracture
- Laceration
- Myositis ossificans
- Open joint injury
- Peripheral nerve injury
- Rhabdomyolysis
- Tendon injury
- Vascular injury
Evaluation
Laboratory Evaluation
- 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)
Laboratory Test | Clinical Importance |
Complete blood count | Hemoglobin and hematocrit (but note that value may be falsely reassuring, due to time necessary to equilibrate); thrombocytopenia |
Electrolyte panel | Potassium in CKD, often elevated in crush injuries; sodium in head injury or altered mental status |
Liver function tests and lipase | Determine blunt injury to these organs, underlying liver disease, or shock liver in setting of hypoperfusion |
PT/INR and PTT | Determine developing or underlying coagulopathies; provide clues to anti-coagulation use and need for reversal such as INR and coumadin |
Pregnancy test in women | May change medication management; may need to consult OBGYN |
Blood type and screen or type and cross depending on injury severity | Prevent transfusion reactions; prevent Rho antibody formation in women of childbearing age |
Urine studies | Gross hematuria or microscopic hematuria > 20-50 RBC in urine suggests urinary tract injury; toxicology screen may indentify cause of AMS |
Lactate, arterial blood gas, base excess, anion gap | Assess tissue perfusion and help guide fluid resuscitation; assess pH |
Troponin | Myocardial damage if concern for cardiac contusion |
Radiographic Evaluation
- 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
Classes of hemorrhagic shock[9]
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.
Management
Initial evaluation objectives
- Rapidly identify life-threatening injuries
- Initiate supportive therapy
- Organize definitive therapy
Specific Treatments
Reassessment
- Continually reassess all multiple trauma patients as their disposition is fluid and their clinical status can change rapidly
Disposition
- Depends on underlying injury
- Decide whether to observe in the emergency department, admit to inpatient, transfer to a tertiary care facility with resources that the current facility does not have, or redline to the OR
Complications
- Hypothermia
- Acidosis
- (Dilutional) coagulopathy
- Hypocalcemia
See Also
External Links
References
- ↑ Mikhail J. The trauma triad of death: hypothermia, acidosis, and coagulopathy. AACN Clin Issues. 1999;10(1):85-94.
- ↑ Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300
- ↑ American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
- ↑ Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.
- ↑ Goutcher CM, Lochhead V. Reduction in mouth opening with semi-rigid cervical collars. Br J Anaesth. 2005;95(3):344-348. doi:10.1093/bja/aei190
- ↑ Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300
- ↑ American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
- ↑ Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.
- ↑ American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81