Approach to Trauma Patients Joseph Turner, MD Indiana University School of Medicine.

Approach to Trauma Approach to Trauma PatientsPatients

Joseph Turner, MDJoseph Turner, MD

Indiana University School of Indiana University School of MedicineMedicine

ObjectivesObjectives

Describe the initial approach to the injured patient, Describe the initial approach to the injured patient, including the primary and secondary surveys.including the primary and secondary surveys.

Describe the clinical presentation and initial Describe the clinical presentation and initial treatment measures for life threatening injuries.treatment measures for life threatening injuries.

Identify the types and clinical presentations of Identify the types and clinical presentations of shock. Identify the classes (I, II, III, IV) of shock. Identify the classes (I, II, III, IV) of hemorrhagic shock.hemorrhagic shock.

Understand the benefits and downsides of imaging Understand the benefits and downsides of imaging trauma patientstrauma patients

Describe approach to assessing cervical spine Describe approach to assessing cervical spine traumatrauma

Case 1Case 1

32 yo female restrained driver in a 32 yo female restrained driver in a rollover MVArollover MVA– 25 minute extrication 25 minute extrication – complaining of chest pain and difficulty complaining of chest pain and difficulty

breathingbreathing– EMS reports that the windshield is EMS reports that the windshield is

starred and the steering column was starred and the steering column was bentbent

Mechanism of InjuryMechanism of Injury

Gives information about the forces Gives information about the forces potentially involved in the traumatic potentially involved in the traumatic mechanismmechanism– Guides diagnostic testingGuides diagnostic testing

More force more likely to have injuryMore force more likely to have injury

– Determines Trauma center activationDetermines Trauma center activation Shorter time to arrive at definitive careShorter time to arrive at definitive care Determined by mechanism and vitalsDetermined by mechanism and vitals

Case 1Case 1

VitalsVitals– HR 94 BP 88/56 RR 26 Biox 93%HR 94 BP 88/56 RR 26 Biox 93%

Where do you take the patient?Where do you take the patient?

Would you be more or less Would you be more or less concerned if this were a 83 yo concerned if this were a 83 yo female?female?

Susceptibility to InjurySusceptibility to Injury

Some populations more vulnerable to Some populations more vulnerable to injuriesinjuries– ElderlyElderly

More likely to have injuries from given forceMore likely to have injuries from given force– Lower bone density, brain atrophy, co-morbitiesLower bone density, brain atrophy, co-morbities

– AlcoholicsAlcoholics Brain atrophy leads to more subdural Brain atrophy leads to more subdural

hematomashematomas

– CoagulolopathicCoagulolopathic warfarin, cirrhoticwarfarin, cirrhotic

Primary SurveyPrimary Survey

Goal is to identify and treat any life Goal is to identify and treat any life threatening injuriesthreatening injuries

– Some components are evaluated Some components are evaluated simultaneously in large trauma centerssimultaneously in large trauma centers

– All resources are directed toward All resources are directed toward stabilizing that injury until it is correctedstabilizing that injury until it is corrected

AirwayAirway

Evaluate for patency and secure it if Evaluate for patency and secure it if it is not adequateit is not adequate– Usually endotracheal intubation Usually endotracheal intubation – Keep cervical spine immobilized inline if Keep cervical spine immobilized inline if

any concern for spine fractureany concern for spine fracture

Identify injuries that if not treated Identify injuries that if not treated will threaten the airwaywill threaten the airway– Intervene before it becomes too difficultIntervene before it becomes too difficult

What are some signs or What are some signs or symptoms that might indicate symptoms that might indicate that the patient needs an that the patient needs an airway intervention?airway intervention?

Airway obstructionAirway obstruction Severe respiratory distressSevere respiratory distress Altered mental status Altered mental status (GCS < 8 --> (GCS < 8 -->

Intubate)Intubate)

Critically illCritically ill

If something changes – start If something changes – start over at the topover at the top

BreathingBreathing

Listen to breath soundsListen to breath sounds– Look, feel, trachea positionLook, feel, trachea position

OxygenationOxygenation– Skin color, pulse oxSkin color, pulse ox

CirculationCirculation

Heart rate and blood pressureHeart rate and blood pressure– Look for signs of shockLook for signs of shock

Cap refill, mental statusCap refill, mental status

Feel pulsesFeel pulses– Check above and below waist and on Check above and below waist and on

both sidesboth sides Looking for vascular injuryLooking for vascular injury

Listen for muffled heart tonesListen for muffled heart tones– Ultrasound helpfulUltrasound helpful

DisabilityDisability

Rapid neurologic assessmentRapid neurologic assessment

– Formal Glasgow Coma ScoreFormal Glasgow Coma Score– Eye opening, verbal and motorEye opening, verbal and motor

– Gross motor exam for quadro/paraplegiaGross motor exam for quadro/paraplegia Heighten suspicion for spinal cord injuryHeighten suspicion for spinal cord injury

– Palpate spinal cordPalpate spinal cord

– Rectal tone?Rectal tone?

Exposure/Exposure/Environmental ControlEnvironmental Control

Remove clothing to Remove clothing to evaluate for evaluate for external evidence external evidence of injuryof injury

Keep patient warmKeep patient warm– hypothermia will hypothermia will

complicate many complicate many injuriesinjuries

Secondary SurveySecondary Survey

Starts once the primary survey is Starts once the primary survey is complete and all injuries identified complete and all injuries identified there have been stabilizedthere have been stabilized

Head to toe examination of the Head to toe examination of the patient to evaluate for additional patient to evaluate for additional injuriesinjuries– Evaluate need for imaging studies to Evaluate need for imaging studies to

identify injuriesidentify injuries

Case 2Case 2

24 yo male patient involved in a 24 yo male patient involved in a drive by shootingdrive by shooting

Suffered with multiple gunshot Suffered with multiple gunshot wounds to the chest and abdomen. wounds to the chest and abdomen. There were 2 fatalities at the sceneThere were 2 fatalities at the scene

Vs HR 124 BP 76/p RR 36Vs HR 124 BP 76/p RR 36

Primary SurveyPrimary Survey

AirwayAirway

BreathingBreathing– Breath sounds diminished on right side, Breath sounds diminished on right side,

trachea deviated to lefttrachea deviated to left

What is going on and what are you What is going on and what are you going to do about it?going to do about it?

Tension PneumothoraxTension Pneumothorax

Diminished breath sounds and Diminished breath sounds and hypotensionhypotension– Hyper-resonance, JVD; deviated trachea late Hyper-resonance, JVD; deviated trachea late

signsign

Treatment is needle thoracostomy, Treatment is needle thoracostomy, followed by tube thoracostomyfollowed by tube thoracostomy– large gauge angio in 2nd intercoatal space large gauge angio in 2nd intercoatal space

in mid clavicular linein mid clavicular line– get rush of air and improvement in vsget rush of air and improvement in vs– needs immediate tube thoracostomyneeds immediate tube thoracostomy

Primary SurveyPrimary Survey

AirwayAirway BreathingBreathing CirculationCirculation

– Low blood pressure and elevated heart rateLow blood pressure and elevated heart rate HR 124 BP 76/pHR 124 BP 76/p

SHOCKSHOCK

Top 10 Types Top 10 Types of Shock of Shock in Trauma in Trauma PatientsPatients

1.1. HemorrhagicHemorrhagic2.2. HemorrhagicHemorrhagic3.3. HemorrhagicHemorrhagic4.4. HemorrhagicHemorrhagic5.5. HemorrhagicHemorrhagic6.6. HemorrhagicHemorrhagic7.7. HemorrhagicHemorrhagic8.8. HemorrhagicHemorrhagic9.9. CardiogenicCardiogenic10.10.NeurogenicNeurogenic

Hemorrhagic ShockHemorrhagic Shock

Class I- <15% blood lossClass I- <15% blood loss– Minimal symptoms and normal vitalsMinimal symptoms and normal vitals

Class II- >15% blood loss (800-1500 cc)Class II- >15% blood loss (800-1500 cc)– Tachycardia, decreased pulse pressure, Tachycardia, decreased pulse pressure,

delayed cap refilldelayed cap refill

Class III- >30 % blood loss (1500-2000 Class III- >30 % blood loss (1500-2000 cc)cc)– Tachycardia, tachypnea, hypotensionTachycardia, tachypnea, hypotension– Usually requires transfusionUsually requires transfusion

Hemorrhagic ShockHemorrhagic Shock

Class IV- > 40% blood loss (>2000 Class IV- > 40% blood loss (>2000 cc)cc)– Immediately life threateningImmediately life threatening– Marked abnormalities in vitalsMarked abnormalities in vitals– Skin cool, diaphoreticSkin cool, diaphoretic– Negligible urinary outputNegligible urinary output– Depressed mental statusDepressed mental status

Treatment of Treatment of Hemorrhagic ShockHemorrhagic Shock

Stop the bleedingStop the bleeding– Locate and control Locate and control

bleeding sitesbleeding sites– Body sites an adult can Body sites an adult can

bleed and develop bleed and develop shockshock ChestChest AbdomenAbdomen RetroperitonealRetroperitoneal PelvisPelvis FemurFemur External lossesExternal losses

Volume Volume ResuscitationResuscitation– Isotonic fluid Isotonic fluid

Start with 1-2 litersStart with 1-2 liters

– BloodBlood Switch to quickly if not Switch to quickly if not

stable with crystalloidstable with crystalloid If hypotensive start If hypotensive start

early with O-negearly with O-neg Send type and cross to Send type and cross to

get type specific ASAPget type specific ASAP

J Trauma Acute Care Surg. 2013 May;74(5):1215-21

Assure that the patient has adequate IV Assure that the patient has adequate IV access in order to deliver large amounts access in order to deliver large amounts of volume quicklyof volume quickly– Two 18 G or larger IvsTwo 18 G or larger Ivs– Or Central AccessOr Central Access

Key is short and fat catheters deliver Key is short and fat catheters deliver fluids and blood fasterfluids and blood faster– Flow directly proportional to diameter of Flow directly proportional to diameter of

catheter and inversely proportional to catheter and inversely proportional to length of catheterlength of catheter

Tranexamic Acid?Tranexamic Acid?

Antifibrinolytic agentAntifibrinolytic agent

Decreases bleeding and need for Decreases bleeding and need for transfusiontransfusion

Reduced mortality in CRASH-2 trialReduced mortality in CRASH-2 trial

Primary SurveyPrimary Survey

AirwayAirway

BreathingBreathing

CirculationCirculation– Low blood pressure and elevated heart Low blood pressure and elevated heart

raterate shockshock

– No palpable pulse in right leg with gsw No palpable pulse in right leg with gsw to thighto thigh

Assess neurovascular Assess neurovascular statusstatus

Vascular ExamVascular Exam– Hard SignsHard Signs

No palpable or dopplerable pulse, visible pulsatile No palpable or dopplerable pulse, visible pulsatile bleeding, bruit or thrill over artery, expanding bleeding, bruit or thrill over artery, expanding hematomahematoma

– Soft SignsSoft Signs Decreased pulse compared to extremities, neurologic Decreased pulse compared to extremities, neurologic

abnormality, fracture or penetrating injury in abnormality, fracture or penetrating injury in proximity to arteryproximity to artery

Neuro examNeuro exam– Assess motor and sensory nerve function Assess motor and sensory nerve function

distal to injurydistal to injury

Ankle-Brachial IndexAnkle-Brachial Index

Useful adjunct in vascular assesmentUseful adjunct in vascular assesment

– SPB in leg/SBP in arm while patient SPB in leg/SBP in arm while patient laying downlaying down Normal is >0.9Normal is >0.9

– Less than 0.9 is indication for further Less than 0.9 is indication for further diagnostic testingdiagnostic testing Angiogram (CT or fluoroscopic)Angiogram (CT or fluoroscopic) ExplorationExploration

Case 2:OutcomeCase 2:Outcome

GSW to right chest with tension GSW to right chest with tension pneumothoraxpneumothorax– Chest tube placed and 300 cc blood removedChest tube placed and 300 cc blood removed

>1000 cc (20cc/kg) initally or 150cc/hr continuing>1000 cc (20cc/kg) initally or 150cc/hr continuing– indications for exploration in the ORindications for exploration in the OR

Pulse in right leg dopplerable, but ABI 0.4Pulse in right leg dopplerable, but ABI 0.4– Get angiogram to evaluate when stableGet angiogram to evaluate when stable

Case 3Case 3

38 yo female fell from a 338 yo female fell from a 3rdrd story story windowwindow

She complains about a headache and She complains about a headache and abdominal painabdominal pain– Very brief loss of consciousnessVery brief loss of consciousness

VitalsVitals– P 94 BP 110/60 RR 20 Biox 97% on RAP 94 BP 110/60 RR 20 Biox 97% on RA

Primary SurveyPrimary Survey

AirwayAirway– Intact, patient speakingIntact, patient speaking

BreathingBreathing– No distress, normal bioxNo distress, normal biox

CirculationCirculation– No evidence of shock or pulse deficitNo evidence of shock or pulse deficit

DisabilityDisability– GCS 15, non focal neuroGCS 15, non focal neuro

Secondary SurveySecondary Survey

HEENT - PERLA, EOMI, no scalp lac, HEENT - PERLA, EOMI, no scalp lac, hematoma over left templehematoma over left temple

Chest - TTP in right lower chest, equal bsChest - TTP in right lower chest, equal bs

Abdomen - soft tender in right upper Abdomen - soft tender in right upper quadrant, no peritonitisquadrant, no peritonitis

Pelvis - stable to rock and compression, pain Pelvis - stable to rock and compression, pain on palpation of right hipon palpation of right hip

Neurologic exam - GCS 15, 5/5 strength Neurologic exam - GCS 15, 5/5 strength throughout, no sensory deficitsthroughout, no sensory deficits

What tests do you What tests do you order at the bedside?order at the bedside?

Chest X-rayChest X-ray– To look for pneumothroax, pulmonary To look for pneumothroax, pulmonary

contusion or wide mediastinumcontusion or wide mediastinum

Pelvis X-rayPelvis X-ray– To look for pelvic fracturesTo look for pelvic fractures

FAST ScanFAST Scan– Bedside ultrasound to evaluate for Bedside ultrasound to evaluate for

abdominal fluidabdominal fluid

Focused Assessment with Sonography Focused Assessment with Sonography for Traumafor Trauma

FAST ScanFAST Scan

PortablePortable Non-invasiveNon-invasive Evaluates for Evaluates for

intraperitoneal and intraperitoneal and pericardial fluidpericardial fluid– as little as 300 cc detectedas little as 300 cc detected

Reliably predicts need for Reliably predicts need for laporotomy in hypotensive laporotomy in hypotensive trauma patientstrauma patients

Not sensitive for solid organ Not sensitive for solid organ injury and retroperitoneal injury and retroperitoneal injuriesinjuries

E-FAST (extended-FAST)E-FAST (extended-FAST)– Looks for Looks for

pneumo/hemothoraxpneumo/hemothorax

Case 3Case 3

CXR, FAST negativeCXR, FAST negative– Now what?Now what?

PanScan?PanScan?– Routine CT imaging of head, cervical Routine CT imaging of head, cervical

spine, chest, abdomen for trauma spine, chest, abdomen for trauma patientspatients

– Probably beneficial for critically injured Probably beneficial for critically injured patientspatients

Downsides to ImagingDownsides to Imaging

Radiation exposureRadiation exposure

Contrast nephropathyContrast nephropathy

Cost/chargeCost/charge

Resource utilizationResource utilization

Incidental findingsIncidental findings

What tests do you What tests do you order?order?

Head CTHead CT– Identifies intercranial hemorrhageIdentifies intercranial hemorrhage

Subdural, epidural, subarachnoid or Subdural, epidural, subarachnoid or interparyenchymalinterparyenchymal

– Will identify patients who need evacuation of Will identify patients who need evacuation of blood prior to clinical deteriorationblood prior to clinical deterioration

– Many patients with severe brain injury have Many patients with severe brain injury have normal head CTsnormal head CTs From diffuse axonal injuryFrom diffuse axonal injury Don’t let a normal head CT fool you into thinking that Don’t let a normal head CT fool you into thinking that

the patient doesn’t have a head injurythe patient doesn’t have a head injury

Who needs a head CT?Who needs a head CT?

Decision RulesDecision Rules

– Nexus 2, Nexus 2, Canadian Head CTCanadian Head CT, CHIP Rule, , CHIP Rule, New Orleans CriteriaNew Orleans Criteria

– Fairly sensitive though not 100% and Fairly sensitive though not 100% and specificity may not be enough to reduce specificity may not be enough to reduce CT use that much compared to clinical CT use that much compared to clinical judgmentjudgment Work better for ‘clinically important injuries’Work better for ‘clinically important injuries’

– Requiring observation or neurosurgical interventionRequiring observation or neurosurgical intervention

Who needs a head CT?Who needs a head CT?

Generally accepted indications:Generally accepted indications:– Persistent altered mental status Persistent altered mental status – Focal neurologic deficitsFocal neurologic deficits– Signs of basilar skulls fractureSigns of basilar skulls fracture– CoagulopathicCoagulopathic

Other factorsOther factors– Loss of consciousness, vomiting, age >60, severity Loss of consciousness, vomiting, age >60, severity

of headache, scalp hematoma/contusionof headache, scalp hematoma/contusion

Important to take mechanism of injury into Important to take mechanism of injury into account when deciding to order head CTaccount when deciding to order head CT

ACEP GuidelinesACEP Guidelines

Level A recommendations. A noncontrast head CT is indicated Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or GCS score less than 15, focal neurologic deficit, or coagulopathy.coagulopathy.

Level B recommendations. A noncontrast head CT should be Level B recommendations. A noncontrast head CT should be considered in head trauma patients with no loss of considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.*than 15, coagulopathy, or a dangerous mechanism of injury.*

Abdominal CTAbdominal CT

Used to evaluate for intra-abdominal, Used to evaluate for intra-abdominal, retroperitoneal and pelvic injuriesretroperitoneal and pelvic injuries

Excellent detail of solid organ injuriesExcellent detail of solid organ injuries– Spleen and Liver Laceration classificationSpleen and Liver Laceration classification

Abdominal CTAbdominal CT

Bone windows allow visualization of Bone windows allow visualization of spine and pelvic fracturesspine and pelvic fractures– Equivalent or better than plain filmsEquivalent or better than plain films

Hollow viscous injuryHollow viscous injury– Historically a weakness of CTHistorically a weakness of CT– New generation multi-slice spiral New generation multi-slice spiral

scanners much higher sensitivityscanners much higher sensitivity

Chest CTChest CT

Evaluates for aortic injuryEvaluates for aortic injury– High risk patients – rapid decelerationHigh risk patients – rapid deceleration– Abnormal mediastinum on plain chest xrayAbnormal mediastinum on plain chest xray

More sensitive than chest x-ray for small More sensitive than chest x-ray for small pneumothorax or pulmonary contusionpneumothorax or pulmonary contusion– Some are so small they don’t need treatmentSome are so small they don’t need treatment

Case 4Case 4

Two patients on backboards and c-Two patients on backboards and c-collars after being in a motor vehicle collars after being in a motor vehicle accidentaccident

Patient A is complaining of neck pain Patient A is complaining of neck pain and Patient B is screaming in pain from and Patient B is screaming in pain from his left shoulder. They are yelling that his left shoulder. They are yelling that the collar and backboard are making the collar and backboard are making things worse.things worse.– They want the collars off and to be taken off They want the collars off and to be taken off

the board. What do you want to do?the board. What do you want to do?

Patient APatient A

24 yo female complaining of neck pain, 24 yo female complaining of neck pain, unrestrained passenger who has also unrestrained passenger who has also been drinking alcohol and her speech is been drinking alcohol and her speech is slightly slurred. No other injuries notedslightly slurred. No other injuries noted– Neck seems non-tenderNeck seems non-tender– Neuro exam reveals no focal deficitsNeuro exam reveals no focal deficits

Can you clinically clear this patients c-Can you clinically clear this patients c-spine?spine?

Restrained driver and is complaining of Restrained driver and is complaining of left shoulder pain and left ankle pain. left shoulder pain and left ankle pain. He denies alcohol use and doesn’t seem He denies alcohol use and doesn’t seem intoxicated clinically. intoxicated clinically.

States that his left shoulder commonly States that his left shoulder commonly dislocates and that he needs out of the dislocates and that he needs out of the collar so he can turn his head to pop it collar so he can turn his head to pop it back in.back in.

Patient BPatient B

Physical ExamPhysical Exam

Patient B’s neck is non-tender on Patient B’s neck is non-tender on examexam

Left shoulder with obvious anterior Left shoulder with obvious anterior dislocationdislocation– Neurovascular exam is intactNeurovascular exam is intact

Left ankle with swelling and Left ankle with swelling and deformity, tender on palpationdeformity, tender on palpation

Can you clinically clear this patient’s Can you clinically clear this patient’s c-spine?c-spine?

Clinical C-spine Clinical C-spine ClearanceClearance

Based on NEXUS Criteria (NEJM, 343(2), 2000)Based on NEXUS Criteria (NEJM, 343(2), 2000)– Study involved 34,000 patients who had imaging Study involved 34,000 patients who had imaging

of the cervical spine after blunt traumaof the cervical spine after blunt trauma

All criteria must be met in order to clear pt.All criteria must be met in order to clear pt.– Absence of tenderness in the posterior midline Absence of tenderness in the posterior midline

over the cervical spineover the cervical spine– Absence of a focal neurologic deficitAbsence of a focal neurologic deficit– Normal level of alertnessNormal level of alertness– No evidence of intoxicationNo evidence of intoxication– Absence of clinically apparent pain that might Absence of clinically apparent pain that might

distract the patient from the pain of a cervical distract the patient from the pain of a cervical spine injuryspine injury

Clinical Spine ClearanceClinical Spine Clearance

If patient meets all five NEXUS criteria If patient meets all five NEXUS criteria they can be taken out of c-collar they can be taken out of c-collar without x-rayswithout x-rays– Study had 99% sensitivity for clinically Study had 99% sensitivity for clinically

significant injuriessignificant injuries

Palpate thoracic and lumbar spine in Palpate thoracic and lumbar spine in midline to determine need for imagingmidline to determine need for imaging– Take off backboard and leave flat if Take off backboard and leave flat if

imaging indicatedimaging indicated

Patient B continuedPatient B continued

The patient also had an ankle The patient also had an ankle fracture/dislocation as well as fracture/dislocation as well as obvious anterior shoulder obvious anterior shoulder dislocationdislocation

The patient undergoes procedural The patient undergoes procedural sedation with reduction and sedation with reduction and stabilization of both injuriesstabilization of both injuries

After the procedure the patients After the procedure the patients neck was reexamined and there neck was reexamined and there was tenderness over C5-C6 in the was tenderness over C5-C6 in the midline.midline.

On CT the patient has On CT the patient has a fracture of the a fracture of the articular process and articular process and lamina of C5lamina of C5

Patient’s neck kept Patient’s neck kept immobilizedimmobilized

Patient went to surgery Patient went to surgery for fusion of C5-C6 and for fusion of C5-C6 and has no neurologic has no neurologic deficits after fixation.deficits after fixation.

Take Home PointsTake Home Points

Primary Survey for TraumaPrimary Survey for Trauma– ABCDEABCDE– Systematic approachSystematic approach– Treat life-threatening injuries as you encounter Treat life-threatening injuries as you encounter

themthem

Mechanism of InjuryMechanism of Injury– More force means more injuriesMore force means more injuries

Carefully consider risks/benefits of Carefully consider risks/benefits of imagingimaging