26: MULTIPLE TRAUMA PATIENT - rEMERGs

26: MULTIPLE TRAUMA PATIENT
PREPARE
Room and equipment
Staff
Discuss case/interventions
Paramedic report
PRIMARY SURVEY (Assessment and Management)
Airway
Breathing
Circulation
Disability
Exposure
Full vitals
ADJUNCTS TO PRIMARY SURVEY
Pulsox, cardiac monitors, BP monitor, CO2 monitor
NG tube
Foley
ECG
Xrays: Cspine, CXR, pelvis
Trauma blood work
ABG
DPL/ABUS if appropriate
SECONDARY SURVEY
AMPLE history
H/N
Chest
Abd
U/G
Neuro
Msk
Roll pt
ADJUNCTS TO SECONDARY SURVEY
Xrays
CT head, chest, pelvis, abd, spine
ABUS
DPL
Contrast studies
Endoscopy
Angiography
Esophagoscopy
Bronchoscopy

PRIMARY SURVEY
Airway and C-spine
‣ LOOK
‣
‣
‣
­ level of consciousness, agitated, cyanosis, retractions, AMU,
evidence of facial or laryngeal injury, evidence of UAW burn
(carbenaceous sputum, singed hairs, soot around mouth)
LISTEN
­ speech clear, stridor, gurgling, hoarseness
FEEL
­ maxillofacial trauma, laryngeal trauma, trachea midline, crepitus,
subcutaneous emphysema
MANAGE
­ manage airway while maintaining C-spine control
­ hierarchy: jaw thrust, oropharyngeal airway, nasopharyngeal
airway, nasotracheal intubation, endotracheal intubation, jet
insufflation, cricothyroidotomy; clear foreign bd and suction
Breathing and Ventilation
‣ LOOK
­ RR, depth of respirations, chest wall mvmts, chest wall injuries
‣ LISTEN
­ breath sounds, heart sounds, bowel sounds in chest
‣ FEEL
­ subcutaneous emphysema, trachea midline, dull or tympanic to
percussion, chest wall injury, look for internal bleeding
‣ MANAGE
­ 100% 02: face mask with NRB at 10 - 12 L/min
­ pulsoximeter, end tidal C02
­ ventilation by BVM or ETT as necessary
­ thoracentesis for pneumo, chest tube for hemo/pneumo, seal
open chest wounds
Circulation and Hemorrhage
‣ LOOK
­ identify external bleeding, skin color, diaphoresis, JVD
‣ LISTEN
­ muffled heart sounds, murmur
‣ FEEL
­ pulse rate, pulse quality, BP, cool/clammy skin
­ quick feel of abdomen and pelvis to identify major hemorrhage
‣ MANAGE
­ cardiac monitor, BP monitor
­ two large bore IVs, send blood for trauma panel and ABG
­ bolus 2L RL for hypotension
­ direct pressure to bleeding sites; no clamps unless direct
visulualzn
­ consider yourself STUCK on C if hypotensive; give initial tx and
rember to return to see response and look for cause
­ consider need for DPL or ABUS in primary survey if hypotensive
Disability
‣ PUPILS
‣ GCS
‣ Manage: RSI intubation, hyperventilation, mannitol for impending herniation
Exposure/Environment
‣ Full exposure and prevent hypothermia
Full Vitals
‣ Repeat vitals including core temp; are you stuck on primary survey b/c of poor

vitals??
ADJUNCTS TO PRIMARY SURVEY
Most should already be done
Monitors: Pulsox, BP and cardiac monitor, ET CO2 monitor
Xrays: C-spine, CXR, and pelvic Xrays (TRY to get CXR and pelvis early; C-spine can
wait until secondary survey)
DPL, ABUS
NG and urinary tubes if not contraindicated (foley after rectal)
SECONDARY SURVEY
AMPLE history and details of accident including condition of vehicle, ejection, other
injured passengers, seat belts, blood loss at seen, vitals on route, interventions on route,
etc
Head and Neck
‣ Head: lacerations, contusions, fractures, burns
‣ Face: maxillofacial fractures, racoon eyes, battle signs, look in mouth,
burns, carbenaceous sputum, soot, singed hairs, nose for CSF leak
‣ Eyes: pupil size and reactivity, EOM, visual acuity, hemorrhage, racoon
eyes
‣ Ears: battle signs, hemotympanum, CSF leak
‣ Cranial nerves: II - XII if not already tested; occulocephalics and
occulovestibular reflexes, corneal reflex, gag reflex
‣ Neck: inspect for blunt injury, penetrating injury, tracheal deviation,
accessory muscle use; palpate for deformity, tenderness, swelling, subQ
emphysema, tracheal deviation, symmetry of pulses; listen to carotids,
palpate C-spine.
Chest
‣ Look: blunt or penetrating trauma, acc muscle use, chest expansion, JVD
‣ Listen: breath sounds and heart sounds
‣ Feel: tenderness (AP and lateral compression), rib tenderness,
crepitation, subcutaneous emphysema, percuss for hyperresonance or
dullness
Abdomen
‣ Look: blunt or penetrating trauma (look closely at sides re hepatic and
splenic injury may be suspected by lower rib cage lateral abrasion)
‣ Listen: bowel sounds
‣ Feel: palpate for tenderness, guarding, rebound; percuss for tenderness
‣ DPL, ABUS, ABCT, pelvic Xrays as appropriate
Urogenital
‣ Look: contusions, lacerations, urethral/vaginal/rectal bleeding
‣ Rectal: prostate position, bone fragments, wall integrity, sphincter tone,
blood
‣ Vaginal: laceration, blood, bone fragments
MSK
‣ Look, feel, move all joints of upper and lower limb looking for lacerations,
contusions, deformities, crepitus, possible fractures
‣ Compress pelvis AP and lateral
‣ Assess limb pulses and neuro status distal to suspected fractures
‣ Obtain Xrays of injured parts
Neuro
‣ Mental status and GCS

‣
‣
Roll Pt
‣
Cranial nerves
Strength, Reflexes, Sensation, Coordination
Look, feel for any injuries, lacerations, contusions, spine tenderness,
rectal
MULTIPLE TRAUMA CONCEPTS
EPIDEMIOLOGY/INTRO
MCC of death < 40 yo; #1 cause of PYLL
Huge economic costs and chronic dz and societal loss
MOST/ALL preventable
MOI very important
MOI and suspected injury patterns: table 26-1
TRIAGE
Multiple casualties = the number and severity of the injuries do NOT exceed the ability of
the facility to render care. Treat life-threatening injuries first.
Mass casualties = the number and severity of the injuries EXCEED the capability of the
facility and staff. Those w/ the greatest chance of survival, with the least expenditure of
time, equipment, supplies, and personnel are managed first.
TRAUMA SYSTEM
Trauma centers
ATLS approach
Prehospital system
Triage scheme (Box 26-1)
Quality assurance programs
Trauma logs and review: M&M rounds
Trauma scoring system
CLINICAL MANAGEMENT KEYS
Prehospital
‣
ED phase
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Prevent additional injury, rapid transport, advanced notification,
appropriate triage, initial tx
Organized team approach with TTL doing initial assessment, coordinating
procedures and investigations
High priority Mx: ABC and impending herniation
Low priority Mx: neuro, cardiac, abdomenal, msk, SCI, burns
Treat before diagnosis in critically ill
Thorough physical examination for injuries
Frequent reassessment
Monitoring vitals, ins/outs, serial Hb/lactate, CVP and Swan Ganz, art line

PITFALLS/KEY POINTS
PRIMARY SURVEY
AIRWAY + C-SPINE CONTROL PITFALLS
‣ Equipment failure
‣ Pt cannot be intubated a/f RSI and paralysis
‣ Surgical AW cannot be performed b/c of obesity
‣ Intubation of pt w/ unknown laryngeal fractureor incomplete UAW
obstruction may ppt total AW obstrstruction
‣ Indications for intubation: AWO real or impending, ventilation, inc ICP
‣ C - spine not big concern with penetrating trauma
‣ RSI with oral intubation is preferred route of AW mx
BREATHING AND VENTILATION PITFALLS
‣ Profound SOB and cyanosis may suggest airway problem but may be
ventilation problem (ie; pneumothorax)
‣ Intubation of the unconscious may produce a pneumo
CIRCULATION PITFALLS
‣ Elderly can have diminished tacchycardic response to hypovolemia :. they
are hypovolemic and you don’t suspect it. Must suspect hypovolemia
even in absence of tacchycardia. BP has little correlation w/ cardiac
output in elderly.
‣ Children have excellent physiological reserve :. CRASH very quickly a/f
having previously normal vitals
‣ Athletes have unusally low heart rates
‣ Central line or cut down necc. for difficult access
‣ If hypotensive, look for source in primary survey (Chest, abdomen, pelvis)
DISABILITY PITFALLS
‣ Rapid deterioration in neurological status is imp
‣ Lucid interval commonly associated w/ epidural hematoma is an example
of how the pt can “ talk and die” .
‣ Reassesment is critical
EXPOSURE PITFALLS
‣ Early control of hemorrhage to prevent req’t for massive fluids/blood which
induce hypothermia
FULL VITALS
‣ Failure to repeat vitals
‣ Failure to take core temperature
‣ Failure to focus on primary survey: do not move on to secondary
survey until happy with primary survey; or do quick secondary looking
for etiology of primary survey problem
ADJUNCTS TO THE PRIMARY SURVEY
ECG monitoring
‣ Essential in all trauma pts

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Blunt cardiac injury: tachycardia, Afib, PVCs, ST changes
PEA: cardiac tamponade, tension pneumo, profound hypovolemia
Hypoxia, hypovolemia: bradycardia, abereant conduction, premature
beats
Foley Catheter
‣ Monitor fluid status
‣ Must not put in b/f genital and rectal examination
‣ Contraindicated if urethral transection suspected.......
(1) penile meatus blood
(2) perineal echymosis
(3) blood in scrotum
(4) high-riding or nonpalpable prostate
(5) pelvic fracture
Gastric Catheters
‣ Reduce stomach distension and decrease (NOT prevent) the risk
of aspiration
‣ May induce vomiting; must have suction ready
‣ MUST be placed orally if cribriform plate fracture is suspected
Monitoring
‣ Ventilatory rate and ABGs: colorimetric carbon dioxide detector
confirms that the ETT is in the airway but DOES NOT confirm
proper placement
‣ Pulse oximetry: do not place distal to the BP cuff.
‣ BP monitor: can be placed on leg if arms are burned
Xrays
‣ Must do even in the pregnant pt
TRAUMA ARREST
Combination of ATLS and ACLS
CPR inneffective b/c either exsanguination or tamponade
Epinephrine ineffective
Thoracotomy
‣ Indicated in penetrating trauma unless dead at scene
‣ NOT indicated in blunt (may consider with loss of vitals in ED)
PEA in trauma pt
‣ ABCs: hypoxia
‣ Fluids: hypovolemia
‣ Needles
­ Bilateral tension pthrx decompression
­ Pericardiocentesis decompression: debatable in
trauma setting b/c basically useless