Approach Overview
1. Preparation → Known & Potential Problems, People, Plan, & Props
• Equipment
Airway trays, BVM, C-spine equipment
Breathing →... [Show More] chest tube tray x2, decompression needles
Circulation → warmed IVF, O+/-
PRBCs, tourniquet, splints, thoracotomy tray
Drugs → code cart, RSI drugs, pain meds
Extras → foleys, blankets, NG tube
2. Triage → Check for surgeon/TT/Trauma transfer cirteria → activate TT ± surgeon
3. Primary Survey (ABCDE) & Resus
4. Adjuncts to Primary & Resus → ECG, FAST, CXR, C-spine XR, AP pelvis XR, ABG, coags, CBC, C7, Foley, NG
• Adjuncts should not interrupt resus
5. Decide to transfer or not
6. Secondary Survey & AMPLE Hx
7. Continuous Post-Resus Monitoring & Re-evaluation
8. Transfer to Definitive Care
Criteria for any
• Trauma Activation
• Transfer to Trauma Centre
• Presence of surgeon in trauma (Only the first 4 criteria)
• Shock (SBP<90)
• Required ETT
• GCS<8
• Pentrating trauma to head, neck or torso
• Limb amputation prox to wrist/ankle
• 2 long bone #
• Evidence of spinal cord injury
• Major peds or preg >20w trauma
Chest trauma + unstable VS + suspected HTX or PTX
1) Immediate needle/finger thoracostomies → chest tube
2) If >1500ml or >200ml/h → urgent thoracic consult
Classification of Hemorrhagic SHOCK
Class 1 → Normal VS (<750ml)
Class 2 → Tachy, ↓PP (750-1500ml)
Class 3 → HypoTN (1.5-2L)
Class 4 →↓LOC/lethargic (>2L)
Airway in trauma
• Always maintain C-spine
In trauma intubations, always ues
• Manual n-line stabilization
• A bougie
• RSI unless predicted difficult intubation or mid-face trauma or CI (→ awake ± cric)
• VL if possible (↓ c-spine movement)
Trauma Primary Survey
Airway & C-Spine precautions
• Decide to ETT or not
• If ETT → do neuro exam before ETT
Breathing & Ventilation
• Check: BS B/L, distress, asym, lacs/contusion/deformity/crepitus
• R/O & treat ATOM-FC
• O2 for all trauma patients
Circulation & Hemorrhage Control
• Check: Pulses, body-wide check for obvious bleeding (incl logroll+DRE , pelvis & FAST
• R/O non-hemorrhagic shock
→ ATOM-FC + neurogenic shock
→ If suspect c-spine injury then expect neurogenic shock to follow (fluids won't work, need pressors!)
• Circulation: If shock → warm NS/LR 2L bolus (20ml/kg PEDS) → O±blood & surgeon if refractory
• Hemorrhage Control: quickly inspect the abdomen, pelvis & limbs for obvious massive bleeds
→ External: direct pressure & splint
→ Internal: Pelvic binder & OR
Disability
• Check: GCS/AVPU, pupils, 4 limbs for lateralizing signs, suspicious head/neck/spinal trauma
• R/O Intracranial (herniation) or spine injury that require urgent interventions
• Spinal precautions PRN
Exposure
• COMPLETELY UNDRESS, LOGROLL & DRE
• Look for penetrating trauma, deformity, and contusions
• Commonly missed areas → Axilla, Perineum, Skin folds
• Blankets & warm IVFs
Order Adjuncts
Massive HTX criteria
ADULTS
• >1500ml initial output
• >200 ml/h over next 2-4h
PEDS
• >15ml/kg initial output
• 2 ml/kg over the first 4h
Primary Survey Breathing/THORAX & Interventions
ATOM FC → Critical intervention
Airway obstruction → ETT/nasoTT/cric
TPTX → decompression
OPTX → 3 sided dressing
Massive HTX → chest tube & surgical consult
Flail chest → ETT
Cardiac Tamponade → pericardiocentesis
Trauma Secondary Survey
Ensure primary survey is complete
General GCS, LOC, specific complaints
HEAD
• Pupils, contusions, lacs, signs of skull#
→ skull #, ICH, herniation, spinal injury
FACE
• Midface instability, malocclusion
→ leforge #, mandibular #
EYE
• ↓EOM/vision/diplopia
→ blowout # or retrobulbar hematoma
NECK → Maintain C-spine
• Lacs, contusions, trach dev, JVD, crepitus, focal masses, c-spine TTP, voice
→ Penetrating neck injury
→ Blunt neck injury
→ C-spine #
THORAX → ATOM FC
• Lacs, contusions, resp effort/asym, TTP/crepitus, HS & BS
Aortic injury
Thorax injuries → non-massive HTX, simple PTX
Oesphageal perforation
Muscular diaphragmatic injury
Fistula (bronchopleural) and other tracheobronchial injury
Contusion to the heart or lungs
ABDO/FLANK
• Lacs, contusions, TTP, peritoneal signs
→ Diaphragmatic injury
→ Solid organ injury
→ Hollow organ injury
→ Retroperitoneal injury or bleeding
GU & PELVIS
• Lacs, contusions, sympheal TTP, DRE, blood/hematoma of meatus, penis, scrotum, PV
→ Pelvic #
→ Bladder & urethral injuries
→ External genital injury (scrotal & penile)
NEURO
• MS, parasthesias, motor or sensory deficits, mid-line spine TTP or deformity, rectal tone, peri-A sensation
→ Neuro/spinal injuries
EXTREMITIES
• Lacs, contusions, deformity, pulses, cap-refill, compartments
→ # or dislocations
→ Soft tissue injuries
→ Peripheral vascular injuries
→ Potential compartment syndromes
Scalp Lac
• Must close galeal defects
• R/O the following in any scalp laceration
→ Underlying skull #
→ FBs
→ ICI
Skull #
Basilar # = temporal bone #
• Clinical dx → NeuroSx consult & Abx AND CT to R/O other associated injuries
• Signs → raccoon, battle, hemo-TM, CSF leak (rign sign), CN7 palsy, vertigo/hearing change
Open #
• Clinical dx → NeuroSx consult & Abx [Show Less]
