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APPROACH TO TRAUMA Resident Rounds July 17 th , 2003 Rob Hall PGY4 PowerPoint PPT Presentation

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APPROACH TO TRAUMA Resident Rounds July 17 th , 2003 Rob Hall PGY4. What is your approach?. Ouch …… . Key Points . Systematic approach to trauma is a must Triage tools Prehospital trauma management How to “ manage the trauma room ” Priorities in the multitrauma patient

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APPROACH TO TRAUMA Resident Rounds July 17 th , 2003 Rob Hall PGY4

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Approach to trauma resident rounds july 17 th 2003 rob hall pgy4 l.jpg

APPROACH TO TRAUMAResident Rounds July 17th, 2003Rob Hall PGY4

What is your approach?

Slide2 l.jpg


Key points l.jpg

Key Points

  • Systematic approach to trauma is a must

  • Triage tools

  • Prehospital trauma management

  • How to “manage the trauma room”

  • Priorities in the multitrauma patient

  • PEARLs of the primary survey

  • PEARLs of adjuncts and investigations

Case presentation you know you re having a bad day when l.jpg

Case Presentation: you know you’re having a bad day when………….

  • 50ish yo female

  • Gets up in am, lights a smoke

  • Gas leak overnight ->EXPLOSION

  • She is blown out the second story patio door and is found lying on a driveway ON THE OTHER SIDE OF THE STREET

  • Husband is dead inside burning building

Who needs transport to a trauma center l.jpg

Who needs transport to a trauma center?

  • Case: does this patient need a trauma center? Why?

  • What criteria do you use?

    • Triage decision scheme from ACS (see ATLS)

    • Revised Trauma Score (RTS)

    • Injury Severity Score (ISS)

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How to prepare for a trauma patient?

  • How would you prepare for this case?

  • Personel

    • RN, RT, DI, Notify trauma surgeon if nasty

  • Equipment

    • Think of what you will need in primary survey

    • Anticipate what you will use

      • GSW to abdomen, BP 50 ->get some blood hanging in the level I infuser

      • Draw RSI drugs in advance

      • Make sure you have all of the equipment you will need if you are working in a smaller center

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The Paramedic Report

  • What do you want to hear in the report?

  • Mechanism of injury

    • Key point of history

    • Pay close attension

    • Predicts certain injuries

  • Suspected injuries

  • Stability of vital signs

  • Treatments they have given

  • PMHx/med/all if known and relevant

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Driver side impact


Left h/pthrx

Splenic lac

Lateral compression pelvic fracture

Left femur fracture

Front end collision


Mediastinal injury

Any intraadbo injury

Anterior compression pelvic fracture

Posterior hip dislocations

Bilateral femur/tib/fib fractures

Calcaneal fractures, pilon fractures

Example of importance of MOI:Side impact VERSUS Front impact

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Prehospital Trauma Management

  • Case: what do you want the medics to do?

  • BLS

    • C spine, spine board, basic airway maneuvers, oxygen and BVM, control of external hemorrhage, scoop and run

  • ALS

    • Some controversy re advanced airway mx

    • Iv fluids: no evidence for prehospital fluids

  • BLS care and RAPID TRANSPORT are the most important

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Case: the trauma arrives…

MOI: 70% burn + trauma

Unable to intubate X 2; BVM

Agonal resps, BP 60 palp, HR 140

No sat obtainable, No iv access

? Head injury: GCS 3, external signs of head trauma

What is your approach?

Atls approach good but not perfect l.jpg







Full Vitals


CXR, PXR, Cspine

NG, foley, ECG

Monitors, trauma panel

DPL, FAST if needed



Full head-to-toe



Extremity Xrays



Contrast studies

ATLS approach: good but not perfect

Case how do you actually do the primary survey the airway l.jpg

Case: how do you actually do the primary survey? The Airway………

Breathing l.jpg

Breathing ……

Circulation l.jpg

Circulation ……

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Disability, Exposure, Full Vitals ……

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PEARLS of the ABCs

  • Consider yourself stuck until you have dealt with an issue

  • Frequent reassessment

  • Start from A whenever there is a problem

  • Secondary survey is truly secondary

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  • 25 yo male

  • Motorbike into pole at 80 km/hr

  • Helmet damaged

  • Intubated by EMS

  • HR 75 BP 60 palp Sats 97% GCS 6

  • What is the differential dx of shock in a trauma patient?

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Ddx of shock in the trauma patient

Hypovolemic/Hemorrhagic shock

  • Chest (note: not likely aortic injury)

  • Belly

  • Pelvis

  • Femurs

  • External hemorrhage (esp scalp)

  • Neurogenic

  • Brainstem herniation (preterminal)

  • Other: example -> MI then crashed car

  • Pearls of managing shock l.jpg

    How much initial fluid?

    Which fluid?

    When to give blood?

    When to give blood products?

    What tests will help you?

    2-3L (20-60ml/kg)


    After 2-3L or 20-60ml/kg crystalloid

    > 4 units prbc.s: order 4 units FFP and 10 units platelets

    EARLY CXR/PXR and FAST will help you identify the etiology of shock

    PEARLS of managing shock

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    PEARLS of the ABCs

    • 50 yo male

    • Small plane crash

    • Transported by STARS

    • Intubated by STARS

    • HR 120 BP 100 Sats 75% on 100% oxygen

    • What is the differential dx of hypoxemia in a trauma patient?

    Differential dx of hypoxemia in trauma l.jpg

    Differential Dx of Hypoxemia in trauma

    • Airway obstruction

    • Pneumothorax

    • Hemothorax

    • Pulmonary contusion

    • Trachobronchial transection

    • Aspiration

    • Atelectasis

    • ARDS

    • Pulmonary hemorrhage

    • Fat Embolism

    • Intubated patient: GDOPE

    Pearls of diagnositic imaging l.jpg

    PEARLS of diagnositic imaging

    • Oral Contrast and CT abdomen

      • Theoretic increase in pick up of small bowel perforation and pancreatic injuries

      • Increases risk of vomiting and aspiration

      • Evidence doesn’t support that it increases sensitivity of CT for bowel injuries

        • ?Why: doesn’t get past stomach

      • Oral contrast OK but do NOT delay the CT in a patient that needs it sooner than later

    Head injured drunk combative what sedative would you use l.jpg

    Head injured, drunk, combative: what sedative would you use?

    • Midazolam: risk of hypotension and respiratory depression

    • Haldol: theoretical risk of lowering seizure threshold, longer duration

    • Haldol probably preferred

    What comes first head or belly l.jpg

    What comes first: head or belly?

    • CASE: Hypotensive trauma patient that needs laparotomy and has blown left pupil and signs of head trauma

    • What comes first?

      • To OR for laparotomy: pack off bleeding

      • Burr hole in OR (“blind”) or go back to CT for CT head

      • In general, belly comes first

    The trauma arrest l.jpg


    • What type of rhythm is usually present?

    • What is your approach to the PENETRATING trauma arrest?

      • Thoracotomy if ever had vitals

    • What is your approach to the BLUNT trauma arrest?

    The trauma arrest26 l.jpg


    • Intubate: crash intubation, no drugs

    • Ventilate: hyperventilate

    • Volume: blood through bertha

    • Needle the chest

    • CPR/Epi/atropine

    • Run for 5 – 10 minutes

    • NO thoracotomy

    How to manage the trauma room l.jpg

    How to MANAGE the trauma room

    • Should be ONE leader: only leader should be talking and giving orders

    • Too many “cooks in the kitchen” is bad

    • RTs and RNs need to stick to their roles

    • Be decisive

    • Err on the side of being aggressive

    • Move rapidly if the patient is sick

    • CXR and pelvic Xray BEFORE trauma labs, ABG, foley, NG, Cspine Xray

    The trauma question on the exam l.jpg

    The Trauma question on the exam

    • Same approach

    • Be methodological

    • Stick Man

    Key points29 l.jpg

    Key Points

    • Have a systematic approach to trauma

    • Have a systematic approach to the hypotensive and hypoxemic trauma patient

    • Be ready for the trauma arrest

    • Manage the trauma room

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