1 / 24

The Trauma Evaluation

The Trauma Evaluation. Kenneth DeSart , MD. University of Florida Oral Exam Review. Primary Survey. A irway Conscious? Talking? Clear secretions, intubation if needed Inhalational/Burn injury? B reathing Inspect for penetrating injury, tracheal deviation Auscultate lung sounds

zuzela
Download Presentation

The Trauma Evaluation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Trauma Evaluation Kenneth DeSart, MD University of Florida Oral Exam Review

  2. Primary Survey • Airway • Conscious? Talking? • Clear secretions, intubation if needed • Inhalational/Burn injury? • Breathing • Inspect for penetrating injury, tracheal deviation • Auscultate lung sounds • Palpate subcutaneous emphysema • Consider: need for artificial ventilation, tension pneumothorax, flail chest

  3. Primary Survey • Circulation • Vital signs: BP, HR, pulse, UOP • IV access (2 large bore IV), resuscitation, stat labs • Check abdomen/pelvis for obvious s/s of bleeding • Stop external bleeding (esp. scalp) • Disability • Mental status, GCS • Exposure • Stabilize neck, remove clothing to check for signs of injury • Roll patient to look at back and do rectal • Maintain body temperature

  4. Trauma Deaths Trimodal distribution 1st peak: 0-30min. Dead at the scene. Massive neuro trauma, aortic injuries, etc. 2nd peak: 30min-4hr. Head injury and hemorrhage. These patients can be saved! “Golden Hour” 3rd peak: days to weeks. MSOF and Sepsis

  5. Glasgow Coma Score • GCS (max = 15) • Motor (max = 6) • 6 follow commands, 5 localizes pain, 4 withdraws from pain, 3 flexion with pain, 2 extension with pain, 1 no response • Verbal (max = 5) • 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 no response • Eye opening (max = 4) • 4 spontaneous eye opening, 3 to command, 2 to pain, 1 no response

  6. Glasgow Coma Score GCS ≤ 14  head CT GCS ≤ 10  intubation GCS ≤ 8  Intra-cranial pressure (ICP) monitoring

  7. Sources of Massive Hemorrhage Chest Abdomen Pelvis Long bone (thigh) Retroperitoneum Scalp laceration (blood left at the scene)

  8. FAST Exam • Focused Assessment with Sonography in Trauma • Performed during/after primary survey • Replaced Diagnostic Peritoneal Lavage (DPL) • 4 areas: pericardium, perihepatic (Morrison’s pouch), perisplenic, pelvic, & repeat perihepatic • Detects intra-abdominal bleeding • 100cc in Morrison’s pouch • most dependent area in peritoneum in supine position • 250cc total • Does not detect retroperitoneal bleeding or hollow viscous injury

  9. FAST Exam Sonoguide.com/FAST.html

  10. FAST Exam - Perihepatic Negative Positive

  11. FAST Exam - perisplenic Negative Positive

  12. FAST Exam - pelvis Negative Positive

  13. Secondary Survey • Performed immediately following primary survey • AMPLE history – allergies, meds, PMH, last meal, events • Head to toe physical examination • Re-assess vital signs, changes in neurologic status • Need for more IV access? Arterial-line? • Imaging: CXR, pelvis XR, +/- extremity XR • Place foley catheter after rectal exam to rule out urethral injury • Blood at meatus, high riding prostate, severe pelvic fx, perineal hematoma • Check spine injury (“tenderness, step-offs”) • Remove back board

  14. Decompensation If the patient’s condition changes during the resuscitation, go back to your ABC’s. Assess-> Intervene-> Reassess All trauma patients are bleeding until proven otherwise

  15. CT Scan • Contraindicated in unstable patients • Use if patient intoxicated or if distracting injuries • Assess active hemorrhage (“blush”) • Assess degree of organ injury • Various grades affect management in liver, spleen, kidney, etc. • Intracranial bleeding • Low sensitivity for hollow viscous injury • Low sensitivity for diffuse axonal injury (brain)

  16. Tertiary Survey The infamous “Tert” Performed within 24 hrs of initial evaluation Complete history and physical examination Assess need for further imaging (extremity XR) Review labs, imaging findings Summarize diagnoses, treatment plan Important to ensure nothing gets missed

  17. Special cases - Airway • Intubation – maintain in-line stabilization of cervical spine • Listen for right main stem intubation • Unable to intubate  surgical cricothyrotomy • Through cricothyroid ligament • Between thyroid and cricoid cartilage

  18. Special cases - Breathing • Tension pneumothorax • Large bore needle decompression at mid-clavicular line above 2nd rib • Tube thoracostomy (“chest tube”) • Open pneumothorax (“Sucking chest wound”) • 3 sided patch to allow expiration but not inspiration of air through hole • Tube thoracostomy

  19. Special cases - Circulation • Scalp laceration • Potential for massive bleeding • Suture lacerations • Apply compressive bandage for 30 minutes and re-assess • Pelvic bleeding • Pelvic binder in ED • Pelvic packing • Imaging, arterial embolization • Cardiac tamponade (75-100ml) • Pericardial drain (via pericardial window) • Thoracotomy if in extremis

  20. Special cases - Circulation • Positive FAST and unstable  Exploratory laparotomy (ex-lap) • Stab abdominal injury  selective laparotomy if fascia violated • Some say laparoscopy first to see if peritoneum violated. • GSW abdominal injury  ex-lap • Penetrating “box” injuries (b/t clavicles, xiphoid, nipples) • Immediate pericardial fast. May need pericardial window, bronchoscopy, esophagoscopy, and/or barium swallow

  21. Special Cases: Circulation • Need for transfusion  O+ blood for males, O- blood for women of child bearing age or younger • No time for results of type and screen or cross • Indication for OR thoracotomy • 1500cc blood at initial chest tube insertion • 200cc blood for 4 hrs • 2500cc in 24hrs • Additional vascular access • Subclavian/Femoral introducer • Saphenous vein cutdown

  22. The Pregnant Patient • “To save the fetus, one must save the mother” • Provide all essential diagnostic or therapeutic procedures • CT scans if necessary • Kleihauer-Betke (K-B) test • Detects fetal blood in maternal circulation • Sign of abruption • C-section during exploratory laparotomy • Persistent maternal shock, >34wks and mother with severe injuries, pregnancy a threat to mother’s life (DIC, etc), Mechanical obstruction to injury, risk of fetal distress exceeds risk of immaturity, or direct uterine trauma

  23. Trauma Pearls • Most commonly injured organ in blunt trauma • Liver (spleen is very close 2nd) • Most commonly injured organ in penetrating injury – small bowel (liver is close 2nd) • MCC epidural hematoma – middle meningeal artery • MCC subdural hematoma – venous plexus • Femur fractures – up to 2L blood can pool • Open extremity fractures – reduce fracture, reassess pulse • No pulse – angiography or OR

More Related