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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 l.jpg

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

What is your approach?

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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

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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

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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?

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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

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Breathing ……

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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?

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    Differential Dx of Hypoxemia in trauma

    • Airway obstruction

    • Pneumothorax

    • Hemothorax

    • Pulmonary contusion

    • Trachobronchial transection

    • Aspiration

    • Atelectasis

    • ARDS

    • Pulmonary hemorrhage

    • Fat Embolism

    • Intubated patient: GDOPE

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    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

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    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

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    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

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    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

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    The Trauma question on the exam

    • Same approach

    • Be methodological

    • Stick Man

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    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