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The Multiple Trauma Patient

The Multiple Trauma Patient. Shawn Dowling, PGY-2 Preceptor: Rhonda Ness. Objectives. Will not go over these topics in great detail Head trauma C-spine trauma Chest trauma Abdo trauma Pediatric trauma. Why it’s important.

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The Multiple Trauma Patient

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  1. The Multiple Trauma Patient Shawn Dowling, PGY-2 Preceptor: Rhonda Ness

  2. Objectives • Will not go over these topics in great detail • Head trauma • C-spine trauma • Chest trauma • Abdo trauma • Pediatric trauma

  3. Why it’s important • Leading Cause of Death for those aged 1-44yrs (in developed countries) • MVC’s account for most injuries • Followed by assaults, drownings, falls, burns

  4. Distribution of Death

  5. What is ATLS? • Structured algorithm designed to prioritize management issues • Designed as a team-based approach • Applicable to both Academic and Rural Settings • It’s useful – take it.

  6. What ATLS isn’t? • A substitute for clinical acumen – trust your instinct • Most up-to-date, most evidence based approach (revised q4yrs, most recently 2004)

  7. Why is the ATLS protocol so nice? • Overall, the tenets are • Greatest threats to life are identified and treated 1st • Lack of definitive Tx should never impede the application of an indicated Tx • Detailed Hx was not essential to begin the evaluation of the acutely injured patient

  8. Preparation Triage Primary Survey (ABCDE’s) Resuscitation Adjuncts to primary survey and Resus Secondary Survey Adjuncts to Secondary survey Continued post-resus monitoring and R/A Definitive Care ATLS overview

  9. ATLS Overview CANNOT MOVE ON UNTIL YOU ADDRESS THE PROBLEM!!! Primary Survey Reassess Adjuncts Reassess Secondary Survey

  10. ATLS – Primary Survey • Airway & C-spine Immobilization • Breathing • Circulation • Disability • Exposure/Environmental Control • Full Vital Signs

  11. Case 1 • 60ishM • Coming in by STARS, ETA 10 mins • MVC – no more details • Facial fractures, unable to intubate • Significant Chest trauma, hypotense • Great...I’ll just go see this LBP patient and wait till I hear the call to the Trauma Bay

  12. Preparation Triage Primary Survey (ABCDE’s) Resuscitation Adjuncts to primary survey and Resus Secondary Survey Adjuncts to Secondary survey Continued post-resus monitoring and R/A Definitive Care ATLS overview

  13. Organizing the Trauma Bay • What do you want? • Who do you want?

  14. What do you want prepare before he arrives? 1° SURVEY • Airway: Intubation equipment incl difficult airway cart, drugs, +/- anasthesia • Breathing: RT, bilateral CT set-up • Circulation: fluids hung, blood ready, level 1 infuser primed, +/- central access • Adjuncts • X-ray, FAST, B.W., U/S

  15. What’s the best way to mobilize the right people… • Soil your scrubs and hope someone notices and calls for help • Call Trauma Code • Consult Hospitalist

  16. Who do you want? Trauma Team Activation • RT, RN’s – 3 ideal, DI techs, U.C. • ER res/doc • +/- Level 1 Call-out (trauma, gen surg, ICU) • FAST provider – ER IP or Radiology • Others: Ortho, NA, SW, 6. ER doc discretion

  17. ER #1 FAST ICU Rez Muco Man ER #2/TTL

  18. Organizing the Trauma Bay • ONE leader: • only leader should be talking and giving orders • FMC ER doc 1o survey and stabilization THEN trauma junior/ortho/plastics 2o survey • Small rural centers you’re it • Be decisive • Short window of opportunity for sick patients • Rapid decision making important • Err on the side of being aggressive Thanks Trevor

  19. Learn names and use them • Be directive • Minimize noise/people in room • Close the Loop • Verbalize your findings and thought process. • i.e. I think he has a tension PTX – I’m gonna fix it

  20. Now what? • What do you want to know from EMS?

  21. Important Historical Features • MVC • Wgt/size vehicle • Speed • Location of pt in veh • ?ejected • Mech’m of accident • Amt of damage (esp windshield, steering wheel) • ?seatbelt (type) • Airbag • ?Other deaths

  22. Motorcycle Same + ?helmet Pedestrian vs MVC Speed Damage to windshield Assault Weapon used ?trajectory ?sexual assault GSW’s Type of gun Handgun: low velocity Rifles: high velocity Type of Ammunition Distance shot from Route of Entry

  23. Injury Patterns • Frontal/Side Impact • Side Impact • Rear Impact • MVC versus pedestrian • Adult • Peds

  24. Preparation Triage Primary Survey (ABCDE’s) Resuscitation Adjuncts to primary survey and Resus Secondary Survey Adjuncts to Secondary survey Continued post-resus monitoring and R/A Definitive Care ATLS overview

  25. Airway Thanks Trevor/Rob

  26. Breathing Thanks Trevor/Rob

  27. Circulation Thanks Trevor/Rob

  28. Disability • GCS • Pupils Exposure/Environment/Full VS • Fully Expose patient • Prevent heat loss, warm blankets, warm fluids*

  29. *NABISH II (Pre-hospital Enrolment)

  30. *NABISH II (ED Enrollment) 3. w/i 2 hrs of injury Goal is moderate hypothermia (32-33°) for 48 hr

  31. Preparation Triage Primary Survey (ABCDE’s) Resuscitation Adjuncts to primary survey and Resus Secondary Survey Adjuncts to Secondary survey Continued post-resus monitoring and R/A Definitive Care ATLS overview

  32. Adjuncts • X-rays: which ones do you want • Blood Work: which ones do we get routinely • Foley, NG: do we need the NG? • FAST/dpl: Who can do it? More to come in the future.

  33. X-rays • CXR • C-spine(we’ll come back to this) • Pelvis • Do we need to this in every trauma patient? • Order others you deem necessary (but if unstable prioritize them until after secondary survey)

  34. Routine pelvic radiography in severe blunt trauma: is it necessary? ALL STUDIES ARE LEVEL II or III, so interpret w/caution… Civil ID, Ross SE, Botehlo G and Schwab CW. Ann Emerg Med 17(5):488-490. (1988) All patients were classified as unconscious; impaired; awake, alert, and symptomatic; or alert, oriented, and asymptomatic for pelvic fracture on admission. All underwent a plain anterior- posterior radiograph of the pelvis. N=265, 26 pelvic #. 7/26 were unconscious,11/26 were impaired, 8/36 Sx. No fractures were identified in 110 awake, alert, oriented, and asymptomatic patients (P less than .0001). They conclude that pelvic radiographs are required in unconscious or impaired victims of severe blunt trauma and those with signs or symptoms of pelvic fractures but are not required in the awake, alert, and asymptomatic patient. CONCLUSION: Err on the Side of Caution

  35. Preserve clot - minimal movement, gentle handling, minimum of rolling. Punch anyone who tries to 'spring' the pelvis. Fit pelvic belt (elasticated version of the old 'many-tailed-bandage' with velcro fastening) on basis of mechanism of injury. Minimal iv fluid to preserve systolic of 70 (90 mmHg if associated head injury). Take to a hospital that understands the condition! Timothy J Coats MD FRCS FFAEMSenior Lecturer in Accident and Emergency/Pre-Hospital CareRoyal London Hospital, UK.

  36. Trauma/B.W. • What blood work do we get when this is ordered? • If you had only one blood test what would it be Sultana or Heather?

  37. Trauma/B.W. • What blood work do we get when this is ordered? • If you had only one blood test what would it be Sultana or Heather? • T&S, T&C • What’s the diff? • Unmatched – immediate (F: 0-, M: 0-/+) • T&S – approx 10 min (screens for ABO &Rh) • T&C- approx 30min-1 hr (screens for ABO, Rh, other antibodies)

  38. Utility of CBC

  39. Utility of CBC • Hgb – helpful if low, not helpful if N • Initial hgb fxns more as baseline • WBC- who cares • Plts-helpful if low • Coags • Probably useful, some good evidence for HI, ?elderly

  40. Lytes • 913 Trauma pts bw – 54 had clinically significant abN, only 6 changed Tx (all hypokalemia) • authors concluded that a history of hypertension, age older than 50, and a Glasgow Coma Scale (GCS) score less than or equal to 10 appeared to be useful criteria Tortella B, Lavery R, Rekant M. Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med 1995;2:190-194 • Cr/BUN • No evidence but likely worthwhile, esp if potential for CT and contrast • EtOH • Allows you to correlate clinical picture with EtOH

  41. Amylase • No role • Mure A, Josloff R, Rothberg J, et al. Serum amylase determination and blunt abdominal trauma. Am Surg 1991;57:210-213. • LFT’s • No Role in detecting liver injuries • Lactate/Base Deficit • Multiple studies showing that the higher/more –ve these values are the sicker the patients are and more aggr mngmt is needed – DUHH! • Trop • No helpful, unless you think it’s the cause of accident • For cardiac contusion – may be a role, but not likely in the ED

  42. ?Trops

  43. Case 2 • 64M, Farmer • Brought in by STARS • Bucked off horse, c/o of mild lower abdo/pelvis pain, walked to his house to get help • What do you want to do? • What do you think is going on?

  44. Airway/Breathing N • Circulation: BP140/50, HR 80 • Disability: GCS- 14, PERLA • Exposure - N • Rest of vitals N • Now what?

  45. What films? • CXR – Yes • Pelvis – Yes (symptomatic) • Can you clear his C-spines clinically? • According to CCR? • According to NEXUS?

  46. Canadian C-spine Rule Stiell. NEJM Dec 2003; 349:2519-8.

  47. NEXUS Hoffman et al. NEJM 2000

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