II. Epidemiology

  1. Trauma is the leading cause of death under age 40 years

III. Precautions

  1. See Emergency Decision Cycle (OODA Loop, AAADA Model)
  2. Overhead Page all full Trauma Team Activations
  3. Maintain careful, time-stamped records of evaluation and management of the Trauma patient
  4. Deliver medications intravenously (instead of IM, SQ) due to erratic or delayed medication absorption in Trauma
  5. Ensure smooth hand-offs from EMS
    1. Consider en-route triaging to the most appropriate facility (see Trauma Triage in the Field)
    2. Hand-off in the emergency department (MIST mnemonic)
      1. Mechanism and time of injury
      2. Injuries identified (or suspected)
      3. Symptoms and signs
      4. Treatment initiated (by EMS or outside facility)

IV. Pitfalls: Common

  1. Inadequate airway maintenance
    1. Delayed definitive airway (e.g. Endotracheal Intubation)
    2. Inadequate protection of Cervical Spine
    3. Airway obstruction by foreign matter (e.g. blood)
    4. Airway obstruction by Tongue or epiglottis
  2. Inadequate fluid Resuscitation in head injured child
  3. Failure to recognize and treat internal Hemorrhage
  4. Inadequate exposure (missed sites of injury)

V. Background: Protocol Changes

  1. "Fingers and Tubes in every orifice" mantra has caveats in 2014 ATLS
    1. Urinary Catheterization and Gastric Catheterization have specific indications in 2014
    2. Rectal Exam in the Trauma Secondary Survey has specific indications

VI. Protocol: Primary Survey (Mnemonic: ABCDEFG)

  1. See ABC Management
  2. See Rapid ABC Assessment
  3. Airway maintenance with C-Spine Control
    1. See Primary Survey Airway Evaluation
    2. See Advanced Airway for intubation indications
  4. Breathing and Ventilation
    1. See Primary Survey Breathing Evaluation
    2. Use lung protective Ventilator settings if intubated (Tidal Volume 5-7 ml/kg, low PEEP, increased rate)
  5. Circulation with Hemorrhage control
    1. See Primary Survey Circulation Evaluation
    2. See Emergent Reversal of Anticoagulation
    3. See Hemorrhage Management
  6. Disability: Neurologic Status
    1. See Primary Survey Disability Evaluation
    2. Glasgow Coma Scale, Pupil Reaction, and movement of all extremities (prior to RSI)
  7. Exposure and Environmental Control
    1. See Primary Survey Exposure Evaluation
    2. Assess for easily missed sites of injury
      1. Mnemonic: Armpits, Back and Breasts, Butt cheeks and Sac
      2. Log roll the patient (and remove the Backboard)
    3. All clothing should be removed to completely assess for injuries
      1. Expose Penetrating Trauma first
    4. Apply warm blankets
  8. FAST Exam (trauma Ultrasound survey)
    1. Evaluate for Pneumothorax and Hemothorax
    2. Evaluate for Pericardial Effusion
    3. Evaluate for intra-abdominal Hemorrhage
  9. Glucose/Girl
    1. Check Serum Glucose
    2. Check serum or Urine Pregnancy Test

VII. Protocol: Secondary Survey

  1. See Trauma Secondary Survey
  2. Backboard may be discontinued when secondary survey log-roll is performed (if no contraindication)
    1. See Backboard Clearance
    2. Backboards do not typically have a role in the hospital (outside the pre-hospital and transfer setting)
  3. Obtain Trauma History
  4. Other initial measures
    1. Urinary Catheterization
      1. See Urinary Catheterization for contraindications (e.g. blood at Urethral meatus, perineal or scrotal hematoma)
      2. Indicated for monitoring of fluid Resuscitation (and adequacy of hydration)
    2. Gastric Catheterization (e.g. Nasogastric Tube or Orogastric Tube)
      1. Indicated for aspiration risk
      2. No longer automatically recommended for all Trauma patients (as of 2014 ATLS)

VIII. Diagnostics

IX. Imaging

  1. Precautions: Transfer
    1. Avoid pan-scan (head to Pelvis CT) if Transferring a patient to a Trauma Center
    2. Make electronic copies (e.g. CD) of all imaging to send with patient
    3. Avoid imaging that will not acted upon at your sending facility (unless no delay)
  2. CT Head
    1. Indicated for signs of Head Injury including Altered Level of Consciousness (especially if anticoagulated, Intoxication)
    2. See Head Injury CT Indications in Adults
    3. See Head Injury CT Indications in Children (PECARN)
  3. CT C-Spine
    1. Indicated for any ill patient who needs Cervical Spine imaging (replaces Cross Table lateral XRay)
    2. See Cervical Spine Imaging in Acute Traumatic Injury (e.g. NEXUS Criteria)
  4. Chest XRay
    1. Indicated in nearly all Trauma patients (especially for confirmation of ET placement prior to transport)
    2. Consider placing xray cassette during log roll
    3. However, Chest XRay misses major injuries in significant Chest Trauma or Mechanism
      1. FAST Scan followed by Chest CT is preferred in these cases
      2. Langdorf (2015) Ann Emerg Med 66(6): 589-600 +PMID:26169926 [PubMed]
  5. Pelvis XRay
    1. Indicated for suspected Pelvic Fracture (optional if CT Abdomen and Pelvis are performed immediately)
    2. Consider placing xray cassette during log roll and performing at same time as Chest XRay
  6. CT Abdomen and Pelvis
    1. Not needed if benign Abdomen and Pelvis without pain, tenderness and if vitals signs stable

X. Management: Fluid Resuscitation and Hemorrhage Management

  1. See Hemorrhagic Shock
  2. See Fluid Resuscitation in Trauma
  3. See Emergent Reversal of Anticoagulation
  4. Initial fluids - Replace up to the first liter with crystalloid
    1. Precaution
      1. Trauma patients do not bleed saline
      2. Blood loss replacement should be with blood as soon as available (see below)
    2. Start with Isotonic crystalloid (Normal Saline or Lactated Ringers)
      1. Use minimal crystalloid if no signs of blood loss and hemodynamically stable
      2. Expect mild Sinus Tachycardia from pain and stress of emergency evaluation
      3. Excessive crystalloid dilutes blood, Hemoglobin And Coagulation Factors
    3. Use warmed crystalloid
      1. Trauma patients are typically hypothermic (and secondarily coagulopathic)
    4. Hypertonic Saline may be used instead (?antiinflammatory) but studies do not support benefit
      1. Bulger (2011) Ann Surg 253(3): 431-41 [PubMed]
  5. Subsequent fluids (after first liter)
    1. Replace blood loss with Packed Red Blood Cells
    2. Massive Blood Transfusion is typically accompanied by platelet and Plasma Transfusion
      1. Replace 1 unit of plasma for every 1-2 units of Packed Red Blood Cells
      2. Replace 1 unit of apheresis platelets for every 8 units of Packed Red Blood Cells
      3. Holcomb (2012) Arch Surg 15:1-10 [PubMed]
  6. References
    1. Inaba and Herbert in Majoewsky (2013) EM:Rap 13(7): 4

XI. Management: Disposition of Seriously Injured Patient

  1. See Trauma Team Activation (TTA)
  2. Decide early if transfer to Trauma Center is appropiate
    1. Among other criteria, Glasgow Coma Score <= 8 should be cared for at Trauma Center
    2. Focus on speed and efficiency
      1. Do just enough to allow safe transport to definitive care
    3. Call for transport early in course
      1. If available, a second provider in the Trauma Evaluation can break-off to contact the Trauma Center
      2. Relay a focused hand-off (MIST mnemonic: Mechanism, injuries, symptoms/signs, treatment)
  3. Obtain focused imaging only (for stabilization only, not diagnosis)
    1. See Imaging above for precautions
    2. Make electronic copies (e.g. CD) of all imaging to send with patient
    3. CT Head
      1. Indicated in Altered Level of Consciousness (evaluate for intracranial bleeding such as Epidural Hematoma)
      2. Obtain CT Cervical Spine at same time as CT Head (if indicated)
    4. Chest XRay
    5. Consider Pelvic XRay (if suspicion of Fracture)
    6. Focused assessment sonography for Trauma (FAST)
  4. Perform Primary Survey and secondary survey
  5. Focus on acute stabilization and Resuscitation to ensure safe transport
    1. RSI and Intubation (or surgical airway)
      1. Indicated in unstable airway, respiratory distress, Altered Mental Status
      2. Secure an Advanced Airway prior to transport if any chance it will be needed en-route
        1. Definitive airway management is very difficult en-route (especially on air transport)
    2. Chest Tubes (if indicated)
      1. Especially for air transport during which a small Pneumothorax is likely to expand
    3. Vascular Access and Hemorrhage Management
      1. Start Blood Products prior to transfer if indicated or
      2. Give transport paramedics blood to start if needed in route
      3. Apply Tourniquets if needed to control life threatening bleeding
        1. See Tourniquet and Hemorrhage Management for precautions
    4. Major Fracture stabilization
      1. Pelvic stabilization (Pelvic Binder)
      2. Splinting
      3. Traction Splinting
    5. Avoid procedures that may be deferred to the accepting facility
      1. Avoid Fracture reduction that may be safely delayed
      2. Immediately reduce Fractures with neurovascular compromise or active bleeding

XII. Management: Disposition of patients with Trauma and reassuring clinical findings

  1. Neuroimaging negative in Mild Head Injury
    1. See Management of Mild Head Injury for discharge criteria
  2. Abdominal imaging negative in stable blunt Abdominal Trauma
    1. Adults: Abdominal imaging may miss a serious adult injury in 0.5% of cases
      1. Overall safe to disharge if exam, imaging are reassuring and reliable follow-up in place
    2. Children: Abdominal imaging may miss a serious pediatric injury in 1 per 2600 cases
      1. Overall safe to discharge if exam, imaging are reassuring and reliable follow-up in place
      2. (2010) Acad Emerg Med 17(5): 469-75 [PubMed]

XIV. Reference

  1. Herbert and Inaba in Herbert (2014) EM:Rap 14(3): 5-6
  2. Mell in Herbert (2015) EM:Rap 15(2): 1-2
  3. (2008) ATLS Manual, American College of Surgeons
  4. (2012) ATLS Manual, 9th ed, American College of Surgeons

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