Carla Smith RN, BSN, CEN, NREMT-P, CE-I

*Trauma is the 4th leading

cause of death in the US

*Leading cause of death in

people under the age of 45

*First peak instantly (brain,

heart, large vessel injury)

*Second peak minutes to hours

*Third peak days to weeks

(sepsis, prolonged

hypoperfusion, MSOF)

*ATLS focuses on the second

peak, minutes to hours.

*Death from:

TBI, skull fractures, spinal cord

syndrome, penetrating injuries, cardiac

tamponade, tension pneumo, flail chest,

liver lac, splenic injury, pelvic fractures,

femur fractures…

*Treat the greatest life threat first

*Utilize and ABCDE approach

*A detailed history should not delay

evaluation and treatment

*Lack of a definitive diagnosis should not

impede treatment

*Subsequent mortality and morbidity are

tied directly to the initial assessment

and resuscitation

*Scene size up

*Initial primary assessment

*Rapid resuscitation

*More thorough secondary

assessment

*Disposition

*MOI (Mechanism of Injury)

*Falls (distance, surface)

*GSW (long/short barrel, caliber, distance)

*MVC (speed, damage, location of impact,

seatbelt, airbag, windshield damage, steering

wheel damage)

*Drowning (length of submersion, water temps)

*Number of patients

*Utilize trauma triage to prioritize status

*Rapid- 60-90 seconds

*A-airway

*B-breathing

*C-circulation

*D-disability

*E-exposure

*Only interrupt primary survey to treat life threats

*Airway should be assessed for patency

*Is the patient able to communicate verbally?

*Inspect for any foreign bodies

*Utilize jaw thrust technique

*Examine for stridor, hoarseness, gurgling, pooled secretions or blood.

*Assume c-spine injury in patients with multisystem trauma

*Maintain C-spine precautions in any patient

with injury above the clavicle

*Supplemental oxygen

*Suction

*Chin lift/jaw thrust

*Oral/nasal airways

*Definitive airways

*ETI for comatose patients (GCS<8)

*RSI/ETI for airway protection or expected clinical

course (obstruction from blood or vomitus, neck

hematoma, facial burns or trauma)

*RSI for agitated patients with c-spine immobilization

*Airway patency alone does not

ensure adequate ventilation

*Observation of respiratory rate,

oxygen saturation, and overall work

of breathing

*Inspect, palpate, and auscultate

*Deviated trachea, crepitus, ecchymosis, flail

chest, sucking chest wound, absence of breath

sounds

*Ventilate with 100% oxygen

*Needle decompression if tension

pneumothorax suspected

*Occlusive dressing to sucking chest

wound

*PPV for flail chest

*If intubated, evaluate ETT position

*Rapid assessment of hemodynamic status

*Level of consciousness

*Skin color

*Pulses in four extremities

*HR

*Blood pressure

*Hemorrhagic shock should be assumed in any

hypotensive trauma patient

*Control external bleeding

*Cardiac monitor

*Apply pressure to sites of external hemorrhage

*Establish IV access

*2 large bore peripheral IV’s (at least 18 gauge)

*Volume resuscitation

*“3:1 rule” 3cc crystalloid for every 1cc of blood loss

*New treatment standard

*R. Adams Crowley Shock Trauma Hospital at The University of Maryland Medical Center

*Research shows attempts to restore blood pressure with crystalloids resulted in increased hemorrhage volume and higher mortality*Dilutes remaining circulating blood

*Hampers bodies compensatory mechanisms

*Hinders clot formation

*Use of SBP and HR not completely accurate

*Medical history

*Medications (ie: beta blockers)

*The Journal of the American Medical

Association published a study showing

patients managed with a MAP of 50 mmHg

had decreased mortality rates then those

maintained at the previous standard of 65

mmHg

*250 ml boluses

*5 Places life threatening hemorrhage can

occur

-Chest

-Abdomen

-Pelvis

-Thighs

-Externally

*

*TXA

Tranexamic acid

-inhibits natural clot breakdown

*Cardiac Tamponade can cause

hypotension with little blood loss.

*Becks triad: hypotension, distended

neck veins, muffled heart sounds

*Pericardiocentesis

*Blunt chest trauma

*Cardiac arrest

*Abbreviated neurological

exam

*Level of consciousness

*Pupil size and reactivity

*Motor function

*GCS

*Completely expose patient

*Inspect both axillae and

peritoneum

*Logroll to inspect back

*Warm blankets/external warming

device to prevent hypothermia

*

*28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.

*HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask

*Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle

*What are the management priorities at this

time?

*What are this patient’s possible injuries?

*What are the interventions that need to

happen now?

*Physical exam from head to toe

*DCAP-BTLS

*AMPLE history

*Allergies, medications, PMH, last meal,

events

*Frequent reassessment of vitals

*Some patients you may never make it to

the secondary survey

*Level of consciousness or loss of consciousness

*Headache

*Pupillary assessment

*Speech

*Increased ICP

*Posturing

decerebrate, decorticate

*Seizures

*Elevate Head

*Cushing’s reflex

* Bleeding between the Dura

and the brain

*Usually venous

* Typically caused by trauma

* Tearing of the vessels along

the surface of the brain

* Places pressure directly on

the brain and causes

swelling and shifting

* Deadliest of the injuries

* Bleeding between the skull

and the Dura

*Often associated with skull

fractures

*Usually arterial

* Patients may exhibit a LOC,

followed by alertness, and

then decreased mentation

or another LOC

Raccoon Eyes

Battle’s Sign

Rhinorrhea

Bleeding from the ears

CSF leakage (halo)

*Common source of traumatic injury

*Mechanism is important

*Bike accident over the handlebars

*MVC with steering wheel trauma

*High suspicion with tachycardia, hypotension, and abdominal tenderness

*Can be asymptomatic early on

*Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis

*Most commonly

injured organ in

blunt trauma

*Often associated

with other injuries

*Left lower rib pain

may be indicative

*Graded I-V

*Second most

common solid organ

injury

*Can be difficult to

manage surgically

*Graded I-VI

*Bowel sounds in the chest cavity

*Left > right due to liver protection of the diaphragm.

Trace the Diaphragm Outline. Where is theDiaphragm on the left?

Abdominal contentsUp in the chest on theleft

High risk for

hemorrhage into the

pelvis

Severe pain

Instability

Open Book Pelvic

Fracture

*Femur and Humerus fractures present greater

risk for blood loss.

*Stability is best intervention for pain

management

*Consider application of traction for femur

fractures.

*Don’t delay transport to stabilize long bone

fractures in critical patients

*Consider MOI with femur fractures

*Key is SUSPICION!!!

*Incongruent stories of mechanism

*Delay in seeking treatment

*Multiple stages of injuries

*Pattern Injuries

*Multiple hospital visits

*Injury mechanism beyond the scope of the age of child (6week old rolled over off the bed)

*Bite marks, submersion injury, cigarette burns

So where does your patient need to go and how

fast do they need to get there?

*Central Ohio Trauma System (COTS) has

devised specific guidelines as to what

constitutes a level I or level II trauma and must

be transferred to a Trauma Center

*0-15 years of age – pediatric

70+ years of age - geriatric

*If your ground transport time exceeds 15min

consider air medical transport

*Respiratory compromise

* Intubation

*Hemodynamic instability

*GCS <8

*GSW to abd, chest, neck

*ERP direction

* GCS <13

* Flail chest

* Blunt abd trauma with pain

* Amputation proximal to wrist/ankle

* 2 or more proximal long bone fxs (1 in geriatric)

* Open long bone fx

* Clinically apparent pelvic fx

* Traumatic paralysis

* Major burns (>10%)

* Open/depressed skull fracture

* Penetrating injury to the head, neck, chest, abd, or proximal extremities

* Geriatric, falls from any height with TBI or on anticoagulants

*ATLS Student Course Manuel, 6th edition.

*Emergency Care in the Streets, 6th edition.

*UNC College of Medicine, Approach to Trauma

Management