The Bullet- Trauma Review and

the 20-Second Shout Out for TraumaDustin Stuart DO

Central Montana EMS Conference

3/23/2019

Objectives

What is trauma and what is my role?

What is a trauma center and how does it benefit my patient?

How do I concisely share the information I have gained about my patient to

the accepting trauma team?

This is Trauma

What is Truama?

Traumatic injury is a term which refers to physical

injuries of sudden onset and severity which require

immediate medical attention. The insult may cause

systemic shock called “shock trauma”, and may require

immediate resuscitation and interventions to save life and

limb.- University of Florida

Multi system trauma approach

The most dramatic injury usually is NOT

the most dangerous

Primary Survey

Secondary Survey

Re-evaluation

Initial Management

Airway

Breathing

Circulation

Disability

Exposure

Correct problem before moving on

Airway

Assess for Patency

Look

FB in Airway

Blood/Vomit/Secretions

Listen

Noisy Breathing = Obstructed Breathing

Normal speech = No Obstruction

Feel

Tracheal Location and Midline Shift

Airway Obstruction

Be Vigilant with

Maxillofacial Trauma

Neck Trauma

Laryngeal Trauma

Nonverbal Patients

Airway Interventions

Remove FB/Secretions/Emesis

Chin lift/Jaw Thrust

Oral/Nasopharyngeal airways

Reassess after interventions

Maintain C spine precautions

Breathing

Open airway does not equal Ventilation

Look

Chest rise/Symmetric movement

Listen

Symmetric and adequate BS/Adequate rate

Feel

Crepitus

Breathing

Danger Signs

Respirations <10

Respirations >24

Poor Chest Rise

Labored breathing

Crepitus

Breathing

If inadequate ventilation/airway

BVM→ 2>1

LMA

ET intubation

Breathing

Remember:

If Adequate BVM +/- Intubating

All trauma patient deserve Oxygen

Face mask is best

Protect the Spine

Circulation

Look

Skin Color

Listen

BP→ Late sign

Level of Consciousness

Feel

Pulse

Perfusion

Circulation

Interventions

IV→ Fluids

Control Hemorrhage

Tourniquet→ uncontrolled bleeding in unstable patient

Reassess after interventions

Disability

GCS

AVPU

Exposure

Remove from toxic exposures

Remove wet clothing

Prevent hypothermia

Expose for exam

Secondary Survey

After primary → If stable

No Secondary → No problem

Multiple Trauma Prehospital Goals

Goal → Stabilize patient and transport to definitive care

Definitive Care unstable patient → OR

Minimum time on scene

Maximum treatment in route

Continue reassessment → ABC’s

Goal

10

. . . in the right amount of time.

. . . to the right place

Get the right patient . . .

Where do I take my patient?

Accessibility to Trauma Centers

Branas CC, et al; JAMA, 2005:

Almost 90% of the US population lives in areas accessible to designated trauma care (Level I, II or III centers) within a one hour

period of time

Access to Level I and II TC’s within 60 mins

Ground EMS (5% land area, 60 % pop)

Access to Level I and II TC’s within 60 mins

Ground + Air Medical EMS

(35% land area, 90% pop)

Trauma Center

An institution committed to the care of injured patients, from acute care to rehabilitation

Initial resuscitation

Operative management

Critical care

Continuing care

Trauma Center

Immediate availability on a 24-hr basis:

Specialized surgeons

Physician specialists

Nurses

Allied health personnel

Resuscitation and life support equipment

Teamwork

Physicians:

Surgery

EM

Ortho

etc

Therapists:

Respiratory

Physical

Occupational

Technologists:

Lab

Xray

Nurses:

ED

OR

ICU

Ward

Clinic

Trauma Centers

Levels- established by ACS-COT:

Level IV

Level III

Level II

Level I

“Designated”- state agency

“Verified”- ACS-COT site visit

Level IV

24 hrs: ED, Lab

Does not need 24 hr Emer Med

Desirable: 24 hr Gen Surg, Anesth

Initial resuscitation

Refer to higher level center

Level III

General Surgery- immediately available*

Available 24 hrs: EM, Orthopedics, Plastics, Radiology, Anesthesia

Neurosurgery is desirable

Required (24 hr) : Xray, CT, PACU

Desirable (24 hr): Xray Tech, Resp Tech

* = within 15 minutes of patients arrival in ED

Level II

Level III Criteria, plus:

Physicians*: Neurosurg, Hand, OB/GYN, Ophth, OMFS, Thoracic, CCM

24 hr OR is desirable

Injury Prevention outreach

*Inhouse trauma surgeons NOT required

Level I

Level II criteria, plus:

Physicians*: Cardiac surg, Microvascular

Services: CPB, inhouse OR personnel, inhouse SICU service

Teaching facility (Surg residency, ATLS)

Research

Admissions: 1,200/yr; 240 with ISS > 15

Tertiary referral / resource center

*Inhouse trauma surgeons NOT required

Effect of Trauma-Center Care on

Mortality

Trauma patients managed at 18 Level I trauma centers compared to 51 non-trauma centers (14 states)

Complete records available for:

1104 patients who died

4087 patients discharged alive

CDC funded

MacKenzie EJ, et al, NEJM, 2006

Effect of Trauma-Center Care on

Mortality

In-hospital mortality :

Trauma center: 7.6%; relative risk 0.80

Non-trauma center: 9.5%

One year mortality rate:

Trauma center 10.4%, relative risk 0.75

Non-trauma center: 13.8%

Differences in mortality rates primarily confined to patients with more severe injuries

You (or your patient) are 25%more likely to survive if

taken to a trauma center.

Level I vs Level II

Traditionally outcome between Level II and Level I centers viewed to be equivalent

Criteria for clinical care nearly identical

Level I primarily teaching / research facility

Superiority of Level I

Retrospective review using NTDB

pts > 14 yrs, ISS >15

One of the following injuries:

Aortic

vena cava

iliac vessels

Cardiac

Grade IV/V liver injuries

quadriplegia

complex pelvic fxDemetriades D, et al., Ann Surg, Oct 2005

Trauma Transfer Criteria

Physiologic Criteria

Take to Trauma Center:

Glasgow Coma Scale Score < 13

Systolic blood pressure < 90 mm Hg

Respiratory rate < 10 or > 29

<20 in infant (under one year of age)

Or need for ventilatory support

Physiologic derangement correlates well with severity of injury and can predict mortality

Baxt WB, et al., Ann Emerg Med, 1989

Patients with significant tachycardia and hypotension have typically lost 30 – 40% of their blood volume and often are in need of emergent transfusion and surgical intervention

Physiologic Criteria

Anatomic Criteria

All penetrating injuries to head, neck, torso and extremities proximal to elbow or knee

Chest wall instability or deformity ( i.e., flail chest

Two or more proximal long bone fractures

Crush, degloved, mangled or pulseless

Amputation proximal to wrist or ankle

Pelvic fractures

Open or depressed skull fractures

Paralysis

Some patients with lethal injury may present with normal vital signs, especially if EMS response has been rapid

Reliance on only physiologic criteria may result in undertriage

Anatomic Criteria

Mechanism of Injury

Falls

Adults > 20 ft (one story is equal to 10 ft)

Children < 15 yrs: > 10 ft or 2-3 X height of the child

High-risk auto crash*

Intrusion, including roof: > 12” occupant site; > 18” any site

Ejection (partial or complete) from automobile

Death in same passenger compartment

Vehicle telemetry data consistent with high risk of injury

Auto-pedestrian / auto-bicyclist thrown, run over, or with significant (> 20 mph) impact

Motorcycle crash >20 mph

* Removed: rollover, deformation to vehicle

Special Circumstances

Older adults: risk of injury death increases after age 55 SBP < 110 may represent shock after age 55

Low impact mechanisms (e.g., ground level falls) may result in severe injuries

Children: should be triaged preferentially to pediatric-capable trauma center

Anticoagulation and bleeding disorders Patients with head injury are at high risk for deterioration

Burns

Without other trauma: burn facility

With other trauma: trauma center

Pregnancy > 20 weeks

EMS provider judgment

Above all, do no further harm

Mortality:

28.8% EMS Transport

14.1% Private Transport

Scene time

More than 20 mins for both

blunt and penetrating trauma

PreHospital Trauma

Life Support

Based on ATLS

10

Platinum

10 minutes

Golden

Period

For critically injured

patients, initiate

transport to the closest

appropriate facility

within 10 minutes of

arrival on scene.

PHTLS

Limited, key field interventions:

Airway control

Oxygenation and ventilation support

Hemorrhage control

Spinal Immobilization

Rapid Transport to appropriate facility

Initiate IVs enroute

NOT “scoop and run”

IV Fluids

No data has ever documented improved survival based upon prehospital IV fluid therapy

One study suggests increased mortality rate in hypotensive trauma patients given prehospital fluid

Transportation

Gasoline (or diesel or

JetA) is the most important

fluid in prehospital trauma

care

Who needs to know?

Heads Up

Give the accepting trauma center time to prepare

Obtain pertinent information to give in hand off

What

When

How

20 Second Shout Out For Trauma

Improve communication between team members

Standardize timing and format for verbal reports

Preserve prehospital, life-saving interventions during

transition to definitive care.

20 Second Shout Out for Trauma

After Primary survey is completed by the physician

1. Age, gender, MOI, Time of event

2.Prehospital VS, HR, Blood Pressure, O2 sat, Resp rate

3. Identified Injuries

4.Prehospital Interventions

5. Changes in Pt status, LOC, Hypotension

6. Past Medical History, Allergies, Meds, Blood Thinners

Put it all together case

20’s y/o M, single car

MVA into tree, ejected,

found on ground,

unresponsive, Heavy

bleeding from open

Femur Fx

Assesment and Plan

Airway- Gurgling, Deviated trachea

Breathing- Sonorous, Absent on left

Circulation- Weak, thready pulse

Disability- GCS- Eyes 2, Speech 3,

Motor 4

Exposure- Wet clothes, Obvious

open femur with active

hemorrhage

Jaw thrust, airway adjunct, CSI

Assist breathing, Needled chest

2 Large Bore IVs, 1L warm Saline

Reevaluate GCS with treatment

Remove wet clothes, fx to neutral

and splinted, Direct

pressure>tourniquet

20 Second shout out report

20 yo Male, unrestrained driver, front impact at high speed, partially ejected at 1925.

P-128, BP-88/52, O2-92% @ 15L, R 12

Absent lung sounds left, Open Femur with hemorrhage, GCS 9

Airway, C-spine, assisted ventilations, Bilateral AC 18g, 1L NS, splint with tourniquet @1941, 100mcg Fentanyl

Blood pressure and Pulse improved with fentanyl and IVF

Hx per family, No medical conditions, allergy to PCN, No meds, No blood thinners

1. Age, gender, MOI, Time of event

2.Prehospital VS, HR, Blood Pressure, O2 sat, Resp rate

3. Identified Injuries

4.Prehospital Interventions

5. Changes in Pt status, LOC, Hypotension

6. Past Medical History, Allergies, Meds, Blood Thinners

Questions?

Mechanism of Injury

https://www.youtube.com/watch?v=0HAGMb_jAdU