Trauma

1. Assess and stabilize trauma patients with an organized approach, anticipating complications in a timely fashion, using the primary and secondary surveys.
2. Suspect, identify, and immediately begin treating lifethreatening complications (e.g., tension pneumothorax, tamponade).
3. When faced with several trauma patients, triage according to resources and treatment priorities.
4. In trauma patients, secure the airway appropriately (e.g., assume cervical spine injury, use conscious sedation, recognize a difficult airway, plan for back-up methods/cricothyrotomy).
5. In a patient with signs and symptoms of shock:
   1. Recognize the shock.
   2. Define the severity and type (neurogenic, hypovolemic, septic).
   3. Treat the shock.
6. In trauma patients, rule out hypothermia on arrival and subsequently (as it may develop during treatment).
7. Suspect certain medical problems (e.g., seizure, drug intoxication, hypoglycemia, attempted suicide) as the precipitant of the trauma.
8. Do not move potentially unstable patients from treatment areas for investigations (e.g., computed tomography, X-ray examination).
9. Determine when patient transfer is necessary (e.g., central nervous system bleeds, when no specialty support is available).
10. Transfer patients in an appropriate manner (i.e., stabilize them before transfer and choose the method, such as ambulance or flight).
11. Find opportunities to offer advice to prevent or minimize trauma (e.g., do not drive drunk, use seatbelts and helmets).
12. In children with traumatic injury, rule out abuse. (Carefully assess the reported mechanism of injury to ensure it corresponds with the actual injury.)

See Abuse.

General Overview

• MIST hand-over from EMS
  • Mechanism of injury, injury found/suspected, symptoms/signs, treatments initiated
• Preparation
  • Warmed IV fluid (consider microwave if no fluid warmer)
  • Warm blankets
  • Chest tube tray
    • Adult chest tube sizes 28-32Fr
  • Intubation set
  • Supraglottic (LMA): Size 3 small female, 4 large female or small male, 5 large male
  • Cricothyroidotomy
  • Medication
  • Broselow tape for pediatrics
  • Fabric pelvic binders
  • Blood
  • Monitoring
  • Precautions (Face mask, eye protection, gown, gloves)
• Triage
  • Treat life-threatening and multiple-system injuries first
  • In mass-casualty event (number of patients and severity of injuries exceed capability of facility and staff), treat patient with greatest chance of survival requiring least amount of time, equipment, supplies, personnel

Primary Survey with Simultaneous Resuscitation

• Airway with C-spine protection - anticipate airway compromise (eg. airway burn)
  • Inspect (foreign bodies, facial/mandibular/tracheal/laryngeal injuries, burn)
  • Clear airway (suction)
  • Oxygen (mask, nasal prongs)
  • Open Airway
    • Jaw-thrust, chin-lift
    • Oropharyngeal airway (if unconscious)
  • Secure airway
    • Definitive airway if airway not maintainable (eg. GCS ≤8)
      • Intubation, supraglottic, cricothyroidotomy
        • Consider assess with LEMON (Look, Evaluate 3-3-2 rule, Mallampati, Obstruction, Neck mobility)
      • Consider quick neuro exam prior to sedation
• Breathing and ventilation - RR, WOB, tracheal deviation, signs of injury to chest wall, auscultate
  • Oxygen + pulse oximeter (O2 sat)
  • Needle decompression, tube thoracostomy
  • r/o pneumothorax, hemothorax, flail chest
• Circulation with hemorrhage control - bleed, pulse, BP, skin colour
  • If possible, control hemorrhage before volume resuscitation
    • Avoid "exploring" wounds unless directed by Trauma consultant
    • Direct manual pressure to bleeding sites
      • Consider tourniquet (or alternative, eg. BP cuff) if pressure not effective and risk to patient life
        • Attempt to remove tourniquet within 2-6 hours
        • If tourniquet not effective, consider clamping artery
    • Identify internal hemorrhage (chest, abdomen, retroperitoneum, pelvis, long bones)
      • Pericardial decompression
      • Pelvic binder, extremity splints, surgery
  • Monitors
  • IV x2
    • Consider IO, central venous access
    • 1L warmed fluids then blood products
      • Note: Aggressive IV fluids have been suggested to increase mortality (increase wound bleeding, coagulation factor dilution, abdominal compartment syndrome)
    • Consider Tranexamic acid 1g over 10 mins then 1g over 8 hours (onset ideally within 3h of injury)
• Disability (neuro) - GCS (LOC), pupils, lateralizing signs, glucose
  • Change in mental status -> rule out ABC cause for decreased brain perfusion
  • Consider CNS injury, hypoglycemia, CO, drugs (alcohol, narcotics)
    • If suspect TBI, prevent hypotension, hypoxia
      • Raise head of bed
      • Consider mannitol (care as lowers BP) vs. hypertonic saline (preferred in hypotensive patient)
      • Use ASIA tool to determine spinal cord injury level
• Exposure and environmental control - Undress but prevent hypothermia (warm blankets)
  • Microwave can be used to warm crystalloids (eg. 50s in 800W microwave), but not blood products
  • IV fluid warmer (Level One, Ranger) for blood products

Secondary Survey

• AMPLE history from patient, family, EMS
  • Allergies, Meds, PMH, Last meal, Events
• Recheck ABCDE
• Head to toe (including log roll, rectal exam, vaginal exam)
  • NG or OG tube if no sign of basal skull fracture
  • Urinary foley catheter if no blood at meatus or perineal ecchymosis
    • Urine output goal of 0.5mL/kg/h in adults (1mL/kg/h in pediatric, 2mL/kg/h in <1yo)
  • Pelvic binder
  • Immobilize deformed joints/bones
  • Resolve reversible arterial compromise (dislocations)
• Bedside ultrasound (eFAST), Chest/Pelvis X-rays, DPL
• Medications
  • Analgesia, Antibiotics, Tetanus

Investigations

• ECG
• Labs: CBC, coag, electrolytes, VBG, blood type and crossmatch, serum ETOH, bhCG
• If stable, consider imaging
  • CXR, Pelvis XR
  • CT head
    • Canadian CT Head rule
    • PECARN Pediatric Head Injury
  • C-spine (conscious, alert, communicative >3yo, no drugs/ intoxication or distracting injuries)
    • Canadian C-spine Rule
    • NEXUS (Neuro deficit, Spinal tenderness, Alert, Intox, Distracting injury)
    • If <3yo, consider immobilization, X-ray imaging, and remove collar if normal
      • If child guarding/torticollis: CT C-spine
  • CT Chest/Abdo/Pelvis

Transfer

• Do not waste time doing investigations if you cannot treat (eg. don't do CT abdo if you don't have surgery)
• Refer to trauma center
  • Consider most appropriate mode of transfer (ground vs. airplane vs. helicopter)
    • Be wary of air travel for pneumothorax or low O2 saturations
  • Consider intubation/chest tubes/procedures prior to transfer

Life-threatening complications

• Tension pneumothorax
  • Needle thoracostomy at 2nd ICS mid-clavicular line or 5th ICS anterior/mid axillary line, do not wait for X-ray (can do bedside ultrasound)
  • Chest tube at fifth intercostal space at anterior axillary line
• Cardiac tamponade
  • Penetrating chest wound, Beck triad (hypotension, distended neck veins, muffled heart sounds), pulsus paradoxus, Kussmaul sign (rise in JVP on inspiration)
  • Confirm with echochardiogram, guide pericardiocentesis
• Hemothorax
• Flail chest
• Upper airway obstruction
• Aorta lesion

Shock/Hypotension

• Suspect shock or occult shock if
  • Isolated or persistent sBP<110mmHg (ask about lowest recorded BP)
  • Shock Index ≥1 (ie. HR>sBP)
  • Change in Shock Index from field to arrival ≥0.1
  • Hemorrhage with flat IVC
  • Loss of central pulses or signs of poorly perfused extremities

Types of Shock

• Hypovolemic
  • Hemorrhagic (Ectopic) until proven otherwise
  • Non-hemorrhagic (GI, skin-burns, renal, third space, pancreatitis)
• Obstructive
  • Pulmonary vascular (PE)
  • Mechanical (Tension pneumothroax, pericardial tamponade)
• Cardiogenic
  • Cardiomyopathic (MI)
  • Arrhythmogenic (tachy/bradyarrhythmia)
  • Mechanical (valvular)
• Distributive
  • Sepsis
  • Neurogenic (TBI, spinal cord injury)
  • Anaphylactic
  • Inflammatory
• Endocrine (adrenal insufficiency, thyrotoxicosis, myxedema coma)
• Metabolic (acidosis, hypothermia)
• Drugs (CCB, BB, Digoxin)