Approach to Trauma Patient

Supervisor: Dr Teo
INTRODUCTION
According to the most current
information from the World Health
Organization (WHO) and the Centers
for Disease Control (CDC), more than
nine people die

every minute from injuries or violence,

and 5.8 million people of all ages and
economic groups die every year from
unintentional injuries and violence
TRIMODAL DEATH
DISTRIBUTION
Implies that death due to injury occurs
in one of three periods, or peaks.

1. First peak
2. Second peak
3. Third peak
FIRST PEAK

- Occurs within seconds to minutes of injury

- Deaths generally result from apnea due to severe brain or high spinal cord injury or rupture of heart, aorta, or other
large blood vessels

SECOND PEAK

- Occurs within minutes to several hours following injury

- Cause of deaths are usually to subdural and epidural hematomas, hemopneumothorax, ruptured spleen, lacerations
of the liver, pelvic fractures, and/or multiple other injuries associated with significant blood loss.
- The golden hour of care after injury is characterized by the need for rapid assessment and resuscitation,

THIRD PEAK

- occurs several days to weeks after the initial injury, is most often due to sepsis and multiple organ system
dysfunctions.
- Care provided during each of the preceding periods affects outcomes during this stage.
- The first and every subsequent person to care for the injured patient has a direct effect on long-term outcome.
KEY COMPONENTS APPROACHING TRAUMA PATIENT
Primary survey Airway assessment with C-spine stabilization and airway management

Breathing assessment with respiratory support and related procedures

Circulation assessment with immediate hemodynamic support and hemorrhage control

Disability assessment with TBI management and neuroprotective measures

Exposure with environmental survey and hypothermia management

Diagnostic adjuncts, e.g., FAST , portable CXR

Secondary survey AMPLE history

Head-to-toe physical examination

Comprehensive diagnostic studies and imaging

Supportive care

Tertiary survey Detailed history and physical to identify missed injuries

PRIMARY SURVEY
- Encompasses ABCDEs of trauma care and identifies life
threatening conditions:
- Airway maintenance (with restriction of cervical spine motion)
- Breathing and ventilation
- Circulation (with hemorrhage control)
- Disability (assessment of neurologic status)
- Exposure/Environmental control
LIFE THREATENING INJURIES TO IDENTIFY
Airway obstruction
Tension pneumothorax
Massive internal or external hemorrhage
Open pneumothorax
Cardiac tamponade
Intracranial bleed
AIRWAY
- to ascertain patency
- signs of airway obstruction includes inspecting for foreign bodies; identifying
facial, mandibular, and/or tracheal/laryngeal fractures and other injuries that can
result in airway obstruction;
- suctioning to clear accumulated blood or secretions that may lead to or be
causing airway obstruction
- patients with severe head injuries who have an altered level of consciousness or a
Glasgow Coma Scale (GCS) score of 8 or lower usually require the placement of a
definitive airway
- Establish a definitive airway if there is any doubt about the patient’s ability to
maintain airway integrity.
- Protect the spine from excessive mobility to
prevent development or progression of a
deficit.
- Cervical collar is used to protect the cervical
spine
- When airway management is necessary, the
cervical collar is opened, and a team
member manually restricts motion of the
cervical spine
BREATHING AND VENTILATION
- Visual inspection and palpation can detect injuries to the chest wall
- Percussion of the thorax to identify abnormalities
- Auscultation to ensure gas flow in the lungs
- Pulse oximeter to monitor adequacy of hemoglobin oxygen saturation.
CIRCULATION
- Rapid and accurate assessment of an injured patient’s hemodynamic status is
essential
1. Level of Consciousness—When circulating blood volume is reduced, cerebral
perfusion may be critically impaired, resulting in an altered level of
consciousness.
2. Skin Perfusion— helpful in evaluating injured hypovolemic patients.
3. Pulse—A rapid, thready pulse is typically a sign of hypovolemia. Assess a
central pulse (e.g., femoral or carotid artery) bilaterally for quality, rate, and
regularity.
- major areas of internal hemorrhage
- chest
- abdomen
- retroperitoneum
- Pelvis
- long bones
- Vascular access must be established (typically two large-bore peripheral venous
catheters)
- EFAST
DISABILITY
- GCS
EXPOSURE
- Undress patient completely for thorough examination and assessment
- Cover the patient with warm blanket to prevent them from developing
hypothermia

DIAGNOSTIC
- Xray, EFAST
SECONDARY SURVEY
- head-to-toe evaluation of the trauma patient.
- Reassessment of the patient
- Consists of
- History- AMPLE (Allergies, Medications, Past medical history, Last
meal, Events related to the injury)
- Physical examination
POTENTIAL LIFE THREATENING INJURIES
Aortic disruption
Tracheobronchial injury
Oesophageal injury
Myocardial contusion
Pulmonary contusion/pneumothorax
Diaphragmatic rupture
Head Inspect and palpate the head.
Perform ocular examination and pupillary examination
Assess mental status and GCS
Evaluate cranial nerves.

Maxillofacial Inspect ears, nose, and mouth.

Assess for malocclusion

Cervical spine Inspect for signs of tracheal injury or tracheal deviation

and neck Palpate for crepitus.
Auscultate carotid arteries.
Palpate for cervical spine tenderness.

Chest Inspect and auscultate the chest.

Palpate the chest wall for tenderness and crepitus

Abdomen and Inspect and auscultate the abdomen.

pelvis Palpate the abdomen for tenderness, abdominal guarding, or rebound tenderness
Assess for pelvic instability
Genitourinary Assess for urethral injury.
Perform a digital rectal examination and/or pelvic examination as indicated.

Back and flank Inspect ears, nose, and mouth.

Assess for malocclusion

Cervical spine Perform a log roll to examine the back of patients under C-spine precautions
and neck Palpate the thoracolumbar spine for tenderness and step deformities.
Evaluate for signs of retroperitoneal hemorrhage

Musculoskeletal Inspect upper and lower extremities for lacerations or deformities.

Palpate upper and lower extremities for tenderness.
Palpate peripheral pulses.

Neurological Assess motor and sensory functions of upper and lower extremities.
DIAGNOSTIC STUDIES
1. Xrays
- CXR, pelvic xray, extremities xray, spine xray
1. CT
- CT brain, CT spine , CT abdomen
1. ECG
2. Blood investigations
CT brain criteria
● GCS less than 13 on initial assessment in the emergency department
● GCS less than 15 at 2 hours after the injury on assessment in the emergency department
● suspected open or depressed skull fracture
● any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose,
Battle's sign)
● post-traumatic seizure
● focal neurological deficit
● more than one episode of vomiting
● dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor
vehicle or a fall from a height of more than 1 m or 5 stairs)
Medications
- IV Tranexamic acid 1g in 10 min, then 1g over 8hours (if trauma <3 hours)
- Non variceal bleed: IV pantoprazole 80mg stat, 8mg per hour
- Variceal bleed: IV Terlipressin 2mg bolus, or IV Somatostatin 250mcg bolus,
250mcg per hour or IV Octreotide 50mcg bolus, 50 mcg per hour
- IM ATT 0.5mg
- IV Tramadol 50mg
- IV Maxolon 10 mg
Damage Control Resuscitation (DCR)
- methodology for stabilizing severely injured trauma patients with massive hemorrhage by aggressively pursuing hemostasis and
proactively addressing the lethal triad of coagulopathy, acidosis, and hypothermia
- Lethal diamond: coagulopathy, acidosis, hypothermia, hypocalcaemia
- Current practice: to transfuse as close to a 1:1:1 ratio of warmed pRBCs, plasma, and platelets in patients who meet massive
transfusion protocol (MTP)
References
1. ATLS 10th edition
2. Management of trauma patients. Amboss. (n.d.).
https://www.amboss.com/us/knowledge/management-of-trauma-patients/
3. Kostiuk M, Burns B. Trauma Assessment. [Updated 2023 May 23]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK555913/
4. Initial management of trauma in adult. UpToDate. (n.d.).
https://www.uptodate.com/contents/initial-management-of-trauma-in-adults
5. Approach to trauma patient. MSD Manual. (n.d.).
https://www.msdmanuals.com/professional/injuries-poisoning/approach-to-
the-trauma-patient/approach-to-the-trauma-patient