Recommended
More Related Content
What's hot
What's hot (20)
Similar to Trauma 101
Similar to Trauma 101 (20)
Recently uploaded
Recently uploaded (20)
Trauma 101
- 1. Your Crash Course on Trauma Care (puns should always be intended)
- 2. You are not alone • Nicole Krumrei (ATMD) (732) 789-5401 • Rajan Gupta (TMD) (732) 595-6635 • In house ACS attending (COVID unit) • Backup ACS attending within 30 minutes • In house chief • PGY3: Trauma senior phone (732) 532-5850 • PGY1: Trauma intern phone (732) 519-1212
- 3. Look in your email - will send a link with: • Trauma Bay video orientation • Trauma Bay primary and secondary videos • Trauma Bay positions scheme • Trauma Bay flow document • Trauma Bay Adult and Pediatric Cart presentations • PMGs for Solid Organ Injury, BCVI, BCI, Pelvic Trauma • This powerpoint
- 4. Call expectations • 5pm to 7am • If it is your first time on call, please come at 4pm so we can show you the “call room” and the bay (Lisa Falcon or Irene Sudah) • We are seeing less volume • Expect ~ 4 EGS consults (one likely operative) and ~4 traumas – Appendectomy, cholecystectomy (done next day), closed loop obstruction, free air • Trauma is likely NON-operative (doesn’t necessarily make it easier) • At 7am, come to morning report (8th floor, East Tower conference room, by the Foundation) to give handoff
- 5. Trauma Bay Roles/Responsibilites • Trauma Attending – team leader/supervise resuscitate efforts • Trauma Senior Resident – (team leader) and procedures • Trauma Intern – primary and secondary survey • ED attending – airway 7a-7p, report from EMS prior to arrival • Anesthesia – airway 7p-7a • Nurse – manual BP, IV insertion, patient care at bedside • CCT – vitals, transport, setup • Scribe – needs to know who you are • (Pharmacy, RT,, security, registration)
- 6. TRAUMA TEAM ONLY PAST THIS POINT (Personal Protective Equipment required) Clinical Care Technician Primary Nurse Trauma Provider #1 Team Leader Security Officer Pharmacist (0830-2230) Scribe Nurse Resp. TherapyAirway* Registration Chaplain Trauma Provider #2 MTP Nurse (as requested) X-Ray Tech All activations Alpha & Bravo As requested Trauma Attending **Remains outside trauma bay during resuscitation
- 7. Blood refrigerator PPE CartPyxis Scribe RN Phone Pharmacy Trauma Surgeon Cart Equipment including surgical trays for emergent: Tracheostomy Thoracostomy Thoracotomy Line Insertion Cardiac MonitorsUltrasound for FAST** not pictured** Color-coded (Broselow) Trauma Surgeon Cart for patients <40kg Each drawer contains weight-based sized equipment in trauma surgeon cart CT Scan Resource Numbers • Lisa Falcon, Trauma Program Manager: • 732-354-2254 • ED Charge RN: x6777 • ED Flex RN: x6706 • Nursing Supervisor: x8649 • CT Scan: x2387 • OR: x2282 • Transfusion Services: x2060 • Admitting: x8602 • Transfer Center: x8011 Lead located outside room
- 8. Trauma Triage: • Trauma Code • Trauma Alert • Trauma Consult TRAUMA CODE (full) Physiologic: Age <= 12 years Age 13-64 years Age > 64 years Airway Prehospital airway or assisted ventilations Breathing Infant: RR>60 or apnea 2-5 years: RR <24 or > 40 or apnea 6-12 years: RR < 10 or > 29 RR < 10 or > 29 breaths/min Circulation Infant: SBP < 70 mmHg 2-5 years: SBP < 80 mmHg 6-12 years: SBP < 90 mmHg SBP < 90 mmHg, or Sustained HR > 120 or < 40 beats/min SBP < 100 mmHg, or Sustained HR > 120 or < 40 beats/min Prehospital blood transfusion to maintain vital signs Active hemorrhage Disability GCS < 9 Anatomic: Penetrating injuries to the head, neck, torso or extremities proximal to the elbow/knee Crushed, degloved, mangled, or pulseless extremities proximal to the wrist/ankle TRAUMA ALERT (partial) Physiologic: GCS 9-13 Anatomic: Open or depressed skull fracture Paralysis or suspected spinal cord injury Chest wall instability or deformity Pelvic instability or deformity Amputation proximal to wrist or ankle Two or more proximal long bone fractures Burns > 10% BSA and/or inhalation injury Seatbelt sign Mechanism of Injury: Falls: Pediatric (<= 12 years) > 10 ft or 3X the height of the child Falls: Adults > 20 ft Ejection from motor vehicle (partial or complete) Pedestrian struck by motor vehicle > 20 mph Bicyclist struck by motor vehicle > 20 mph Patients on anticoagulation with GCS < 15 High energy electrical injury Other: All inter-facility trauma transfers (unless meets criteria for TRAUMA CODE) All helicopter scene flights EMS/ED provider judgement
- 9. Trauma Bay 101 • Trauma Pager goes off – the ETA is always wrong • Arrive to trauma bay before patient arrival • PPE • Introduce yourself and perform briefing/assign roles – Minimize number of people necessary in TB • Await arrival of patient
- 10. PPE • Lead • Gown • Head covering • Eye covering • Mask • Gloves (nonsterile) • Shoe covering
- 11. Trauma is Done the Same Way Every Time
- 12. Trauma Bay 101 • EMS arrival, will give report when patient is still on their stretcher – MIST • Mechanism • Injuries • Signs and Symptoms • Therapies • Patient transferred over to trauma bay bed (slot for XR film) Vitals – Hypotension/Tachycardia; Hypertension/Bradycardia Origin – transfer vs from scene Mechanism Injuries Therapies
- 13. Primary Survey • A - Airway • B - Breathing • C - Circulation • D - Disability • E - Exposure/Environment -Intubation, Cricothyroidotomy -Chest tube -IV, Blood resuscitation, Cavitary triage -HTS -Everything off, Warm blankets, warm room
- 14. Airway • Is the airway Patent? • Is the airway Protected? • If patient presented with ETT -> is there positive ETCO2 at six breaths? • Rescue airways are not definitive airways and will need to be addressed.
- 15. Breathing • Bilateral breath sounds? • Equal breath sounds? • Crepitus? • (if intubated, careful of right main stem intubation)
- 16. Circulation • Peripheral pulses – radial, pedal • BP and HR monitor • Evidence of exsanguination – Scalp wounds – Degloving injuries – Lacerations • PIV access ABC score (> or = 2, high risk MTP HR > 120 BP < 90 + FAST Penetrating injury
- 17. Hemodynamically Insufficient Five main ”areas” • Abdomen • Chest • Retroperitoneum • Long bone fractures • External (floor) Cavitary Triage • FAST • CXR • PXR • Physical exam • Physical exam or EMS
- 18. Resuscitation • Goal is to maintain adequate perfusion, not normal BP – Permissive hypotension • Give emergency release blood – If you need to give more than 2 units of pRBC, you should probably should be in the OR • Please do not take an unstable patient to CT
- 19. Disability • GCS score – Eye opening – Verbal answers – Motor response • Pupil exam – Reactive vs nonreactive – Bilateral vs Unilateral
- 20. Exposure • EVERYTHING comes off – Includes prehospital dressing, splints – May consider not removing a cast until orthopedic surgery present – Hold on tourniquet removal • Warm blankets
- 21. Trauma Cart 5-1-2-4 1st Drawer: General supplies 2nd Drawer: AIRWAY Tracheostomy Tray, Shileys 3rd Drawer: BREATHING Chest Tube Kits, Chest Tubes, Needle Decompression Needle 4th Drawer: CIRCULATION Tourniquet, Thoracotomy Tray, EZIO, Internal Paddles 5th Drawer: CIRCULATION Cordis Catheters 6th Drawer: General supplies TPOD, lap pads, blue towels Side of Cart: Sterile Gloves, Sterile Gowns
- 22. Pediatric Trauma Cart <40kg Color Coded Broselow Each Drawer Organized– “A” “B” “C” Circulation IV Access Module IO Access Module IO Needle Airway Intubation Module Nasal Airway Miller Blade NGT ET Tube Breathing Oxygen mask 14g Angiocath Chest TubeSurgical Trays Bottom Drawer
- 23. End of Primary Survey, patient is still alive. Now what? • Re-assess patient. Are they stable? • If yes, now you can go on to your SECONDARY SURVEY • Can ask for CXR to be performed, labs to be drawn • NO FAST until completion of secondary survey in STABLE PATIENT • AMPLE history • If no, why are they still unstable? Go back to “A” if necessary. If a patient’s condition CHANGES during your evaluation, always go back to the start of the primary survey
- 24. Secondary Survey – Head to Toe exam • Head • Eyes • Ears • Nose • Face • Mouth • Neck • Spine • Chest wall • Lungs • Abdomen • Pelvis • Perineum • Upper and Lower extremities • Neuro exam
- 25. Rectal exam - indications Has a high probability of influencing management • Abnormal neurologic findings • Penetrating abdominal or perineal trauma with possible rectal involvement • ? Pelvic trauma - CAREFUL
- 26. Adjuncts to Secondary Survey • CT scans • Formal Radiographs
- 27. Special Circumstances – Traumatic Cardiac Arrest
- 28. Special Circumstances – Blush on CT • Radiology resident to call IR attending
- 29. BCVI Screening (when to do CTA neck) Symptoms: • Arterial hemorrhage • Cervical bruit • Cervical hematoma • Focal neurologic deficit (TIA, hemiparesis, vertebrobasilar symptoms, Horner’s Syndrome) • Neurologic examination incongruous with head CT findings • Stroke on CT scan Risk Factors: • Mechanism consistent with hyperflexion/extension • Cervical ligamentous injury • Cervical spine fracture (transverse foramen fx, any body fx, any fracture of C1-3) • GCS < 6 • LeForte II or III fracture (may be unilateral) • Mandible fracture • Complex skull fracture, Basilar skull fracture, occipital condyle fracture, or petrous bone fracture • Scalp degloving injury • TBI and thoracic injuries • Great vessel or cardiac injury • Seatbelt sign on neck/hanging or near hanging injury
- 30. Special Circumstances - TBI • Airway control (?) • Neurologic monitoring – Do they really need the ICU? • Coagulopathy correction • Neurosurgical consultation • Anti-epileptic medication Talk to a trauma surgeon, may be able to go to cluster for Q2H checks instead Small No anticoagulation/antiplatelet GCS 15
- 31. Special circumstances - Transfer Center • We basically accept almost everything, however: • NO BURNS • NO EYES • If isolated orthopedics, may want to have them talk to the orthopedic surgery first prior to accepting
- 32. A quick manual: • $60.79 on Kindle • I purchased two for the residents a year and a half ago – could try to borrow it on your night of call.
- 33. What questions do you have?