This document discusses trauma management according to the EMST (Early Management of Severe Trauma) approach. Key points include: 1. EMST provides a systematic, stepwise approach to identify and treat life-threatening injuries before progressing to less severe issues. 2. The primary survey focuses on airway, breathing, circulation, disability, and exposure to address critical life-saving interventions. 3. Secondary surveys involve a more thorough head-to-toe examination, imaging, and monitoring to identify less severe injuries. 4. Several case examples are provided to demonstrate applying the EMST approach and managing specific trauma scenarios like hemorrhagic shock, spinal injuries, and tension pneumothor

1. Trauma Management - EMC
Dr Dane Horsfall FACEM
Cabrini Hospital

2. Summary
• EMST (Early Management of Severe Trauma)-
Aust
– aka ATLS(Advanced Trauma Life Support)-USA
• Systematic, stepwise approach, identify and
treat injuries before progressing
• Focus on critical, life saving interventions
• Cases

3. Trauma
• Do we see Trauma at Cabrini?
• Effect of centralization of ED Trauma Care
• How should we manage trauma?

4. Trimodal Trauma Mortality
• Reduce Immediate
deaths with
prevention
• Early ED Mx prevents
early deaths-“Golden
Hour”
– ICH
– Haemorrhagic shock
– Haemo/Pneumothor
ax
• Late –
sepsis/DVT/Pneumo
nia

5. EMST algorithm-Primary Survey
• A irway, Cx spine
• B reathing/Ventilation
• C irculation/Hemorrhage control
• D isability-GCS/Pupils
• E xposure of pt/check Temp

6. Primary Survey
• A:
• obstruction – safe maneuvers? –
• only Jaw Thrust,
• CxSpine – ?immobilise/?image
• Trauma = Difficult Airway
• B:
• Tension PTx
• Open PTx
• Flail Chest – Definition, Real problem
• Massive Haemothorax
• C:
• Cardiac Tamponade,
• Hemorrhagic shock, External/Identified vs Occult – abdo vs pelvis
• IV access – Resistance = Length/Radius4
• D –
• expanding intracranial hematoma

7. EMST - Secondary Survey
• Brief Hx
• Head toe exam
• Log Roll
• Spring Pelvis once only
• including Neuro, check ears/spine/PR
• Check for minor injuries eg finger #
• FAST
• Adjuncts:
– “Trauma Series Xrays” Cx spine lateral/CXR/PXR
– Monitoring
– Bloods
– ECG
– IDC
• Common Language – write notes Primary/Secondary survey

8. Cx Spine with Airway
• NEXUS
– Neurologic Deficit
– Midline tenderness
– Altered Conscious State
– Intoxication
– Distracting injury
• Canadian Cx spine rules-
– 1. High risk: >65yo, mechanism (fall>3m/axial load/MVA >100km/hr/bike),
paraesthesia = image
– 2. Low Risk- non tender, sitting/walking, low speed MCA = can asses rotation
– 3. 45° rotation = clear
• If in doubt –immobilize
• Elderly at high risk for Cx spine injuries
– Osteoporosis/osteoarthritis/spinal canal stenosis

10. Case 1: 80 yo F with fall
• Fall in kitchen, L forehead laceration,
confused, L shoulder pain
• On warfarin for AF
• How do you manage this patient?

11. Primary Survey:
• A - clear, Cx spine nontender ? Collar
• B - equal AE bilat O2sats 96%RA RR 16
• C - HR 95 BP 140/80 no external bleeding
• D - GCS 12 (M5 V4 E3) PEARL
• E - T 35.5
• Management?

12. CT Brain

13. Management
• Prevent Secondary Brain Injury
– Maintain cerebral perfusion (MAP – ICP)
• Head 30° up
• Maintain Normal BP/O2sats/CO2
• NeuroSurg Ref
• Reverse Warfarin (MJA 2013)
Clinical Setting Management – all w/h Warfarin
INR >1.5 + life threatening
bleeding
Vit K 5-10mg, PTX 50 Units/kg, FFP
150-300mls
INR >2.0 clinically significant
bleeding
Vit K 5-10mg, PTX 35-50 Units/kg
INR > 4.5 + bleeding risk high Vit K 1-2mg PO or 0.5-1mg iv
Any INR and minor bleeding risk Just W/H and recheck next day

14. Case 2 - 26 yo M stab to R anterior chest
• Knife insitu
• Vitals T 36 HR 130 BP 100/40 RR 35 O2sats
91% RA
• Approach?

15. Primary Survey
• A patent
• Cx spine?
• B
– Open Pneumothorax/Haemothorax
– Mx ICC at separate site, leave knife insitu
• C –
– Haemorrhagic Shock Mx IV resus – iv access/rapid
infuser, urgent Cardiothoracic surgery

17. Patient Removes Knife…
• Sucking chest wound
• Mx

18. Case 3 – High speed MCA
• 56 yo F front seat passenger 100km/hr head
on collision, seat belt worn, airbags deployed,
no cabin intrusion
• On arrival to ED T 36 HR 120 BP 90/40 RR 30
O2sats 98%RA
• Approach?

19. Primary Survey
• A - clear
• Cx Spine - ? Collar
• B – equal AE O2 sats 98%RA
• C – HR 120 BP 80/40
• D – GCS 15 PEARL
• E – T 36

20. Internal Hemorrhage in Trauma
• Adult Blood Volume 5 L
• ICH : 100-300mls (Brain volume 1.2L)
• Femoral Shaft # : 1-1.5L
• Chest/Abdo/Pelvis : Up to entire Blood
Volume

21. Where is the Blood?
• Chest – CXR/ICC
• Abdo – FAST/CT*
• Pelvis - PXR

22. Back to Case 3
• A/Cx Spine/B stable
• C – HR 120 to 140, BP 80/40 to 70/40
• D – GCS 15 to 14, PEARL
• Management?

23. • Refill the tank - IV resus – crystalloid then
blood
• Find and stop the bleeding

24. Abdo vs Pelvis
• FAST +ve
• Pelvic #

25. Haemostasis
• Pelvic Binder
• Laparotomy
• Embolization

26. Case 4 - 18 yo M MCA
• Ejected high speed rollover Ute crash in
Malvern
• Rx in field- O2, Cx collar, 1 x IVC 500mls
N/Saline bolus
• On arrival in ED: T 34.8 HR 65 BP 80/30 RR 25
O2sats 92%RA

27. Management
• A – clear
• Cx spine – Leave Collar on
• B – RR 25 O2sats 90%RA – Rx O2, reduce AE L
side
• C – HR 65 BP 80/30 - 2nd IVC Fluid resus, seek
hemorrhage
• D – GCS 15 but unable to move legs, PEARL
• E – 34 - warm

28. B – Deep Sulcus Sign Rx L ICC

30. C – Causes of shock?
• HR 60 BP 70/40
• Hemorrhagic
• Neurogenic:
• Spinal injury - loss of sympathetic
outflow, from injuries T6 or higher.
– Hypotension
– Bradycardia
– Peripheral vasodilatation
• Spinal Shock-Not shock but a
– flaccid areflexia after spinal cord injury,
– lasts hours to weeks,
– ‘concussion’ of spinal cord, resolves as
swelling improves

31. Management
• Haemorrhagic – fluid resus, stop bleeding
• Neurogenic- Fluid Resus, Atropine,
Vasopressors-Noradrenaline, Inotropes-
Adrenaline, address Spinal injury

32. Spinal Injury Mx
• PR ? Complete/incomplete
• Image entire spine (10% have 2nd #)
• Immobilization - ?Keep on spinal board
• Treat Neurogenic Shock
• A/B(Diaphragm/intercostals)C/D/E
• Pressure care/IDC
• Steroids – No evidence
• Transfer

33. Case 5 – 8 yo M Bicycle accident
• Hit by car while riding his bike down Wattletree Rd
• Wearing helmet, knocked off bike, MAS scoop and
run
• On arrival Vitals T 36 HR 130(60-130) RR 30 (14-26)
O2sats 93% RA BP 90/50(85/45)

34. Primary Survey
• A - patent
• Cx spine - ? Collar
• B – contusions L lateral chest wall, reduced AE
L side
• C - HR 130 - 150 BP 90/45 – 80/45, Abdo SNT
FAST negative, Deformed swollen R mid-thigh,
• D GCS 15 PEARL
• E T 36

35. Primary Survey Interventions
• A -patent
• Cx Collar
• B – O2
• C – 2 x iv attempts unsuccessful,
– IO inserted IVF bolus 20ml/kg
– Splinted femur #
• D/E stable

36. Progress
• Post initial Mx HR 180 BP
60/30, no AE L chest,
• Possible Dx?
– L Tension Pneumothorax
– L Haemothorax
• Intervention?
– Needle decompression L
chest – hiss of air
– L ICC placed

37. Progress
• Post insertion L ICC
• HR 130 BP 95/50, but O2sats 93 – 95%
• Notice L chest wall paradoxical movement
with respiration:
• www.youtube.com/watch?v=mJ_FYwUqzsM
• What is happening, and what do you need to
do?

38. Flail segment
• Causes paradoxical chest wall movement and
ineffective breathing
• Worsened by underlying pulmonary
contusions
• Mx Intubation/Ventilation – Positive pressure
ventilation

39. Summary:
• EMST structure
• Cx spine assessment with airway
• Seek/Treat life threatening injuries in Primary
Survey – aggressive chest decompression/IVF
resus
• Prompt Warfarin Reversal with hemorrhage

40. References
• EMST/ATLS Course Manual 8th Edition
• www.mja.com.au/journal/2013/198/4/update
-consensus-guidelines-warfarin-reversal
• www.lifeinthefastlane.com