EMERGENCY MEDICINE TRAUMA

1. Trauma Resuscitation in
Emergency Department
DR SURESH NAIDU
Friday, May 18, 2018 1

2. Trauma Resuscitation in Emergency Department
It was 1.00 a.m. and raining heavily
….it was dull day in ED….
Red zone is empty…
And then ……
Friday, May 18, 2018 2

3. Trauma Resuscitation in Emergency Department
It was 1.00 a.m. and raining
heavily
….it was dull day in ED….
Red zone is empty…
You are on your Facebook
….surfing emergency medicine
sites
Friday, May 18, 2018 3

4. Trauma Resuscitation in Emergency Department
Doctor , there is a MVA car vs lorry
near Sungai Dua toll ,
2 victims , one has severe facial injury
and poor conscious level, while another
is alert, but complain of difficulty in
breathing and abdominal pain
ETA 10 MINUTES.
Friday, May 18, 2018 4

5. Trauma Resuscitation in Emergency Department
Friday, May 18, 2018 5

6. Trauma Resuscitation in Emergency Department
Initial
assessment
• Preparation
• Triage
• Primary survey
• Resuscitation
• Need to transfer
• Secondary survey
• Continued post resuscitation
and monitoring
• Definitive careFriday, May 18, 2018 6
WITH ADJUNCTS
WITH ADJUNCTS

7. Trauma Resuscitation in Emergency Department
Preparation and triage
People
Place
Equipment
Drugs
Friday, May 18, 2018 7

8. Trauma Resuscitation in Emergency Department
CASE 1
57 year old with laceration over chin,
bleeding from mouth and nose.
Orophyrangeal airway is in place, and the
paramedics are ambubagging him….with
each bagging blood oozed out of his
deformed nostrils
BP= 170/100
HR= 120/min
SpO=85% on manual bagging
Friday, May 18, 2018 8

9. Trauma Resuscitation in Emergency Department
CASE 2
30 years old ,restless and agitated
tachypneic,
BP=80/44
HR=140/min
Spo2=80% on HFMO2
Friday, May 18, 2018 9

10. Trauma Resuscitation in Emergency Department
Initial
assessment
• Preparation
• Triage
• Primary survey
• Resuscitation
• Need to transfer
• Secondary survey
• Continued post resuscitation
and monitoring
• Definitive care
Friday, May 18, 2018 10
WITH ADJUNCTS
WITH ADJUNCTS

11. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY
A-Airway with cervical control
B-Breathing and ventilation
C-Circulation with hemorrhage control
D-Disability: Neurologic status
E-Exposure/Environmental control
Friday, May 18, 2018 11

12. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY -A
Objective signs of airway compromise
1. Patient agitated, abusive or
obtunded, cyanotic , or maybe even
be pale
2. Abnormal breathing sounds.
3. Location of trachea
4. Use of accessory respiratory muscles
Friday, May 18, 2018 12

13. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY -B
Objective signs of inadequate
ventilation
1. Look for symmetrical chest rise and
fall
2. Look for signs for difficulty of
breathing
3. Listen for movement of air both side
of chest.
3. Use of pulse oximeter.
Friday, May 18, 2018 13

14. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY -A and B -AIRWAY and VENTILATION MANAGEMENT
VENTILATION
PROBLEM
NPO2/Facemask
oxygen
Ambubag
Non invasive
ventilation
Needle
thoracocentesis
Finger thoracotomy
Chest tube
AIRWAY
MAINTAINENCE
Chin lift/jaw thrust
Orophyrangeal airway
Nasopharyngeal
airway
Supraglottic airway
Endotracheal tube
Surgical airway
Friday, May 18, 2018 14

15. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY
A-Airway assessment and maintenance:
Need for Definitive
airway
A –impending airway obstruction
B –Respiratory insufficiency due to a
large pulmonary contusion, flail chest,
or other thoracic injury.
C –multisystem trauma with shock
D –Reduced GCS (especially <8).
Friday, May 18, 2018 15

16. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY -A and B -AIRWAY and VENTILATION MANAGEMENT
HOW AIRWAY IS SECURED IN TRAUMA?
CRASH
INTUBATION
RAPID SEQUENCE
INTUBATION
AWAKE
INTUBATION
SURGICAL AIRWAY
- NEEDLE CRIC
- SURGICAL CRIC
Friday, May 18, 2018 16

17. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY -A and B -AIRWAY and VENTILATION MANAGEMENT
PREDICTOR OF DIFFICULT
INTUBATION
LEMON
• LOOK EXTERNALLY
• EVALUATE 3-3-2
RULE
• MALLAPATI
• OBSTRUCTION
• NECK MOBILITY
PREDICTOR OF DIFFICULT
VENTILATION
MOANS
• Mask seal
• Obesity
• Aged
• No teeth
• Stiffness
(resistance to
ventilation)
Friday, May 18, 2018 17

18. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY -A and B -AIRWAY and VENTILATION MANAGEMENT
Friday, May 18, 2018 18
PREOXYGENATION
ABLE TO PREOXYGENATE DEFINITIVE AIRWAY/SURGICAL AIRWAY
ASSESS AIRWAY ANATOMY DIFFICULT
Call for
assistance
Intubation +/- drugs/cricoid pressure
Consider airway adjuncts
Definitive airway/surgical airway
PREPARATION

19. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY
ATOM-FC
(thoracic trauma)
• Airway obstruction or disruption
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Cardiac tamponade
Friday, May 18, 2018 19

20. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY
ATOM-FC
(thoracic trauma)
• Airway obstruction or disruption (A)
• Tension pneumothorax (B/C>A)
• Open pneumothorax (B/A>C)
• Massive haemothorax (B/C>A)
• Flail chest (B>A)
• Cardiac tamponade (C>A/B)
Friday, May 18, 2018 20

21. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY
A-Airway with cervical control
B-Breathing and ventilation
C-Circulation with hemorrhage control
D-Disability: Neurologic status
E-Exposure/Environmental control
Friday, May 18, 2018 21

22. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C- SHOCK
Friday, May 18, 2018 22
HEAMORRAGIC
OBSTRUCTIVECARDIOGENIC
DISTRIBUTIVE
Shock in trauma is
hemorrhagic unless
proven otherwise

23. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C- SHOCK
ASSESSMENT OF SHOCK
Look, Touch and Pulse
Blood Pressure
Spo2
Urine output
Ultrasonography
X ray
Blood investigation
Friday, May 18, 2018 23

24. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C- SHOCK
Difficulty in recognizing shock in trauma
• systolic blood pressure falls only after
loss of 30-40% of blood
• Tachycardia may present only from class
II shock, and even later in elderly or
use of some medication.
• Heamotocrit and heamoglobin maybe
normal in early heamorrgic shock.
• Presence of more then one type of shock
may make diagnosing more challenging
Friday, May 18, 2018 24

25. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C- SHOCK
6 regions which may account for major
blood loss:
‘Street': scalp and external sources
(especially small children)
Chest
Abdomen
Long bones (especially femurs)
Pelvis
Retroperitoneum
Friday, May 18, 2018 25

26. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C- SHOCK
ASSESSMENT OF SHOCK
Friday, May 18, 2018 26

27. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C- SHOCK
ASSESSMENT OF SHOCK
Friday, May 18, 2018 27
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28. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Goal of hemorrhagic shock management
• “FIND the bleeding, STOP the
bleeding”
• Rapid and effective restoration of
blood volume
• Maintain functional blood composition
to preserve blood function:—
hemostasis, oxygen carrying capacity,
oncotic pressure and biochemistry
Friday, May 18, 2018 28

29. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhage control
Friday, May 18, 2018 29
INVASIVE MEASURES
Sutures Tamponade Packing Cautery
Interventional
surgery
DCR
INITIAL MEASURES
Direct pressure& elevation
Adrenaline gauze, hemostatic
dressing
Reduce, Splinting , tourniquet
GET HELP & FIND CAUSE

30. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 30
1-2 L crystalloid run fast…
• dilutional coagulopathy
• impaired oxygen delivery due to
dilutional anaemia
• hypothermia
• worsening metabolic acidosis
• clot dislodgement and haemorrhage
from blood pressure elevation

31. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 31
2 L crystalloid
run fast…

32. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 32

33. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 33

34. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 34
Damage Control Resuscitation
Permissive hypotension( minimal
normotension)
Early Hemostatic resuscitation
Damage control surgery

35. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 35
Damage Control Resuscitation
Permissive hypotension( minimal
normotension)
TARGET MAP > 65mmHg
TARGET MAP > 90mmHg if head injury

36. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 36
Damage Control Resuscitation
Early Hemostatic resuscitation
Minimise crystalloids
Early blood products
Activate massive transfusion protocol if needed
Iv tranexamic acid
Recombinant Factor VIIa
Calcium
Prevent hypothermia

37. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- C– SHOCK
Approach to hemorrhagic shock management-volume
restoration.
Friday, May 18, 2018 37
Damage Control Resuscitation
Permissive hypotension( minimal
normotension)
Early Hemostatic resuscitation
Damage control surgery

38. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY
A-Airway with cervical control
B-Breathing and ventilation
C-Circulation with hemorrhage control
D-Disability: Neurologic status
E-Exposure/Environmental control
Friday, May 18, 2018 38

39. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- D –DISABILITY
ASSESMENT
Friday, May 18, 2018 39
• Assess GCS
• Assess pupillary size and responsiveness
• Assess gross motor and sensory function in all
4 limbs
• If you suspect a spinal injury is present a full
neurological assessment is vital at the earliest
opportunity — check for priapism, loss of anal
sphincter tone and the bulbocavernosus
reflex
• Check glucose

40. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- D –DISABILITY
MANAGEMENT
Friday, May 18, 2018 40
• Airway maintenance
• Seizure control
• Treat hypoglycemia
• Anxiety or agitation
• Treat raised intracranial pressure

41. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY- E–EXPOSURE&ENVIROMENT
Friday, May 18, 2018 41
EXPOSE PATIENT BUT MAINTAIN
THERMOSTASIS
If not yet done, consider log-rolling the patient now
Areas where potentially life threating injuries can
be missed are:
• Back of head
• Back
• Buttocks
• Perineum
• Axillae
• Skin folds

42. Trauma Resuscitation in Emergency Department
Initial
assessment
• Preparation
• Triage
• Primary survey
• Resuscitation
• Need to transfer
• Secondary survey
• Continued post resuscitation
and monitoring
• Definitive care
Friday, May 18, 2018 42
WITH ADJUNCTS
WITH ADJUNCTS

43. Trauma Resuscitation in Emergency Department
PRIMARY SURVEY-ADJUNCTS
Friday, May 18, 2018 43
ABG, LAB WORK UP
ETCO2
ECG/CARDIAC MONITAR
CXR&PELVIC XRAY
ULTRASOUND (EFAST)
DPL
CBD, NG TUBE

44. Trauma Resuscitation in Emergency Department
Initial
assessment
• Preparation
• Triage
• Primary survey
• Resuscitation
• Need to transfer
• Secondary survey
• Continued post resuscitation
and monitoring
• Definitive care
Friday, May 18, 2018 44
WITH ADJUNCTS
WITH ADJUNCTS

45. Trauma Resuscitation in Emergency Department
Initial
assessment
• Preparation
• Triage
• Primary survey
• Resuscitation
• Need to transfer
• Secondary survey
• Continued post resuscitation
and monitoring
• Definitive care
Friday, May 18, 2018 45
WITH ADJUNCTS
WITH ADJUNCTS

46. Trauma Resuscitation in Emergency Department
SECONDARY SURVEY
Friday, May 18, 2018 46
Systematic ‘top-to-toe’ examination
Head, face, eyes, ears, nose and throat —
carefully check the scalp and the oral cavity
Neck
Chest
Abdomen
Pelvis
The back
Extremities
All wounds
…..AMPLE HISTORY

47. Trauma Resuscitation in Emergency Department
SECONDARY SURVEY
ATOM-FC
(thoracic trauma)
• Aortic injury
• Thorax injuries ( haemothorax,
pneumothorax)
• Oesphageal perforation
• Muscular diaphragmatic injury
• Fistula (bronchopleural) and other
tracheobronchial injury
• Contusion to the heart or lungsFriday, May 18, 2018 47

48. Trauma Resuscitation in Emergency Department
SECONDARY SURVEY-ADJUNCTS
Friday, May 18, 2018 48
Remaining xray
Ct scan
Angiography
Contrast urography bronchoscophy
Esophagoscophy
Transsophageal ultrasound
Doppler

49. Trauma Resuscitation in Emergency Department
Initial
assessment
• Preparation
• Triage
• Primary survey
• Resuscitation
• Need to transfer
• Secondary survey
• Continued post resuscitation
and monitoring
• Definitive care
Friday, May 18, 2018 49
WITH ADJUNCTS
WITH ADJUNCTS

50. Trauma Resuscitation in Emergency Department
CASE 1
57 year old with laceration over chin,
bleeding from mouth and nose.
Orophyrangeal airway is in place, and the
paramedics are ambubagging him….with
each bagging blood oozed out of his
deformed nostrils
BP= 170/100
HR= 120/min
SpO=85% on manual bagging
Friday, May 18, 2018 50

51. Trauma Resuscitation in Emergency Department
CASE 1
You decided to take over airway, but
used RSI, BUT FAILED despite
attempting with bougie and McCoy. You
called for help , meanwhile placing a
supraglottic device(SPO2 at 80-85%
while bagging)
A senior colleague took over , and
finally managed to secured airway by
surgicalFriday, May 18, 2018 51

52. Trauma Resuscitation in Emergency Department
CASE 1
Patient was transfered to Seberang
Jaya Hospital for CT scan and you don’t
think patient will be send back to your
hospital
Friday, May 18, 2018 52

53. Trauma Resuscitation in Emergency Department
CASE 2
30 years old ,restless and agitated
tachypneic,
BP=80/44
HR=140/min
Spo2=80% on HFMO2
Friday, May 18, 2018 53

54. Trauma Resuscitation in Emergency Department
CASE 2A
You found patient had distended neck
veins, tracheal shift to right, absent
breath sounds on his left side . You
noticed bruise on left side with limited
chest movement. There is crepitation on
palpation.
Friday, May 18, 2018 54

55. Trauma Resuscitation in Emergency Department
CASE 2A
You diagnosed tension pneumothorax and
performed finger thoracotomy while
waiting chest tube getting prepared.
Meanwhile your colleague secured
airway by means of RSI as there is so
much subcutaneus emphysema upto
neck. Intubation was successful in
single attempt. Chest tube was inserted
soon after….Friday, May 18, 2018 55

56. Trauma Resuscitation in Emergency Department
CASE 2A
Iv Hartman was in progress , spo2
picked up to 100%, Patient remained
hypotensive and tachycardia. YOU
ordered “emergency o” and performed
E-FAST
You noticed gross free fluid in Morrison
pouch and perisplenic space. Others
areas are normal finding.
Friday, May 18, 2018 56

57. Trauma Resuscitation in Emergency Department
CASE 2B
You found patient had distended neck
veins, tracheal shift to left, absent
breath sounds on his right side . You
noticed bruise on right side with limited
chest movement.
Friday, May 18, 2018 57

58. Trauma Resuscitation in Emergency Department
CASE 2B
You diagnosed tension pneumothorax and
performed finger thoracotomy while
waiting chest tube getting prepared. A
gush of blood splattered on your
apron…and it seems unstoppable.
Your colleague secured airway by means of
RSI. Intubation was successful in a single
attempt. Chest tube was inserted within
Seconds.
Friday, May 18, 2018 58

59. Trauma Resuscitation in Emergency Department
CASE 2A
Iv Hartman was in progress , spo2
picked up to 100%, Patient remained
hypotensive and tachycardia. YOU
ordered “emergency o” and performed
E-FAST
You noticed gross free fluid in Morrison
pouch
Friday, May 18, 2018 59

60. Trauma Resuscitation in Emergency Department
CASE 2B
Iv Hartman and normal saline was in
progress in each arm, EMERGENCY O
on the way. Chest tube inserted ,
drains about a litre of blood(excluding
on your apron and floor). Spo2 remains
around 80% , BP=60/40mmHg. HR=140
to 150/min
And you performed ultrasound…
Friday, May 18, 2018 60

61. Trauma Resuscitation in Emergency Department
CASE 2B
And you performed ultrasound…
Ultrasound on right unable to get clear
definite image. Your can’t even
identify spleen. You thought see bowels
all the way up where lung should be.
On left side , there is free fluid in
Morrison pouch.
Friday, May 18, 2018 61

62. Trauma Resuscitation in Emergency Department
Friday, May 18, 2018 62
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