Trauma and Mass Casualty

She's about to be hefty fam

100% O2 via NRB or BVM, 2 large bore IVs (pull a rainbow), vitals, remove all clothes/jewelry, EKG, limb splints if fractures have been identified, obtain blood (if hemodynamically unstable or hemorrhaging)

What should be done in the 1st 2 minutes of arrival?

Tranexamic acid (TXA)

What is the 1st and only drug that decreases trauma mortality rates if given within 3 hours from the injury?

CBC, type and screen/cross (screen for later, cross for now), CMP, PT/PTT, amylase/lipase, CK/troponin, U/A, hcg, EtOH, tox screen

Rainbow Labs

CXR, pelvis, X-table lateral C-spine (portable); CT Head, C-spine, Chest, abdomen, pelvis when stable; FAST exam on U/S

Imaging studies in a trauma patient

Airway, breathing, circulation/control of bleeding, disability

Trauma primary survey

Chin lift/jaw thrust (open it up), Suction secretions, vomitus, blood; Oropharyngeal airway (no gag), nasal trumpet (gag), Protect C-spine (until radiographically cleared)

What does airway include in the primary assessment?

Unable to protect/maintain airway, inadequate ventilation/oxygenation, expanding neck hematoma, severe shock, severe head injury, GCS under 8, thermal/caustic inhalation, combative patient, facial/mandible injury WITH airway compromise

Indications for intubation - COME IN WITH A BACKUP PLAN

Orotracheal method or Cricothyrotomy (if surgical airway is indicated)

What should be used for midfacial trauma?

Orotracheal intubation with inline immobilization, CRIKE, Nasal trumpet (controversial - may push tube in the cranial vault)

Airways for C-spine injuries

Pretreat with lidocaine or fent, consider a defasciculating dose of non-depolarizing paralytic (vecuronium)

Airway tips for severe head trauma

Loads up the RBCs with O2, gives ya a little more time

Why should you hyperventilate a patient during an RSI?

assess presence/adequacy of respiration, intervene as needed, respiratory effort/rate, pulse ox (keep it above 93%), equal breath sounds (after intubation too), deformity, ecchymosis, crepitus, subcutaneous, emphysema, tracheal deviation, chest excursion, sucking/open chest wounds, flail chest

What are we looking for when it comes to the B of ABCCDE?

Apnea/poor ventilation, high spinal cord injury, flail chest, hypoxia without 100% NRM

Which patients should be ventilated with 100% O2?

tension pneumo (IMMEDIATE needle decompression), possible tracheal fracture, expanding neck hematoma

Tracheal deviation could be due to

occlusive dressing taped on 3 sides, chest tube (definitive)

Gameplan for sucking/open chest wounds

intubate, ventilate

Gameplan for flail chest

4/5th intercostal space midaxillary (finger thoracostomy to ensure adequate decompression of the chest)

Where should a needle decompression be placed?

Stop obvious bleeding, 2 large bore (16 G minimum, IO if you can’t get anything, central line), FAST/RUSH exam

What are we doing as a part of circulation in the primary assessment?

thoracic computerized tomographic angiography, REBOA, Beta blockers (bpm under 80, MAP of 60-70)

Gameplan for blunt aortic injury

Check BP, pulse, venous filling, skin temp, control obvious bleeding, Pneumatic antishock garment (PASG - splinting of pelvic fractures, intra-abd hemorrhage)

What are we doing as a part of control of bleeding in the primary assessment?

pulmonary edema (ABSOLUTE), pregnancy, evisceration, thoracic injury with hemorrhage, diaphragm injury, impaled objects

C/I for PASG

Base deficit (BD - loss of bicarb)

What is a key stage indicator for shock?

1.5 L of crystalloids fluids

Infusion of more than _________________ has been associated with increased mortality

10 units of blood in 24 hours, 4 units in 1 hour

How is a massive transfusion defined?

BP, JVD, heart tones, mental status

How is volume status monitored?

Just use them above the area of injury in uncontrolled extremity hemorrhage

What is the ruling on tourniquets?

Apply pressure, Consider TXA, persistent bleeding (>2 mm suture, <2 mm electrocautery), pack with type 1 gauze

Tips and Tricks for External Bleeding

Check for obvious deformities, elevate wound (maybe), irritate, disinfect, re-examine in 24 hours for secondary closure, evacuate any hematoma

Dr. Allen’s Pro tips for External bleeding

CXR, Pelvic, EFAST, diagnostic peritoneal lavage (low sens/spec), CT if stable, surgery

Okay so there’s no obvious bleeding, what are we going to do to check the body cavities for bleeding?

Neuro exam - BEFORE sedation/intubation/paralysis, AMPLE hx, glasgow, revised trayma score, pupillary rxn

What are we doing as a part of Disability in the primary assessment?

AVPU (awake, verbal, painful, unresponsive)

QUICK there’s no time for a glasgow, what’s the back up plan?

Hypoxia (administer 100% O2), hypoglycemia (D50), Opioid intoxication (narcan), Wernicke’s, check CN, Check head and face, tympanic membranes (hemotympanum = bsf)

If there’s an AMS what do we need to r/o?

0.4-2 mg for adults (0.01 for peds)

Narcan dosing

Palpate (check for step-offs), deep tendon reflexes, motor and sensory (document lowest functioning levels), Assess for sacral and posterior column function-sparing, rectal tone

Cervical Spine assessment if there’s AMS

light touch, vibration, 2 point discrimination, proprioception

Posterior column testing?

Mannitol (1 g/kg) for ICP management, sedate and intubate (midazolam/prop), lower ICP if herniation is suspected (not in shock peeps)

Management of AMS

Remove all clothing and jewelry then cover the patient IMMEDIATELY after primary assessment

What are we doing as a part of Expsosure/Environment in the primary assessment?

Keep the room at 85 degrees, cover patients with warmed blankets, warm fluids, blood PRN, may require active rewarming

Gameplan to prevent hypothermia

Head, Neck, Shoulders, Chest, Abdomen, Spine, Pelvis, Extremities, Reassess (HNSCASPER)

Dr. Allen’s Pro tips for never forgetting anything in a secondary assessment

Scene safe, direct casualty to move to cover and to apply self-aid (if unable to reach), Get’em out of burning buildings/cars (within your limitations)

1st steps in a Mass Casualty

Establish a collection point, move casualties to a safer area if threat still exist, HEAD ON A SWIVEL

Okay so we need to move us and casualties - what is the game plan?

breathing

Screaming equals what?

Massive Hemorrhage, Airway, Respiration, Circulation, Head injury/Hypothermia (MARCH)

What is the mnemonic we use in the field for mass casualties?

tourniquet if you can (gotta have a windlass), direct pressure (if homeboy is conscious), do what you can with what you have to stop the bleeding

What are we doing in the M of MARCH

Chin lift/Jaw thrust, throw’em in left lateral decubitus (avoid obstruction)

What are we doing in the A of MARCH

Decompress tension pneumos, seal open chest wounds (chip bags work), support ventilation/oxygenation as required

What are we doing in the R of MARCH

IV/IO access, Fluids if available, Pulse checks if no equipment

What are we doing in the C of MARCH

Prevent hypotension and hypoxia, treat any hypothermia

What are we doing in the H of MARCH?

shock, hypovolemia, hypothermia

What is the terrible triad of trauma?

Severe/progressive respiratory distress, Severe/progressive tachypnea (guppy breathing), absent or decreased breath sounds, Hemoglobin O2 sat under 90%, shock, traumatic cardiac arrest without fatal wounds

When should we suspect a tension pneumo in a patient with torso trauma or primary blast injury (decompress with a 14/10G 3.25” needle)?

H+ ion concentration (acidosis), Hyper/hypokalemia, hypothermia, hypovolemia, hypoxia

What are the 5Hs of cardiac arrest

Tamponade, tension pneumo, thrombosis, toxins, thromboembolism

What are the 5Ts of cardiac arrest

Burp the wound/remove the dressing, needle decompression

After applying a vented chest seal, your patient becomes hypotensive, hypoxic and there are increasing signs of respiratory distress, what do you want to do?

shock, unable to closely monitor for re-bleeding, traumatic amputation, on for more than 6 hours, will arrive at medical facility within 2 hours

Do not attempt to convert any tourniquets IF