Trauma & Emergency Preparedness Notes

Objectives: Understand disaster preparedness/response, discuss blunt/penetrating/traumatic injuries and assessments, apply assessment format for life-threatening injuries (primary/secondary surveys), discuss injury management, link complications to interventions.
Types of Emergent Situations: Terrorism, Natural Disasters, Nuclear/Radiological Events, Emerging Infections, Bioterrorism, Chemical Incidents, Explosions/Blast Events.

Aspects of Disaster Response: Assess Risk, Disaster Phases, Incident Command Systems (ICS) (Incident Commander, Operations/Planning/Logistics/Finance Chiefs, Public Information/Safety/Liaison Officers), Hospital Response.
START Triage (Simple Triage and Rapid Treatment):
- Green (Minor): "Walking wounded," no treatment needed.
- Yellow (Delayed): Non-immediate, stable for now.
- Red (Immediate): Life-threatening, urgent care needed.
- Black (Deceased): No respirations after airway positioning.
- Assessment (RPM):
  - Respirations: No/yes ($\le 30/min$ / $>30/min$).
  - Perfusion: Radial pulse present/absent, Capillary refill ($\le 2$ $\text{seconds}$ / $>2$ $\text{seconds}$). Control bleeding.
  - Mental Status: Follows simple commands/cannot follow simple commands.
Hospital Response: Decontamination, Surge Capacity, Hospital Evacuations, Mental Health, Personal Protective Equipment (PPE).

Risk Factors: Age (15-24 $\text{years}$, $>65$ $\text{years}$), Gender (Male), Alcohol/Substances (present in $1/3$ of Motor Vehicle Accidents).
Types of Injuries (MOI - Mechanism of Injury):
- Blunt: Deceleration, acceleration, compression, shearing. Often involves multiple organs.
- Penetrating: Severity based on velocity, energy, object type, angle, wounds.
- Other MOI: Crush, Burns, Blast (energy type, location, shock, velocity, fragments, surface area, contamination).

A – Airway & Alertness (with C-spine stabilization): Assess airflow obstruction, position airway (jaw thrust), remove foreign objects, stabilize C-spine.
B – Breathing: Rate, rhythm, depth, sounds, chest movement, cyanosis.
C – Circulation: Pulse (pedal/brachial/carotid), rhythm, quality, active bleeding, signs of shock. Systolic Blood Pressure (BP) correlation: pedal $\ge 60$ $\text{mmHg}$, brachial $\ge 70$ $\text{mmHg}$, carotid $\ge 80$-$90$ $\text{mmHg}$.
D – Disability (Neurological Status): Alert, responds to Verbal stimuli, responds to Painful stimuli, Unresponsive (AVPU).
E – Exposure & Environmental Control: Visualize all external injuries, spinal precautions, administer fluids/blood products, prevent hypothermia.

Comprehensive Head-to-Toe Assessment: Includes neurological examination (Glasgow Coma Scale - GCS, pupils), palpation for deformities/fractures, inspection for lacerations/contusions, auscultation of chest/abdomen, and evaluation of all body systems (Maxillofacial, Cervical spine/neck, Chest, Abdomen, Pelvis/perineum/genitalia, Musculoskeletal, Back).

Three Peaks of Trauma Deaths:
- Peak 1 (Seconds to Minutes): Massive injuries (brainstem, aorta, cord, heart). Accounts for $50\%$ of trauma deaths.
- Peak 2 (Hours): Hemorrhage (hemopneumothorax, pelvic/long bone fractures, abdominal injuries). Accounts for $30.1\%$ of trauma deaths. The "Golden Hour" occurs in this phase.
- Peak 3 (Days to Weeks): Complications (Sepsis, Multiple Organ Failure - MODS, Acute Respiratory Distress Syndrome - ARDS). Accounts for $20.1\%$ of trauma deaths.
Golden Hour: Critical first hour after injury where $30\%$ of deaths occur. Focus on reperfusion. "Load & Go" versus "Stay & Play" (depending on resources) to restore breathing, circulation, perfusion, and oxygenation.

Triad of Death: Hypothermia, Acidosis, Coagulopathy. These exacerbate hemorrhage.
Management: Warm patient, correct acidosis (which helps correct coagulopathy). Isotonic fluids like Lactated Ringer's (LR) ($0.9\%$) are preferred over Normal Saline (NS) ($0.9\%$ for resuscitation.

Traumatic Brain Injury (TBI):
- Primary Injury: Direct mechanical injury from the force of trauma.
- Secondary Injury: Subsequent response including ischemia, inflammation, cerebral swelling.
- Interventions: Keep Intracranial Pressure (ICP) $<20$ $\text{mmHg}$, maintain perfusion, prevent complications (immobility, delirium, Hospital-Acquired Conditions - HAC, Deep Vein Thrombosis - DVT), use hypertonic fluids (e.g., mannitol).
Spinal Cord Injury (SCI): Stabilize, support symptoms, allow time for recovery.
Thoracic Injuries: Airway/ventilation management (PEEP), pain medications, oxygen, chest tube management, fluids/blood, pressors.
- Hemothorax: Blood in pleural cavity, requiring a chest tube (placed low).
- Pneumothorax: Air in pleural cavity.
  - Closed: Air from inside the lung (requires a high chest tube).
  - Open: Air from outside (initially bubbles in chest tube, then stops).
- Tension Pneumothorax: Air trapped, causing lung collapse and mediastinal shift. A medical emergency.
- Chest Tube Management: Occlusive dressing at insertion site, assess drainage (amount, color), ensure tubing is straight.
Abdominal Injuries: Often require surgery, blood, and fluids.
Spleen: Highly vascular, common site of injury. Risk of delayed rupture (days to a week post-injury).

Common Complications: Infection, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, MODS, ARDS, Acute Kidney Injury (AKI), Disseminated Intravascular Coagulation (DIC), DVT/Pulmonary Embolism (PE).
Interventions: Early feeding for nutrition, ventilator management, antibiotics (if SIRS progresses to sepsis), maintain normothermia, keep ICP $<20$ $\text{mmHg}$.