Trauma

Trauma Emergency Care Overview

Objectives

  • Review the concept of trauma and the role of healthcare providers.

  • Understand different levels of trauma and their implications.

  • Learn about the various types of trauma encountered in emergency departments.

  • Gain skills on how to examine trauma patients entering the ED.

  • Define the concept of the "Golden Hour" and the "Lethal Triad."

  • Familiarize with the seven components of trauma examination.

  • Understand trauma scoring tools and their significance.

  • Explore the body's physiological response to trauma.

Definition of Trauma

  • Trauma: An injury to living tissue caused by an external source.

    • Can also refer to psychological or emotional stress responses.

    • Types of trauma:

      • Blunt Trauma: Caused by impact without penetration of the skin.

      • Shear Force: Injury involving tearing of tissues.

      • Penetrating Trauma: Caused by objects penetrating the body (e.g., stab wounds).

      • Crushing Injuries: Result from prolonged pressure on body tissues.

Levels of Trauma

  • Level 1 Trauma Center: Offers total care for the most severely injured patients.

    • Staff includes neurosurgeons, trauma surgeons, and additional specialists (e.g., pediatric trauma, burn centers).

  • Trauma centers categorized into Levels I through IV based on resource availability and specialties.

Trauma Room Organization

  • Roles in the trauma room:

    • ER Attending

    • ER Resident

    • Surgical Residents

    • Respiratory Therapists

    • Nursing staff

Types of Injuries

Blunt Trauma/Shear Force

  • Description: Causes injury through compression and speed change without penetrating the skin.

    • Common injuries include:

      • Contusions

      • Flail chest

      • Hemothorax

      • Pneumothorax

      • Rib fractures

      • Ruptured organs

Crushing Injuries

  • Description: Result from prolonged application of force.

    • Directly damages soft tissue and can cut off circulation, leading to swelling in confined spaces.

Penetrating Traumas

  • Description: Caused by penetrating objects.

    • Examples include stab wounds or gunshot wounds.

    • Risks include infection, blood loss, and damage to underlying structures.

Gunshot Wounds

  • Factors influencing damage:

    • Velocity of the bullet.

    • Secondary effects such as cavitation and the mushroom effect.

Falls

  • Statistics:

    • Cause approximately 16,000 deaths annually; known as the second leading cause of accidental death.

    • Assess factors: fall distance, body position upon impact, and landing surface.

Examination Phase

Examination Steps

  • Assess the scene for safety and triage needs.

  • Conduct systemic reexamination (head to extremities).

  • Continuous vital sign checks every 5-30 minutes.

  • Identify potential cervical spine injuries during the assessment.

The Golden Hour

  • First 60 minutes post-trauma: critical for deciding treatment outcomes.

  • Importance of rapid assessment and stabilization to mitigate mortality.

Trauma and Shock Response

Hypothermia

  • Significantly affects the ability to coagulate.

  • Risk factors include hemorrhagic shock and underlying health issues (e.g., diabetes).

Lethal Triad

  • Composed of:

    • Coagulopathy (blood clotting issues)

    • Acidosis (decreased blood pH)

    • Hypothermia

  • Treat aggressively to interrupt the cycle.

Airway Management

  • Considerations:

    • Manage hyperventilation.

    • Assess for hemothorax and potential chest tube insertion.

Pneumothorax Treatment

  • Tension pneumothorax: require immediate decompression (needle thoracostomy) to relieve pressure.

Triage Basics

  • In mass casualty situations:

    • Implement hospital protocols (e.g., START triage).

    • Focus on critical assessment: RPM - Respiration, Pulse, Mental state.

Detailed Examination Protocol

Head Exam

  • Assess neurological status, including Level of Consciousness (LOC).

  • Look for bruises, lacerations, and potential cerebrospinal fluid (CSF) leakage.

Neck Exam

  • Always rule out cervical spine injuries; stabilize the neck.

  • Inspect for tracheal deviation or signs of fluid overload.

Chest Exam

  • Check for:

    • Bruises and lacerations, punctures, and fractures.

    • Auscultate for heart and breath sounds.

Abdominal Exam

  • Inspect for tenderness, guarding, and assess bowel sounds.

General and Extremity Exam

  • Look for deformities and assess range of motion and strength in limbs.

Trauma Scoring Tools

Common Trauma Scoring Metrics

  • AVPU Scale: Gauge responsiveness (Alert, responds to Voice, responds to Pain, Unresponsive).

  • Abbreviated Injury Scale (AIS): Classifies injury severity on a 6-point scale.

  • Injury Severity Score (ISS): Ranges from 0-75; higher scores indicate worse outcomes.

  • Glasgow Coma Scale (GCS): Assesses neurological response categorized into eye opening, verbal, and motor responses.

Next Steps in Trauma Care

  • Prioritize oxygenation and frequent clinical reexaminations.

  • Monitor vital signs, urine output, and gather lab results.

  • Implement imaging and prepare for potential surgeries.

The Body's Response to Trauma

  • The body goes through metabolic changes:

    • Shock response: Increased heart rate and glucose mobilization.

    • Activation of the sympathetic nervous system to enhance contractility.

Blood Loss Considerations

  • Blood loss thresholds: 600–800 mL in adults is critical, 200–300 mL in children, and 25–30 mL in infants.

Key Trauma Takeaways

  • Level 1 trauma centers provide the highest care.

  • The Golden Hour is crucial in trauma management; immediate action is vital.

  • Comprehensive examination must rule out cervical spine injuries and address the lethal triad.

  • Trauma scoring tools aid in assessing injury severity and treatment planning.

  • Blood loss management is essential in all trauma cases.