Trauma

• Trauma


  A physical injury or wound caused by external forces
• Mechanisms of injury


  • MVC
  • Thermal: burns
  • Chemical: air, gasses
  • Electrical: electrical power lines, tree fell on someone
  • Radiant: usually heat, burns
  • O2 deprivation: drowning
• Force


  Causes stress on body- Internal: compression, External: deceleration or acceleration
• Types of Injuries


  • Blunt Trauma: skin is intact but the underlying tissues are damaged
  • Penetrating Trauma: breaks the skin
• Blunt Trauma examples: MVCs, contact sports
• Penetrating Trauma examples: Stabbings, Firearm injuries, Amputations, Impalement
• Patterns of Injury depend on what side of body was hit with blunt trauma
• Potential injuries to an unrestrained driver in a MCV
• Trauma Patients with Obesity


  • Higher rates of comorbid conditions
  • Heart and respiratory disorders that are more complex
  • Issues with moving and getting out of vehicle
  • Need special equipment like gurneys and collars
  • Less likely to have abdominal injuries due to excess adipose tissue
• Older Adult Trauma Patients

  • #1 injury: musculoskeletal
  • Do not have the physiological reserve as younger patients
  • Recommendations: all geriatric patients should go to Level 1 trauma center
• Pregnant Trauma Patients


  • #1 cause of morbidity and mortality: maternal hemorrhage and shock
  • Physiological changes like decreased respiratory reserve
  • Assess fetus with ultrasound
  • Turn patient to the left to improve cardiac output
• Pediatric Trauma Patients


  • Different equipment needed
  • Larger heads
  • Bigger respiratory rate, metabolic rate, O2 demand
  • Hypotension is a late sign of shock
  • Use Glasgow Coma Scale appropriate for developmental age
  • Risk of hypoglycemia and hypothermia
• Mass Casualties: An event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time
• Triage Categories


  • Green: Walking Wounded
  • Yellow: Delayed
  • Red: Immediate
  • Black: Expectant
• Triage Examples


  • Open fracture of RUE, non-ambulatory, a&ox3, rr 26, strong radial pulse: Yellow
  • Eviscerated bowel, multiple penetrating wounds to chest, head. Brain matter exposed, unresponsive to stimuli: Black
  • Walking hysterical, screaming blood in ears, a&ox3, rr 36, strong radial pulse: Green
• Trauma Death Peaks


  • First peak: Death within minutes
  • Second peak: "The Golden Hour" - Death within the hour
  • Third peak: Death days to weeks later
• Trauma Center Classifications


  • Level I: Specialty people, definitive care
  • Level II: Could provide definitive care but not as intricate as Level I
  • Level III: Able to resuscitate and stabilize then transfer
  • Level IV: ACLS/ACLT, stabilize then transfer
• Pre-Hospital Resuscitation


  1. Airway maintenance

  2. Control of external bleeding and shock

  3. Immobilization

  4. Immediate transport

  5. Communication with receiving ED
• ED Resuscitation


  1. Primary survey (A, B, C, D, E)

  2. Airway maintenance

  3. Breathing and ventilation

  4. Circulation and hemorrhage control

  5. Disability and neurological status

  6. Exposure / environmental control
• Airway (A)


  Assess if patient can speak to determine if airway is patent
• Breathing (B)


  Look, listen, feel for breathing adequacy
• Circulation (C)


  Stop bleeding, obtain vascular access, assess perfusion
• Disability (D)


  Assess neurological status using Glasgow Coma Scale
• Exposure (E)


  Fully expose the patient to assess for injuries
• Chest injuries account for 60% mortality in trauma
• Potential Causes of Breathing Problems

  • Open chest wound
  • Open pneumothorax
  • Tension pneumothorax
  • Massive hemothorax
  • Flail chest
• Assessments for Circulation


  • LOC
  • Skin perfusion
  • Temperature
  • Color
  • Moisture
  • Heart sounds
  • Pulses
• Classifications of Hemorrhage


  • Class I: <15% loss of total blood volume
  • Class II: 15-30% loss
  • Class III: 30-45% loss
  • Class IV: >40% loss
• Massive Transfusion Protocols (MTP)


  Administration of >10 units of packed red blood cells in 24 hours, with replacement in a 1:1 ratio of blood products
• Complications of Massive Fluid Resuscitation: fluid-electrolyte imbalances, hypothermia, coagulopathies, third-spacing and organ dysfunction, ARDS, AKI, MODS
• Disability (D)


  Refers to patient's mental status, assessed using Glasgow Coma Scale
• Lethal Triad of Trauma: Coagulopathy, Hypothermia, Metabolic Acidosis
• Secondary Survey (F, G, H, I, "J")

  1. Full set of vital signs

  2. Give comfort measures

  3. History and head-to-toe exam

  4. Inspect posterior surfaces

  5. Just keep evaluating
• Revised Trauma Score (RTS)

  Assessment tool using Glasgow Coma Scale, systolic blood pressure, and respiratory rate
• Traumatic Brain Injuries (TBI)


  • Mechanism: Penetrating or blunt trauma
  • Primary injury: Direct injury to brain parenchyma
  • Secondary injury: Biochemical and cellular response to initial trauma
• Types of Brain Injuries

  • Skull fracture
  • Concussion
  • Contusion
  • Acceleration-deceleration injuries (coup-contrecoup)
• Types of Cerebral Hematomas

  • Subdural hematoma
  • Epidural bleed
  • Intracerebral hematoma
• Spinal Cord Injury (SCI)

  • Mechanism: Hyperflexion, sudden deceleration, hyperextension, rotation, axial loading, vertical compression
  • Primary injury: Neurological damage at time of impact
  • Secondary injury: Complex biochemical processes affecting cellular functions
• Types of Spinal Cord Injuries

  • Complete injury: Quadriplegia, Paraplegia
  • Incomplete injury
• Spinal Cord Injury Complications

  • Spinal shock
  • Neurogenic shock
  • Autonomic dysreflexia