EMED

• Trauma cases are not uncommon in the practice of emergency medicine
• 20-30% of patients coming in the ER and prehospitally are trauma in nature
• Program goal


  • Assess the patients condition rapidly and accurately
  • Resuscitate and stabilize patients according to priority
  • Determine if the need of the patient exceed that of the facility or the provider
  • Arrange appropriately patients interhospital/intrahospital transfer
  • Ensure optimal care is provided and level of care does not deteriorate during evaluation, resuscitation and transfer
• Road Traffic Accidents are the major cause of long-term morbidity and mortality in developing nations
• WHO 2017 death RTA Philippines 10,769 or 1.74% total deaths
• Death rate 11.82 per 100,000 population
• Motorcycle related and pedestrian injuries are the majority
• WHO predicts that by 2020, Road Traffic Accidents will be second leading cause of loss of life for world's population
• High Morbidity = Loss of income to society
• Affects the highly productive group the society → resulting to this income loss
• Challenges in Developing Countries include lack of infrastructure for trauma management such as EMS and pre-hospital notification, and lack of MD/RN training in trauma care
• WHO compared trauma mortality to deaths secondary to infection
• Trauma mortality is 5.8 million deaths/year
• Trauma deaths are 10% of world's deaths
• Trauma deaths are 32% more than HIV, TB and Malaria combined
• In 2002, developed countries have a higher mortality resulting to road accidents compared to the underdeveloped/developing countries
• This is primarily due to the more productive economy and infrastructures, like roads, are predominant
• Trimodal distribution of trauma deaths

  • Most trauma deaths occur immediately or in the first hour, challenge is to deliver rapid trauma care during these times to significantly decrease death
• Second wave shows the deaths happening in the hospital setting which may be secondary to severe blood loss after maybe a failed operation
• Third wave is due to prolonged stay of patients especially those with unstable comorbidities putting them at a higher risk in developing infection that may result to death
• Prehospital notification


  Alerting hospitals prior to patient arrival
• Prehospital management in the Golden Hour of trauma

  • Plays a vital role bringing trauma management on the site
• Online medical control


  • Helps EMT decide on where to transport patient
  • Allows notification to the receiving hospital on the arrival of the trauma patient allowing preparation of the trauma team on standby
• Prehospital management


  1. Initial assessment may be done prehospitally

  2. Initial airway management using a bag valve mask ventilator

  3. Application of direct pressure on bleeding sites

  4. In-line immobilization of affected limbs

  5. Complete spine restriction before transport via air or land (as the need may be)
• Field triage decision scheme

  • When in doubt, transport to a trauma center
  • Using the field triage algorithm to decide where to bring a trauma patient
  • Initially based on the vital signs and the level of consciousness
  • May also use assessment of anatomy
  • Kinematics or the mechanism of injury or evidence of high energy impact causing severe damage to the patient
  • Assess special patient or system considerations, like active comorbidities, that will aggravate patient's condition after an injury
  • If EMS team is unable to assess patient properly or there is doubt, transport patient to a trauma center
• Nebraska Cornfield, Orthopedic Surgeon piloted a plane and crashed, lead to development of ATLS because care delivered in the scene and initial facility was inadequate

  1976
• Trauma systems development


  • First developed by military in wartime → i.e. MASH Units – improved survivability of severely injured soldiers providing advance trauma life support in the battle field
  • Expanded in US to Level 1, 2, 3 Trauma Centers
  • Level 1 - Highest level of care, Leaders in research, clinical care and education
  • Level 2 - Provides definitive care in wide range of complex traumatic patients
  • Level 3 - Provides initial stabilization & treatment. May care for uncomplicated trauma patients
  • Level 4 - Provides initial stabilization and transfers all trauma patients for definitive care
• Blunt trauma


  • Compression forces - Cells in tissues are compressed and crushed
  • Shear forces - Acceleration/Deceleration Injury - When organ and organ attachment do not acc. Or dec. at the same time or rate of speed
  • Overpressure - Body cavity compressed at a rate faster than the tissue around it → rupture of the closed space
• Vehicular collision injuries


  • Frontal Impact Collisions
  • Lateral Impact Collisions (T bone)
  • Rear Impact Collisions
  • Rollover Mechanism
  • Open Vehicle or Motorcycle/Moped
  • Pedestrian vs. Car
• Types of injury


  • Penetrating
  • Blunt
  • Blasting
• Basics of trauma assessment

  • Preparation - Team Assembly, Equipment Check
  • Triage - Sort patients by level of acuity (SATS)
  • Primary Survey - Designed to identify injuries that are immediately life threatening and to treat them as they are identified
  • Resuscitation - Rapid procedures and treatment to treat injuries found in primary survey before completing the secondary survey
  • Secondary Survey - Full History and Physical Exam to evaluate for other traumatic injuries
  • Monitoring and Evaluation, Secondary adjuncts
  • Transfer to Definitive Care - ICU, Ward, Operating Theatre, Another facility
• Preparation for patient arrival

  • Organize Trauma Response Team
  • Team approach in the management of the injured patient is emphasized → Usually lead by a team leader
• Primary survey


  • Identify injuries that may be immediately life threatening and treat them as they are identified
  • Order of evaluation corresponds to the severity of the injury to cause bad outcomes - Airway maintenance with restriction of spine control, Breathing and Ventilation, Circulation, Disability (assessment of neurologic status), Exposure and Control of the Environment
• Key principles of primary survey

  • When you find a problem during the primary survey, FIX IT
  • If the patient gets worse, restart from the beginning of the primary survey
  • 10-second assessment
  • Some critical patients in the ED may not progress beyond the primary survey
• Airway and protection of spinal cord

  • Loss of airway can result in death in < 3 minutes
  • Prolonged hypoxia = inadequate perfusion, end-organ damage
• Airway assessment


  • Vital signs = RR, O2 sat
  • Mental status = agitation, somnolent, coma
  • Airway patency = secretions, stridor, obstruction
  • Traumatic injury above the clavicles
  • Ventilation status = accessory muscle use, retractions, wheezing
• Clinical pearls for airway assessment

  • Patients speaking normally generally do not have a need for immediate airway management
  • Hoarse or weak voice may indicate subtle tracheal or laryngeal injury
  • Noisy respirations frequently indicate an obstructed respiratory pattern
• Airway interventions


  1. Maintenance of Airway Patency - Suction of Secretions, Chin Lift/Jaw thrust, Nasopharyngeal Airway, Definitive Airway

  2. Airway Support - Oxygen, NRBM (100%), Bag Valve Mask, Definitive Airway

  3. Definitive Airway - Video laryngoscopes, Endotracheal Intubation, Surgical Cricothyroidotomy, Drug assisted intubation
• Video laryngoscopy


  • Visualize glottic opening using a monitor/screen
  • Prevents movement of head and neck, specially in trauma patients
• Surgical cricothyroidotomy


  Fastest way to establish airway patency in cases of failed intubation