Trauma and Resilience: A Parenting Perspective Kenneth Barish, Ph.D.
THE TRAUMA EVALUATION Kenneth DeSart, MD University of Florida Oral Exam Review.
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Transcript of THE TRAUMA EVALUATION Kenneth DeSart, MD University of Florida Oral Exam Review.
![Page 1: THE TRAUMA EVALUATION Kenneth DeSart, MD University of Florida Oral Exam Review.](https://reader030.fdocuments.net/reader030/viewer/2022032702/56649cd65503460f9499da70/html5/thumbnails/1.jpg)
THE TRAUMA EVALUATION
Kenneth DeSart, MD
University of Florida Oral Exam Review
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Primary Survey
• Airway• Conscious? Talking? • Clear secretions, intubation if needed• Inhalational/Burn injury?
• Breathing • Inspect for penetrating injury, tracheal deviation• Auscultate lung sounds• Palpate subcutaneous emphysema• Consider: need for artificial ventilation, tension
pneumothorax, cardiac tamponade, flail chest
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Primary Survey
• Circulation • Vital signs: BP, HR, pulse, UOP• IV access (2 large bore IV), resuscitation, stat labs• Check abdomen/pelvis for obvious bleeding risk• Stop external bleeding (esp. scalp)
• Disability • Mental status, GCS
• Exposure • Stabilize neck, remove clothing to check for signs of injury• Maintain body temperature
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Glasgow Coma Score
• GCS (max = 15)• Motor (max = 6)
• 6 follow commands, 5 localizes pain, 4 withdraws from pain, 3 flexion with pain, 2 extension with pain, 1 no response
• Verbal (max = 5)• 5 oriented, 4 confused, 3 inappropriate words, 2
incomprehensible sounds, 1 no response• Eye opening (max = 4)
• 4 spontaneous eye opening, 3 to command, 2 to pain, 1 no response
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Sources of Massive Hemorrhage
• Chest• Abdomen• Pelvis• Long bone (thigh)• Retroperitoneum• Scalp laceration (blood left at the scene)
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FAST Exam
• Focused Assessment with Sonography in Trauma• Performed during/after primary survey• Replaced Diagnostic Peritoneal Lavage (DPL)• 4 areas: pericardium, perihepatic (Morrison’s pouch),
perisplenic, pelvic, & repeat perihepatic• Detects intra-abdominal bleeding
• 100cc in Morrison’s pouch • most dependent area in peritoneum in supine
position• 250cc total
• Does not detect retroperitoneal bleeding or hollow viscous injury
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FAST Exam
Sonoguide.com/FAST.html
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FAST Exam - Perihepatic
Negative
Positive
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FAST Exam - perisplenic
Negative
Positive
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FAST Exam - pelvis
Negative
Positive
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Secondary Survey
• Performed immediately following primary survey• AMPLE history – allergies, meds, PMH, last meal, events• Head to toe physical examination• Re-assess vital signs, changes in neurologic status
• Need for more IV access? Arterial-line?
• Imaging: CXR, pelvis XR, +/- extremity XR• Place foley catheter after rectal exam to rule out urethral
injury• Blood at meatus, high riding prostate, severe pelvic fx, perineal
hematoma• Check spine injury (“tenderness, step-offs”)• Remove back board
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Decompensation
• If the patient’s condition changes during the resuscitation, go back to your ABC’s.
• Assess-> Intervene-> Reassess
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CT Scan
• Contraindicated in unstable patients• Assess active hemorrhage (“blush”)• Assess degree of organ injury
• Various grades affect management in liver, spleen, kidney, etc.
• Low sensitivity for hollow viscous injury• Low sensitivity for diffuse axonal injury (brain)
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Tertiary Survey
• The infamous “Tert”• Performed within 24 hrs of initial evaluation• Complete history and physical examination• Assess need for further imaging (extremity XR)• Review labs, imaging findings• Summarize diagnoses, treatment plan
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Special cases - Airway
• Intubation – maintain in-line stabilization of cervical spine• Listen for right main stem intubation
• Unable to intubate surgical cricothyrotomy• Through cricothyroid ligament• Between thyroid and cricoid cartilage
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Special cases - Breathing
• Tension pneumothorax• Large bore needle decompression at mid-
clavicular line above 2nd rib• Tube thoracostomy (“chest tube”)
• Open pneumothorax (“Sucking chest wound”)• 3 sided patch to allow expiration but not
inspiration of air through hole• Tube thoracostomy
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Special cases - Circulation
• Scalp laceration• Potential for massive bleeding• Suture lacerations• Apply compressive bandage for 30 minutes and re-
assess
• Pelvic bleeding• Pelvic binder in ED• Imaging, arterial embolization
• Cardiac tamponade (75-100ml)• Pericardial drain• Thoracotomy if in extremis
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Special cases - Circulation
• Positive FAST Exploratory laparotomy (ex-lap)• Stab abdominal injury selective lap if fascia violated• GSW abdominal injury ex-lap• Need for transfusion O+ blood for males, O- blood for women of
child bearing age or younger• No time for results of type and screen or cross
• Indication for OR thoracotomy• 1500cc blood at initial chest tube insertion• 200cc blood for 4 hrs• 2500cc in 24hrs
• Additional vascular access• Subclavian introducer• Saphenous vein cutdown
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Special cases - Disability
• GCS ≤ 14 head CT• GCS ≤ 10 intubation• GCS ≤ 8 Intra-cranial pressure (ICP)
monitoring
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The Pregnant Patient
• “To save the fetus, one must save the mother”• Provide all essential diagnostic or therapeutic
procedures• CT scans when concern for intra-abdominal injury
• Place patient in left lateral decubitus position as possible• Reduces IVC compression
• Kleihauer-Betke (K-B) test• Detects fetal blood in maternal circulation
• History and ultrasound to estimate fetal age• Cardiotocographic (CTM) monitoring beyond 24 weeks
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Trauma Pearls
• Most commonly injured organ in blunt trauma• Liver (spleen is very close 2nd)
• Most commonly injured organ in penetrating injury – small bowel (liver is close 2nd)
• MCC death • 0-60 min: cardiac, aortic, brainstem injuries• 1-4 hrs: brain injury, hemorrhage “golden hour”• days to weeks: MSOF, sepsis
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Trauma Pearls
• MCC epidural hematoma – middle meningeal artery
• MCC subdural hematoma – venous plexus• Femur fractures – up to 2L blood can pool• Open extremity fractures – reduce fracture,
reassess pulse• No pulse – angiography or OR
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