Trauma Resuscitation

Abdullah Bakhsh, MBBS FAAEM

Assistant Professor
Emergency Medicine
 Objectives
 Describe the components of the primary survey in trauma

 Discuss possible pathologies and stabilization measures in each

domain of the primary survey

 Discuss the secondary survey components

 Discuss appropriate work-up (labs, imaging, etc.)

 Describe appropriate disposition of a trauma patient

 Resuscitation

“The action of making something

active and vigorous again”
February 17, 1976
Nebraska
Dr. James Styner
Wife + 4 kids
Trauma Center Designation

Designated by a higher organization

(e.g. American College of Surgeons)

No such organization in Saudi Arabia

 Major Trauma Criteria
GCS< 13
HR> 140
SBP< 90 mmHg
RR< 10 or >30
Compromised airway (stridor, blood in airway, maxillofacial trauma)
Penetrating injuries to head, neck, chest, abdomen, pelvis, extremities proximal to the
elbow and knees
Flail chest
Depressed skull fracture
Combination with burns: > 20% of BSA
Pregnant >20 weeks in combination with trauma
Multiple proximal long-bone fracture (>2)
 Severe Mechanism Trauma Criteria
Ejection from vehicle
Fall: > 20 ft. (6m)
Death in same passenger compartment
High speed motor vehicle crash> 40 mph (65 kph)
Intrusion into the passenger compartment> 12 inch (>30
cm)
Pedestrian struck by vehicle
Motorcycle crash> 20 mph (30 kph)
All Major Trauma Victims

Oxygen
2-large bore IV lines (18, 16, 14 gauge)
Flat on bed
Cardiac monitor
Full set of vital signs
Primary Survey

Airway + C-Spine
Breathing
Circulation
Disability
Exposure
 Airway Assessment

Assessment Decision

Ability to phonate Rapid sequence intubation

Noisy breathing Basic airway maneuvers
Blood/Vomit/Burn in oral Suction
cavity Surgical airway
Severe facial trauma
 Airway Interventions

Basic Advanced

Jaw-thrust Rapid Sequence intubation

Stif cervical collar Surgical airway
Oropharyngeal airway
Injuries Causing Airway Issues

Head injury
Drugs/Intoxication
Face/Neck injuries
Jaw Thrust
Stif Neck Collar
 Who Needs a Collar

All patients with major trauma/severe mechanism need it

on the primary survey

Decision to remove after primary survey

Surgical Airway Landmark
 Breathing Assessment

Assessment Decision

Pulse oximeter Needle decompression

Chest auscultation Tube thoracostomy
Tracheal deviation
 Breathing Intervention

Clinical fndings Intervention

Diminished/Absent breath Needle decompression (5th

sounds one 1 side ICS at anterior axillary line)

BP< 90/60 mmHg Followed by tube

thoracostomy in safe
triangle
 Pneumothorax (PTX)

Tension Simple

Diminished/Absent breath Diminished breath sounds

sounds on 1 side on 1 side
BP< 90/60 mmHg Normotensive
Pulse oximeter< 92% Normoxic or hypoxic
Tachypneic Normal RR or tachypneic
Tension PTX = Obstructive Shock
 PTX Intervention

Tension Simple
Needle decompression Can wait until after chest X-
(large angiocath in 5th ICS ray (after primary survey)
anterior axillary line)
If>20% -> tube
Tube thoracostomy in safe thoracostomy
triangle If<20% -> oxygen and
repeat CXR in 4-6 hours
Must be done during B
Safe Triangle

The higher the safer

Forget about counting ribs

(highly subjective)
Don’t Kill Your Patients
 Hemothorax (HTX)

Massive Simple

Diminished/Absent breath Diminished breath sounds

sounds one 1 side on one side
BP< 90/60 mmHg Normotensive
Pulse oximeter< 92% Normoxic or hypoxic
Tachypneic Normal RR or tachypneic
 Massive Hemothorax

1,500 mL on initial output

Or
200 mL/hr for 4 hours

Need thoracotomy
 Circulation Assessment

Assessment Decision

Peripheral pulses Intravenous fuid

Blood pressure Blood transfusion
External bleeding Tranexamic acid
FAST exam Compress active bleeding
Pelvic instability Pelvic binder
Operative intervention
Abdomen Surface Anatomy
Cardiac Box Surface Anatomy
Causes of Shock in Trauma
Tension PTX
Massive HTX
Cardiac tamponade
Blunt cardiac injury (BCI)
Intra-abdominal bleeding
Spinal cord injury
Pelvic fracture (open book)
Long bone fracture
External bleeding (scalp, penetrated vessel, etc.)

(Solitary intracranial bleeding DOES NOT cause shock)

 Peripheral Pulses

Grading Location

0: No palpable pulse Radial (bilateral)

+1: Faint, but palpable Dorsalis pedis (bilateral)
+2: Decent pulse
+3: Normal
+4: Bounding
 Blood Pressure Target

Without TBI With TBI

Target SBP 90 mmHg Target SBP 100-110 mmHg

(or MAP of 80 mmHg)
Permissive hypotension AVOID permissive
(maintain perfusion but hypotension to maintain
prevent exsanguination) cerebral perfusion
Volume Replacement in Trauma

1 Liter bolus IVF over 10-15 mins (to target BP)

If still not reached target BP, then;

1) Packed RBC transfusion +- Plt +- FFP
(1 unit pRBCs = 250-300 mL = raises Hgb by 1g/dL)
2) Tranexamic acid

BP is your guide for transfusion (NOT HEMOGLOBIN)

 ABC Score in Trauma

Score Utility

Penetrating trauma +1 Predicts the need for blood

SBP< 90 mmHg +1 transfusion and tranexamic
acid
HR> 120 bpm +1
Positive FAST +1

2 or more is a positive
score
Focused Abdominal Sonography in
Trauma (FAST)
Detects intra-peritoneal abdominal fuid (blood)

Sensitivity; 42%
Specifcity; 98%

Picks up as little as 100 mL free fuid

Sites; 1) Hepatorenal recess, 2) Subxiphoid, 3)
Splenorenal recess, 4) Suprapubic
Hepatorenal Recess (RUQ)

Normal Abnormal
 Subxiphoid

Normal Abnormal
Splenorenal Recess (LUQ)

Normal Abnormal
 Suprapubic

Normal Abnormal
 Decisions

Unstable (BP< 90/60 mmHg) Stable

+ Pericardial fuid -> + FAST exam -> A/P CT
pericardiocentesis or imaging
thoracotomy

+ Intra-peritoneal fuid -> - FAST exam -> manage as

Laparotomy needed

- FAST exam -> look for other

cause/repeat FAST/Ex-Lap
 Pelvic Instability

Unstable pelvis on palpation +

unstable -> apply pelvic binder
Pelvic Binder
 Indications for Ex-Lap
Peritonitis
Evisceration
Penetrating injury
Hemodynamic instability + positive FAST exam
Free air on CXR or CT image
Multisystem trauma + unclear source of hemodynamic
instability
 Blunt Cardiac Injury (BCI)
Consider when no other cause of shock identifed

Findings;
1) Sinus tachycardia/other dysrhythmias (without
obvious cause)
2) Shock without obvious cause

If normal Troponin/ECG/Echocardiogram -> BCI ruled out

 Disability Assessment

Assessment Decision

Glasgow coma scale Rapid sequence intubation

Gross motor movement Keep bed fat (spine
Pupillary reaction to light precautions)
Cushing refex Reverse Trendelenberg
Hyperosmolar therapy
Glasgow Coma Scale (GCS)

GCS 15-13: mild TBI

GCS 12-9: moderate TBI

GCS≤ 8: severe TBI

 Causes of low GCS in Trauma

TBI Non-TBI

Cerebral contusion Drugs/Intoxication

Epidural hematoma CO poisoning
Subdural hematoma Concussion
Subarachnoid hemorrhage
Difuse axonal injury
 Brain Protective Measures
Target SpO2> 94%
Keep in reverse Trendelenberg
Target PCO2 = 35-40 mmHg
Target SBP = 100-110 mmHg
Avoid hyponatremia Na 145-155 mEq/L
Maintain normoglycemia = 140-180 mg/dL
Avoid fever (Give antipyretic if T≥ 38 ºC)
Prophylactic antiepileptic drugs for TBI
Target cerebral perfusion pressure (CPP) = 60-70 mmHg
Target INR 1.5 (Give FFP if> 1.5)
Target platelet count at least 100,000 (Give platelets if< 100,000)
 Hyperosmolar Therapy

Methods Indications

Mannitol (must have Asymmetrical pupils

normal renal function and Focal neurologic defcit
be normotensive)
Cushing refex
Midline shift> 5mm on CT
Hypertonic Saline (requires brain
central line)
(all eventually need OR)
 Exposure

Assessment Action

Log roll Remove all cloth

Palpate entire spine Provide warm blanket
(tenderness/step-ofs) Remove backboard
Rectal exam (tone/blood)
 Primary Survey Adjuncts
Immediately after primary survey

Chest X-ray
Pelvis X-ray
(Skull, C-spine, and Abdomen X-rays are useless)

Orogastric tube (avoid NG in TBI)

Foley catheter (avoid if blood at urethral meatus, pelvic Fx,
hematoma on perineum)
 Blood Work
Blood type/Cross match (the most critical test)
CBC
Renal function/Electrolytes
Liver function (liver injury)
Amylase/Lipase (bowel injury)
Troponin
PT/INR/PTT
Blood gas (acidosis in occult hemorrhage)
Pregnancy
Urine drug screen
Alcohol blood level
 Secondary Survey
Head; lacerations, wounds, hematomas
Face; tenderness (Le Forts Fx), basal skull Fx
Nose; septal hematoma
Mouth; teeth alignment, oral trauma
Ear; hemotympanum
Neck; spinal tenderness
Chest, Abdomen, Pelvis, Extremities, CNS
Extremities; palpate and mobilize each extremity
Indications for CT Imaging in Trauma

Patient MUST be hemodynamically stable

(BP> 90/60 mmHg) for a CT
 Indications for CT brain

GCS 13-15 GCS≤ 12

Period of LOC/Amnesia +
On anticoagulants All patients require brain CT
Seizure
Vomiting
Focal neurological defcit
Age> 65 years old
Evidence of skull Fx/Basilar skull Fx
Intoxication
Dangerous mechanism
 Indications for CT C-Spine

GCS 15 GCS< 15

Focal neurologic defcit Consider for all patients

(motor/sensory)
(unreliable examination)
Midline spine tenderness
Intoxication
Distracting injury
Age> 65 years old
Dangerous mechanism
 Indications for CT Chest

GCS 15 GCS< 15

Abnormal CXR Consider for all patients

Chest wall (unreliable exam)
tenderness/bruising
Distracting injury
Age> 65 years old
Dangerous mechanism
Indications for CT Abdomen/Pelvis

GCS 15 GCS< 15

Abdominal tenderness
Costal margin tenderness
Consider for all patients
Abnormal CXR
(unreliable exam)
Pelvis Fx (PXR)
Spinal cord injury
Unexplained tachycardia
HCt< 30%
Abnormal LFT/Amylase/Lipase
 Disposition

Normal vital signs + normal work-up/imaging -> DC

Serious injury identifed on exam/imaging -> Admit/OR
Hemodynamically unstable -> OR
Normal work-up/imaging but unexplained tachycardia ->
observe
Normal work-up/imaging but persistent abdominal
tenderness -> observe