Trauma in the Emergency Department

| In Articles | 20th May 2020

In the emergency department the term trauma refers to a physical injury.

A major trauma can be generated by:

  • a fall from higher than 3 metres
  • road traffic collision with a net speed of 30km/hour or more
  • thrown or trapped in a vehicle
  • pedestrian or cyclist hit by a car
  • unrestrained occupant of a vehicle
  • injury from a high or low velocity weapon

Triage

When patients are sent to the emergency department of a hospital they first go thru Triage. This is where the assessment of illnesses and wounds (trauma) takes place and the patient order for consultation and treatment is established. The first patient treated is the one with the greatest threat to life.

A detailed history is not essential to begin the evaluation of the trauma and the lack of a definitive diagnosis should never impede the application of an indicated treatment.

ABCDE approach:

Airway and cervical spine (C-spine) protection

Breathing and ventilation

Circulation and haemorrhage control

Disability and neurological status

Exposure and environmental control

A - Airway:

  • can the patient communicate verbally?
  • foreign bodies blocking the airway?
  • stridor, hoarseness, gurgling, pooled secretions, blood?

Stridor = harsh vibrating noise when breathing caused by obstruction of the windpipe or larynx

Hoarseness = abnormal voice changes in volume and pitch

Gurgling = hollow bubbling sound

Pooled secretions = accumulated oropharyngeal secretions

Trauma as a result of cervical spine condition
Cervical spine protection: collar (neck brace) in place

Airway interventions:

  • administer oxygen
  • suction
  • chin lift/jaw thrust
  • rapid sequence induction and intubation (RSII)
  • endotracheal intubation (ETI)

B - Breathing:

  • An open and unobstructed airway alone does not ensure adequate ventilation
  • Inspect, palpate, and auscultate
  • Deviated trachea, crepitations in the lungs, flail chest, sucking chest wound, absence of breath sounds
  • Chest Xray to evaluate lung fields

Flail chest = life threatening medical condition due to detachment of a rib cage segment. Symptoms include chest pain and shortness of breath

Sucking chest wound = hole in the chest due to puncture (gunshot, stabbing)

Breathing Interventions

  • Ventilate with 100% oxygen
  • Needle decompression if tension pneumothorax suspected
  • Chest tubes for pneumothorax /hemothorax
  • Occlusive dressing to sucking chest wound

Needle decompression = insertion of a large-bore needle or cannula through the chest wall and into the pleural space to allow air trapped within the pleural cavity to escape.

Tension pneumothorax = air trapped in the pleural cavity under positive pressure, resulting in the loss of normal negative pressure between the 2 pleural membranes.

Hemothorax = accumulation of blood within the pleural cavity.

Occlusive dressing = an air and water tight, totally sealed medical dressing

C - Circulation

  • Hemorrhagic shock should be assumed in any hypotensive trauma patient
  • Rapid assessment of hemodynamic status (dynamics of blood flow)
  • Level of consciousness
  • Skin colour
  • Pulses in four extremities
  • Blood pressure

Circulation Interventions

  • Cardiac monitor
  • Apply pressure to sites of external haemorrhage
  • Establish intravenous access
  • 2 large bore intravenous catheters inserted
  • Central lines (type of intravenous catheter placed in a large vein that allows multiple IV fluids to be given and blood to be drawn)
  • Cardiac tamponade (fluid in the pericardium - the sac around the heart - builds up, resulting in compression of the heart) decompression if indicated
  • Have blood ready for transfusion if needed
  • Level one infusers available (devices that provide warmed intravenous fluids)
  • Foley catheter insertion (flexible tube that passes through the urethra and into the bladder to drain urine)

HEMORRHAGIC SHOCK - large volumes of blood may be hidden in the thoracic, abdominal and pelvic cavities, or from femoral shaft fractures.

5 Places where life threatening haemorrhage can occur:

  • Chest
  • Abdomen
  • Pelvis
  • Thighs
  • Externally

To decrease bleeding:

  • Apply pressure to external wounds
  • Apply splint to possible femur fracture
  • Apply pelvic binder to possible pelvic fracture
  • If the patient is pregnant, she should not be on her back, put her on her left side
  • Send blood to the lab for type and crossmatch

Primary Survey - Circulation

  •  Begin volume resuscitation with litre boluses of crystalloid (low-cost salt solutions, e.g. saline, with small molecules, which can move round easily when injected into the body) for class I or II haemorrhage
  • Begin crystalloid and blood for class III or IV haemorrhage
  • O negative blood until type specific is available
  • Constant reevaluation is paramount! If class I or II haemorrhage and the patient is still showing signs of shock after 3L of crystalloid, begin blood “3:1 rule” 3cc crystalloid for every 1cc of blood loss
  • Cardiac Tamponade (fluid - blood, fluid, pus, clots, or gas - in the pericardium builds up, resulting in compression of the heart) can cause hypotension with little blood loss
  • Becks triad: hypotension, distended neck veins, muffled heart sounds
  • Pericardiocentesis: fluid aspiration from the pericardium 

D - Disability

  • Abbreviated neurological exam
  • Level of consciousness
  • Pupil size and reactivity
  • Motor function
  • Glasgow Coma Score (GCS) = eyes +verbal + motor scores
    • Utilised to determine severity of injury
    • Guide for urgency of head CT and intracranial pressure (ICP) monitoring
trauma evaluation scale
  • Severe head injury: GCS 8 or less
  • Moderate head injury: GCS 9-12
  • Mild head injury: GCS 13-15

GCS is to be repeated and recorded frequently! It is the best way to monitor patient deterioration.

Disability Interventions

  • Spinal cord injury: high dose steroids if within 8 hours
  • Intracranial pressure ICP monitor- measures the pressure in the brain directly using a small pressure-sensitive probe that is inserted through the skull
  • Elevated ICP:
    • Head of bed elevated
    • Mannitol - sugar alcohol, used as an osmotic diuretic to reduce brain swelling and intracranial pressure
    • Hyperventilation
    • Emergent decompression: removal of a flap of the skull and incision of the dura mater for relief of intracranial pressure

E- Exposure

Always inspect the back!!

REASSESSMENT

  • Always perform an ABCDE primary survey if patient deteriorates
  • Signs of adequate resuscitation
  • Slowing of tachycardia
  • Urine output normalizes
  • Blood pressure increases

Secondary Survey

  • AMPLE history: allergies, medications, past medical history, last meal, events
  • Physical exam from head to toe, including rectal exam
  • Frequent reassessment of vitals (body temperature, blood pressure, pulse -heart rate, and breathing rate - respiratory rate, often notated as BT, BP, HR, and RR)
  • Diagnostic studies at this time simultaneously
  • X-rays, lab work, CT if indicated
  • Focused assessment with sonography in trauma (FAST exam) is a rapid bedside ultrasound examination used as a screening test for blood around the heart ( pericardial effusion) or abdominal organs ( hemoperitoneum) after trauma

Head Exam

  • Scalp, eyes, ears
  • Soft tissues

Neck Exam

  • Penetrating injuries
  • Swelling or crepitus

Neurological Exam

  • Glasgow Coma Score GCS
  • Motor examination
  • Sensory examination
  • Reflexes

Chest Exam

  • Clavicles, ribs
  • Breath, heart sounds

Abdominal Exam

  • Penetrating injury
  • Blunt injury: nasogastric tube
  • Rectal exam
  • Urinary catheter

Pelvis and Limbs

  • Fractures
  • Pulses
  • Lacerations (body tissue tearing)
  • Ecchymosis (nonraised skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels)

Standard trauma labs
Complete blood count (CBC), potassium (K), creatinine (Cr), partial thromboplastin time (PTT), toxicology screen (UTOX), ethanol level (EtOH), arterial blood gases (ABG)

Standard trauma radiographs

  • Chest X-ray, pelvis, lateral cervical spine (traditionally)
  • CT/FAST scans

Pacient should only go to radiology if stable!

Abdominal Trauma = common source of traumatic injury

  • Bike accident over the handlebars
  • MVC with steering wheel trauma
  • High suspicion with tachycardia, hypotension, and abdominal tenderness
  • Can be asymptomatic early on
  • FAST exam can be early screening tool
  • Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis
  • Be suspicious of free fluid without evidence of solid organ injury

Splenic Injury

  • Most commonly injured organ in blunt trauma
  • Often associated with other injuries
  • Left lower rib pain may be indicative
  • Often can be managed non-operatively

Liver injury

  • Second most common solid organ injury
  • Can be difficult to manage surgically
  • Often associated with other abdominal injuries

Hollow Viscous Injury

  • Injury can involve stomach, bowel or mesentery
  • Symptoms are a result from a combination of blood loss and peritoneal contamination
  • Small bowel and colon injuries result most often from penetrating trauma
  • Free fluid without solid organ injury is a hollow viscus injury until proven otherwise
  • Deceleration injuries can result in bucket-handle tears of mesentery

CT Scan in Trauma

  • Abdominal CT scan visualizes solid organs and vessels well
  • CT does NOT see hollow viscus, duodenum, diaphram, or omentum well
  • Some recent surgery literature advocates whole body scans on all trauma
  • !!!Keep in mind that there is an increase in mortality related to cancer from CT scans

FAST Exam

  • Focused Abdominal Scanning in Trauma
  • 4 views: cardiac, right upper quadrant, left upper quadrant, suprapubic
  • Goal: evaluate for free fluid

!!! STABILIZATION AND TRANSFER

  • Resuscitation completed
  • Analgesia administered
  • Laboratory specimen sent
  • Fractures immobilised
  • Documentation completed
  • Transfer
  • Ward
  • Operating theatre
  • Higher level of care centre

Summary

  • Trauma is best managed by a team approach (there’s no “I” in trauma)
  • A thorough primary and secondary survey is key to identify life threatening injuries
  • Once a life threatening injury is discovered, intervention should not be delayed
  • Disposition is determined by the patient’s condition as well as available resources