Rapid Trauma Assessment

S. Jason Moore, PhD, PA

Trauma/Critical Care Services Vail Valley Medical Center, Colorado Rapid Trauma Assessment

• Systematicevaluation of the injured patient with the goal of identifying and treating potentially preventable causes of death in a timely manner.

• Stabilize and transport the injured patient with appropriate re-assessment as determined by assumed severity of injury. “Systematic evaluation…”

• A • B • C • D • E » (when prudent) Rapid Trauma Assessment • Potentially Preventable Causes of Death:

– Airway

– Breathing (ventilation) • Incl. Tension PTX

– Hemorrhage

– Spinal cord injury Airway

– #1 Priority

– Does NOT ensure ventilation

– Evaluate by talking to patient

– ANY response besides speaking in a normal voice warrants further investigation &/or intervention Airway

• If patient is unconscious this warrants a more aggressive approach to airway management…

• Transport considerations – Reassessment options – Resources » Personnel Airway

• Jaw Thrust • OPA/NPA • Orotracheal/Nasotracheal Intubation • Cricothyroidotomy • ALL INTERVENTIONS REQUIRE FREQUENT RE-ASSESSMENT DURING TRANSPORT SO PLAN YOUR STOPS ACCORDINGLY!! Airway

• The more aggressive you are in your management of the airway…

• Goals:

• INCREASE Oxygenation

• IMPROVE Ventilation Airway

• Aggressive Airway Management means you should remove the helmet to gain the best anatomical alignment possible when indicated… • During transport is NOT the time to be frantically attempting to access the airway Breathing

• Ventilation

– Injury to the Thorax WILL interfere with the bellows mechanism and impair ventilation (oxygenation) • (the degree of this interference is the only variable…) Breathing

• Increasing agitation, respiratory rate, and work of breathing coupled with thoracic injury is a recipe for disaster …

• Be aware and re-assess FREQUENTLY

Circulation

• Athletes have considerable physiologic reserve …

• Be ready for a precipitousdeterioration in condition… • Helpful to compare to pediatric trauma patients …

– Not to be trusted Circulation

• Heart Rate is your best indicator of volume status and continued blood loss but …

• Tachycardia in this population is relative as a “traditional ” response is unlikely …

• So …have a heightened suspicion with only minor increases in heart rate and look for trends … Circulation

• Blood Pressure measurements are logistically difficult in this setting and remember …

– You can lose roughly 30% of your volume before there is an appreciable drop in pressure …

– Wait for a more controlled setting so repeat measurements are more trustworthy Circulation Stop Hemorrhage -Direct Pressure

Catecholamine induced cool, clammy skin is a worrisome finding Disability • Neurological Status is evaluated by: – Movement of Extremities • On command/Purposeful – Glasgow Coma Score – Pupillary Size/Reactivity

• All measurement tools provide a “snapshot ” in time … – Repeat evaluation is mandatory and an appreciation of trends is critical Disability

• All patients with TBI have the potential for rapid deterioration and the need for aggressive airway management

Be thinking ahead …

Disability

• Protect the CNS by correcting:

– Hypoxia • Airway • Breathing – Hypotension • Circulation – Which will maintain CPP(MAP-ICP) – Immobilize

Rapid Trauma Assessment • Be safe • Talk to Patient – Strong response indicates: – Patent airway (for now!) – Adequate ventilation (for now!) – ICP is not too high (TBI) nor too low (hypovolemia) • Physical Examination (head to foot) • Interventions as you identify the need! • Spinal Immobilization • Initiate Transport • Re-evaluation en-route Assessment

• Head (face, ears)

• Neck (throat)

• Shoulders/Upper Extremities

• Chest (Back)

• Abdomen

• Pelvis

• Lower Extremities

Assumptions

1. Respiratory compromise is a pending event.

2. The patient has internal injuries.

3. A Traumatic Brain Injury (TBI) is present.

4. The patient has an unstable spine fracture (regardless of your initial assessment).

5. The patient is cold …and getting colder.

Considerations

• Where are you on the hill?

• Transport terrain and logistics of re-assessment of patient condition/interventions.

• Time: 1) from injury, 2)during transport, and 3)to definitive care.

• Capabilities of facilities in close proximity-or lack thereof!! Considerations

•COMMUNICATE!!! •Questions? Conflict of Interest Disclosure

S. Jason Moore PhD, PA

Has no real or apparent conflicts of interest to report. References

• American College of Surgeons. (2004).Advanced Trauma Life Support, 7th Ed. American College of Surgeons. IL. • Moore, EE.,et al. (2004). Trauma,5th Ed. McGraw-Hill, NY. • Parks, S. (2004).ACS. Surgery. Principles and Practice. WebMD. NY.