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Rapid Trauma Assessment Rapid Trauma Assessment S. Jason Moore, PhD, PA Trauma/Critical Care Services Vail Valley Medical Center, Colorado Rapid Trauma Assessment • Systematic evaluation 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 precipitous deterioration 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..
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