Table Of Contents
Primary Survey
Airway
- –If trauma patient comes in unconscious: Intubate!
- –If GCS < 8: Intubate!
- –If guy stung by a bee, developing stridor and tripod posturing: Intubate!
- –If guy stabbed in the neck, GCS = 15, expanding mass in lateral neck: Intubate!
- –If guy stabbed in the neck, crackly sounds w/ palpating anterior neck tissues: fiberoptic bronchoscope
- –If huge facial trauma, blood obscures oral and nasal airway, & GCS of 7: cricothyroidotomy
Breathing
- –After Intubating a patient, next best step: Check bilateral breath sounds
- –If decr on the left: Means you intubated the right mainstem bronchus
- –What to do: Pull back your ET tube
- –Next step: Check pulse ox, keep it >90%
Secondary Survey
5 Thoracic causes of immediate death
Cardiac Tamponade
Presentation | |
– JVD – hypotension – muffled heart sounds |
Hemoperitoneum
Work up | |
FAST scan – Morrison’s pouch: R kidney and liver – splenorenal recess: L kidney and spleen – pouch of Douglas: posterior to bladder – pericardium |
Isotonic Fluids
Fluid Replacement | |
Isotonic fluids (NS or LR) are repleted in a 3:1 ration (fluid to blood loss). – start w/ fluid bolus of 1-2L in adults – recheck vitals and the continue repletion as indicated – if still tachycardic or hypotensive, after the first 2L of isotonic fluid, transfusion w/ pRBCs may be indicated |
Head Trauma
- GCS -> eyes 4, motor 6, verbal 5
- Hematoma, edema, tumor can cause increased ICP
- Symptoms: Headache, vomiting, altered mental status
- Treatment: Elevate HOB, hyperventilate to pCO2 28-32, give mannitol (watch renal fxn)
- Surgical intervention: Ventriculostomy
Epidural Hemorrhage
- Def:
- MC Cause:
- Presentation:
- 1. (immediate or slow) loss of consciousness followed by a lucid interval (minutes to hours).
- 2. Uncal herniation leads to coma with a “blown pupil” (fixed and dilated ipsilateral pupil)
- 3. ultimately ipsilateral hemiparesis
- Note: Mental status changes associated with an expanding epidural hematoma occur within minutes to hours and classically have a lucid
interval.
- 1. (immediate or slow) loss of consciousness followed by a lucid interval (minutes to hours).
- Diagnosis:
- Treatment:
- Complications:
Subdural Hemorrhage
- Def:
- Cause:
- Types: Acute and Chronic
- Presentation:
- Diagnosis:
- Treatment:
Glitzy queen00 at English Wikipedia / Public domain
Neck Trauma (penetrating)
- Penetrating Trauma -> GSW or stab wound
- Zone 3 = ↑ angle of mandible
- w/u: Aortography and triple endoscopy.
- Zone 2 = angle of mandible-cricoid
- w/u: 2D doppler +/-exploratory surgery.
- Zone 1 = ↓ cricoid
- w/u: Aortography
- Zone 3 = ↑ angle of mandible
- Work-up:
- 1) intubate early
- 2) immediate surgical exploration is mandatory for pts w/ shock and active ongoing hemorrhage from neck wounds
- – all wounds that violate the platysma are considered true penetrating neck trauma.
- – assess based on neck zones (3)
- —1) above angle of mandible
- —2) between angle of mandible and cricoid
- —3) below cricoid
- 3) Continue dx work-up w/ appropriate tests
- – angiography or aorta
- – carotid/cerebral arteries
- – CT scan of the neck w/ or w/o CT angiography
- – Doppler U/S
- – contrast esophagography/esophagoscopy
- – bronchoscopy
Injuries
Management | |
Nerve | surgical repair |
Vascular | arteriography and surgical |
Contaminated wounds
Management | |
early wound irrigation tissue debridement THEN Abx and tetanus prophy |
Penetrating Abdominal Trauma
- If GSW to the abdomen: Ex-lap. (plus tetanus prophylaxis)
- If stab wound & pt is unstable, with rebound tenderness & rigidity, or w/ evisceration: Ex-lap. (plus tetanus prophylaxis)
- If stab wound but pt is stable: FAST exam. DPL if FAST is equivocal.
Ex-lap if either are positive. - If blunt abdominal trauma pt with hypotension/tachycardia:If you see this? Do not pass go, go directly to exploratory laparotomy. Ex-lap. (plus tetanus prophylaxis) Ex-lap. (plus tetanus prophylaxis) Ex-lap.
- If Air under the diaphragm: Do not pass go, go directly to exploratory laparotomy.
Blunt Abdominal Trauma
- If unstable: Ex-lap.
- If stable: Abdominal CT
- –If lower rib fx plus bleeding into abdomen: Spleen or liver lac.
- –If lower rib fx plus hematuria: Kidney lac.
- –If Kehr sign & viscera in thorax on CXR: Diaphragm rupture.
- –If handlebar sign: Pancreatic rupture.
- –If stable w/ epigastric pain?
- Best test: Abdominal CT.
- If the retroperitoneal fluid is found? Consider duodenal rupture.
Pelvic Trauma
- If hypotensive, tachycardic -> FAST and DPL to r/o bleeding in the abdominal cavity.
- Can bleed out into pelvis -> stop bleeding by fixing fx -> internal if stable, external if not.
- If blood at the urethral meatus and a high riding prostate: Consider pelvic fracture w/ urethral or bladder injury.
- Next best test: Retrograde urethrogram (NOT FOLEY!)
- If normal: Retrograde cystogram to evaluate bladder
- What are you looking for: Check for extravasation of dye. Take 2 views to ID trigone injury.
- If extraperitoneal extravasation: Bed rest + foley
- If intraperitoneal extravasation: Ex-lap and surgical repair
Ortho Trauma
- Fractures that go to the OR:
- –Depressed skull fx
- –Severely displaced or angulated fx
- –Any open fx (sticking out bone needs cleaning)
- –Femoral neck or intertrochanteric fx
Anterior Shoulder dislocation
- –Arm outwardly rotated, & numbness over deltoid
Posterior Shoulder dislocation
- –Shoulder pain s/p seizure or electrical shock
Boxers fracture
- –Punching a wall: Metacarpal neck fracture “Boxer’s fracture”. May need K wire
Clavicle fracture
- –Clavicle is most commonly broken where: Between middle and distal 1/3s. Need figure of 8 device
Colles fracture
- –old lady FOOSH, distal radius displaced
Depressed skull fracture
Femoral Neck fracture
Intertrochanteric fracture
Scaphoid fracture
- –young person FOOSH, anatomic snuffbox tender
Child Abuse
Signs | Diagnosis |
spiral fractures in the limbs bucket-handle fractures bruises rib fractures | Imaging: subdural hematoma coupled w/ retinal hemorrhages |
Procedures
Indications | |
Open thoracotomy | pts w/ penetrating chest trauma that leads to cardiac arrest, provided that the pt arrested in the ED or shortly before arrival |
Immediate exploratory laparotomy | – gunshot wounds (some pts who are stable can be managed conservatively) – stab wounds in a hemodynamically unstsable pt – pt w/ peritoneal signs or evisceration |
EM Notes
References
- Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. / CC BY