Snapshot A 30-year-old man presents to the ED after being hit by a large truck. He is brought on a backboard with a cervical collar. Oropharyngeal airway mask and one peripheral IV with fluid running are in place. Multiple lacerations on his scalp and thighs are wrapped in dressings. Blood pressure is 80/40 mmHg, pulse is 140/min, respirations are 40/min, and SaO 2 is 92% on RA. introduction Most common method of initial trauma assessment in the United States is based on Advanced Trauma Life Support (ATLS) course from American College of Surgeons goal is to treat greatest threats to life immediately lack of definitive diagnosis and detailed history should not impede therapy Presentation Trauma patient can present to the ED from multiple different scenarios blunt trauma, motor vehicle collisions, falls are most common penetrating trauma (guns/knives/others) environmental injuries burn cold electric smoke bite Precipitating factors to trauma must also be considered: 6 S's Seizure, Syncope, Sugar (hypoglycemia), Suicide, Sleep (abnormality), Sauce (alcohol) Diagnosis Primary survey (often concurrent with resuscitation): ABCDE Airway signs of obstruction: agitation, confusion, respiratory distress, failure to speak, cyanosis Breathing observe for altered mental status, chest movement, nasal flaring listen for signs of obstruction (stridor, asymmetry, air escape) feel for trachael shift, crepitus, flail segments, subcutaneous emphysema objective signs: rate, oximetry, ABG, A-a gradient Circulation look for evidence of shock shock in trauma patient is hemorrhagic until proven otherwise early signs: tachycardia, tachypnea, narrow pulse pressure, reduced capillary refill, cool extremities late signs: hypotension, altered mental status, reduced urine output Disability level of consciousness assessed by Glasgow Coma Scale (GCS) good indicator of injury severity and neurosurgical prognosis change in GCS with time is more relevant than absolute number reported as 3-part score based on eye movement, verbal response, motor response score 13 - 15: mild injury score 9 - 12: moderate injury score < 9: severe injury must protect airway in this situation Exposure/Environment undress patient completely and assess entire body for injury logroll to examine back digital rectal exam Management Resuscitation done at the time as primary survey, with focus on ABC Airway temporizing measures protect C-spine head-tilt or jaw thrust to open airway nasopharyngeal airway if gag reflex present without concern for airway loss (i.e., conscious) oropharyngeal airway if impending concern for airway loss or gag reflex absent (i.e., unconscious) - preferred method of airway protection definitive measures endotracheal tube intubation indications unable to protect airway (GCS < 8; airway trauma) inadequate oxygenation (SaO 2 <90% on 100% O 2) profound shock anticipatory: in trauma, overdose, CHF, asthma, COPD, smoke inhalation injury anticipated transfer of critically ill patient contraindication: supraglottic / glottic pathology does not provide 100% protection against aspiration surgical airway (if unable to intubate and unable to ventilate) cricothyroidotomy Breathing in order of increasing FiO 2: nasal cannula, face mask, non-rebreather, CPAP/BiPAP bag-valve mask and CPAP/BiPAP used to supplement inadequate ventilation Circulation monitor vital signs, ECG, oxygen saturation if bleeding externally, apply direct pressure and elevate extremities if possible do NOT remove impaled objects as they tamponade hemorrhage impaled objects are only removed in the OR tourniquet as last resort resuscitation 1 to 2 L crystalloid (NS, LR) with large bore IVs (warmed if possible) consider pRBC transfusion if severely hypotensive crossmatched or type-specific blood ideal if unavailable, use O-negative in children/women of child-bearing age or O-positive in all others with significant hemorrhage, massive transfusion protocol may be necessary Advance Cardiac Life Support (ACLS) algorithm as necessary for arrhythmias Foley catheter and NG tube if indicated contraindications to Foley insertion blood at urethral meatus scrotal hematoma high-riding prostate on digital rectal exam contraindications to NG tube insertion significant mid-face trauma basilar skull fracture proceed to detailed secondary survey and definitive care