Trauma

People involved in trauma die immediately, within a few hours (hypovolemia) or within a few days.  Always start with ABC’s and vitals.

Airway

  • Assessment
    • Look: obvious trauma involving airway (mouth, nose, neck), failure of airway protection (pooling secretions, absence of spontaneous swallowing), angioedema, FB
    • Listen: are they talking, what do their respirations sounds like (i.e. stridor)
    • Feel: if in doubt explore airway
  • C-spine immobilization
  • Supplemental O2
  • Establishing an airway
    • Head tilt, chin lift, jaw thrust
    • Suction
    • Oral airway
    • Intubation
    • Cricothyrotomy/Tracheostomy

Breathing

  • Assessment
    • Look: respiratory rate and pattern, increased WOB (accessory muscle use, indrawing, tracheal tug), signs of hypoxia
    • Listen: auscultate
    • Feel: subcutaneous emphysema



 

Circulation

  • Assessment
    • Look: evidence of bleeding, colour of extremities, injuries which may result in large volume loss (pelvis stability, long bones)
    • Listen: heart sounds
    • Feel: pulse rate and depth, prolonged capillary refill time, peripheral pulses

Disability

  • LOC – if head trauma assess GCS
    • ≤ 8 then intubate
  • Pupils and localizing signs

Exposure

  • Disrobe patient, and survey whole body
  • Log roll (assess for vertebral tenderness, rectal exam for tone/prostate)
  • Keep patient warm

Canadian C-spine Rule

Patient must be alert and stable – but complain of neck pain.  The rule was designed to identify patients who are unlikely to suffer significant C-spine fractures.  Those who fit the rule will receive C-spine X rays.

High risk factors (if yes X ray):

  • ≥65 years old
  • Dangerous mechanism
    • Fall from ≥ 3 feet or 5 stairs
    • High speed (roll over, ejection, ≥ 100kph)
    • Motorized recreational vehicle (ATV, snowmobile)
    • Bicycle collision
    • Axial load (diving)
  • Paresthesias in extremities

Low risk factors that allow safe assessment of ROM (if no X ray):

  • Simple rear-end motor vehicle collision
    • Excludes pushed into oncoming traffic, rollover, hit by large vehicle, hit by high speed vehicle
  • Sitting position in ED
  • Ambulatory at any time
  • Delayed onset of neck pain
  • Absence of midline C-spine tenderness

If deemed safe to assess ROM, and unable to rotate neck 450 to each side must X ray.

Canadian CT Head Rule

Designed to identify patients who have sustained minor head injuries requiring CT.  In order to apply the rule, patients must meet the criteria for minor head injury (witnessed LOC, definite amnesia, or witnessed disorientation with GCS of 13-15), they must be older than 16 years old, have no history of bleeding disorder, and have no obvious open skull fracture.

High Risk (for neurological intervention)

  • GCS score <15 at two hours after injury
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture (haemotympanum, “racoon” eyes, CSF otorrhoea, rhinorrhoea, Battle’s sign)
  • Vomiting two or more times
  • Age more than 64 years

Medium Risk (for brain injury on CT)

  • Amnesia before impact ≥ 30 minutes
  • Dangerous mechanism (pedestrian, occupant ejected, fall from elevation)

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