Approach to trauma: Clinical sciences

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Introduction 0:00–0:53

Trauma is one of the major causes of mortality and morbidity worldwide. A standardized approach to trauma known as the trauma protocol allows providers to systematically assess and quickly identify potentially life threatening injuries while simultaneously initiating resuscitation.
The trauma protocol is composed of primary, secondary, and tertiary surveys performed one after another. The goal is to first identify life threatening injuries and stabilize the patient.
Then perform a more thorough head to toe assessment to catch the not so obvious injuries and finally follow up 24 hours later to make sure no other injuries were missed.
This protocol is performed on every trauma patient regardless of the mechanism of injury. So when a patient presents with trauma, start with a primary survey which can be summarized as A, B, C, D, and E.

Acute Management/Primary Survey 0:53–5:42

A stands for airway. Ensure your patient has an open airway and the ability to maintain a patent airway.
Start by asking them their name and what happened. If they can speak, they have an open airway.
However, if they show any signs of airway compromise such as altered mental status, gurgling noises, inability to speak clearly, or evidence of an expanding neck hematoma, secure the airway as soon as possible.
In this case, intubate or consider obtaining a surgical airway via cricothyroidotomy. Also, stabilize the C-spine to maintain cervical spine restriction by placing a cervical collar and keeping it in place until a traumatic injury to this area has been ruled out.
The next step in the primary survey is B for breathing. This part focuses on identifying any injuries that affect ventilation and oxygenation.
Key assessments include checking for tracheal deviation, evaluating for symmetrical chest rise, auscultating for lung sounds, and palpating the chest wall for evidence of trauma.
Any injuries that can impair ventilation such as pneumothorax or hemothorax should be addressed immediately with bedside procedures such as rapid needle decompression with subsequent chest tube placement, needle thoracocentesis, or tube thoracostomy.
Also remember to place supplemental oxygen on all adult trauma patients and monitor oxygen saturation with pulse oximetry.
OK, let's move on to C for circulation. Hypotension in an adult trauma patient is assumed to be from bleeding until proven otherwise.
So look for any signs of external or internal bleeding. Additionally, place two large bore intravenous or intraosseous catheters for fluid resuscitation and transfusion of blood products.
Be sure to place them away from the area of trauma in case there's a major vascular injury. Finally, monitor their hemodynamic status by observing their level of consciousness, skin profusion, and vital signs.
Now here's a clinical pearl. The chest, abdomen, retroperitoneum, and long bones like the femur are areas that can accommodate large amounts of blood if an internal hemorrhage is present.
If you suspect injuries to these areas, keep a close eye on your patient's BP and heart rate, since hemorrhagic shock can occur very quickly.
Next up is D for disability, focusing on neurological status assessment. Assess your patient's level of consciousness by calculating the Glass glaucoma scale or GCS.
Also check pupillary size and reaction to light and look for signs of spinal cord injury by assessing motor function and sensation in all four extremities.
Here's another clinical pearl. The GCS is a scoring tool used to assess a patient's neurological condition.
It evaluates eye opening, verbal response, and motor response. Eye opening can be assessed as spontaneous, 4 points to verbal stimuli, 3 points.
Only to pain stimuli, 2 points, or no response, 1 point. You can remember this by C's, 4 letters for 4 eye points.
Similarly, verbal response is evaluated as oriented and coherent. 5 points.
Confused or inappropriate words, 4 points. Incomprehensible sounds, 3 points.
Verbal response to pain, 2 points. No verbal response, 1 point.
Remember this by talks 5 letters for 5 verbal points. Lastly, motor response has 6 categories.
Obeys commands, 6 points. Localizing to pain, 5 points.
Withdraws to pain, 4 points. Flexion to pain, also known as decorticate posturing, 3 points.
Extension response to pain or decerebrate posturing, 2 points, and no response, 1 point. Remember this by moving six letters for six points.
Now the score can range from 15, indicative of a normal functioning patient, to 3, which is indicative of a comatose patient.
Any patient with a GCS of 8 or less needs to be intubated. Remember, GCS of 8, intubate.
Lastly, let's discuss E for exposure and environmental control. Remove all of your patient's clothing for a thorough assessment and to eliminate any potential contamination.
Remember to place warm blankets on your patient to prevent hypothermia. All right, now that the primary survey is completed and your patient has been stabilized, let's discuss the secondary survey.

Stable/Secondary Survey 5:42–7:35

This involves a thorough history and physical examination and additional workup to identify any underlying traumatic injuries that were not obvious during the primary survey.
Now essential components of your patient's history include known allergies, current medications, past illness, pregnancy status, timing of their most recent oral intake, and events related to the injury.
The physical exam should follow a head to toe sequence and includes obtaining labs and imaging to assist in identifying underlying traumatic injuries.
Typical labs include a type and cross, CBC and CMP. Keep in mind that primary and secondary.
Surveys are not like your typical A B C DE and H&P. They need to be done fast as there is no time to waste in trauma.
Primary survey typically takes 1 to 2 minutes, and H&P portion of the secondary survey usually takes about 5 minutes. Additional tests to consider are ABGs, coagulation studies, including a rotational thermoelectrometry, also known as rhodum, lipase, and serum alcohol level.
Also order urine studies like urinalysis, urine pregnancy test for biological female patients, and urine toxicology screen.
Useful imaging studies include a chest and pelvic X-ray and any relevant CT scans that might narrow down your differential.
Another important test is a focused abdominal sonography and trauma or FAST exam, which is a bedside ultrasound that quickly scans the pericardium.
A pedorinal space on the right. Splenorenal space on the left.
And pelvis for evidence of free fluid which could be from bleeding or hollow viscous injury. OK, let's discuss some abnormal physical exam findings to look out for during the secondary survey.

Abnormal Physical Exam Findings 7:35–8:33

These include palpating the face to identify maxillofacial trauma, looking for leakage of cerebrospinal fluid from the nose or ears, rolling your patient onto their side to evaluate for spinal tenderness or deformities of the spinal column.
Palpating the chest for crepitus and the rib cage to identify fractures and auscultating for muffled heart sounds that could indicate cardiac tamponade.
Also check the abdomen for distention and tenderness which could indicate solid organ damage. Check for pelvic instability to assess for fracture and perform a full neurovascular check to identify signs of compromised blood flow or nerve damage.
In addition, check for soft tissue injuries and long bone fractures. Provide immediate treatment based on your findings and remember to administer prophylactic intravenous broad-spectrum antibiotics as needed.
OK, now let's talk about abnormal lab findings. Be on the lookout for low hemoglobin and hematocrit, coagulopathy, acidosis, and an abnormal rotum.

Abnormal Labs 8:33–8:52

If any of these are present, initiate fluid resuscitation and transfusion of blood products if not yet started and search for the source of bleeding.
Moving on, let's talk about abnormal urine studies. The presence of blood in the urine or positive urine toxicology screen warrant prompt evaluation by specialty teams like urology.

Abnormal Urine Studies 8:52–9:11

In addition, a positive urine pregnancy test is concerning in this setting, so alert the obstetrics team immediately. Lastly, let's discuss potential abnormal imaging findings and next steps.

Abnormal Imaging Studies 9:11–9:58

Major cardiothoracic injuries, free abdominal air under the diaphragm, and pelvic fracture can typically be identified on chest and pelvic X-rays.
A supine chest X-ray can show signs of a pneumothorax like the deep sulcus sign, where pleural air accumulates at the lateral claustrophrenic angle.
A fast exam can identify free intraabdominal fluid. Additional injuries are often detected on CT scans, which can include the CT of the head, neck, abdomen, and pelvis, spine, and extremities.
Abnormal imaging findings require immediate treatment of these injuries, including chest tube placement, pelvic binding, and fracture reduction, as well as evaluation by specialty teams.
Now you should always maintain a low threshold for operative intervention in any adult trauma with abnormal physical exam findings, labs, urine studies, and imaging findings.

Low Threshold for Emergent Operative Intervention 9:58–10:30

For example, if they have suffered a severe penetrating injury to the chest that's highly suspicious of injuries to the heart or the great vessels, they'll need to be transferred to the OR for an emergent thoracotomy to identify and repair the injury because timing is key to their survival.
Nothing should delay surgical intervention in these patients. All right, let's discuss the tertiary survey where you'll ensure you've identified and addressed all of your patients' injuries.

Tertiary Survey 10:30–11:06

A tertiary survey includes a reassessment of your patient's history and physical exam within 24 hours of presentation. The patient's lab tests and imaging studies are reviewed, and additional diagnostic tests are obtained as needed.
Based on these findings, prompt treatment and specialty consultation is initiated as indicated. Finally, if your patient experienced a penetrating wound or if their vaccine history is unclear, be sure to administer the Tdap vaccine for tetanus coverage.
All right, as a quick recap, the first step in assessing any trauma patient is the primary survey composed of the ABCDEs.

Review 11:06–11:44

Once your patient is stabilized, you can move on to the secondary survey, which involves a more detailed head to toe history and physical exam and obtaining basic trauma labs, urine studies, and diagnostic imaging.
Once all major injuries are taken care of, perform a tertiary survey, which is a repeat thorough history and physical exam, within 24 hours of your patient presenting to the hospital.
Any additional injuries discovered during the tertiary survey should undergo additional workup, consultation, and treatment.