General Trauma Management

Table of Contents

Aliases

None noted

Patient Care Goals

  1. Rapid assessment and management of life-threatening injuries
  2. Safe movement of patient to prevent worsening injury severity
  3. Rapid and safe transport to the appropriate level of trauma care

Patient Presentation

Inclusion Criteria

  1. Patients of all ages who have sustained an injury as a result of mechanical trauma, including:
    1. Blunt injury
    2. Penetrating injury
    3. Burns

Exclusion Criteria

No recommendations

Patient Management

Assessment

  1. Assess scene safety: evaluate for hazards to EMS personnel, patient, bystanders
    1. Determine number of patients
    2. Determine mechanism of injury
    3. Request additional resources if needed. Weigh the benefits of waiting for additional resources against rapid transport to definitive care
    4. Consider declaration of mass casualty incident if needed
  2. Use appropriate personal protective equipment
  3. Primary survey
    1. Hemorrhage control
      1. Assess for and stop severe hemorrhage [see Extremity Trauma/External Hemorrhage Management guideline]
    2. Airway
      1. Assess airway patency by asking the patient to talk to assess stridor and ease of air movement
      2. Look for injuries that may lead to airway obstruction including unstable facial fractures, expanding neck hematoma, blood or vomitus in the airway, facial burns/inhalation injury
      3. Evaluate mental status for ability to protect airway (patients with a GCS less than or equal to 8 are likely to require airway protection)
    3. Breathing
      1. Assess respiratory rate and pattern
      2. Assess symmetry of chest wall movement
      3. Listen bilaterally on lateral chest wall for breath sounds
    4. Circulation
      1. Assess blood pressure and heart rate
      2. Signs of hemorrhagic shock include: tachycardia, hypotension, pale, cool clammy skin, capillary refill 2 seconds
    5. Disability
      1. Perform neurologic status assessment [see Appendix VII]
      2. Assess gross motor movement of extremities
      3. Evaluate for clinical signs of traumatic brain injury with herniation including:
        1. Unequal pupils
        2. Lateralizing motor signs
        3. Posturing
    6. Exposure
      1. Rapid evaluation of entire body to identify sites of penetrating wounds or other blunt injuries. Be sure to roll patient and examine the back
      2. Prevent hypothermia

Treatment and Interventions

  1. Hemorrhage control
    1. Stop severe hemorrhage [see Extremity Trauma/External Hemorrhage Management guideline]
  2. Airway
    1. Establish patent airway with cervical spine precautions, per the Airway Management and Spinal Care guidelines
    2. If respiratory efforts are inadequate, assist with bag-mask ventilation and consider airway adjuncts. If patient is unable to maintain airway, consider oral airway (nasal airway should not be used with significant facial injury or possible basilar skull fracture)
    3. If impending airway obstruction or altered mental status resulting in inability to maintain airway patency, secure definitive airway
  3. Breathing
    1. If absent or significantly diminished breath sounds, consider tension pneumothorax and perform pleural decompression
      1. Traumatic Cardiac Arrest and Tension Pneumothorax is possible – bilateral pleural decompression
        1. Use Finger Thoracostomy to definitely relieve tension pneumothorax.
    2. For open chest wound, place occlusive dressing
    3. Monitor oxygen saturation and, if indicated, provide supplemental oxygen
  4. Circulation
    1. If pelvis is unstable and patient is hypotensive, place pelvic binder or sheet to stabilize pelvis
    2. Establish IV access
    3. Calcium Replacement
      1. If hemorrhagic shock present/suspected, give calcium chloride IV/IO, 20 mg/kg (0.2 mL/kg), max of 1000 mg (10 mL).
    4. Fluid resuscitation
      1. Adults
        1. If SBP greater than 90 mmHg, no IV fluids required
        2. If SBP less than 90 mmHg or HR greater than 120, give bolus of 250cc of NS and reassess
        3. Penetrating trauma: target SBP 90mmHg or palpable radial pulse
        4. Head injury: target SBP 110 mmHg. Hypotension should be avoided to maintain cerebral perfusion
          1. If SBP less than 110 mmHg, give bolus of 250cc of NS and reassess
      2. Pediatrics
        1. If child demonstrates tachycardia for age with signs of poor perfusion (low BP, greater than 2-second capillary refill, altered mental status, hypoxia, weak pulses, pallor, or mottled/cool skin), give 20ml/kg crystalloid bolus and reassess.
        2. Target normal BP for age [see Appendix VIII – Abnormal Vital Signs]
  5. Disability
    1. If clinical signs of traumatic brain injury [see Head Injury guideline]
  6. Exposure
    1. Avoid hypothermia
      1. Remove wet clothing
      2. Cover patient to prevent further heat loss
  7. NOTE: Patients with major hemorrhage, hemodynamic instability, penetrating torso trauma, or signs of traumatic brain injury often require rapid surgical intervention. Minimize scene time (goal is under 10 minutes) and initiate rapid transport to closest TCD-approved Trauma Center.
  8. Decisions regarding transport destination should be based on the TCD Plan for Trauma Patients [see Appendix X]

Secondary Assessment, Treatment, and Interventions

  1. Assessment
    1. Obtain medical history from patient or family including:
      1. Allergies
      2. Medications
      3. Past medical and surgical history
      4. Events leading up to the injury
  2. Secondary survey: Head to toe physical exam
    1.  Head
      1. Palpate head and scalp and face and evaluate for soft tissue injury or bony crepitus
      2. Assess pupils
    2.  Neck
      1. Check for:
        1. Contusions
        2. Abrasions
        3. Hematomas
        4. JVD
        5. Tracheal deviation
      2. Palpate for crepitus
      3. Spinal assessment per the Spinal Care guideline
    3.  Chest
      1. Palpate for instability/crepitus
      2. Listen to breath sounds
      3. Inspect for penetrating or soft tissue injuries
    4.  Abdomen
      1. Palpate for tenderness
      2. Inspect for penetrating or soft tissue injuries
    5. Pelvis
      1. Inspect for penetrating or soft tissue injuries
      2. Palpate once for instability by applying medial pressure on the iliac crests bilaterally
    6.  Back
      1. Maintain spinal alignment. Refer to Spinal Care guideline
      2. Inspect for penetrating or soft tissue injuries
    7. Neurologic status assessment [see Appendix VII]
      1. Serial assessment of mental status
      2. Gross exam of motor strength and sensation in all four extremities
    8.  Extremities
      1. Assess for fracture/deformity
      2. Assess peripheral pulses/capillary refill
  3. Additional treatment considerations
    1. Maintain spine precautions per the Spinal Care guideline
    2. Splint obvious extremity fractures per the Extremity Trauma/External Hemorrhage Management guideline
    3. Provide pain medication per the Pain Management guideline

Notes – General Trauma Management