4. The Golden Hour
• originated by R Adams Cowley
• first sixty minutes after the occurrence of multi-
system trauma
• victim's chances of survival are greatest if they
receive definitive care in the OR within the first
hour after a severe injury
5. The Golden Hour
• "There is a golden hour between life and death.
If you are critically injured you have less than
60 minutes to survive. You might not die right
then; it may be three days or two weeks later --
but something has happened in your body that
is irreparable."
- R Adams Cowley
6.
7.
8. Trauma Deaths
• Trimodal Distribution
• Minutes – massive injury to brain, brain
stem, heart, aorta, great vessels
• Hours – “golden hour”**
• Days- sepsis or multisystem organ failure
9. CONCEPTS OF INITIAL ASSESSMENT
1. Preparation
2. Triage
3. Primary survey
4. Resuscitation
5. Adjuncts to primary survey and resuscitation
6. Secondary survey
7. Adjuncts to secondary survey
8. Continued postresuscitation monitoring and
reevaluation
9. Definitive care
12. Preparation
• Prehospital phase
➣ coordination of EMS with hospital physicians
before the patient transport from the scene
• Time of injury
• Mechanism of injury
• Patient history
➣ airway maintenance
➣ control external bleeding and shock
➣ immobilization
➣ immediate transport to closest, appropriate facility
13. Triage Decision Scheme
Step1 Triage Decision Scheme level of
Measure vital signs and
conscious
Step2 Assess anatomy of injury
Step3 Evaluate for mechanism of injury/evidence
of high-energy impact
Step4 Assess Age, status,
underlying disease
14. Triage decision scheme
Step 1
Measure of vital signs and level of
consciousness
• GCS < 14
• RR < 10 or > 29
• Systolic BP < 90
• RTS < 11
YES - Take to Trauma center
NO - Assess Anatomy of Injury
15.
16. Triage decision scheme
Step2 Assess Anatomy of Injury
• Pelvic fracture
• Flail chest
• Two or more proximal long-bone fractures
• Combination trauma with burns of 10% or inhalation
injuries
• All penetrating injuries to head, neck, torso, and
extremities proximal to elbow and knee
YES - Take to Trauma center
NO – Evaluate for evidence of mechanism of injury and
high-energy impact
17. Triage decision scheme
Step3. Evaluation for evidence of mechanism
of injury and high-energy impact
• Ejection from automobile
• Death in same passenger compartment
• Pedestrian thrown or run over
• High speed autocrash
– Initial speed > 40 mph
– Velocity change > 20 mph
• Major auto deformity > 20 inches
18. Initial trauma management
Triage decision scheme
Step3. Evaluation for evidence of mechanism
of injury and high-energy impact
• Intrusion into pasenger compartment > 12 inches
• Extrication time > 20 min
• Falls > 20 feet
• Roll over
• Auto-pedestrian injury with significant (>5 mph) impact
• Motocycle crash > 20 mph or with separation or rider
and bike
YES - Take to Trauma center
NO – Take Anamnesis
19. Triage decision scheme
Step 4
• Age <5 or > 55 years
• Known cardiac disease; respiratory disease; or
psychotics taking medication
• Diabetics taking insulin; cirrhosis; malignancy;
obesity; or coagulopathy
YES – contact medical control and consider transport
to trauma center
NO – re-evaluate with medical control
WHEN IN DOUBT, TAKE TO A TRAUMA CENTER!
20. Inhospital phase
• Planning arrival
• Trauma room with equipment:
– For resuscitation
– Monitoring
– Warmed solutions
• Trauma staff
• Laboratory and radiology personnel
• Personnel protection from communicable
diseases (hepatitis & AIDS)
21. Minimum precautions
• Face mask
• Eye protection - goggles
• Water impervious apron
• Leggings
• Gloves
• Head covering
• Needles, blades, body fluids and tissues –
strictly enforced
23. Triage
• The term triage, derived from
the French word “to sort,”
military application involves
prioritizing victims into
categories based on severity of
injury, likelihood of survival,
and urgency of care
• Goal of triage is to identify
high-risk injured patients who
would benefit from the
resources available
• A second goal of triage is to
limit the excessive transport of
non–severely injured patients
so as not to overwhelm the
trauma center
24. Triage
Sorting of patients based on the need of
treatment and the available resources to
provide that treatment
Two types of triage situation
- Multiple Casualties
- Mass Casualties
26. Triage
Multiple Casualties
Number and severity of patients do not
exceed the ability of the facility to render care.
Patients with life-threatening problems and
sustaining multiple system injury are treated first
27. Triage
Mass Casualties
Number and severity of patients exceed
the capability of the facility and staff.
Patients with greatest chance of survival
and with the least expenditure of time,
equipment, supplies, and personel are managed
first
29. Primary survey
ABCDE
A : Airway maintenance with cervical spine
protection
B : Breathing and ventilation
C : Circulation with hemorrhage control
D : Disability : Neurologic status
E : Exposure / Environment control
30. A : Airway maintenance
with cervical spine
protection
31. A : Airway maintenance with
cervical spine protection
1.Rapid assessment for sing of airway
obstruction inspection for ;
- abnormal breathing: dyspnea, FB, aspiration
- snoring, gurgling, stridor
- maxillofacial Injuries
- neck,chest injuries : tracheal/laryngeal fx.
- unconscious
If pt. able to communicate verbally , the airway is
not likely to be in immediate jeopardy
32. A : Airway maintenance with
cervical spine protection
2.Protection C- spine
Assume C - spine injury in any pt. with ;
- Unconscious
- Multiple system trauma
- Blunt injury above clavicle (head and neck)
- Pain of neck with neurologic deficit.
- Unable to active flexion of neck due to pain.
33. A : Airway maintenance with
cervical spine protection
If C-spine injury can’t be rule out
•Initially, the chin lift or jaw thrust maneuvers are
recommended to open airway and protect C - spine
•Immobilizing devices: Philadelphia collar (prevent
excessive movement of the C-spine)
•If Immobilizing devices must be removed temporary , 1
members of team should manually stabilize the
patient‘s head and neck using inline immobilization
technique
34. A : Airway maintenance with
cervical spine protection
Head tilt
38. A : Airway maintenance with
cervical spine protection
- Neurological examination alone dose
not exclude C- spine injury.
Role out C – spine injury by;
- Active neck flexion if the patient
cooperate.(not tender)
- Film x-ray lateral C-spine is normal.
39. A : Airway maintenance with
cervical spine protection
-Remove particular matter
-Chin lift/ modified jaw thrust
-Oropharyngeal or Nasopharyngeal
airway
-Laryngeal mask airway
-Definitive airway
-Reassess frequently
40. A : Airway maintenance with
cervical spine protection
Definitive airway ( Advance )
Three Varities:
1. Orotracheal tube
2. Nasotracheal tube
3. Surgical airway.
( Cricothyroidotomy , Tracheostomy )
50. B : Breathing and Ventilation
• Ventilation requires adequires adequate fuction
of the lungs, chest wall, diaphragm. Each
component must be examined and evaluation.
• The patient’ s chest should be exposed to
adequately assess chest wall excursion.
• Auscultation should be performed to assure gas
flow in lungs.
• Percussion may demonstrate the presence of air
or blood in the lungs.
• Visual inpection and palpation may detect
injuries to the chest wall that may compromise
ventilation.
51. B : Breathing and Ventilation
• Severe life threatening condition
Tension pnuemothorax
Massive hemothorax
Open pneumothorax
Flail chest
• Need emergency care
52. B : Breathing and Ventilation
• Tension pnuemothorax
– Temporary : needle (no.14-16) at
second intercostal space ,midclavicular
line
– ICD : fifth intercostal space ,midaxillary
line
54. B : Breathing and Ventilation
• Massive hemothorax
– ICD : fifth intercostal space ,midaxillary
line
– Rapid bolus of IV : RLS
– Blood transfusion
55. B : Breathing and Ventilation
• Massive hemothorax
Indication for surgery
– Bleed > 1500 cc on first ICD attempted
– Continuous bleed > 200 cc/hr in 3-4 hrs
and hemodynamic unstable
– Caked hemothorax
56. B : Breathing and Ventilation
• Open pneumothorax
– Vaseline guaze ปิดแผลโดยปิดพลาสเตอร์ 3 ด้าน
– ใส่ ICD
– ทาความสะอาดและรักษาบาดแผลต่อไป
57. B : Breathing and Ventilation
• Flail chest
– Analgesic drugs
– If respiratory discomfort present :
• endotracheal intubation
• on volume respirator
• treat pulomary contusion
• may use up to 3 weeks)
59. Shock
• Initial step in managing shock in the
injured patient : Recognize its presence
and clinical presence of inadequate
tissue perfusion and oxygenation.
60. Blood volume and cardiac output
• rapid and accurate assessment of the
injured patient’s hemodynamic status is
essential.
• Elements of clinical observation
: Level of consciousness
: Skin color
: Pulse
61. Shock
• Second step : Identify the probable
cause of the shock state. For the trauma
patient is related to mechanism of injury.
• Hemorrhage is the most common cause
of shock in the injured patient.
65. External hemorrhage
• External hemorrhage is identified and
controlled in the primary survey.
• Hemorrhage control :
– Manual compression
– Splint
– Elastic bandage
66. Internal hemorrhage
Major sources of occult blood loss :
• Thoracic
• Abdominal cavities
• Soft tissue surrounding major long bone
fracture
• Retroperitoneal space from pelvic fracture
67. Classification of hemorrhage
Class I Class II Class III Class IV
Blood loss(ml) < 750 750-1500 1500-2000 >2000
Blood loss(%BV) <15 15-30 30-40 >40
Pulse rate <100 >100 >120 >140
Blood pressure normal normal decrease decrease
Pulse pressure normal decrease decrease decrease
CNS/mental Slightly Mildly Anxious, Confused,
anxious anxious confused lethargic
Fluid Crystalloid Crystalloid Crystalloid, Crystalloid,
replacement Blood Blood
69. Initial Management of Hemorrhagic Shock
• Stop bleeding and replaces the volume loss.
• Vascular access lines : insert 2 large caliber (#16
gauge)
• Vital sign stable (class 1,2) :
– IV fluid 1 extremity
• Vital sign change (class 3,4) :
– IV fluid 2 extremities
• basilic or saphenous venous cutdown
• Central line – internal jugular v., subclavian v.
70. Initial Management of Hemorrhagic Shock
• Initial fluid therapy : crystalloid solution
(Ringer lactated solution) อัตราเร็วตามภาวะของ
ผู้บาดเจ็บ
• ถ้าอยู่ในภาวะ shock จะให้ load 2 litres in 15 min
(adult) , Ringer lactate bolus 20 ml/kg in
pediatric
71. Evaluation of fluid resuscitation
• General : sign & symptoms of inadequate
perfusion
• Urinary Output : 0.5 ml/kg/hour in adult
• Acid/Base Balance : respiratory alkalosis
follow by metabolic acidosis
72. Therapeutic decision based on response
1
to initial fluid resuscitation
• Rapid Response
• Transient Response
• Minimal or no response
12000 mL RLS in adult, 20 mL/kg Ringer’s lactate bolus in children
73. Responses to Initial Fluid
Resuscitation
RAPID TRANSIENT NO RESPONSE
RESPONSE RESPONSE
Vital signs Return to normal Transient Remain abnormal
improvement,
recurrence of BP
drop and HR
increase
Estimated blood Minimal (10%-20%) Moderate and Severe (>40%)
loss ongoing (20%-40%)
Need for more Low High High
crystalloid
Need for blood Low Moderate to high Immediate
Blood preparation Type and Type-specific Emergency blood
crossmatch release
Need for operative Possibly Likely Highly likely
intervention
Early presence of Yes Yes Yes
surgeon
80. Neurologic Evaluation
• Level of consciousness
• Pupillary size and reaction
• Lateralizing signs
• Spinal cord injury level
• Serial neuro sign reevaluation
81. Neurologic Evaluation
Brief neurologic examination
• A – Alert
• V – Responds to Vocal stimuli
• P – Responds to Painful stimuli
• U – Unresponsive
• Pupillary size & reaction
➣ More detailed evaluation - during the
secondary survey
83. Exposure
• Undresses for assessment
• After assessment is completed, it is
imperative to cover patient with warm
blankets or external warming devices to
prevent ‘Hypothermia’
• IV should be warmed before infusion and
warm environment
87. Resuscitation
• Breathing/Ventilation/Oxygenation
– Every injured patient should receive
supplemental oxygen
– Endotracheal intubation with C-spine
protection
– Surgical airway for contraindicated patient
– Use pulse oximeter to ensure adequate Hb
saturation
88. Resuscitation
• Circulation
– The minimum fluid infusion :
• 2 large-caliber IV catheter (warm IV)
– The maximum rate :
• internal diameter of cetheter, not the size of the vein
– Type of IV fluid
• Ringer’s lactate solution is preferred
• also draw blood for type, crossmatch, UPT before IV
insertion
• If remain unresponsive to bolus IV, give type-specific blood
(O-negative blood as a substitute)
89. Resuscitation
• Hypothermia :
– a potentially lethal complication in the injured patient
– Use a high-flow fluid warmer or microwave oven to
heat crystalloid fluids to 39oC is recommened
– Blood products should not be warmed in a microwave
oven
• Aggressive and continued volume
resuscitation is not a substitute for manual or
operative control of hemorrhage
91. Adjuncts to primary survey
and resuscitation
ECG monitoring
Urinary and Gastric Catheters
Monitoring
X-rays and Diagnostics Studies
92. Adjuncts to primary survey
and resuscitation
ECG monitoring
Should be performed in all trauma patients
Dysrhythmia, including unexplained tachycardia,
AF, PVC, and ST segment changes : Blunt cadiac
injury
PEA : cardiac tamponade, tension pneumothorax,
profound hypovolemic shock
Bradycardia, aberant conduction and premature
beats : hypoxia and hypoperfusion should be
suspected immediately
93. Adjuncts to primary survey
and resuscitation
Urinary and Gastric Catheters
1. Urinary Catheters
Urine output is a sensitive indicator of volume status of
the patient and reflects renal perfusion
Urinary Catheters should not be inserted before an
examination of the rectum and genitalia
94. Adjuncts to primary survey
and resuscitation
Urinary and Gastric Catheters
1. Urinary Catheters
Contraindication : Suspected urethral injury
- Blood at penile meatus
- Perineal ecchymosis
- Blood in scrotum
- High riding or nonpalpaple prostate
- Pelvic fracture
In suspected case : Retrograde urethrogram
95. Adjuncts to primary survey
and resuscitation
Urinary and Gastric Catheters
2.Gastric Catheters
A gastric tube is indicated to reduce stomach distention and
decrease the risk of aspiration.
For the tube to be effective, it must be positioned properly,
attached to appropriate suction and be functioning.
Blood in the gastric aspirate may represent oropharyngeal
(swallowed) blood, traumatic insertion, or actual injury to the
upper digestive tract.
If the cribiform plate is fractured is suspected, the gastric
tube should be inserted orally to prevent intracranial
passage.
96. Adjuncts to primary survey
and resuscitation
Monitoring
1. Ventilatory rate and ABG
Monitor the adequacy of respiration
Confirm that the ETT is located somewhere in the airway
2. Pulse oximetry
Measure the oxygen saturation of hemoglobin colorimetrically
Not measure the partial pressure of oxygen
Should not be placed distal to the blood pressure cuff
3. Blood pressure
97. Adjuncts to primary survey
and resuscitation
X-rays and Diagnostics Studies
Chest x-rays AP
Pelvis AP
Lateral C-spine
DPL or FAST
• Films can be taken in resuscitation area, usually with
portable x-ray
• Should not interrupt the resuscitation process
98. Indication for DPL
Equivocal abdominal sign
Unexplained hypotension
Impaired mental status
Paraplegia or spinal cord injueries
102. DPL procedure
Peritoneal catheter in cul de sac aspiration
if gross blood or GI content not aspirate larvage with
1000 ml warm LRS (10 ml/kg in child) adequate mixing
larvage fluid for analysis
105. Focused Assessment with
Sonography for Trauma (FAST)
Detect intraabdominal fluid
Rapid, noninvasive, accurate, inexpensive, can
repeat frequently
Indication same as DPL
Factors that compromise its utility are obesity,
presence of subcutaneous air, previous
abdominal operation
108. DPL
• Advantages
– Fast
– Sensitive
– Can be performed while resuscitation ongoing
• Disadvantages
– Invasive
– Learning curve
– Organ spacific
109. FAST
• Advantages
– Fast
– Noninvasive
– Can be performed while resuscitation ongoing
– Can be very sensitive
• Disadvantages
– Operator dependent
– Body habitus may limit quality/sensitivity
– Organ spacific, hollow viscous and retroperitoneal
injuries
110. Abdominal CT
• Advantages
– Noninvasive
– Fairly sensitive and specific
• Disadvantages
– Inexperienced radiologist may miss injuries
– A bad place to be if patient “crashes”
112. Secondary Survey
• Does not begin until the primary survey
(ABCDEs) is completed
• Head-to-toe evaluation (complete history,
physical examination, reassessment of all
vital signs)
113. History
•A Allergy
•M Medication currently being taken by the
patient
•P Past illness and operation
•L Last meal
•E Event and Environment related to the injury
115. Blunt trauma
• Automobile collisions, falls, transportation-,
recreation- and occupation-related injuries
• Automobile collisions: seat belt usage,
steering wheel deformation, direction or
impact, ejection of the passenger from
vehicle (ejection increases the chance of
major injury)
117. Mechanisms of Injury and Related
Suspected Injury Patterns
Frontal Impact • Cervical spine fracture
- Bent steering wheel • Anterior flail chest
- Knee imprint, dashboard • Myocardial contusion
- Bull’s-eye fracture, • Pneumothorax
windscreen • Traumatic aortic
disruption
• Fractured spleen or liver
• Posterior
fracture/dislocation of hip,
knee
118. Mechanisms of Injury and Related
Suspected Injury Patterns
• Side Impact • Contralateral neck sprain
• Cervical spine fracture
• Lateral flail chest
• Pneumothorax
• Traumatic aortic
disruption
• Diaphragmatic rupture
• Fractured spleen/liver,
kidney depending on side
of impact
• Fractured pelvis or
acetabulum
119. Mechanisms of Injury and Related
Suspected Injury Patterns
• Rear Impact • Cervical spine injury
• Soft-tissue injury to
neck
120. Mechanisms of Injury and Related
Suspected Injury Patterns
• Motor vehicle • Head injury
impact with • Traumatic aortic
pedestrian disruption
• Abdominal visceral
injuries
• Fractured lower
extremities/pelvis
123. Adjuncts to the Secondary survey
Further investigation for specific injuries
that non-life threatening condition e.g.
- x-ray spine and extremities
- CT scan
- contrast urography and angiography
- Transesophageal ultrasound
- Bronchoscopy
- Esophagoscopy
124. Re-evaluation
• Continuous monitoring of
- vital signs, Hct
- urinary output: adult keep > 0.5 mL/kg/hr
children keep > 1 mL/kg/hr
- Arterial blood gas
- Cardiac monitoring
- Pulse oximetry
- End tidal CO2
• Relief of severe pain and anxiety
- IV opiates and anxiolytics
- Small dose: avoiding respiratory depression
127. Level 1
(Not Required of Levels II, III, and IV
Trauma Centers)
• 24hr availability of all surgical subspecialties
(including cardiac surgery/bypass
capability)
• Neuroradiology and hemodialysis available
24hr/day
• Program that establishes and monitors effect of
injury prevention/education
efforts
• Trauma research and QA programs in place
128. Level 2(not Required of Levels III and
IV Trauma Centers)
• Cardiology, ophthalmology, plastic
surgery, gynecologic surgery available
• Operating room ready 24hr/day
• Neurosurgery dept.. In hospital
• Trauma multidisciplinary quality assurance
committee
129. Level 3 (Not Required of Level IV
Trauma Centers)
• Trauma and emergency medicine services
• 24 hr x-ray capability
• Pulse ox, central and arterial catheter
monitoring capability
• Thermal control equipment for blood
products
• On call schedule for surgeons
• Trauma registry
130. Level 4
• Believe me, you don’t want to crash your
car way out the middle of nowhere next
the the town that has this level of support.
• Consists of anything less than previously
mentioned.
131. Trauma Team Members
Team Leader: Surgeon, Emergency Physician,
Mid-level provider
Anesthesia, CRNA, OR Team
Emergency/Other RNs (X 2-3)
Charge/House Nursing Supervisor
EMTs stay/assist
Respiratory therapy
XRAY, CT, Radiologist
Lab, Blood bank
Documentation/Scribe
LPN, Aide, HUC, Support Staff
Social Services, Chaplain
Other Medical Specialties if/as available:
ENT, Ortho, GU, Pediatricians, etc.
132. Procedure:
• The charge nurse, House Supervisor or designee will assign roles if possible prior to patient arrival. Roles will be
assigned as described below if enough staff is available.
• If staff is not available, roles will be assigned and adapted as indicated by the charge nurse and/or provider.
Guidelines for Roles and Responsibilities
Role Staff/Type Duties Position
Airway: RT/EMT Ventilation, Head of Trauma bed
Assist with intubation
Keep patient informed
C-Spine: EMT Maintain c-spine stabilization Head of Trauma Bed
Alert MD of any change in LOC
IV/Procedures: RN Insert large bore IV On patient LEFT side
Remove clothing from left side of body,
Neuro assessment, assist with procedures
Intake/output
Provider Assistant: RN Assist with procedures as directed On patient LEFT side
Vitals & Recorder: LPN/EMT Take, monitor and record vitals On patient LEFT side,
toward foot of bed
Scribe: EMT/LPN Record case on white board White board
IV/Med: RN Insert large bore IV, On patient RIGHT side
Remove clothing from right side of body On patient RIGHT side
Attach/observe cardiac monitor On patient RIGHT side
Prepare/administer medications
Foley as appropriate
Runner: Ward Clerk/Secretary/EMT Retrieve equipment, supplies, ED Desk
Make copies, assist with ER traffic control,
Answer/make phone calls
Team Captain Provider: Manage/direct team efforts Head/foot of patient
Initiate interventions, care as indicated
133. TRAUMA TEAM ROLES - Guidelines
Airway: RT/EMT C-Spine: EMT
Alert physician of any
Ventilation,assist with intubation,
change in LOC
keep patient informed
Scribe: EMT/LPN
Record case on white board IV /Procedures: RN
Insert large bore IV, remove clothing
from left side of body, Intake/Output
neuro assessment, assist w/procedures PRN
IV/Meds: RN
Insert large bore IV, remove clothing Patient
from right side of body,
attach/observe monitor, access crash cart
Prepare/Administer Meds
Foley as appropriate
Provider Assist: RN
Assist with procedures as directed
Runner: EMT/CNA/Secretary Vitals & Recorder: LPN/EMT
Retrieve equipment/supplies, assist with
ER traffic control, answer phone
Provider Takes serial vitals and records on Trauma Form
Other duties as needed
