- Advanced Cardiac Life Support (ACLS) - ACLS - Iowa Family Practice Handbook - AHCPR Guidelines - eMedicine Online Text:
- Advanced Trauma Life Support (ATLS) - fluid management: (in the trauma patient) - immobilization: - patients should be transported to the ER with the neck immobilized in C-collar and head taped between two sandbags (or equivalent); - pediatric cervical spine - children are immobilized so that the shoulders are raised on a folded sheet (which counteracts the tendency for the C-spine to be flexed on the trauma board - due to the child's larger head size); - without exception, trauma patients need to be taken off the trauma board ASAP to prevent decubiti; - while moving one assistant controls the head while the others help turn, check the scalp and back for lacerations and deformities, and then help to transfer to a padded mattress; - references: - Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. - Pediatric cervical spine immobilization: achieving neutral position? C Curran et al. J. Trauma. Vol 39(4). 1995. p 729-732. - orthopaedic assessment: - cervical spine and spine: - management of the spine injured patient - cervical radiographs: - even in the emergent situation (such as knee dislocation with vascular comprimise), a lateral radiograph (or swimmer's view) from occiput down to T1 is manditory; - while some unstable cervical spine injuries can be surgically managed on a delayed basis (if cord compression is not present) other injuries such as a bilateral facet dislocation usually need to be managed acutely (and this is why a good cross table lateral view is required in the ER); - it is a mistake, however, to routinely order a full set of cervical, thoracic, and lumbar radiographs in the ER (inorder to "clear the spine") for trauma patients with limb threatening injuries; - always ask yourself, how will this change my management strategy? - for instance, if a Jefferson frx were diagnosed from an odontoid view, it would not change the fact that a patient w/ a limb threatening injury would still require GEA and management in the OR; - pelvis: - radiographs: AP view will help diagnose open book pelvic injuries, femoral neck frx, or verticle shear injuries; - extremities: - fractures - dislocations - compartment syndromes - vascular injuries note: it is difficult to assess for vascular injuries when the SBP is less than 90 mm Hg; - mangled extremity severity score - generalized assessment: - neuro and head injury (see Glasgow) - cranio-maxillo-facial - spine - pulmonary: - pulmonary contussion: - pneumothorax - cardiac - renal - abdominal assessment: - coagulation
- Initial Orders for the Trauma Patient: - NPO p Midnight x Meds - fluids: IVF D5W LR at 100 ml/hr (in stable patients use D5W 1/2 NS w/ 20 KCl) - 2 large bore IV - foley - monitoring; - EKG and/or Continuous Cardiac Monitoring; - Continuous Pulse Ox monitoring; - preOp labs: - Type & Cross 2-4 units pRBC and/or FFP - musculoskeletal labs: - urinalysis - meds (trade names) - prophylactic ATB - DVT prophylaxis - steroids: - for spinal cord injured patient; - for FES prophylaxis - DVT prophylaxis heparin 5000 units SQ q8 hrs - zantac - morphine - tetanus or pneumovax if appropriate; - traction: (Buck's vs. skeletal) - decubiti prophylaxis: egg crate / pillow and turn 20 deg q2hr - hiboclens shower and Bactroban to nares q12 hrs until OR - cleocin solution 300 mg per 100 ml NS q6hr as mouth wash
Multiple Trauma and General Principles
Stabilization and Primary Survey
Remember ABCDE: Airway, Breathing, Circulation, Drugs/Disability/Allergies and Eating/Exposure
Airway. If depressed level of consciousness or upper airway bleeding, intubate without moving neck.
Intubation safe even with neck fracture, but avoid Sellick maneuver.
Confirm placement with a radiograph and by auscultation.
Breathing. Ventilate with 100% O2.
Check breath sounds and place chest tubes as needed for hemothorax, pneumothorax, tension pneumothorax.
Circulation. For "all" multiple trauma victims:
Stop obvious bleeding with pressure,
Consider the chest and abdomen to be sights of potential blood loss in the hypotensive patient.
Two large-bore peripheral IV lines (14 to 16 gage). The short catheters allow more rapid volume replacement than longer central lines.
Run NS or LR wide open if tachycardic or hypotensive. Using warmed fluids will decrease mortality and help preserve hemostatic mechanisms.
As a rule of thumb, if more than 2 liters of isotonic fluid are needed in a trauma setting, the patient will need blood.
Can also use 7.5% saline (250 ml over 1 to 5 minutes) if unable to infuse large volumes, and although not standard, use of 7.5% saline is associated with an increased survival in those with head trauma.
For children, use 20 ml/kg IV and repeat to a total of 60 ml/kg. Consider blood at this point if child still hypotensive from hypovolemia.
In pediatric septic shock there is evidence that the administration of at least 60 ml/kg of fluid in the first hour is associated with an increased survival.
There is no advantage to colloids in this setting.
Not all people in shock are tachycardic. Use clinical judgment.
Hypotension is not caused by isolated brain injury in adults except near death.
Drugs, allergies, disability. Document functional status for a baseline examination.
Eating and exposure. Time of last meal. Uncover the patient including visualizing the back.
A Foley catheter should be inserted after ruling out GU trauma (see section on urologic trauma). Urine output is a good indication of adequate perfusion. Try to maintain output at 30 to 60 ml/hour in adults or 0.5 to 1 ml/kg/hour in children.
Laboratory and X-ray Evaluation of the Multiple Trauma Patient
CBC, electrolytes, BUN, creatinine, glucose, coagulation studies, liver enzymes, amylase, lipase, urinalysis, pregnancy test, ABG. Not all patients need all tests; use clinical judgment. (CBC, complete blood count often indicates an anemia with acute blood loss but may not reflect the true magnitude of the problem until blood equilibrates with infused fluids.)
If patient known to be hypotensive in the field, get two units of type O-negative blood ready.
Radiographs. Cross-table C-spine, CXR, AP pelvis.
Remember antibiotics as indicated, CT as indicated, full spine series when stable, tetanus prophylaxis, etc.
Secondary Survey to Set Further Priorities
Stabilize patient first.
Complete head-to-toe examination.
Pass NG tube if no contraindication such as basilar skull fracture. Can pass oral gastric tube if midface trauma, etc.
Identify possible internal injuries. See specific sections below. Any head-injured multitrauma patient should have the abdomen evaluated by CT or DPL (diagnostic peritoneal lavage) because of an inability to report pain accurately.
Splint bones, etc.
A comment on MAST (military antishock trousers, pneumatic antishock garment). They are contraindicated in penetrating cardiac trauma, cardiogenic shock, impaled objects/evisceration, diaphragmatic injury. Head injury is not a contraindication. Seem to help in intra-abdominal bleeding from the spleen and aorta. Overall benefit probably less than previously believed. Useful when stabilizing pelvic and femur fractures.
There is growing evidence that a prophylactic vena cava filter can reduce mortality in major trauma. This is still an evolving area.