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A. Initial Assessment navigator

  1. Mnemonic = "ABCDE"
  2. Airway - look in mouth. May have to pull tongue forward, jaws (TMJ) forward
  3. Breathing - look at chest, listen at mouth, listen at both axilla
  4. Circulation - pulse, blood pressure. Note any external bleeding
  5. Deficiency - change in mental status, narcotics, hypoglycemia (Dextrose + Narcan)
  6. Exposure - remove all clothing, look for signs of bleeding, check pulses distally, neck brace

B. Primary Resuscitation navigator

  1. Vital Signs checked at least every 5 minutes
  2. Intravenous access
    1. For bleeding from chest wounds, need 2-3 large bore IV, above and below Right Atrium
    2. Should have at least one large bore intravenous (IV), usually in groin (femoral vein)
  3. Oxygen (minimum 40%)
    1. By face mask, intubation if necessary
    2. If hypoxemia is present, consider pneumothorax
    3. Hypoxemia, cyanosis, and hypotension can occur with tension pneumothorax
  4. Electrocardiogram (ECG) - assess for low voltage, ischemia, electrical alternans
  5. Nasogastric (NG) tube - mainly for gastrointestinal bleeding
  6. Pelvic Shake for broken bones before Foley Catheter (especially in men)
  7. Check for blood in all containers around patient

C. Secondary Surveynavigator

  1. Proximal and Distal Vascular Control if Needed
  2. Signs of Heart Failure - often require Central Venous Line
  3. Hemorrhage
    1. Take serial hematocrits
    2. Monitor for acidosis due to shunting, hypoxia
    3. Recombinant erythropoietin (EPO) reduced transfusions in trauma patients [18]
    4. Recombinant epo also increased thrombotic events by 40% in critically ill patients [18]
  4. Broken Bones - including pelvic shake; immobilized neck!!
  5. Rectal - feel prostate (urethral evulsion), blood
  6. Hematuria
  7. Amylase, Bilirubin
  8. Diagnostic Peritoneal Lavage or CT scan to assess for Abdominal Bleeding
  9. Tetanus Toxoid ± Tetanus Globulin
  10. Glascow Coma Scale
  11. Non-penetrating Chest (Thoracic) Trauma [8]
    1. Increases risk of severe arrhythmia and suddent death
    2. Also called commotio cordis

D. Glascow Coma Scale (GCS)navigator

  1. Add Points from Three Categories
    1. Mild traumatic injury GCS 14-15
    2. Moderate 9-13 (lethargic or stuporous)
    3. Severe 3-8 (comatose)
  2. Eye Opening
    1. Spontaneous 4 points
    2. To speech 3 points
    3. To Pain 2 points
    4. None
  3. Motor Response
    1. Obeys 6
    2. Localizes 5
    3. Withdraws 4
    4. Abnormal flexion 3
    5. Extensor response 2
    6. None 1
  4. Verbal Response
    1. Oriented 5
    2. Confused 4
    3. Inappropriate 3
    4. Incomprehensible 2
    5. None 1

E. Head Trauma [1] navigator

  1. Also called traumatic brain injury (TBI)
  2. Epidemiology
    1. About 1.6 million traumatic brain injuries annually in USA
    2. Outpatient care 800,000 / year
    3. Hospital admissions 270,000 / year
    4. Deaths 52,000 / year
    5. Permanent severe neurologic disability 80,000 / year
  3. Concussion [7]
    1. Defined as immediate and transient loss of consciousness (LOC) accompanied by a brief period of amnesia after a blow to the head
    2. Grade 1: confusion with no amnesia and no LOC
    3. Grade 2: amnesia without LOC
    4. Grade 3: LOC or altered mental status at 24 hours
    5. Concussion is due to disruption of electrophysiological and subcellular activities of neurons
    6. Neurons specifically in reticular activating system that are situated in the midbrain and diencephalic region are major ones involved (in consciousness)
  4. Secondary Neurological Injury Common
    1. Leading cause of inhospital deaths after TBI
    2. Vasogenic fluid accumulation in brain causes cerebral edema
    3. Result is elevated intracranial pressure (ICP)
    4. Increased ICP reduces cerebral blood flow increasing ischemia
    5. Hemorrhage or other cause of shock reduces systolic blood pressure (SBP)
    6. Cerebral perfusion pressure (CPP) = SBP - ICP
    7. Therefore, shock further exacerbates cerebral ischemia by reducing CPP
    8. Increased ICP can also lead to cerebral herniation
    9. Hypoxemia and hypotension are common prior to hospital admission
  5. Prehospital evaluation and initiation of therapy is critical to good outcome
    1. First priority is ALWAYS standard ABCs: airway, breathing, circulation
    2. Maintain SBP >90mmHg (Ringer's lactate and/or saline or hypertonic saline)
    3. Maintain oxygen saturation (SaO2) >90%
    4. Check circulation integrity (fluids should be given in adults)
  6. Assess for signs of cerebral herniation
    1. Signs include: fixed, dilated or asymmetric pupils OR
    2. Asymmetric motor responses or extensor posturing OR
    3. No movement on administration of noxious stimuli
    4. In the field, these signs should prompt immediate hyperventilation
  7. Triage of Head Trauma
    1. GCS 14, 15 go to emergency room for evaluation
    2. GCS 9-13 go to trauma center
    3. GCS <9 go to trauma center with TBI resources
    4. TBI resources include neurosurgical expertise, 24 hour CT scan, trauma care
  8. Cervical Spine films in ALL cases unless ALL of the following are true:
    1. No complaint of cervical pain
    2. No focal neurologic symptoms
  9. Computerized Tomograpy (CT) of the head for [4]:
    1. Patient is anticoagulated
    2. Loss of consciousness or any memory deficits
    3. Pupil abnormalities: unequal or non reactive
    4. Any new focal sensory deficit or weakness
    5. Ethanol or other drug abuse (controversial)
    6. Mental status deteriorating or not improving after observation (within 2 hours)
    7. Blood in tympanic membrane
    8. Canadian and New Orleans criteria have been developed to determiine who needs CT after minor head injury
  10. Canadian CT Head Rule (CCTR) [4,7]
    1. Any patient with any ONE of the following should undergo head CT scan
    2. GCS score <15 at 2 hours after injury
    3. Suspected open or depressed skull fracture
    4. Any sign of basal skull fracture: hemotympanum, racoon eyes, cerebrospinal fluid otorrhea or rhinorrhea, Battle's sign
    5. Vomiting >1 episode
    6. Age >64 years old
  11. New Orleans Criteria for Head CT Scan (NOC) [7,14]
    1. Applies only to patients with GCS=15
    2. Headache (HA)
    3. Vomiting
    4. Age >60 years
    5. Drug or alcohol intoxication
    6. Persistent anterograde amnesia (deficits in short-term memory)
    7. Visible trauma above clavicle
    8. Seizure
  12. CCTR versus New Orleans Criteria [14,15]
    1. CCTR and NOC criteria have similar sensitivity for need for CT with GCS=15
    2. CCTR has higher specificity than NOC criteria for clinically important outcomes
    3. For minor head injury and GCS 13-15, CCHR has lower sensitivity than NOC for neurocranial traumatic or clinically important CT findings
    4. CCTR and NOC would identify all cases of minor trauma in GCS 13-15 requiring neurosurgical intervention
  13. CT in Minor Head Injury [3]
    1. CHIP (CT in Head Injury Patients) prediction rule developed
    2. Used in minor head injury regardless of state of consciousness
    3. A CT is indicated in the presence of any one of the following major criteria:
    4. Pedestrian or cyclist versus vehicle
      1. Ejected from vehicle
      2. Vomiting
      3. Post-traumatic amnesia at least 4 hours
    5. Clinical signs of skull fracture (CSF fluid leak, palpable skull discontinuity, racoon eye)
      1. GCS score <15
      2. GCS deterioration at least 2 points 1 hour after presentation
      3. Use of anticoagulant therapy
      4. Post-traumatic seizure
    6. Age at least 60 years
    7. A CT is indicated in the presence of any 2 of these minor criteria:
    8. Fall from any elevation
      1. Persistent anterograde amnesia - any deficity in short-term memory
      2. Post-traumatic amnesia of 2-4 hours
      3. Skull contusion
    9. Neurologic deficit
      1. Loss of consciousness
      2. GCS deterioration of 1 point 1 hour after presentation
      3. Age 40-60
    10. Sensitivity 95% and specificity ~30% for predicting intracranial CT finding (abnormality)
    11. Sensitivity 100% and specificity 25% for predicting neurosurgical intervention
  14. Neurolosurgical Consultation or Admission
    1. GCS less than 13
    2. Trauma related intracranial injury on CT scan
  15. The entire clinical course should be well documented in patient's record
    1. Need for acute neurosurgical interventions: hematomas, expanding mass, persistant ICP
    2. Monitoring ICP and managing cerebral perfusion
    3. Glucocorticoids are not generally indicated
  16. Monitoring ICP
    1. Monitoring and correcting elevated ICP improves outcome
    2. Normal range for ICP is 0-10mm HG; 20-25 mmHg is upper limit of normal
    3. Many physicians initiate therapy at >15 mmHg ICP
    4. Monitoring catheter placed within ventricles and connected to external pressure transducer
    5. Catheter also allows draininage of cerebrospinal fluid (CSF) to reduce ICP
    6. Mild risks (6% infection, <1% hemorrhage) of catheter placement
    7. Maintain cerebral perfusion pressure >70mmHg (greatly improves outcomes)
  17. Routine use of glucocorticoids in head trauma is not supported by data [13]
  18. Postconcussion Syndrome [7]
    1. Constellation of symptoms, sometimes disabling
    2. HA, dizziness, trouble concentrating
    3. HA and dizziness occur in ~90% within 1 month, 25% at 1 year
    4. Difficulty concentrating ~25% over time
    5. Anxiety and depression reported by >30% of patients with postconcussive symptoms
  19. All patients with head trauma should be given an "instruction sheet" on discharge

F. Complicationsnavigator

  1. Organ Loss - especially kidney, spleen
  2. Blood Vessel Damage (occult)
  3. Slow CNS bleeding
  4. Systemic Inflammatory Respose Syndrome
  5. Wound infections, abscess formation

G. Rhabdomyolysis and Acute Renal Failure [10,11,16] navigator

  1. Due to massive release of myoglobin from damaged skeletal muscle
  2. Myoglobin is toxic to renal tubules
  3. Causes
    1. Massive rhabdomyolysis due to traumatic crush injury
    2. Overexertion, particularly in heat
    3. Alcohol abuse
    4. Various toxins
    5. Certain muscular dystrophies
  4. Confirm diagnosis with urine dipstick myoglobin with urine microscopy
  5. Maintenance of Good Renal Function is Critical
    1. Infusion of intravneous fluids before extrication or soon after may lessen severity
    2. Establishment of stable intravascular volume is primary modality
    3. Give normal saline up to 1.5L per hour; confirm urine flow at 300 mL/hour
    4. Forced mannitol-alkaline (bicarbonate) diuresis if oliguria develops with high fluid loads
  6. Prophylaxis against hyperkalemia and ARF
  7. Concern for compartment syndrome acutely or developing over time
  8. Renal replacement therapy must be available in aftermath of disasters [16]

H. Treatment for Brain and Spinal Injury navigator

  1. High dose glucocorticoids (dexamethasone) within 8 hours of spinal injury improves outcome
  2. Glucocorticoids of no overall benefit in patients with head trauma [13]
  3. Nimodipine, a calcium channel blocker, reduces vasopsams in subarachnoid hemorrhage
  4. Therapeutic Hypothermia [9]
    1. Inducing hypothermia to 33°C did not improves outcomes in acute brain injury [2]
    2. Therapeutic hypothermia might reduce mortality and morbidity in traumatic brain injury in adults but is not standard of care [9]
    3. Therapeutic hypothermia in children ages 1-17 years after brain injury showed no benefit and may increase mortality [19]
    4. Hypothermia may help reduce ICP
    5. Note that active rewarming of patients with hypothermia on admission may be detrimental [2]
  5. Active exercise and posture protocol reduce pain in acute whiplash injuries [5]
  6. In post-hoc study of critically ill patients with traumatic brain injury, albumin was associated with higher morality than saline for resuscitation [17]

I. Whiplash Injury [6]navigator

  1. Incidence is ~4 per 1000 persons
  2. Usually due to motor vehicle accident, often being hit from the rear
  3. Mechanism
    1. Rear impact causes cervical vertebra C6 to into extension
    2. This leads to extension of C5, but upper vertebrae are in flexion
    3. Result is an S shape in the cervical spine
    4. If the neck is partially rotated on impact, then damage can be worse
  4. Both clinical and psychosocial symptoms have been well documented
  5. Clinical Symptoms
    1. Neck pain and stiffness; back pain
    2. Headache
    3. Shoulder pain and stiffness; arm pain
    4. Dizziness and Vertigo; Tinnitus
    5. Fatigue
    6. Temporomandibular joint symptoms
    7. Paresthesias, weakness
    8. Visual distrubances
  6. Psychosocial Symptoms
    1. Depression, Anxiety
    2. Anger, Frustraition
    3. Family stress
    4. Occupational stress
    5. Compensation neurosis
    6. Drug dependency
    7. Post-traumatic stress syndrome
    8. Sleep disturbances
    9. Litigation
    10. Social isolation
  7. Radiographic Changes
    1. Most commonly normal or pre-existing degenerative changes
    2. Slight flattening of normal lordotic curvature of cervical spine
    3. Computed tomography or magnetic resonance imaging for neurologic deficit
  8. Treatment
    1. Soft cervical collar should be used while sleeping only
    2. Restriction of motion and rest are detrimental and slow healing process
    3. Exercises to maintain neck muscle strength for >2-4 weeks after injury are beneficial
    4. Active treatment leads to reduced pain and increased cervical flexion versus rest
    5. Very high doses of glucocorticoids given within 8 hours of injury show some benefit
    6. However, unclear which patients should receive such intensive regimen
    7. Cervical radiofrequency neurotomy has been used for severe whiplash injuries
    8. Physical therapy reduces pain as well as inappropriate pain behavior
    9. Psychological consultation should be considered, particularly when monetary gains present

J. Blast Injuries [12]navigator

  1. Primary - direct effects
    1. Overpressurization and underpressurization
    2. Rupture of tympanic membranes
    3. Pulmonary damage
    4. Rupture of hollow viscera
  2. Secondary
    1. Penetrating Trauma
    2. Fragmentation Injuries
  3. Tertiary
    1. Effects of structural collapse and of persons being thrown by the blast wind
    2. Crush injuries and blunt trauma
    3. Penetrating or blunt trauma
    4. Fractures and traumatic amputations
    5. Open or closed brain injuries
  4. Quaternary
    1. Burns
    2. Asphyxia
    3. Exposure to toxic inhalants

References navigator

  1. Ghajar J. 2000. Lancet. 356(9233):923 abstract
  2. Clifton GL, Miller ER, Choi SC, et al. 2001. NEJM. 344(8):556 abstract
  3. Smits M, Dippel DW, Steyerberg EW, et al. 2007. Ann Intern Med. 146(6):397 abstract
  4. Stiell IG, Wells GA, Vandemheen K, et al. 2001. Lancet. 357(9265):1391
  5. Rosenfeld M, Gunnarsson R, Borenstein P. 2000. Spine. 25:1782 abstract
  6. Eck JC, Hodges SD, Humphreys SC. 2001. Am J Med. 110(8):651 abstract
  7. Ropper AH and Gorson KC. 2007. NEJM. 356(2):166 abstract
  8. Maron BJ, Gohman TE, Kyle SB, et al. 2002. JAMA. 287(9):1142 abstract
  9. McIntyre LA, Fergusson DA, Hebert PC, et al. 2003. JAMA. 289(22):2992 abstract
  10. Malinoski DJ, Slater MS, Mullins RJ. 2004. Crit Care Clin. 20(1):171 abstract
  11. Sauret JM, Marinides G, Wang GK. 2002. Am Fam Phys. 65(5):907 abstract
  12. DePalma RG, Burris DG, Champion HR, Hodgson MJ. 2005. NEJM. 352(13):1335 abstract
  13. CRASH Trial Collaborators. 2005. Lancet. 365(9475):1957 abstract
  14. Stiell IG, Clement CM, Rowe BH, et al. 2005. JAMA. 294(12):1511 abstract
  15. Smits M, Dippel DWJ, de Hann GG, et al. 2005. JAMA. 294(12):1519 abstract
  16. Sever MS, Vanholder R, Lameire N. 2006. NEJM. 354(10):1052 abstract
  17. SAFE Study Investigators. 2007. NEJM. 357(9):874 abstract
  18. Corwin HL, Gettinger A, Fabian TC, et al. 2007. NEJM. 357(1):965
  19. Hutchison JS, Ward RE, Lacroix J, et al. 2008. NEJM. 358(23):2447 abstract
  20. Polderman KH. 2008. Lancet. 371(9628):1955 abstract