01-1 Trauma - ABC Flashcards
A patient involved in a car accident is fully conscious, and his voice is normal.
A very brief vignette, but in terms of the airway, the airway is fine.
I. A patient with multiple stab wounds arrives in the emergency room (ER) fully conscious, and he has normal voice, but he also has an expanding hematoma in the neck.
II. A patient with multiple stab wounds arrives in the ER fully conscious, and he has a normal voice, but he also has subcutaneous air (emphysema) in the tissues in the neck and upper chest.
In both 2 and 3, the airway may be fine now, but it is going to be compromised soon. Intubation is indicated now before an emergency situation develops. Orotracheal intubation with rapidsequence anesthetic induction and pulse oximetry (or topical anesthesia) is preferred in the setting of a trauma center. Blind nasotracheal intubation is often performed by paramedics in the field. The patient with subcutaneous emphysema requires fiberoptic bronchoscopy (more
details follow).
A patient involved in a severe car accident has multiple injuries and is unconscious. He is breathing spontaneously, but his breathing sounds gurgled and noisy.
Altered mental status is the most common indication for intubation in the trauma patient. Unconscious patients with Glasgow coma scale of 8 or less may not be able to maintain or protect their airway. As in the previous case, orotracheal intubation would be preferred here,
but no anesthetic is needed.
An unconscious patient is brought in by the paramedics with spontaneous but noisy and labored breathing. They relate that at the accident site the patient was conscious, but was complaining of neck pain and was unable to move his lower extremities. He lost consciousness during the ambulance ride, and efforts to secure a nasotracheal airway were unsuccessful.
Although it is obvious that the patient has a cervical spine injury, his airway has to be managed first. Orotracheal intubation can still be performed with manual in-line cervical immobilization (i.e., intubate without whipping the neck around), or better yet, over a flexible bronchoscope. Some prefer nasotracheal intubation in this setting if facial injuries do not preclude it.
A patient involved in a severe automobile crash is fully awake and alert, but he has extensive facial fractures and is bleeding briskly into his airway, and his voice is masked by gurgling sounds.
Securing an airway is mandatory, but the orotracheal route may not be suitable. Cricothyroidotomy is probably the best choice under these circumstances except in the pediatric population because of the high-risk of airway scarring in children.
An unconscious trauma patient has been rapidly intubated in the ER. He has spontaneous breathing and bilateral breath sounds, and his oxygen saturation by pulse oximetry is above 95.
As far as breathing is concerned, he is moving air (physical examination) and getting oxygen into his blood (oximetry). Deterioration could occur later, but right now we are ready to move to C in the ABCs.
A 22-year-old gang member arrives in the ER with multiple gunshot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, anxious, and asking
for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.
What is it? We recognize the picture of shock (diaphoretic, pale, cold, shivering, anxious, asking
for a blanket and a drink of water, low blood pressure, fast weak pulse). In the trauma setting, shock is most commonly caused by bleeding (hypovolemic shock), but two other possibilities are pericardial tamponade or tension pneumothorax. To be the latter, the chest has to be involved. Here it is not, thus it has to be bleeding.
Management. Several things at once. Big-bore IV lines, Foley catheter, and IV antibiotics in preparation for immediate exploratory laparotomy for control of bleeding, and then fluid and blood administration. The old emphasis on fluid resuscitation first has given way to a preference for control of the bleeding site as the first order of business, particularly when surgery will have to b done anyway (as is the case for gunshot wounds of the abdomen). When surgery might or might not be needed, such as in blunt trauma, fluid resuscitation still is performed first, in part as a diagnostic test (patients who respond promptly and remain stable are probably no longer bleeding).
During a bank robbery an innocent bystander is shot repeatedly in the abdomen. When the emergency medical technicians (EMTs) arrive, they find him to be in
shock. A fully staffed trauma center is 2 miles away from the site of the shooting.
An ambulance can travel 2 miles in 2 minutes—maybe 3. The point of the vignette is that elaborate attempts to start an IV at the site and begin to infuse Ringer lactate would waste precious time that would be best spent moving the patient to a place where the urgently needed laparotomy can be done (“scoop and run”).
A 19-year-old male is shot in the right groin during a drug deal gone bad. He staggers to the hospital on his own, and arrives in the ER with a blood pressure of 90 over 70 and a pulse rate of 105. He is squirting bright red blood from the groin wound.
The point of this vignette is that control of the bleeding by direct local pressure is the first order of business before volume restoration is started. And a gloved finger or a sterile pressure dressing is the way to do it—not blind clamping or a tourniquet. Finger pressure is used in the civilian setting, where typically there is a single patient and multiple health care workers. In the military combat setting, where the ratio is reversed, tourniquets are life-saving.
