Critical Care - Trauma & Burns
Introduction to Trauma
• Third leading cause of death (Leading cause of death to persons younger than 44 years of age)
• Often associated with drugs and alcohol (about 1/3 of traumas)
• Financial implications: Treatment, Rehabilitation, Disability
Levels of Trauma Care
• Level I: regional resource, state-of-the- science care, education, outreach, research
o Most critical patients come here (adequately equip with resources & specialize in trauma)
• Level II: provides care for trauma patients and transfer to level I if needed
o Do not have 24 hour surgeon on premises
• Level III: community hospital where no level I or II exists
o Stabilize patient, then send to another trauma hospital.
• Level IV: provide ACLS and
transfer Initial Assessment and
Management
• Prehospital management
o Maintain the airway, ensure adequate ventilation, control external bleeding and prevent
shock, maintain spine immobilization, and transport to the closest appropriate facility.
o Transporting the patient to a level I facility allows definitive care to be initiated earlier in
the process, thereby reducing patient mortality.
Question: Detailed head to toe assessment is done during which survey secondary
In-Hospital Management
• Primary survey - Airway, breathing, ventilation, and life-threatening injuries identified
• Secondary survey - Detailed head-to-toe survey, plan for appropriate diagnostic tests
• Tertiary survey - On admission to the ICU, another head-to-toe examination, assess response to
interventions, labs and x-rays
reviewed E-I Mneumonic
• A = airway, B = breathing, C = circulation, D = disability
o These are most important, unless patient is bleeding out then stop the bleeding
• E: expose patient/environmental control Remove clothing, re-warm
o After cutting off patient’s clothes, they will be cold warm light, warm fluids, warm blanket
• F: full set VS/5 interventions NGT, SPO2, monitor, blood/urine sample, ID family and update
• G: give comfort measures
o Ex: Verbal reassurance, ice to wound, medication
• H: history/ head-toe assessment
• I: inspect posterior surfaces
Trauma Team
• It is basically another code team
• Team members pre-assigned
, o Trauma surgeons, emergency department physicians, and specialists
o Nurses
o Ancillary services: radiology, laboratory, respiratory therapist and social
work Mechanism of Injury
• Knowledge helps to identify potential problems
o Want to know: how fast car was going, type of accident
• Blunt injury, penetrating injury
• Uncontrolled source of energy
o Kinetic, thermal, chemical, electrical, and
radiation Blunt Trauma
• Common vehicular trauma, assault with blunt objects, falls, sports
• Severity depends on kinetic energy dissipated to the body
o Can be localized: hand, leg, arm or the entire body
• When mass is doubled so is the net energy
• When velocity is doubled energy is quadrupled.
o If car is going 20 mph, then x4 = 80 mph impact on body
• Acceleration
• Deceleration
• Shearing – (ex: aorta rupturing)
• Crushing
• Compression
Penetrating Trauma
• Impalement of foreign objects into the body
• Stab wounds are low-velocity injuries
o Stab wounds are better than gunshot wound
• Gunshot wounds are high-velocity injuries Cavitation
• Injuries depend of body part(s) involved and on the trajectory of the impaled (or sharp) object or bullet
Emergency Care Phase
• Data obtained
• Trauma unit in emergency department must always be in a state of readiness
o Supplies should always be stock, never know what and when is going to happen
• Trauma surgeon must always be present (ED, operating room, and during critical care
interventions) Maintain Airway
• Endotracheal intubation often needed, but when you can’t…
• Cricothyrotomy
o Indications: Facial fracture, unable to intubate, facial/upper airway burns,
oropharyngeal hemorrhage
Ineffective Breathing
, • Causes
o Decreased inspired air o Atelectasis
o Retained secretions o Accumulation of blood
o Lung collapse or compressed o Pain-rib fractures, sternal fracture
• Ongoing assessment is essential
o Respiratory status trauma patient, always give some type of oxygen (it can only help)
o ABGs
o Chest x-rays
o CT imaging
• Improve ventilation and gas exchange as soon as possible, move patient off backboard because it’s
hard to breath and causes more tissue breakdown (backboard is only used for transportation)
• Specific interventions
o Mechanical ventilation
o Needle thoracostomy and chest tube insertion
o Administration of fluids and blood products always monitor
o Administration of sedation and analgesics helps improve oxygenation because when patients
in pain = shunt blood to core
Hypovolemia
• Hypovolemic shock: acute blood loss
o External hemorrhage – something you can see
o Internal hemorrhage – can’t see
▪ Fun Fact…~1500L of blood can be held in the pelvis
• Ongoing assessment of vital signs, urine output, mental status, and hemodynamic parameters
• Management: Fluid Resuscitation (kidney is the first organ to go during shock)
o Shock early sign = restlessness &
agitation Fluid Resuscitation
• Crystalloids - Isotonic, hypotonic, and hypertonic, typically at least 2 liters of isotonic (NS, LR)
o Usually BOLUS for immediate resuscitation: Saline first then LR
• Colloids - Rapid volume expander (albumin, hetastarch)
• Blood products
o Hemodynamically unstable or are showing signs of tissue hypoxia despite crystalloid infusion.
o Crossmatched blood preferred but if not available then O-negative blood can be given.
• Blood substitutes - Don’t require cross-
matching Massive Fluid Resuscitation
• Greater than 10 units of packed RBC in 24 hours or replace patient’s total blood volume in 24 hours
• Goals: Restore O2 transport to tissue, stop progress of shock, prevent complications
o If giving blood always check temperature (because ↓ temp can prevent patient from clotting)
Complications of Massive Fluid Resuscitation
Introduction to Trauma
• Third leading cause of death (Leading cause of death to persons younger than 44 years of age)
• Often associated with drugs and alcohol (about 1/3 of traumas)
• Financial implications: Treatment, Rehabilitation, Disability
Levels of Trauma Care
• Level I: regional resource, state-of-the- science care, education, outreach, research
o Most critical patients come here (adequately equip with resources & specialize in trauma)
• Level II: provides care for trauma patients and transfer to level I if needed
o Do not have 24 hour surgeon on premises
• Level III: community hospital where no level I or II exists
o Stabilize patient, then send to another trauma hospital.
• Level IV: provide ACLS and
transfer Initial Assessment and
Management
• Prehospital management
o Maintain the airway, ensure adequate ventilation, control external bleeding and prevent
shock, maintain spine immobilization, and transport to the closest appropriate facility.
o Transporting the patient to a level I facility allows definitive care to be initiated earlier in
the process, thereby reducing patient mortality.
Question: Detailed head to toe assessment is done during which survey secondary
In-Hospital Management
• Primary survey - Airway, breathing, ventilation, and life-threatening injuries identified
• Secondary survey - Detailed head-to-toe survey, plan for appropriate diagnostic tests
• Tertiary survey - On admission to the ICU, another head-to-toe examination, assess response to
interventions, labs and x-rays
reviewed E-I Mneumonic
• A = airway, B = breathing, C = circulation, D = disability
o These are most important, unless patient is bleeding out then stop the bleeding
• E: expose patient/environmental control Remove clothing, re-warm
o After cutting off patient’s clothes, they will be cold warm light, warm fluids, warm blanket
• F: full set VS/5 interventions NGT, SPO2, monitor, blood/urine sample, ID family and update
• G: give comfort measures
o Ex: Verbal reassurance, ice to wound, medication
• H: history/ head-toe assessment
• I: inspect posterior surfaces
Trauma Team
• It is basically another code team
• Team members pre-assigned
, o Trauma surgeons, emergency department physicians, and specialists
o Nurses
o Ancillary services: radiology, laboratory, respiratory therapist and social
work Mechanism of Injury
• Knowledge helps to identify potential problems
o Want to know: how fast car was going, type of accident
• Blunt injury, penetrating injury
• Uncontrolled source of energy
o Kinetic, thermal, chemical, electrical, and
radiation Blunt Trauma
• Common vehicular trauma, assault with blunt objects, falls, sports
• Severity depends on kinetic energy dissipated to the body
o Can be localized: hand, leg, arm or the entire body
• When mass is doubled so is the net energy
• When velocity is doubled energy is quadrupled.
o If car is going 20 mph, then x4 = 80 mph impact on body
• Acceleration
• Deceleration
• Shearing – (ex: aorta rupturing)
• Crushing
• Compression
Penetrating Trauma
• Impalement of foreign objects into the body
• Stab wounds are low-velocity injuries
o Stab wounds are better than gunshot wound
• Gunshot wounds are high-velocity injuries Cavitation
• Injuries depend of body part(s) involved and on the trajectory of the impaled (or sharp) object or bullet
Emergency Care Phase
• Data obtained
• Trauma unit in emergency department must always be in a state of readiness
o Supplies should always be stock, never know what and when is going to happen
• Trauma surgeon must always be present (ED, operating room, and during critical care
interventions) Maintain Airway
• Endotracheal intubation often needed, but when you can’t…
• Cricothyrotomy
o Indications: Facial fracture, unable to intubate, facial/upper airway burns,
oropharyngeal hemorrhage
Ineffective Breathing
, • Causes
o Decreased inspired air o Atelectasis
o Retained secretions o Accumulation of blood
o Lung collapse or compressed o Pain-rib fractures, sternal fracture
• Ongoing assessment is essential
o Respiratory status trauma patient, always give some type of oxygen (it can only help)
o ABGs
o Chest x-rays
o CT imaging
• Improve ventilation and gas exchange as soon as possible, move patient off backboard because it’s
hard to breath and causes more tissue breakdown (backboard is only used for transportation)
• Specific interventions
o Mechanical ventilation
o Needle thoracostomy and chest tube insertion
o Administration of fluids and blood products always monitor
o Administration of sedation and analgesics helps improve oxygenation because when patients
in pain = shunt blood to core
Hypovolemia
• Hypovolemic shock: acute blood loss
o External hemorrhage – something you can see
o Internal hemorrhage – can’t see
▪ Fun Fact…~1500L of blood can be held in the pelvis
• Ongoing assessment of vital signs, urine output, mental status, and hemodynamic parameters
• Management: Fluid Resuscitation (kidney is the first organ to go during shock)
o Shock early sign = restlessness &
agitation Fluid Resuscitation
• Crystalloids - Isotonic, hypotonic, and hypertonic, typically at least 2 liters of isotonic (NS, LR)
o Usually BOLUS for immediate resuscitation: Saline first then LR
• Colloids - Rapid volume expander (albumin, hetastarch)
• Blood products
o Hemodynamically unstable or are showing signs of tissue hypoxia despite crystalloid infusion.
o Crossmatched blood preferred but if not available then O-negative blood can be given.
• Blood substitutes - Don’t require cross-
matching Massive Fluid Resuscitation
• Greater than 10 units of packed RBC in 24 hours or replace patient’s total blood volume in 24 hours
• Goals: Restore O2 transport to tissue, stop progress of shock, prevent complications
o If giving blood always check temperature (because ↓ temp can prevent patient from clotting)
Complications of Massive Fluid Resuscitation
