GC207 Trauma Evaluation And Management (TEAM)

A – Analyse injury data, B – Build local coalitions, C – Communicate the problem, D – Develop prevention activities, E – Evaluate the interventions. ^[1]

This is a public health mnemonic — less commonly examined in clinical exams but may appear in community medicine or "system-based" questions.

Closest, appropriate facility. Transport guidelines/protocols. On-line medical direction. Mobilization of resources. Periodic review of care. ^[1]

Key concept: "Closest appropriate facility" — not just the nearest hospital. A trauma patient with a penetrating chest wound needs a trauma centre with surgical capabilities, not a small clinic. This concept is the basis of trauma system design.

Preplanning essential. Team approach. Trained personnel. Proper equipment. Lab/x-ray capabilities. Standard precautions. Transfer agreements. QI program. ^[1]

Standard Precautions (PPE for trauma):

Cap, Gown, Gloves, Mask, Shoe covers, Goggles/face shield. ^[1]

Why all of these? Trauma involves high-velocity blood exposure. Universal precautions assume every patient is potentially infectious (HIV, Hepatitis B/C). This is both an infection control and an ethical/legal standard.

Sorting of patients according to: ABCDEs, Available resources, Other factors (e.g. salvageability). ^[1]

Two triage scenarios:

• Multiple casualties (patients > resources but manageable): Treat the most severely injured first (most salvageable who need immediate intervention)
• Mass casualties (patients overwhelm resources): Treat those with the greatest chance of survival — a philosophical shift. You may bypass a patient who needs a 3-hour surgery for 10 patients who each need 15-minute interventions.

Assess for airway patency: Snoring, Gurgling, Stridor, Rocking chest wall motions, Maxillofacial trauma / laryngeal injury. ^[1]

Why these signs matter:

• Snoring → tongue/soft palate obstruction (most common cause in unconscious patients)
• Gurgling → fluid/blood/vomit in the airway
• Stridor → partial upper airway obstruction (laryngeal injury, foreign body)
• Rocking/see-saw chest wall motions → attempts to breathe against an obstructed airway (paradoxical abdominal/chest movement)

Resuscitation — Establishing a Patent Airway:

Chin lift / Modified jaw thrust. Look, listen, feel. Remove particulate matter. Definitive airway as necessary. Reassess frequently. ^[1]

Contraindications for nasogastric tube / nasopharyngeal airway insertion — signs of base of skull fracture:

CSF rhinorrhea/otorrhea, periorbital ecchymosis (raccoon eyes), mid-face instability, hemotympanum ^[1]

If any of these are present, use the orogastric route instead of nasogastric to avoid intracranial passage.

Assessment:

Chest rise and symmetry. Air entry. Rate/Effort. Color/Sensorium. ^[1]

Why each matters:

• Asymmetry → pneumothorax, haemothorax, flail chest
• Absent air entry on one side → tension pneumothorax until proven otherwise in a hypotensive trauma patient
• Tachypnoea → pain, pneumothorax, metabolic acidosis from shock
• Cyanosis → severe hypoxia

Resuscitation — Breathing:

Administer supplemental oxygen. Ventilate as needed. Tension pneumothorax: Needle decompression. Open pneumothorax: Occlusive dressing. Reassess frequently. ^[1]

Oxygen for all trauma patients. ^[1]

Hemorrhagic shock — External: Apply direct pressure. Internal: Chest, abdomen, pelvis, retroperitoneum. Identify: History, physical, and investigation. ^[1]

First principle: In trauma, assume shock is hypovolaemic/haemorrhagic until proven otherwise. The most common cause of shock in trauma is haemorrhage.

Where is the blood? Five places to look for occult haemorrhage:

1. Chest (haemothorax)
2. Abdomen (solid organ injury — spleen, liver)
3. Pelvis (pelvic fracture)
4. Retroperitoneum (renal, great vessel injury)
5. External / "on the floor"

Long bone fractures (femur) can also harbour significant blood loss (up to 1.5L per femur).

Assessing Organ Perfusion:

Level of consciousness. Skin color. Pulse rate and character. ^[1]

Resuscitation — Circulation:

Obtain venous access. Restore circulating volume — Ringer's lactate, 1-2 L. PRBCs if transient response or no response. Reassess frequently. ^[1]

2 large-caliber IVs ^[1]

Why Ringer's Lactate? It is an isotonic crystalloid that closely matches plasma electrolyte composition. The lactate is metabolised to bicarbonate by the liver, providing a mild buffering effect. Normal saline is an alternative but carries risk of hyperchloraemic metabolic acidosis with large volumes.

Classification of Haemorrhagic Shock

Class I: < 15% (750 mL), Responder, Crystalloid. Class II: 15-30% (1500 mL), Transient responder, Crystalloid. Class III: 30-40% (2000 mL), Transient responder, Crystalloid + blood, ?OR. Class IV: > 40% ( > 2000 mL), Non-responder, Crystalloid + blood + OR. ^[1]

Populations that modify shock response:

Children (vigorous initial response but decompensate rapidly), Elderly (diminished reserve, may be on beta-blockers masking tachycardia), Athletes (high baseline fitness, compensate longer), Pregnancy (expanded blood volume — can lose 30-35% before signs appear), Medications (beta-blockers, calcium channel blockers blunt tachycardic response). ^[1]

Non-Haemorrhagic Shock in Trauma:

Cardiac tamponade. Tension pneumothorax. Neurogenic. Septic (late). ^[1]

Resuscitation considerations for C:

Tension pneumothorax: Needle decompression + tube thoracostomy. Massive haemothorax: Volume resuscitation + tube thoracostomy. Cardiac tamponade: Pericardiocentesis + direct operative repair. ^[1]

Bleeding? Find it! — Direct pressure, Operation, Avoid blind clamping. ^[1]

Why avoid blind clamping? You risk clamping nerves, veins, or uninvolved structures, causing iatrogenic injury. Direct pressure is safer and usually effective for external bleeding.

Baseline neurologic evaluation: GCS Score, Pupillary response, Neurosurgical consult as indicated. Reevaluate for neurologic deterioration. ^[1]

Glasgow Coma Scale (GCS):

Eye opening: Range 1–4. BEST Motor response: Range 1–6. Verbal response: Range 1–5. Score = E + M + V. Best = 15. Worst = 3. ^[1]

Intracranial Pressure (ICP) Curve:

The lecture shows the classic ICP vs. Volume of Mass curve. Initially, the brain compensates by displacing CSF and venous blood (flat part of the curve). Once compensatory mechanisms are exhausted, the point of decompensation is reached, and ICP rises exponentially with any further increase in mass (steep part). Beyond this is herniation. ^[1]

This is why early detection and intervention (evacuating haematomas) is critical — by the time the patient herniates, you've lost the window.

Pupillary response:

• Fixed, dilated pupil → ipsilateral uncal herniation compressing CN III → surgical emergency
• Bilateral fixed, dilated pupils → brainstem compression, grave prognosis
• Always check and document pupils during primary survey as a baseline

Completely undress the patient. Remove helmet if present. Look for visible/palpable injuries. Log roll, protect spine. Prevent hypothermia. ^[1]

Why undress completely? Injuries are missed under clothing. A stab wound to the back, an exit wound, perineal injuries — all invisible until the patient is fully exposed. The log roll (with spine protection) allows examination of the back, which is commonly the site of missed injuries.

Prevent hypothermia ^[1]

Why hypothermia is lethal in trauma — the "lethal triad":

1. Hypothermia → impairs coagulation cascade (enzymatic reactions are temperature-dependent), impairs cardiac function
2. Acidosis → from tissue hypoperfusion (lactic acidosis)
3. Coagulopathy → dilutional (from crystalloid resuscitation) + consumptive (DIC) + hypothermia-induced

Each worsens the other in a vicious cycle. Preventing hypothermia means: warm IV fluids, warming blankets, warm room, minimise exposure time.

Vital signs, ABGs, ECG, Pulse oximetry, End-tidal CO2. ^[1]

Chest / pelvis x-ray. C-spine x-rays when appropriate. FAST. DPL. ^[1]

Blood at meatus? Decompress bladder. Monitor urinary output. ^[1]

Contraindications to urethral catheterisation (suspect urethral injury):

Blood at meatus. Perineal ecchymosis/haematoma. High-riding prostate. ^[1]

If any of these are present → do NOT insert a urethral catheter → consult urology → suprapubic catheter.

Why monitor urine output? It is the best bedside marker of renal perfusion and therefore adequacy of resuscitation:

• Target: ≥ 0.5 mL/kg/hr (adult), ≥ 1 mL/kg/hr (child) ^{[2] [4]}

Blood or bile? Decompress stomach. ^[1]

When to use orogastric instead of nasogastric:

CSF rhinorrhea/otorrhea. Periorbital ecchymosis. Mid-face instability. Hemotympanum. ^[1]

These signs indicate base of skull fracture — a nasogastric tube could pass intracranially through the cribriform plate. Use orogastric route instead.

A – Allergies. M – Medications. P – Past illnesses / Pregnancy. L – Last meal. E – Events / Environment. ^[1]

Mechanism of injury → Pattern of injury ^[1]

This is a crucial concept. The mechanism tells you what injuries to actively look for:

Head: Complete neurologic exam, GCS Score, Comprehensive eye/ear exam ^[1]

Maxillofacial: Bony crepitus/instability, Palpable deformity, Comprehensive oral/dental exams ^[1]

C-spine: Palpate for tenderness, Complete motor/sensory exams, Reflexes, C-spine imaging ^[1]

C-spine imaging is needed when:

Injury above clavicles. Altered LOC. Other severe, painful injury (distracting injury). ^[1]

Neck: Blunt vs penetrating. Airway obstruction, hoarseness. Crepitus, hematoma, stridor, bruit. Delayed symptoms/signs. ^[1]

Other secondary survey areas (covered in companion lectures):

• Chest — rib palpation, breath sounds, heart sounds
• Abdomen — tenderness, guarding, distension, perineum (blood at meatus, rectal exam)
• Pelvis — compression/distraction (do ONCE only), perineal injuries
• Extremities — deformity, pulses, compartment syndrome
• Back — log roll examination for wounds, spinal tenderness

Leading cause of death. Immature, anatomic/mechanical features. Vigorous physiologic response. Limited physiologic reserve. Outcome depends on early, aggressive care. ^[1]

Size, dosage, equipment, surface area, and psychology. ^[1]

Anatomic/physiologic changes modify response to injury. Need for fetal assessment. 1st Priority: Maternal resuscitation. Outcome depends on early, aggressive care. ^[1]

Gestation and position of uterus. Physiologic anemia. ↓ PCO2. ↓ Gastric emptying. Supine hypotension. Isoimmunization. Sensitivity of fetus. ^[1]

5th leading cause of death. Diminished physiologic reserve and response. Comorbidities: Diseases/Medications. Outcome depends on early, aggressive care. ^[1]

Inhalation injury: Intubate and administer 100% oxygen. ^[1]

Why early intubation? Airway oedema from thermal/chemical inhalation injury can progress rapidly. A patent airway now may become completely obstructed in 30 minutes. If you suspect inhalation injury (singed nasal hairs, facial burns, carbonaceous sputum, hoarseness, stridor, history of closed-space fire) — intubate early before oedema makes it impossible.

Administer 2–4 mL/kg/% BSA burn in 24 hours (+ maintenance in children). Monitor urinary output. Expose and prevent hypothermia. Chemical burns: Brush and irrigate. ^[1]

Parkland Formula:

• 4 mL × body weight (kg) × % TBSA burned = total fluid in first 24 hours
• Give half in the first 8 hours (from time of burn, not from time of arrival), the other half over the next 16 hours
• Use Ringer's Lactate
• Children need maintenance fluid in ADDITION to resuscitation fluid
• Titrate to urine output ≥ 0.5 mL/kg/hr (adult) or ≥ 1 mL/kg/hr (child)

Palm + fingers = approximately 1% BSA ^[1]

Rule of Nines:

Children have proportionally larger heads and smaller legs compared to adults.

Frostbite: Rewarm with moist heat (40°C); wait for demarcation. ^[1]

Why 40°C? Temperatures above 42°C cause tissue burns. Below 37°C, rewarming is too slow. 40°C is the sweet spot for effective rewarming without additional injury. "Wait for demarcation" — early surgery leads to unnecessarily aggressive debridement. The tissue often demarcates over weeks, and what initially looks necrotic may recover.

Hypothermia: Passive or active rewarming. Monitor: Not dead until warm and dead. ^[1]

"Not dead until warm and dead" is a clinical axiom: hypothermic patients may appear clinically dead (pulseless, apnoeic) but can survive with full neurological recovery if rewarmed. The cold brain requires less oxygen — hypothermia is neuroprotective. You must rewarm to at least 32-35°C before pronouncing death.

• Tension pneumothorax vs cardiac tamponade: Both have distended neck veins and hypotension. Breath sounds differentiate: absent in tension pneumothorax, present in tamponade. Tracheal deviation occurs in tension pneumothorax (late), not tamponade.
• FAST vs DPL: FAST is non-invasive, repeatable, operator-dependent. DPL is invasive but highly sensitive. FAST has largely replaced DPL in most centres.
• Chin lift vs jaw thrust: Both open the airway. Jaw thrust is used when C-spine injury is suspected (it doesn't extend the neck).