Contrast nephropathy risk is secondary in life threat bleeding
Radiation risk higher in pediatrics and pregnancy
Ultrasound
POCUS in trauma
eFAST
Pericardial effusion
Pleural fluid
Pneumothorax
Intraperitoneal free fluid
IVC collapsibility adjunct
Ultrasound pitfalls
Early intraabdominal bleed may be false negative
Retroperitoneal bleed often not detected
Obesity and subcutaneous air limit windows
Special Tests
Bedside and procedural diagnostics
Bedside and procedural diagnostics
Diagnostic peritoneal aspirate or lavage
Consider when unstable and FAST equivocal
Limitations in retroperitoneal injury
Bronchoscopy
Suspected airway injury
Foreign body and blood clearance
Flexible laryngoscopy
Suspected laryngeal injury
Voice change and stridor
Vascular and limb tests
Vascular and limb tests
Ankle brachial index
Screening for extremity vascular injury
ABI under 0.9 abnormal
Compartment pressure measurement
When exam unreliable
Rising pain with neuro deficit concern
Specialty triggered tests
Specialty triggered tests
Cystogram imaging pathway
Gross hematuria with pelvic fracture
Urethrogram pathway
Blood at meatus or high riding prostate
ECG
Indications and timing
ECG indications
Blunt chest trauma
Syncope preceding trauma
Palpitations
Shock unexplained
Older with cardiac risk
Serial ECG logic
If blunt cardiac injury concern then repeat ECG
If evolving symptoms then repeat after resuscitation
High risk patterns
High risk patterns
New arrhythmia
ST elevation pattern
ST depression pattern
Conduction block new
QT prolongation
Hyperkalemia patterns
Interpretation pitfalls
Interpretation pitfalls
Artifact in shivering hypothermia
Tachycardia from pain and hypovolemia
Troponin interpretation requires clinical context
Assessment
Working problems and severity
Problem list and severity
Polytrauma (T07)
Hemorrhagic shock (R57.1)
Traumatic brain injury (S06)
Thoracic trauma
Abdominal trauma
Pelvic trauma
Extremity trauma
Hypothermia (T68)
Coagulopathy secondary to trauma
Risk stratification and complications
Risk stratification and complications
Need for massive transfusion
Persistent hypotension despite blood
Need for operative hemorrhage control
Need for airway protection
Risk of missed injury
Alcohol and drug confounding
Elderly frailty increased mortality
Supporting evidence summary
Supporting features summary
Mechanism high risk
Exam high risk
Labs high risk
Imaging high risk
Plan
First 5 minutes resuscitation
First 5 minutes
Trauma team activation criteria local protocol dependent
Monitor
Cardiac monitor
Pulse oximetry
Blood pressure cycling
Capnography if ventilated
IV access goals
Two large bore IV
IO if IV delayed
Blood sampling with initial access
Oxygen target
SpO2 at least 94 percent
Warming measures
Forced air warmer
Warmed fluids
Hemorrhage control immediate
Direct pressure
Tourniquet for life threatening extremity bleed
Pelvic binder for suspected pelvic fracture
eFAST bedside
Airway and ventilation
Airway and ventilation
RSI indications
Inability to protect airway
Refractory hypoxemia
Severe TBI with GCS 8 or less
RSI adult induction examples
Ketamine IV 1 mg per kg
Etomidate IV 0.3 mg per kg
RSI adult paralytic examples
Rocuronium IV 1.2 mg per kg
Succinylcholine IV 1.5 mg per kg
Post intubation targets
End tidal CO2 35 to 40 mmHg
Avoid hyperventilation unless herniation signs
Circulation and hemorrhage
Circulation and hemorrhage
Massive transfusion protocol triggers local protocol dependent
Shock with suspected hemorrhage
Positive FAST with shock
Pelvic instability with shock
Balanced transfusion strategy local protocol dependent
Early plasma and platelets with RBC
Calcium replacement
Calcium chloride IV 1 g
Repeat based on ionized calcium
TXA within 3 hours when indicated local protocol dependent
TXA IV 1 g over 10 minutes
TXA IV 1 g over 8 hours
Permissive hypotension consideration
Avoid in suspected TBI requiring cerebral perfusion
Target SBP around 90 mmHg until hemorrhage control local protocol dependent
Pelvic hemorrhage pathway
Binder centered over greater trochanters
Early interventional radiology or OR
Tourniquet principles
Place proximal to wound
Document time
Hemostatic dressing
Junctional bleeding control
Thoracic injury interventions
Thoracic injury interventions
Suspected tension pneumothorax
Immediate needle decompression local protocol dependent
Follow with tube thoracostomy
Chest tube indications
Hemothorax
Pneumothorax with ventilation
Open pneumothorax dressing
Three sided occlusive dressing
Definitive chest tube
Neuro protection
Neuro protection
TBI physiologic targets
Avoid hypotension
Avoid hypoxemia
Head of bed elevation if safe
Hyperosmolar therapy local protocol dependent
Hypertonic saline 3 percent IV 250 mL
Mannitol IV 0.5 g per kg
Analgesia and sedation
Analgesia and sedation
Fentanyl IV 25 mcg increments
Morphine IV 2 mg increments
Ketamine IV 0.2 mg per kg analgesic dose
Avoid hypotension worsening agents in shock
Antibiotics and tetanus
Antibiotics and tetanus
Open fracture antibiotics local protocol dependent
Cefazolin IV 2 g
Add gram negative coverage for severe contamination local protocol dependent
Tetanus prophylaxis per immunization status local protocol dependent
Imaging and sequencing
Imaging and sequencing
If unstable then bedside interventions first
If stable then CT trauma imaging pathway
C spine immobilization until cleared
Reassessment loop
Reassessment loop
Repeat vitals every 5 to 10 minutes in resuscitation
Repeat mental status and pupils
Repeat chest exam after interventions
Repeat pelvic stability and bleeding check
Repeat lactate and gas as needed
Consultation plan
Consultation plan
Trauma surgery early
Neurosurgery for intracranial injury
Orthopedics for fractures
Vascular surgery for hard signs vascular injury
Interventional radiology for pelvic bleed pathway
OB for pregnancy trauma
Pediatrics for pediatric trauma
Disposition
Level of care criteria
Level of care criteria
ICU criteria
Ongoing vasopressor requirement
Ongoing transfusion requirement
Mechanical ventilation
Severe TBI
Spinal cord injury
Inpatient criteria
Significant fractures requiring surgery
Solid organ injury
Uncontrolled pain
Observation criteria
Mild TBI with risk factors
Rib fractures with borderline oxygenation
Transfer and trauma center activation
Transfer and trauma center activation
Major trauma criteria local protocol dependent
Need for definitive surgical care unavailable
Need for neurosurgery unavailable
Hemodynamic instability requiring higher level care
Discharge criteria for minor injury patterns
Discharge criteria for minor injury patterns
Normal vitals sustained
Reliable exam and ambulation
No concerning imaging or labs
Reliable supervision
Clear return precautions
Discharge Instructions
Copy discharge instructions
Copy discharge instructions
You were assessed after an injury and no life threatening injuries were found today
Pain may worsen over 24 to 48 hours and then improve
Use prescribed pain medicine as directed
Avoid alcohol and sedating drugs while using opioids
Keep wounds clean and dry as instructed
Return to the ED now for
Trouble breathing
Chest pain that is new or worsening
Fainting
Severe headache
Repeated vomiting
Confusion
New weakness or numbness
Increasing abdominal pain
Black stool or blood in stool
Blood in urine
Uncontrolled bleeding
Increasing swelling or severe pain in an arm or leg
Fever
Follow up with your clinician within 2 to 3 days or sooner if worse
References
Guidelines and key sources
Core references
American College of Surgeons ATLS Advanced Trauma Life Support 10th edition 2018
ACS Trauma Quality Programs Best Practices Guidelines relevant modules 2020 to 2023
Eastern Association for the Surgery of Trauma practice management guidelines various topics updated regularly local protocol dependent
Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury 4th edition 2016
WSES guidelines on trauma and hemorrhage related topics various updates 2017 to 2023
NICE Head injury assessment and early management NG232 2023
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.