I get the fascination with trauma, especially if you work EM or EMS. I get to lecture at EM and EMS conferences, and I ask paramedics, “Hey, what topic do you want me to cover?” They say, “Trauma, we want trauma.” I get that as a guy who’s spent the majority of his career working critical access emergency medicine.
I get it. I get trauma and I’ve run my share of trauma codes. My best estimate on how many trauma codes I’ve run is between 10 and 20. It’s not my forte. With a medical code, I feel very natural at it. I feel very calm, very methodical, very structured and very competent at medical codes. I’ve had hundreds of medical codes. Trauma codes, I’ve always been limited because I don’t see a lot of it. I’ve never worked at a trauma center. So my approach has always been incredibly methodical.
I have the pleasure and privilege of taking advanced trauma life support again next month. This is the fifth time I’ve taken it. There’s a primary assessment approach that I want to talk to you about. It doesn’t make a difference where you practice, whether you practice as a paramedic, a PA or a doc, the cool thing about resuscitation is a structured approach. With a reproducible, structured approach, you do it every single time and you don’t miss things because if you miss something small on a trauma assessment, the patient dies.
The Four Ps
The first thing you do when getting ready to receive a trauma patient is the four Ps.
The first P is prepare. Know your resources. I normally work by myself in the middle of the boonies. So in my initial preparation, I ask myself, “Can I get X-ray on standby? How many units of O negative blood do I have? Who do I have as resources? Is there a backup doc that I can get in there? What is their training capacity? What are the strengths and weakness of my nurses?” So the first thing I do is prepare. If I know I have a trauma coming in, I prepare my troops. I round the wagons.
Number two, protection. I have to protect myself so I get gowned and gloved. I need a face shield mask because I don’t know what’s coming in. I have to be prepared to get splashed.
The third P is protect the C spine. As soon as they come in, my whole focus until I have a really clear mechanism of the trauma and I can rule out C spine injury, either radiographically or clinically depending on the scenario, is the C spine. I assume the C spine is fractured until proven otherwise.
The last P is peek. I have to peek at the naked body. I know that’s under E for expose, but my mindset is always, as soon as they’re coming in, I want to prepare and circle the wagons. I’m going to protect myself and all the staff, make sure that we’re gloved, gowned and masked appropriately. I’m going protect that C spine. That C spine is fractured until proven otherwise. The last thing is making sure I’m coming into a body that I can fully see.
Now we do the ABCs. The A is airway. Is it open and will it stay open and what tools do I have? Remember, I’m not extending the neck because that neck is broken until proven otherwise. Jaw thrusts, I’m going to have my suction available. Do I need an oropharyngeal airway? What are my tools that keep this airway open? It’s important; it’s critical. The first step is keeping this person from dying from an airway obstruction. What are my tools?
Second thing is, how do I get a definitive airway? Can I intubate this patient? If someone has a collar on, this is a more tricky intubation. Do I need to do a cricotracheotomy? Do I need to do a surgical airway on this patient? If I do jet insufflation, am I aware of how to do that and how to set that up? I have to understand its temporizing measure, but I’m ready for it. So for A, is the airway open? Will it stay open?
There are five things that I have to do on B, breathing. The first three of them are with my eyes. First thing I’m going to do is look at his neck. What’s his trachea doing and what are his jugular veins doing? Do I see tracheal deviation of jugular venous distension? Remember, the tracheal deviation points towards tension pneumothorax. Jugular venous distension points to three pathologies. Really, it points toward tension pneumothorax, it points to pericardia tamponade, and it points to CHF. Can someone have CHF and be a trauma patient? Absolutely they can. So, I’m initially going to look at their neck.
Then I’m going look at their chest wall. How are they breathing? What’s the depth? What’s the respiratory rate? Is there any paradoxical breathing? Is it symmetrical? Thirdly, I’m going to look up the O2 saturation. How is he exchanging gases? Then I’m going to listen. Do I have symmetrical lung sounds? Do I hear anything abnormal in the lungs?
And the last thing I’m going to do is start tapping; I’m going to percuss. Do I hear dullness or hyperresonance? So B, breathing. There are five things, look at the neck, look at the thorax, look at the O2 saturation. I’m going to listen and then I’m going to percuss.
C is circulation. Pulse and profusion, that’s what I’m looking for. I don’t want to get burned by not picking up that they’re bleeding into their belly, or they’re bleeding into their pelvis, or they’re bleeding femur fracture, and that’s why they’re dying. So, the first question, is there sneaky bleeding going on? That’s going to be hot on my radar. Then I’m going to assess their pulse. What’s the quality of their pulse, what’s the rate and regularity of the pulse? Is it symmetrical? Think about any aortic disruption.
Then I’m going to look at the skin and the capillary refill. Is it well profused? The last thing is blood pressure.
D is disability, which is three things. I’m going to do the Glasgow Coma Scale. I’m going to look at their pupils and look for lateralizing signs.
The last one is E, expose. You have to expose their body as part of the primary assessment. Remember our whole goal is to identify life-threatening problems and fix them right now. You have to roll them to know if something’s going on in their back that’s causing them to die that you could make an intervention on. So part of the primary assessment is E, expose. I have to log roll them, protecting the C spine in the process.
Test Tubes, Gut Gas
Then, what I’m going to do is cover my adjuncts. What are my adjuncts to the primary assessments? The mnemonic I’m giving you is test tubes, gut gas. Test tube, like a test tube baby. Gut gas, like you could have a carnal excretion of gases.
What tests do I want? I want an EKG, I want a chest X-ray, pelvic X-ray, and a blood gas. I want tubes. I want NG tubes and a Foley in the patient, making sure there are no contraindications, like massive facial trauma, thinking that the tube may go north instead of south. I make sure I can put a Foley in them, that they’re not a high riding prostate. There’s no blood at the medius, there’s nothing that makes me think there’s a disruption of the urethra.
So gut, do they have bleeding in their belly? Can I do a fast exam or peritoneal lavage? And then gases, I want to look at the exchange of O2 and CO2.
I present this material with a tremendous amount of humility because again, I’m not an expert at trauma. I’m a competent trauma provider, but what I can tell you is anytime I’ve taken care of a really sick trauma patient, I’m very methodical. I stay very focused and anytime I’m not sure what to do, I don’t know what to do next, I start over with my ABCs.
- Airway: Is it open and will it stay open?
- Breathing: Neck, thorax, O2 saturation, listen and percuss.
- Circulation: Pulse and perfusion. Is there any sneaky bleeding going on?
- Disability: Is anything going with the Glasgow Coma Scale? Their eyes are lateralizing symptoms.
- Expose: Did I completely expose everything?
And I’m using my adjunctive tests.
I’m still a critical access emergency medical provider, even though my full-time job now is education. I still pull shifts where I’m by myself and I need to be prepared because it could be you. It could be someone in your family driving by an area I’m working and they crash their car, and I need to be sharp.
I’m going to say the same thing to you. If you’re a paramedic, if you’re a nurse, doc, PA, nurse practitioner, I don’t care. But if you take care of acutely sick patients, how ready are you? How ready are you to take care of my daughter? If my daughter is near your facility, and something traumatic happens, are you ready for it?