Basic Trauma Overview - ABC

Dale Dangleben, MD, FACS

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Team

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Extended Team

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Team Leader Decrease chaos / optimize care.

– Remains calm
– Maintains control and provides 
direction
– Stays decisive
– Sees the big picture (situational 
awareness)
– Is open to other team members 
input 
– Directs resuscitation
– Makes early decision to transfer 
the patients that exceed the local 
capabilities

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Team Members

− Know your roles in the trauma team
− Remain calm
− Be responsive to team leader
−Voice suggestions or concerns

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Responsibilities

– Perform the Primary and secondary survey
– Verbalize patient care 
– Report completed tasks

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Responsibilities

– Monitors the patient
– Manual BP
– Obtains IV access
– Administers medications
– Dresses wounds
– Performs or assists in resuscitative procedures

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Responsibilities

 Records data
 Ensures documentation 
accompanies patient 
upon transfer
 Assists team members 
as needed

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Responsibilities

– Obtains needed 
supplies
– Coordinates 
communication with 
local and external 
resources
– Assists team members 
as needed

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 Responsibilities

• Place Oxygen on patient • Manage airway • Hold C spine

• Manage ventilator if  • Manage rapid infuser line 
patient intubated where indicated
• Assists team members as 
needed

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 Organization of trauma resuscitation area

– Basic adult and pediatric equipment for:
• Airway management (cart)
• IV access with warm fluids
• Chest tube insertion
• Hemorrhage control (tourniquets, pelvic binders)
• Immobilization
• Medications 
• Pediatric length/weight based tape (Broselow Tape)
– Warming capabilities

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D-MIST

Age, sex
Demographics
Mechanism/medical complaint Mechanism of injury
Injuries
Time of injury, list injuries,
Signs ( vitals )
Treatment inspections
First set of vitals, any changes,
include glucose
Any treatments
Only EMS is allowed to talk
during DMIST ( ~ 30secs)
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Primary Survey

A Airway ----- C spine

B Breathing
C Circulation
D Disability
E Exposure

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Identify Immediate life-threats

A Airway open? C-spine

B Breathing? Decompression

C BP, pulse? Control bleeding, IV access, fluids

D Disability? GCS, Pupils

E Exposure Keep warm,

look for hidden injuries

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Secondary Survey

Thorough Head to toe exam

– Head and Neck

– Chest
– Abdomen
– Pelvis
– Extremities

Can be delayed until all life‐threatening injuries 
have been dealt with …..

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History

A Allergies
M Medications
P PMHx
L Last Meal
E Events related to injury

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Adjuncts and tests

Adjuncts Diagnostic tests

•Pulse oximeter
•CXR
•Cardiac monitor
•Pelvic x-ray
•Foley catheter
•C-spine x-ray
•NG tube
•EKG
•Pregnancy test
•Labs

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Airway
Recognizing and managing acute airway compromise 
are two of the most difficult yet critical skills which 
the TEAM must master in order to adequately care 
for the trauma patient.  

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Airway: Preparation

Organized equipment
Supplies
Medications
Team skills

Immediate accessibility

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Recognizing Airway Compromise

Can be rapidly accomplished by talking to patient 
and eliciting answers to simple questions.

Look

Listen

Feel

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Recognizing Airway Compromise

 Head, neck and facial trauma
 Bleeding into airway
 Deformity/swelling
 Noisy breathing
 Burns
 Cyanosis
 GCS 3‐8

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Absolute Indications for Definitive Airway

Respiratory insufficiency
GCS 3‐8 
Severe maxillofacial injuries
Severe neck injury with soft tissue swelling
Persistent or uncompensated hemodynamic instability

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Relative Indications for Definitive Airway

 Agitation with possible injury to self or others
 Impending or potential airway compromise ( flail, large 
pulmonary contusion, pneumatocele )
 Potential neurologic deterioration during transport
 Prolonged transport time

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Airway: Basic Management

High‐flow (15 liters) oxygen by mask
– O2 sat monitor
In‐line stabilization
Chin lift
Jaw thrust
Naso/oropharyngeal airway
Bag valve mask assist

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Airway: Advanced Options

Laryngeal mask airway (LMA)
CombitubeTM or King airway
Intubation
– Orotracheal
– Nasotracheal
Surgical 
– Cricothyroidotomy

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Rescue Airways

Laryngeal Mask Airway King Laryngeal Tracheal Airway
LMA LTA

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Airway: Advanced Management

In‐line stabilization
Cricoid pressure (Sellick maneuver)
Choose airway method 
Medications
– Venous access
Equipment (endotracheal tube, laryngoscope, needles, tubing, bag, suction)

(Sellick maneuver)

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 Airway: Advanced Management

Rapid Sequence Intubation (RSI)
– Pre‐oxygenate with 100% O2 
– Support with bag‐valve mask
– Administer medications
• Sedate
• Paralyze
– Intubate

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Rapid sequence intubation

Induction agents
Etomidate is now considered the criterion standard of induction agents in its use in RSI.
Very short acting non-barbiturate hypnotic agent
Its advantages are rapidity of onset, short duration of action,
Lack of cardiodepressant effects, marked safety in patients with head injury

Ketamine has direct negative inotropic effect on the myocardium is masked

by an increase in blood pressure, heart rate, cardiac output, and an overall decrease
in myocardial oxygen consumption

Thiopental has limited role in the ED as induction agents because of their

cardiorespiratory depressant activity. Of all the barbiturates, these possess the
shortest onset and briefest duration of action

Propofol decreases cerebral metabolism and, consequently, ICP also it

is a myocardial depressant, causing a decrease in mean arterial pressure
(MAP). This is compounded by the decrease in the systemic vascular resistance
it causes. Both of these factors contribute to an overall decrease in oxygen
delivery.

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Confirm ET Placement

Listen to bilateral lung fields and epigastrium
Check position of endotracheal tube
Check end tidal CO2
Check O2 saturation
Check position of endotracheal tube with x‐ray

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Pitfalls

Inability to intubate
Esophageal or right main stem intubation
Development of tension pneumothorax 
Loss of airway 
– After paralytic administration
– Dislodged tube
Equipment failure

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Breathing: Impairment
Ventilation volume
– Pneumothorax and hemothorax
– Flail chest
– Diaphragmatic hernia
Mechanics 
– Paralysis
– Disruption of chest wall
Circulation
– Shock
– Tension Pneumothorax
– Contusion

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Breathing Assessment: Look

Chest rise and symmetry
Respiratory rate
Tracheal alignment
Soft tissue abnormalities
Subcutaneous emphysema

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Breathing Assessment: Listen
Breath sounds 
– What do you hear?

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Breathing Assessment: Adjuncts

Pulse oximetry 
Colorimetric end tidal CO2
Portable chest film
NG ‐ OG tube

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Breathing: Life-threatening Injuries

Tension pneumothorax

Massive hemothorax

Flail chest

Open pneumothorax
You will miss 30% of
pneumothoraces on supine
CXR’s

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Tension Pneumothorax

Respiratory distress
Unilateral absence breath sounds 
Shock
Distended neck veins 
Hyper‐resonance on percussion 

Needle Decompression
• Second intercostal space
• Mid‐clavicular line
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Massive Hemothorax

Hemi‐thorax filled with blood
High mortality rate
Mass effect (mediastinal shift)
Exsanguination

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Open Pneumothorax

‘Sucking chest wound’
Impaired ventilation

Treatment is 3‐sided dressing and chest tube

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Breathing Reassessment
How does your team reassess the patient’s 
breathing?
• Repeat primary survey 
• Assure patient is oxygenating 
and ventilating
• Adjuncts
− Pulse oximetry
− End‐tidal C02
− Chest x‐ray
− NG ‐ OG tubes

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Breathing: Treatments
Chest tube insertion
– What size chest tube?

5th intercostal space anterior to 
mid‐axillary line at infra‐
mammary crease

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Breathing Treatment: Pitfalls

Inaccurate pulse oximeter 
readings
Simple to tension 
pneumothorax
Improper placement of chest 
tube
Migration of endotracheal 
tube

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Breathing Summary

A team approach is critical to recognize and treat life‐
threatening breathing problems
Address breathing after airway is secured
Reassess after every intervention, being conscious of 
pitfalls
Team should have the skills and be prepared to 
intervene appropriately

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Circulation

The most common cause of shock in 
trauma is hemorrhage
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Circulation

Identify and control bleeding
Initiate resuscitation
Define and recognize shock in trauma
Anticipate pitfalls

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Trauma Bay Preparation

Warm room
Warm IV fluids
Dressings, splints, sutures, staples
Blood/blood products
Rapid infuser
Tourniquets
Pelvic binder

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 Circulation:
Physiologic Changes in Shock

Increased pulse rate
Decreased mental acuity
Narrowed pulse 
pressure early
Decreased capillary refill
Clammy skin
Decreased blood 
pressure
Decreased urine output

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Circulation: Vascular Access

Peripheral access
– 2 large bore IV's –
16 gauge or larger
– Blood drawn, 
if not already
Central access
Venous cut down
Intraosseous

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Hemorrhagic Shock

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Hemorrhage Control

Direct pressure
Close scalp lacerations
Reduce and splint fractures
Immobilize pelvic fractures
Tourniquet
Operating Room ( 
Lap/Thoracotomy etc ) 

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Circulation: Adjuncts
Urinary Catheter 
– Contraindications
• Blood at urethral meatus
• High riding prostate
• Scrotal/labial hematoma
Pulse oximeter
Lab evaluations
– H/H 
– Type and cross

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Circulation: Controlled Resuscitation

Stop bleeding as soon as possible
Tolerate systolic BP ‐ 90 – 100 until the hemorrhage is 
controlled
Continue resuscitation with blood after 
initial crystalloid

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Circulation: Resuscitation Guidelines

Continue resuscitation with blood after

initial crystalloid

Warmed IV fluid guidelines
– Adults ‐ 2000 cc of lactated ringer’s or saline
– Peds ‐ 20 cc/kg bolus x 2
Blood
– O negative or positive until type specific available

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End Points of Resuscitation

Improving mental status
Change in skin color and temperature
Improved capillary refill
Urine output begins or becomes adequate
Pulse normalizes
Systolic BP 90 to 100 mm Hg

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Rapid Responder

Stable endpoints after:
– 1 to 2 liters for adults 
– 20 cc/kg for children
Establish maintenance IV rate
Monitor for recurrent shock
Reevaluate ABC’s 

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Transient Responder

Shock recurs after initial fluid bolus
Reassess ABCs
Stop all visible bleeding 
Blood or repeat initial crystalloid, to keep systolic BP at 
90‐100 (Peds – refer to chart)
Alert OR 
Alert Blood bank ‐ Check amount of blood availability

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Non-Responder

Shock persists in spite of fluid resuscitation
Reassess ABCs
Stop all visible bleeding 
Transfuse as soon as possible
Alert OR 
– Damage control surgery
Blood and blood product availability ( MTP )

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Persistent Shock

Hemorrhagic
– Unrecognized or uncontrolled bleeding
Non‐hemorrhagic 
– Cardiac tamponade
– Tension pneumothorax
– Neurogenic shock
– Myocardial infarction
– Massive gastric distension (peds)

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Circulation: Pitfalls
 Failure to:
Over resuscitation
 Recognize compensated shock
– Increase BP = increase 
bleeding if   Recognize patients on beta blockers 
bleeding not controlled have blunted response
– Pulmonary edema  Realize tachycardia more significant in 
– Hypothermia
– Coagulopathy pediatric patients
 Decompress stomach of pediatric 
Under resuscitation patients
– Usually not enough blood   Recognize patients on anticoagulant
given
– Bleeding not controlled

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Circulation: Summary

Team and facility preparation
Identify and control bleeding
Begin resuscitation
Define and recognize shock
Define management options
Anticipate pitfalls

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Trauma is a Dynamic Process

Continual reassessment is necessary to identify:
Changes in patient’s condition
Possible ongoing blood loss 
Response to interventions
Iatrogenic problems
– Tension pneumothorax
– Loss of vascular access

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 WE

ARE

CREATING

GUIDELINES

UTILIZE THEM

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 END
( Until next time ) 

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