Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Trauma

Trauma is a serious injury to the body, resulting from violence or an accident, in many cases life-threatening. When a trauma patient arrives, very little is known and rapid stabilization, assessment and treatment must be accomplished. Because of the differential diagnosis and multiple system involvement, trauma cases are important training experiences for third year medical students.

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Prerequisites

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Describe and discuss:

  • anatomy and physiology of all systems susceptible to traumatic injury
    • central nervous system
    • genitourinary system
    • cardiovascular system
    • extremities
    • pulmonary system
    • gastrointestinal system
  • basic physiology of the circulating system and changes that occur due to shock
  • basic techniques of evaluation and resuscitation of trauma patients using the American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) protocol

Demonstrate:

  • ability to take a medical history
  • ability to perform a physical exam
  • basic communication skills

 

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe the trauma services needed for initial evaluation and resuscitation in the hospital setting as well as the appropriate pre-hospital services.

2.     Describe the four phases and principles of Advanced Trauma Life Support (ATLS), to include:

  • primary survey (ABCs)
  • resuscitation
  • secondary survey
  • definitive care  

3.     Describe priorities for the diagnosis and/or assessment of illness/injury for patients presenting to the emergency department.

4.     Describe the considerations for establishing an airway appropriate to the patient's condition.

5.     Describe wound care management.

6.     Describe indications such basic surgical procedures:

  • laparotomy
  • debridement of injured tissues
  • FAST ultrasound
  • splinting
  • thoracostomy
  • hemorrhage control

7.     Describe typical case scenarios for the following life-threatening problems requiring appropriate urgent/emergent action:  

  • multiple system trauma
  • shock
  • traumatic head injuries
  • chest injuries (penetrating and blunt)
  • abdominal and pelvic injuries (penetrating and blunt)
  • vascular injuries (penetrating and blunt)
  • burns, including inhalation injury
  • poisoning
  • hypothermia
  • massive hemorrhage due to coagulopathy

8.     Describe principles of evaluation and management for the following problems:

  • drug abuse and suicide attempts
  • seizures/coma
  • facial injuries
  • hand injuries
  • long bone fractures

9.     Describe principles of evaluation and management for the following common minor problems:

  • evaluation of lacerations
  • wound treatment
  • surgical repair of wounds
  • appropriate dressings
  • wildlife injuries (animal bites, insect and marine envenomations)
  • dental/oral emergencies

10.  Describe the indications and appropriate methods for:

  • nasogastric tube (NGT)
  • urinary bladder catheter
  • chest tube (CT)
  • central venous line (CVL)
  • arterial line ( AL )
  • insertion of chest tubes
  • decompression of tension pneumothorax
  • pericardiocentesis
  • external/transvenous pacemaker placement
  • cricothyrotomy
  • emergency thoracotomy
  • nasopharyngeal or oropharyngeal airways
  • endotracheal intubation (oro- and naso- pharyngeal)

11.  Describe and discuss appropriate fluid resuscitation of a trauma victim including: 

  • choice of IV access
  • choice of fluid and use of blood components
  • the differences between adult and pediatric resuscitation

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Diagnose

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1.     Describe the four phases and principles of ATLS.

2.     Describe the priorities and sequence of a trauma patient evaluation (ABC’s).

3.     Obtain, document and present an age-appropriate medical history.

4.     Perform a physical exam to establish the diagnosis and severity of injury:

  •  primary survey:
    • A B C D E
  • secondary survey:
    • head/skull, maxillofacial, cervical, spine, chest, abdomen, pelvis, perineum, orifices, neurological, musculoskeletal, diagnostic tests/definitive care

5.     Generate a prioritized differential diagnosis.

6.     Recommend when to order diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering them and include consideration of test cost and performance characteristics as well as patient preferences. Interpret the results (with consultation). 

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Develop a Management Plan

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1.     Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for trauma patients.

2.     Design an approach to treatment for the trauma patient based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences when known.

  • stabilize the patient
  • demonstrate emergency airway management
  • insert a variety of tubes as indicated
    • endotracheal
    • thoracostomy
    • urinary bladder catheter
    • intravenous
    • nasogastric tube
    • intra-arterial
  • apply and remove dressings and splints, including the vacuum pack dressing as indicated
  • make and close a variety of incisions and tie knots using sterile technique
  • assess nutritional needs and institute necessary nutritional support
  • formulate rehabilitation plans for trauma patients, including physical therapy, occupational therapy, speech therapy and other rehabilitation services in the patient’s recovery

3.     Describe the diagnostic evaluation, differences between blunt and penetrating mechanisms of injury and the initial management of:

  • closed head injury - consider Glasgow Coma Scale, ICP, subdural hematoma, epidural hematoma,diffuse axonal injury, basilar skull fractures & CSF leaks
  • spine injury - consider mechanism of injury, level of injury, use of steroids, immobilization, neuro exam, management of shock
  • thoracic injury - consider hemo / pneumothorax, tension pneumothorax, tamponade, pulmonary contusion, massive air leak, widened mediastinum, flail chest
  • abdominal injury - consider role of physical exam, ultrasound, CT, operative vs. non-operative management of liver and spleen injury, which patients need urgent laparotomy, management of hematomas
  • urinary injury - consider operative vs. non-operative renal injury, ureteral injury, intraperitoneal and extraperitoneal bladder injury, urethral trauma, when not to place a Foley, candidates for cystogram, relationship to pelvic fracture
  • orthopedic injury - consider open vs. closed fractures, compartment syndromes, concepts of immobilization (splinting, internal fixation), treatment of patients with pelvic fractures, hemorrhage control, commonly associated vascular injuries

4.     Describe the early management of a major burn. Discuss:

  • estimation of total body surface burn and burn depth
  • fluid resuscitation, choice of fluid and monitoring for adequacy of resuscitation (rule of 9’s, differences in pediatric and adult management)
  • options for topical antimicrobial therapy
  • inhalation injury, CO poisoning and triage of patients to burn centers
  • the basic principles of wound coverage, skin grafting, and timing
  • the assessment and need for escharotomy

5.     Describe the recognition of suspected child abuse and domestic violence presenting as trauma and the physician’s role in reporting.

6.     Describe the importance of careful documentation in the medical record for traumatic injury and the basic concepts of a “trail of evidence” in victims of assault.

7.     Communicate the diagnosis, treatment plan, rehabilitation plan and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of the injury and recovery and its potential effect on lifestyle (work performance, sexual functioning, etc.).

8.     Describe the effects of trauma on the individual’s ability to return to full health and employment.

9.     Discuss the economic impact of traumatic injury and disability.

10.  Provide counseling to patients when indicated about issues related to the cause of the injury.

11.  Understand prevention including:

  • the importance of passenger and appropriate infant restraints in motor vehicles.
  • the role of helmets in preventing head injury in motorcycle, bicycle, and roller blade accidents
  • the significant influence of the use of drugs and alcohol in a large percentage of traumatic injuries including assaults, burns, and motor vehicle accidents
  • the value of smoke and carbon monoxide detectors, and evacuation drills in reducing mortality and injury

12.  Refer for psychological support if indicated.

13.  Access and utilize appropriate information systems to ascertain information about health system and community resources.

14.  Plan for follow-up.

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Differential Diagnosis

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Multiple Trauma

  • ABCDE
  • blunt
  • penetrating 

Specific injuries 

  • thoracic 
    • pneumothorax
    • tension PTX
    • hemothorax
    • rib fractures
    • flail chest
    • pulmonary contusion
    • tracheobronchial rupture (extra credit, Kim Lomis – rare injury)
    • cardiac tamponade
    • cardiac contusion
    • aortic rupture
    • aortic dissection
    • diaphragmatic rupture
  • abdominal 
    • splenic injury
    • hepatic  injury
    • hollow viscus rupture
    • vascular injury
    • pancreas
    • kidney
    • potential for missed injuries
  • pelvic fracture 
    • associate genitourinary
  • head 
    • facial/scalp lacerations
    • facial fractures
    • concussion
    • diffuse axonal injury
    • contusion
    • epidural hemorrhage
    • subdural hemorrhage
    • subarachnoid hem
    • intracerebral hem
  • spinal 
    • fracture
    • dislocation
    • ligamentous inj
    • cord injury
  • penetrating cervical 
    • tracheal injury
    • esophageal injury
    • vascular injury
  • extremity 
    • dislocation
    • fracture
    • open vs closed
    • vascular
    • traumatic amputation
    • compartment syndrome
    • fat embolus
  • burns 
    • epidermal, partial vs full-thickness
    • %TBSA
    • inhalation injury
    • assoc traumatic inj
  • hypothermia 
  • special populations 
    • Peds
    • Pregnant Women
    • Elderly
  • abuse