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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 medical students.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with TRAUMA can include:

Medical Knowledge Learning Topics related to TRAUMA:

1. Trauma services for initial evaluation and resuscitation in the hospital setting as well as pre-hospital services

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

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

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

4. Establishment of an airway appropriate to the patient’s condition

5. Wound care management

6. Basic surgical procedures:

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

7. Life-threatening problems requiring 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. Evaluation and management for common problems:

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

9. Evaluation and management for common minor problems:

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

10. Indications and 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. Fluid resuscitation of a trauma victim:

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

Diagnostic Evaluation Learning Topics related to TRAUMA

1. Four phases and principles of ATLS

2. Priorities and sequence of a trauma patient evaluation (ABC’s)

3. Age-appropriate medical history and 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

4. Differential diagnosis

5. Utility and interpretation of diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Consider test cost and performance characteristics as well as patient preferences

Management Plan Learning Topics related to TRAUMA

1. Indications, mechanisms of action, side effects, adverse reactions, and significant interactions of medications prescribed for trauma patients

2. Treatment for the trauma patient based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences when known

  • stabilization of the patient
  • demonstration of emergency airway management
  • insertion a variety of tubes as indicated
    • endotracheal
    • thoracostomy
    • urinary bladder catheter
    • intravenous
    • nasogastric tube
    • intra-arterial
  • application and removal of dressings and splints, including the vacuum pack dressing as indicated
  • creation and closure a variety of incisions and tie knots using sterile technique
  • assessment of nutritional needs and institute necessary nutritional support
  • formulation of rehabilitation plans for trauma patients, including physical therapy, occupational therapy, speech therapy and other rehabilitation services in the patient’s recovery

3. Diagnostic evaluation and initial management of blunt and penetrating mechanisms of injury:

  • closed head injury – consideration of Glasgow Coma Scale, ICP, subdural hematoma, epidural hematoma, diffuse axonal injury, basilar skull fractures & CSF leaks
  • spine injury – consideration of mechanism of injury, level of injury, use of steroids, immobilization, neuro exam, management of shock
  • thoracic injury – consideration of hemo / pneumothorax, tension pneumothorax, tamponade, pulmonary contusion, massive air leak, widened mediastinum, flail chest
  • abdominal injury – consideration of 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 – consideration of 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 – consideration of 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. Early management of a major burn:

  • 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. Recognition of suspected child abuse and domestic violence presenting as trauma and the physician’s role in reporting

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

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

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

9. Economic impact of traumatic injury and disability

10. Counsel patients about issues related to the cause of the injury

11. Trauma 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. Follow-up planning

Potential Differential Diagnosis Topics Include:

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