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EPA Playbook: Blunt or Penetrating Trauma · Behind The Knife: The Surgery Podcast

• Trauma EPA === [00:00:00] Welcome back to the EPA Playbook, our series where we explore entrustable professional activities for general surgery residents. I'm Patrick Georgoff, and with me today are two of our fantastic BTK Surgical Education Fellows. Dr. Agnes Prem Kumar from Creighton, and Dr. Emma Burke from Baylor, and today's episode is focused on the best of all topics, and that is the management of trauma patients. Specifically, we're gonna be talking about how you manage those trauma patients in the bay. To recap, EPAs matter because they translate the abstract language of competencies into the real work you do every day. As a surgical resident, each EPA defines a professional activity. You must eventually be trusted to perform independently. EPAs may also make feedback more meaningful by increasing objectivity and by providing more data points across time, specialty case type, and case complexity. When you demonstrate consistent entrustment on EPAs, it accelerates your progression towards independent operating [00:01:00] and decision making. And that's why we've created the series. It's a perfect way for junior residents to dominate EPAs. Today we're gonna walk through two cases, one blunt and one penetrating, and focus on what residents are expected to do in the trauma bay from the primary survey through the initial resuscitation. But first, we're gonna start with a framework for approaching the sick trauma patient. That's right. And this is a very. Hairy time as a resident, when you step for the first time into the trauma bay and you're leaving the charge and patients are sick and they're trying to die, and there's a big multidisciplinary team in there, it can be heroining. And so this is one of the first steps to understanding the practical aspects of what you can do in the trauma bay. Now let's start with A TLS Advanced Trauma Life Support. This is the absolute bedrock. It's the foundation. It's the framework by which. Everyone around the world frankly works from when it comes to trauma. So as a surgical resident, you'll be expected to go through A-T-L-S-I [00:02:00] highly encourage you to know it well, it is so absolutely important. Having that framework in mind as you approach complex patients is absolutely critical, and we actually have a lot of really fantastic trauma. Content, I'm behind the knife and one of those is a trauma survey video. So it's about 20 minutes long. How you do the trauma survey, it's the basis, it's like a TLS encapsulating into a 20 minute video. But Agnes, let's start with the primary survey. What's number one in the primary survey? 'cause guess what, it's not actually a anymore. Yeah, with the A TL is 11th edition updates, actually X, which is exsanguinating hemorrhage or life threatening bleeding that needs to be addressed. Yeah, that's exactly right. And it was July of 2025 that the American College of Surgeons Committee on Trauma updated A TLS to the 11th edition that Includes XA, B, C, D, E, and again, this is recognition of what largely trauma surgeons had [00:03:00] been practicing before this, but that you really wanna stop bleeding right way. So it could be as simple as someone's. Got it. Maybe a penetrating injury to the femoral artery and blood squirting all, all over. What's the first thing you're gonna do there? It's not start with A, B, C. You're gonna put your hands on that bleeding and try to make it stop, right? So pack that wound, get your hands in there, maybe put a tourniquet on, you wanna directly address that bleeding before moving on, to the next steps. And there are also some other considerations about how bleeding management like resuscitation and getting IV access. Even interacts with things like airway or breathing where you might consider intubating the patient. So we'll come back around to hemorrhage control and how this interacts with c circulation in a moment. But Emma, let's move on to airway then. A, what are we looking for when it comes to airway? So the key to evaluating the airway is checking for patency, and that is just the signal that air can move all the way from the mouth into the lungs. It's not really assessing breathing yet at this point. Yeah, so you roll into the Bay, you ask the [00:04:00] patient their name and they say their name and you yell out, airway is patent so everyone can hear you. The person keeping records knows, it's clear. However, I think it's really interesting, right? What is a patent airway when it comes to trauma? So it's pretty easy to see what a non-paid airway would be. Let's say someone, God forbid, gets shot in the neck. Or the throat, or they fell from a couple stories up, landed on their face and they have terrible facial trauma. Well, if the bones are crushed and there's bleeding and there's swelling and the oral pharynx, that is a non-patent airway and we can all see that, right? So there's three kind of brands or buckets of patients. Flavors of patients in which an airway may not be patent. Number one is direct injury. Okay? Number two, is altered mental status. Which is something we don't really think about. So your airway in and of itself could be totally, normal. And yet if you can't quote, protect that airway, then your airway may not be patent. So maybe you have a really bad [00:05:00] TBI or intracranial hemorrhage or a lot of drug use or alcohol use causing augmental status. Or the third within that group is you're so hypoperfused from hemorrhagic shock. Your GCS drops, and in these patients, they're not protecting their airway anymore, and the airway is no longer patent, and that is simply a matter of the retro pharyngeal structures, your tongue, the soft tissue falling back into the back of your throat, causing that just sound where people can't breathe. There's also some degree of higher functioning in your brain that's required to swallow, cough and clear secretions. So just because the patient doesn't have a grotesque. Injury in which you have physical blockage of the airway doesn't mean their airway is not patent. The third one to consider in this brand or flavors of patients would be burns, especially inhalational injury. These can be sneaky, it can be not so severe, then suddenly very severe. And so when we talk about managing airway, there is really [00:06:00] an escalation of, interventions that we would proceed with to try to make someone's airway more patent or better for us to work with. One is suctioning, right? So if you have blood or secretions, you can suction those out. You can also consider, a chin lift or a jaw thrust. You have to be careful if it's a blunt injured patient who has a c collar on the chin lift is not, what you wanna be performing, but a jaw thrust is, almost always okay in trauma patients. You can consider things like a nasal pharyngeal airway, which is a thin tube that goes into the nose and into the oral pharynx, and it goes deep enough into the oropharynx that it stents open that floppy tissue. So that maybe if you're using something like a bowel bag valve mask, you have a more direct pathway into the airway. Same thing for an oral pharyngeal airway that holds the tongue and the retro pharyngeal soft tissue up and out A bag valve of mask, right? Those big, usually purple or bluish colored bags with the mask that goes on people's face is an extraordinarily important tool in the world of trauma. [00:07:00] Knowing how to get a good seal with the mask and how to appropriately use. The bag valve function is critical. This can be a life-saving intervention in someone who, is in between maybe intubation or just needs to have an increase in their oxygenation and ventilation. Of course, then endotracheal, intubation and cricothyrotomy are key parts about this. If cricothyrotomy in the can't ventilate, can't oxygenate situation in which you're unable to intubate the patient from above, you'd want to consider an incision on the front of the neck to put a cricothyrotomy in. We have some great videos of that, within our trauma surgery video atlas that explains the exact steps to that. Okay, so we kind of talked about this. Agnes, you told me that in the 11th edition we have this, the X ABCs for the ex sanguine patient. And I had mentioned this relates maybe to intubating. So what are the two, how are these two? I think we just need to be aware that patients who have hemorrhagic shock, the impact that we can do on their hemodynamics with [00:08:00] induction medications and positive pressure ventilation. Yeah, that's exactly right. So the physiology of this is pretty interesting, right? If you and, Emma, Agnes, myself, we're sitting here talking on the podcast, and when we take big, deep breaths, our diaphragm contracts, and it drops down, chest wall expands and air is sucked into our airway, right? And then it recoils and pushes air out when we exhale. Positive pressure ventilation is the complete opposite. You're jamming air in for inspiration, and you are relying again on that elastic recoil for expiration. So why does that matter? Well, if you guys remember the Starling curve, you have end diastolic, volume or filling on the x axis and. Cardiac output and the y axis, you remember there's a steep part of the curve and a flat part of the curve. And all of us here today who aren't dying from hemorrhagic shock are on, should be on the flat part of the curve. And if you intubate me right now and you give some positive pressure ventilation, that's gonna, it decrease the end diastolic volume filling. But it's really not gonna have a huge impact in my cardiac output 'cause I'm on the flat part of [00:09:00] the curve. In the world of trauma, if you have hemorrhagic shock, your tank's already empty. You're on the steep part of the curve, positive pressure. Ventilation can decrease filling from the SVC and IVC into the heart leading to a decreased cardiac output. It can have a major impact on hemodynamic stability. And the second thing, Agnes, that you mentioned. Is the induction part of it. We give patients RSI, rapid sequence intubation, drugs, something like ketamine or atomic to make them not remember and then paralytics so that we relax the airway, the vocal cords to be able to more easily place an then be tracheal tube. Well. If you have a patient who's in true hemorrhagic shock, when you feel their extremities, they're cool, cold clamped down. That's because the body's redirecting blood flow to the central portions of the body, like the head, the heart, all those important areas. Well, when you get paralytics, everything relaxes, and then that blood pressure, that blood redistributes to large area, and you can have your blood pressure drop. So critically important that when we think about this x. A, B, C, [00:10:00] X and then airway is that anytime it's possible and sometimes it's not because the, patients are too sick anytime it's possible. We wanna use our adjuncts like a, a oral pharyngeal airway and a bag valve mask to manage ventilation while we get access, while we get blood to tank that person up before. We proceed with intubation. And really you want to know, you really wanna be thinking about, do I have to intubate this patient right now? Because a lot of times if you don't absolutely have to do it, it's usually better to hang tight a little bit, get the rest of your primary survey done, get some of your adjuncts done, like chest x-rays and other things, because then the picture just becomes more clear to you and you'll know, is it safe to proceed with that? Do I need to proceed with that right now? And sometimes by giving people, resuscitating them ideally with blood. Things like their mental status that you might be intubating for 'cause they're, they're ex zonked that will improve maybe if they're hypotensive. So alright, that was a, let's talk about, breathing. Emma, it's pretty simple, right? What are we doing on our primary survey [00:11:00] when it comes to B breathing? So here, you're gonna listen and look. You're gonna pull out the stethoscope, you're gonna listen bilaterally for lung sounds, and you're also gonna look at the movement of the chest wall. That's exactly right. And it really, the key part is that auscultation, do you hear normal breath sounds? Are they distant? Are they absent? And the main thing we're looking out for here, again, with the primary survey being a way that we look for life threatening problems is tension physiology from either a tension, pneumothorax or hemothorax. It can be non tension too. We wanna know about that. But that tension physiology, it can kill people. It can kill people in minutes. And this is when we start talking about chest tube placement. Chest tube placement is a critical skill when it comes to general surgeons in the world of trauma surgery. It is life, saving. And in our trauma video playlist, we have a great video on step by chest step placement of chest tubes. Okay. C circulation. So, we are looking for signs of hemorrhage like we talked about. That's more in the [00:12:00] X area, but more so like, do we have a pulse? So a lot of people get confused. They say circulation is the best blood pressure and heart rate. That's not true. Your vital signs are actually an adjunct. It's not part of the primary survey when it comes to see what's part of the primary survey is checking for a pulse. Usually you wanna start with a central pulse. The vast majority of traumas are blunt in nature. Oftentimes they'll have a C collar around, so getting to the carotid is hard. That's why the femoral iss often the best place to go to feel for a central pulse. And you can describe that central pulse. Is it strong as it weak? You can also check peripheral pulses. That's also useful too, like a radial pulse. For example, if you have a radial pulse, your systolic blood pressure is almost certainly above 90 millimeters of mercury. When we look at patients though, so we're checking for a pulse. Yes. No strong or weak. We're also looking for signs of hemorrhagic shock. On physical exam, what are you looking for there? What can you see? Yeah, so these signs could be things like altered mental status. If you think back to your classes of [00:13:00] hemorrhagic shock, you know that when you're in shock, your mental status is affected as well. You can look if the patient has cool extremities, if they are palor, if they're diaphoretic, if they have delayed Capri refill. All of those clues you in that they might be in shock. That's really important and we'll come talk a little bit more about the shock index, people can compensate a lot of the trauma patients are young people previously healthy driving to work, right? And they can compensate. A liter and a half, even two liters of blood loss before you really start seeing major changes in vital signs. So these physical exam findings, gons, that you mentioned are so important as a trauma surgeon to clue in and say, oh man, yeah, maybe their heart rate and blood pressure aren't terrible, but they have cool, a clammy extremities that tells you an awful lot. You don't want to miss that. So one of the other things to keep in mind, and we'll come back to this when we talk about our adjuncts and how we mix them into the primary survey, things like chest x-ray and, and fast exams, is you're really thinking as a resident [00:14:00] when you're running that bay, you're really thinking, okay, where's this patient bleeding from? Because you take a step back. How do trauma patients dying? They die from terrible brain injury. That stinks. There's only so much we can do about that or they bleed to death. It's about 50 50. Guess what? We can save those patients' lives when they bleed. And that's where trauma patients get their kits. So if someone comes to the trauma bay and they have altered, vital signs, if they're looking tachycardic type ofensive, either the first, you know, answer is hemorrhagic shock, right? The second cause is hemorrhagic shock. The third cause. It's hemorrhagic shock, right? So we're really interested in using our primary survey and our adjuncts to say, Hey, where are they bleeding from? 'cause if they're, if it's hemorrhagic shock, you need to get blood in and go to the OR to make the bleeding stop. That's how you're gonna save their life. It's very simple. The a TS structure and the, and especially the primary survey and adjuncts, are designed to allow us to allow, Emma, if you're a mid-level resident, you're standing in the bay and the patient's super sick and you're confused. Stick with the primary survey, [00:15:00] stick with the adjuncts. 'cause it's gonna start giving you information to say, oh, I think they're bleeding to death in their belly. Well, guess what? Then boom, green light. You go to the operating room, you do your laparotomy. So as things get more and more hairy, you wanna step back and you're always, remember you're doing your primary survey and adjuncts to try to get a better idea of. Are they bleeding to death? And do I need to go to the operating room or can I go to the CT scanner? That's where you're going in a real, in a truly safe trauma patient, it's a split, am I going to this or am I going to the CT scanner? I remember when I first heard this idea of someone asking the trauma surgeon said, Hey, where can people bleed to death from? I'm like, well, you can bleed to death from anywhere. Right. Well, it's actually useful to think about these things and to say them in your brain and when you're in the bay looking at the patient to be able to plan your next step. So. Patients can bleed to death in the chest. They can bleed to death in the abdomen. They can bleed to death in the peritoneum, oftentimes can be linked to pelvic fractures. If they can bleed to death from their extremities specifically into their thighs, and they can bleed to [00:16:00] death, on the floor, which would oftentimes be exsanguinating out from oftentimes extremity injury or really sneaky from a scalp laceration, terrible scalp lacerations that continuously lead. So why does this matter? This matters because it allows you to frame in your mind and have a mental model for what to do next. Tachycardic, hypotensive, not responding to products. I'm using my primary survey and my adjuncts to find chest, abdomen, retroperitoneum, extremity, or floor. That's gonna tell me am I gonna do a laparotomy? Am I gonna do a thoracotomy? Am I gonna put a suture in this big scalp last race and wrap the head really tight? What am I gonna do? Your adjuncts really help you find these things out. So chest. Okay, chest x-ray, abdomen, fast exam. Pelvis and retroperitoneum difficult, without a CT scan. But let's say you have a nasty pelvic fracture and everything else is negative. That might point you in the right direction. Extremity, look at the extremities, see if's bleeding, put your hand on the thighs, make sure you don't see anything bleeding [00:17:00] externally and on the floor slash the scene. Look at their entire body, look at their scalp, especially, and listen to EMS. If EMS comes in and said, holy moly, dude, this guy had a ton of blood at the scene. Believe them and recognize their priority way behind where you want them to be. Alright, so we're still talking about circulation here. So Emma, as part of circulation, having IV access is critical. So what are the three main types of access that you think about? My three main types are going to be peripheral IVs, iOS or Intraosseous lines, and then central venous catheters. And when I'm considering which one to do, we're thinking about. Not only the flow rate for each, but also how quickly we can get any of these established. Yeah, I love that you say that that is the appropriate way to think about it. All three are useful. Okay. But all three have different characteristics and two characteristics which should focus on are flow, rate, and difficulty or time to placement. For all hemorrhagic [00:18:00] shock patients, if you had an instantaneous subclavian line great. Crank a lot of fluid in you're, you have blood in, you're happy. Right? But that is amongst the three things you mentioned, pvs, iOS, and central lines is the hardest to place. It usually takes the longest to place. Guess what the easiest is in io? iOS are O almost foolproof almost, but flow rates are not as high. So you really wanna look at these patients and. If you have to use a combination of access points, I would say the starting point is peripheral IVs. Ideally ultrasound guided with higher success rates. And we all know at our institutions, if you get that really good nurse who's sweet when it comes to per peripherals, and that's amazing. How many peripherals do you need for quote unquote, adequate access. There's no right answer, but you need two or three, ideally. Three. You need sixteens and eighteens. Okay? If you have 2 22 gauge IVs, that's not enough. Flow is too low. Uh so I think this is extremely [00:19:00] important. And, and why are we harping on this? Because if the patient's trying to die on you and they have low blood pressure, well guess what? Getting IV access is really challenging. And so you need to be ready to use each and all of these things sometime in combination to ensure you get adequate rapid IV access to start with resuscitating the patient. So agonist, when it comes to resuscitation, what do we wanna give these patients? The preferred resuscitation is with whole blood, but if you don't have it on hand, you wanna do a balanced transfusion of one to one. To one. Yeah. So whole blood is the best. There's a large, amount of data now that clearly supports that. The best thing to give bleeding trauma patients is give that whole blood right. Whole blood is best, and the presence of whole blood in centers across the United States and even in the pre-hospital setting is growing rapidly as it should be if you don't have whole blood. Or more importantly, maybe if you do have whole blood, you'll oftentimes run out of it. Whole blood is not as available as component therapy. PAX cells, FFP, platelets and cryo. [00:20:00] So you have to understand if you don't have it, then recreate whole blood. Recreate it with a one-to-one to-one balance transfusion. What does that mean? One to one-to-one. Well, you're just matching those components to recreate whole blood. Now, the tricky part about this is if you're actually stacking up bags, it's not one-to-one to-one. You should have an equal stack of PVCs and FFP and you should have a one fifth size or one sixth size stack of platelets. That's because a single bag of platelets is a five or six pack, which is pooled donors from five to six people, as opposed to one bag of pbcs is pbcs from one person. So if you stack it up, it's five pbcs, five FFP, one bag of platelets. Okay, now. These component therapies or any blood that comes in a bag has calcium removed. Calcium is absolutely critical to blood to clot. If you don't have calcium, blood doesn't clot. You don't want the blood to clot in the bag, therefore you take the calcium out, you chiate it out. That means that you're [00:21:00] giving a bleeding trauma patient, someone who you want to clot off that injury. Ideally, you need to give calcium. So how much calcium do you give? When do you give it? You should be giving calcium at a minimum after your fourth unit of any type of product. Maybe even before that, if you know you're on the, the path to massive transfusion, you can give it after the first two units, what do you give? You can start with a gram of calcium chloride that'll cover you. Typically, we give calcium chloride through central lines in an emergency situation with a quality working peripheral iv. Don't be shy. You can put it through there and the patient will be okay. Again, if that IV works well, you can also use calcium gluconate, but remember, calcium gluconate is somewhere between. Around a third, a little bit more, elemental calcium than calcium chloride. So you wanna give, usually if you're doing one gram of calcium chloride, you wanna give two to three grams of calcium gluconate. Last is TXA tranexamic acid. We're not gonna go into that. The vast majority, if not all major trauma centers, who are [00:22:00] using a, massive transfusion protocol to treat their hemorrhagic shock, patients will incorporate TXA into their algorithm. You can give it as a one gram bolus followed by a one gram infusion. More often now, people will give it as a two gram bolus up front. We're not gonna go into the details. That literature are really interesting and how it works is not entirely sorted out, but by and large, we know that it's, very likely, certainly safe and should be part of a massive transfusion protocol. So Emma, massive transfusion. Let's go into that a little bit more because. If you're the resident in the bank and you're making the decision to pull the trigger, you wanna have an understanding of what we're talking about here when it comes to MTP. Yeah. So, you know, I think the first time you order MTP too, it can be really scary because it. MTP protocols can be different across institutions, and you might not know what's gonna show up in your cooler, especially if it's the first time you've ordered it. So all MTP or massive transfusion protocol is, is a process that streamlines, the coordination and delivery of large [00:23:00] quantities of blood products for transfusion. And so a lot of it actually has to do with logistics as well as product delivery. We consider initiating MTP if patients have persistent hemodynamic instability, active bleeding, or an assessment of blood consumption score of two or more and that a, b, C score. Patients get a point for a heart rate over one 20, a systolic blood pressure less than 90 a positive fast or penetrating torso injury. And the positive predictive value of the A BC score is only about 50%. But the negative predictive value is less than 5%, meaning it identifies about 95% of patients who are going to need a massive transfusion. Yeah, and guess what, what you don't want to have happen is you sitting there needing blood and you don't have it because you didn't make the trigger to call so low threshold to call for blood. And every blood program is different in every different trauma institution or hospital. And so you need to understand how you get that blood. It may be, signing a little form and having a runner go get blood. It may be an automated system in [00:24:00] Epic, it may be a blood refrigerator in the Bay. You need to understand that process because you do not wanna get caught with your pants down and no blood available as the patient's trying to die on you. That is extremely, uncomfortable situation. Alright, let's go into D disability. So Agnes, what are we looking at in disability? The two main things in disability are GCS and a pupillary exam. Yeah, so GCS, blast, glaucoma Scale, we have the, three different components, being eyes, a verbal and motor, and, it's kind of confusing, like even still, I've been doing this for a while and it's like, are they mumbling or they saying incoherent words? I don't really know. At Duke, we've put up GCS, signs in the bay and I will literally look at it and together with the team, we'll go through, okay, e is this. A verbal is this motor is this. And we'll look at the, poster together to ensure that we're being as accurate as possible. It's also a good point that you wanna frequently reevaluate. If you worry about neurologic injury and things are dynamically changing, you're resuscitating, whatever it may be, reevaluate the GCS score. Document it, know it. Pupilary exam can give you a window into people's [00:25:00] brains. The most obvious and, egregious thing being a blown pupil would make suggest badness inside. Of the head of note, a lot of times rising, get confused about spinal cord injury. You can be paraplegic, quadriplegic even, and have a normal GCS. Remember, GCS is about mentation, it's about your brain. It's not about the motor function of your extremities. So you can have a terrible spinal cord injury and have a normal GCS. Specifically, uh, you know, eyes verbal that may not be involved. You say, well, what about motor? Well, you can tell a patient, stick out your tongue. Go side to side. They're following your motor commands. This is about brain function and mentation not about the spinal cord. So, e exposure, we want to expose the entire patient. A patient comes in line on their back. Let's say it's a blunt trauma. They're on a board. They have a collar on their neck. You're only gonna see the front half of that. Okay. If it's a penetrating patient, you especially need to see the whole body 'cause you wanna see if there's any holes anywhere. So we're gonna roll every patient as part of the primary survey. If you have any concern about spinal cord injury, they're gonna be log rolls so you don't monkey with their spine at all. And you wanna take a good hard look at everything. [00:26:00] When it comes to penetrating wounds, you wanna be very careful. Small caliber hand handguns, for example, have L really small holes. If they're bleeding from one part of their body and blood's all over their back, it's very easy to miss, like a little tiny wound back there. You wanna be very careful. Look in the axilla, look in the groins, et cetera. Don't miss holes. And oftentimes we'll put radiopaque and we should be putting radiopaque markers, stickers, whatever it may be, of any kind onto the skin where there's holes on the outside, so that when you get imaging, you can start trying to think about trajectory of that penetrating, injury. And as soon as we're done exposing that patient, we wanna cover them with warm blanket. The cold area trauma patient gets, especially if it's a bleeding trauma patient, the closer you get to the diamond of death and this terrible trauma induced coagulopathy where everything goes to hell, you wanna keep the patient warm when you can. Alright, primary survey, we've covered it. Extremely important that you have that down pat and understand how you're working through it. Let's talk about adjuncts 'cause it's not secondary survey, it's notes. Okay? What we're talking about today are patients who are [00:27:00] actually sick, they come to you sick. We have lots and lots of patients at every trauma center. Even the biggest, baddest trauma centers where it's an old person who fell. That is what happens in trauma. You know that's not what I'm talking about right now. So the secondary survey only occurs after the primary survey is complete. You've done your adjuncts and the page is not trying to die on you. If we don't care about a secondary survey until those things are done, and oftentimes if the patient needs to go immediate, the operating room, they're not gonna get a secondary survey. That's okay. Now, you can't do a secondary survey quickly and efficiently. And when it's time to do so, definitely do it and get it done to be complete because you can find some very interesting things on that secondary survey. But let's talk about adjuncts, because adjuncts are kind of the third part of this. This three legged stool of trauma, one being primary survey, second being secondary survey and adjuncts. So that's how you gotta think about it when you come to the bay. Adjuncts should be mixed in where appropriate adjuncts are mixed into your primary survey. So Emma, what are the main adjuncts? 'cause there's really a limited number of things that we are [00:28:00] working from, in the world of trauma surgery. So our main adjuncts that we think of are gonna be vital signs, well, hold on. That's a, again, you mentioned this before. Amazing. Right? Vital signs are not part of the primary survey. Vital signs are an adjunct. You feel e femoral pulse as part of the primary survey, but the heart rate and blood pressure are actually adjunct. Just important to know. Right. And even in your mind, if you're feeling for the pulse and you know they have a peripheral pulse, you kind of mentally can calculate their blood pressure, but you're not gonna actually get that cuff inflated until you move onto your adjuncts. So yeah, vital signs are chest and pelvic X-rays an ultrasound, which for us is really a fast exam. EKGs and then labs. I had CT scan all this too. We have a video on how to lead a CT scan. We have really great videos on how to perform a trauma fast, including EFAs. So check out the, again, the trauma video library for those, pieces of information. Agnes, let's say we're in a good place. We do a primary survey. We do our adjuncts, maybe we got some access and give a unit of blood. They're responding well. [00:29:00] We're making plans for the next step rapidly, making plans for the next step, and we. Have time to do a secondary survey. And, and I guess actually I wanna step back. How long should it take us to do a primary survey? If you go right through it, it should be a minute or two. Okay. We should be like a well-oiled machine getting through a primary survey 1, 2, 3 minutes at most. Assuming you're not stopping to do a bunch of things on someone who's dying. Okay. But we did that agonist. What is a secondary survey? A secondary survey is really just a systematic head to toe exam that we do in our patients who are stable enough to don't need like an emergent or, or a CT run. Yeah. Yeah. Your goal is to identify injuries. So Agnes, how do you actually do a secondary survey? What are you actually doing? Yeah, I just start at the head of the bed and basically go down every single organ system looking for any wounds, abrasions, any place they're bleeding from. And you're just wanna call out all of your pertinent positive findings to your recorder. Who's noting it down? Yeah, it doesn't take any special skill, right? So that's why when if you're [00:30:00] listening to this podcast and you're a junior resident and you're gonna be the one, maybe you're PGY two, and you're gonna be the one doing the trauma, primary and secondary survey, don't be scared, understand what we're talking about, and then call out confidently and loudly every single time your findings. If you don't call 'em out confidently and loudly, you're gonna, they're gonna say, Hey, we can't hear you, and blah, blah, blah. Then all of a sudden you're gonna go, oh my gosh, I'm, I'm nervous and I don't know what I'm doing. Guess what? You do know what you're doing. Do you hear breath sounds or don't you? Do you feel a pulse or don't you call it out confidently? And when you do that secondary survey, exactly like Agnes said, it's a head to toe exam. Feel the skull. Make sure there's no, you know, indentations. Look for that scalp laceration that's hidden in the hair, push on the clavicle range, the arm, all these simple things to say, okay, I think there's a fracture here, or there's a hematoma here, there's a laceration here, and you call 'em out as you go. And then there is something called a tertiary tertiary survey that's a double check thing. We like to do that after the fact outside of the trauma bay, after the patient's been admitted. Within [00:31:00] 24 hours where we do another evaluation, head to toe survey, exam with considerations for additional diagnostics. Oh, maybe they have foot pain that you didn't notice when they first came in. That's when you order, you know, your ankle or your foot x-ray to take a look at it and, oh, shoot, there's a fracture there. Well, you may be forgiven from missing that when they're trying to die in the trauma bay. That's the importance of that tertiary survey to make sure you don't miss injuries that are really secondary to the main thing happening to that patient. And again, I think we should say that repeating your primary survey, repeat, repeating things like GCS, et cetera is really important to reevaluate the patient as things rapidly change. So, Emma, I've made mention of this multiple times. Why is it so hard? I mean, it's hard to be new resident in the trauma base. So talk to us a little bit about that. Yeah. We talk about understanding A TLS and knowing your order and everything else, but equally as important are these non-technical skills leadership, communication, management of a team. It can be really scary to be the junior resident on your trauma service and you're alone. [00:32:00] Maybe you're senior and you're attending, or you know, in another trauma activation, and you are the doctor, you're the person, and it can be really intimidating, especially if you're not sure, or this is your first time. The best thing you can do in those scenarios is have a clear leadership plan and be a clear, loud communicator so that while you might do something out of order, everybody in the room's on the same page. Yeah. I just wanna add, as someone who's like quieter, and I think it's like hard for me to take leadership. I think remembering what your role is and being like this is something that the more that you do it, the more that it gets ingrained into you, and you know how to kind of run it. So just taking your time and understanding what your role is. Yeah, absolutely. So let's, let's move on to some cases and we're gonna do these cases relatively quickly. The goal is not to cover everything in the case. The goal is to solidify some of the key things we just talked about and make it a little less abstract. Alright, Agnes. We have a level one, 3-year-old male gunshot wound to the abdomen. Heart rate's one 10 [00:33:00] systolic blood pressure is 90 ETA is 10 minutes. How do you get this whole thing started? You are the chief resident running the trauma in the bay. Before the team, the EMS comes in, I wanna make sure that I know who's in the bay. Are there residents, are there, anesthesia colleagues? Do we have all the things that we need, such an ultrasound machine? Do we have maybe blood on hold that's ready to be started? And assigning rules Who's gonna be doing the primary survey? Who's gonna be recording all the things that are happening? Yeah, this is a multidisciplinary pit crew, right? You don't watch NASCAR Formula one and see, you know, they're ambling about and the car rolls in and they're like, oh, how about you do this this time? I'll do this this time. You know? So this is a very serious event. Now, if you screw up the pit, then maybe the, car, doesn't get first place. Instead it gets fifth place. If you screw up in the trauma bay, someone might die, right? That's what we're talking about here. So the importance of a huddle. Cannot be overemphasized. If you don't think it's cool, you don't wanna do it. Whatever you think the trauma's gonna be. La No, no, no, no, no. [00:34:00] Stop all that. You as a leader, as a surgeon, as someone leading the trauma team, step into that room and say, hello, I'm Emma, I'm Agnes. I'm your chief resident running this. Let's do a full huddle. You're so-and-so, you're so-and-so. This is your role. Okay. Do we have blood in the room? Do we have our, our central line out our, our chest tubes out? The difference between a prepared trauma team running a trauma and an unprepared trauma team running trauma is astronomical. And I think, for a lot of people who will be listening to this, they will have, I hope not, but likely have participated in a trauma that didn't go as well as they want? You don't feel good when you leave there and you've been part of a trauma that went really well. Maybe even in, for instance, the patient didn't make it. But it went well. You should be proud of that. A lot of times trial patients die, and that's unfortunate. But if you did everything you can, it was a well organized approach that makes you feel much better. Okay. So we get the EMS handoff. It's the same story. Shot in the belly. They were, 10 minutes out, 16 gauge in the right [00:35:00] ac. They have no blood , but they started a normal saline about five hundreds in. They have not given any drugs or performed any other interventions, uh, on the primary survey for the x, no exsanguinating hemorrhage. Okay. There's a, a hole in the belly without any active bleeding airways patent. There's bilateral breast sounds. We talked about the 16 gauge. And, GCS is 15. The patient moves all extremities. They have normal pupilary response, and on e there's a single anterior, periumbilical wound, GSW wound identified. You roll the patient, you don't see any other holes anywhere, and there's a marker, uh a radiopaque marker placed on that ballistic wound. We start with our adjuncts now. Repeat, vital signs, heart rates one 10 systolic blood pressure is a hundred. Emma, what is the shock index and why do we care? The shock index is a way to evaluate if your patient's in hemorrhagic shock, and the way we calculate it is by taking the heart rate and dividing it by the systolic blood pressure. So for our patient, that would be 110 divided by a hundred. That's gonna give us a number greater than [00:36:00] one. And a shock index of greater than one is associated with an increased mortality. If the systolic blood pressure is less than the heart rate, you pretty much automatically know the shock index is gonna be greater than one. Yeah. Why is this important? When we talked about these subtle signs of shock, maybe a call to shock, even people who compensate. Well, again, if you're a normal person, like right now I'm hanging out doing this podcast. My heart rate's probably around 60. My systolic probably one 20 or so. Or maybe I'm driving in the car and then I get in a car crash and I come in if it's flipped, even if my heart rate's one 20 and my systolics are a hundred or 110, you don't walk into the room and go, oh my God, like they're dying. And yet, based on the information I just shared, is about the shock index. You better think they're dying because they may be compensating for a short period of time, actively bleeding, and in another few minutes they fall off that physiologic cliff. And then your heart rate's one 60, systo blood pressure is 60 over pel, and you're in trouble. So recognize [00:37:00] that if your heart rate is greater than your blood pressure, it can be a bad thing. It needs to pique your interest. So we move on with our adjuncts. We get a chest x-ray and an abdominal x-ray in addition to a pelvic x-ray. Why do we get the abdominal x-ray? Usually when you're talking about adjuncts, it's just a chest x-ray, pelvic x-ray, boom, boom, very standard for trauma care. In this case, they got shot in the belly. We have one hole. The number of holes plus BOLs should be even right now we have an odd number one, we wanna find a bullet. So doing a plain film with a belly helps. And in this case, there's a bullet in the left lower quadrant. We know that there, the trajectory is between the per umbilical wound and the left lower quadrant That's squarely through the abdominal contents. Makes things a lot easier for us. On this x-ray, you also don't see anything uh, chest x-ray. Looks fine. Pelvic x-ray looks fine. How about the fast exam? The fast exam is validated for blunt trauma, NBCs falls, et cetera. It's not validated for looking at [00:38:00] the belly from a penetrating wound to the abdomen like. A GSW, but it is very helpful for penetrating thoracoabdominal wounds, chest, abdomen, to look at the heart to do a pericardial fast. So for all thoracoabdominal wounds, I like to use the fast exam to do, it's just a pericardial evaluation. I wanna make no assumptions about trajectory of things. Look at the heart, make sure it's pumping well. Make sure there's no pericardial effusion. Now of note, you can be shocked through the heart. You can be stabbed in the heart and you can be bleeding onto the heart without pericardial fluid or pericardial tampon on. In fact, that blood. And it kind of makes more sense if you think about it, 'cause there's a hole through the pericardium and the heart can come out and dump out into the chest most often. Vast majority of the time, if there's gonna be blood, it'll be a hemothorax in the left chest. So keep that in mind. Labs are also sent, it's usually a standard rainbow of trauma labs. So Agnes, what are the indications for immediate laparotomy in a patient like this? There's [00:39:00] four big main indications. The first one being hemodynamic instability. You can define it really in two different ways. One being the shock index, which was discussed, but also, another area of discussion is like resuscitation responders versus non-responders. Are they responding to the fluids or blood that you're giving them or are they refractory to that? Yeah, and the other indications are viser or impalment, if they have frank peritonitis or if they have hemat emesis or bleeding from their NG tube or per rectum. Yeah, so we got some additional IV access in this patient. They're getting whole blood. They do not respond to that. Resuscitation. They're still hypotensive and tachycardic. What do we do with this patient? Agist. Taking the or? Yeah. Easy peasy. Straight to the or. Now we, in a perfect world, again, this is how trauma surgeons win, right? This is how we save lives, is stopping hemorrhage. All of this that we just talked about should be done as rapidly as possible. The second you see someone with a ballistic wound in your anterior abdomen without an exit wound, and especially if you have an x-ray that shows the [00:40:00] bullets in the belly, doesn't matter what else is going on, you're gonna go to the or. So make that decision as rapidly as possible, ideally within minutes of arrival, so that or can get set up, and that you can get to the operating room as quickly as possible. You don't want to hang out in the Char Bay doing a bunch of goofy stuff. Finish your primary survey app, finish your adjuncts, get your resuscitation, get your fluids going, and then get out of dodge as quickly as possible. The wheel's up. Get to that or get that laparotomy started. Have some fun Now, if we did a good job, which we just did a great job here, right? This patient's doing wonderful. You keep them alive. That means you get to do cool trauma surgery. Now we have Epic Behind the Knife for Trauma Surgery video Atlas. Okay. How do you as a mid-level resident, as a senior resident, as a junior attending, prepare for terrible trauma injuries? Okay. Even if you work at the highest level trauma institution, the busiest in the world, you may deal with one IVC injury, or you may deal with one subclavian every other year. You may deal with one carotid, every year or two. Okay? These are the busiest institutions, let alone not the busiest, right? You need to know how to deal with these things to save a patient's life. [00:41:00] And that's why we made the trauma video atlas, because there was nothing else out there that showed you directly how to do it. The, the book, my favorite book in the whole world, Maddox, top Knife, phenomenal. So this is like the companion to top knife. We have fresh cadavers profuse, a puls tile of blood high def video edited to like look actually professional. Nice. With a step-by-step process of how you would take care of the worst injuries. Let's say this patient has a transection of their IVC Watch the trauma surgery video at list in six minutes, seven minutes. You get complete step-by-step approach by how you're going to manage it. Now, you know, we show you video in there and it's an idealized video 'cause we set it up to be so. And, and that's understandable. All these cases are gonna be different, but you have to have those foundations down of how you're gonna get there and how you're gonna do the key steps to control bleeding. So check that out. Uh, we think it's fantastic. I think it's fantastic and I'm highly biased though, but maybe you do too. Alright, let's go on to the next case. Blunt. Okay. So we have a MPC patient here, [00:42:00] okay. They have a heart rate of one 20 systolic blood pressure of one 10 GCS of 15, saturating, 93% on a non-rebreather mask. And they have chest and abdominal pain. And per the EMS, they have a seatbelt sign. They have a CCO in place, they're on a board. They have a 16 gauge IV in place. No fluids, nomads, no procedures prior to arrival. When they get there, we do a rapid primary survey. There's no exsanguinating hemorrhage, airways patent. There's absent breath sounds on the right. There's palpable femoral pulse. GCS is 14. The patient is a bit confused, but otherwise, moving all four extremities normally and has normal pupilary response. We log roll the patient, we find nothing on their back. So we're gonna move on to our adjuncts. Now we get our blood pressure once again. Heart rate one 20. A blood pressure one 10 over 80. Respiratory rate is 26 on a non-rebreather and oxygen saturation is now 90% Chest x-rays rapidly obtained. It shows a right [00:43:00] pneumothorax pelvis. X-ray shows an open book pelvic fracture agonist. For our chest x-ray, we have a pneumothorax. What are we doing here? So we're gonna do a chest tube, and we have a great video that's going over the steps of the chest tube, but essentially you wanna place it in your fifth intercostal space along your inframammary fold or your mid, and to anterior mid ary line. Yeah, exactly. Open book pelvic fracture. Emma, what, are we doing with that? Yeah. So here we need to get a pelvic binder in place across the greater tro caners to help minimize the bleeding. Yeah, so this helps keep the bone stable. It also helps close that pelvic ring. And most bleeding, we think 85%. That's what I hear. I actually don't know how we, anyone who's ever figured that out before, we'll call it 85% of pelvic bleeding is venous in nature. Right? And that's a low pressure system. The pelvis is a ring, it's a sphere. When you open it up, a slight increase in radius results in a massive increase in falling. So you can bleed more into that space if you close that space down. In [00:44:00] theory, at least, this is what we're talking about by with a binder that you decrease that volume, increase the likelihood of tamponade from a low pressure system. We do a fast in this patient. It shows a very small amount of fluid dem pouch, otherwise unremarkable. Remember, on fast exam, you can't see the retroperitoneum. Okay? Really important to keep that in mind. Labs are sent as well, and on secondary, there are no new findings. So Emma, what do you wanna do with this patient? I think we only have one PIV in place, so we'll definitely wanna get some additional IV access so that we can start either whole blood or our one-to-one to one massive transfusion. Keeping in mind that we're gonna probably need some calcium and TXA, we'll wanna keep an eye on that chest tube output too, because that can change our operative plan depending on how much comes out. And then we'll wanna keep that pelvic binder in place. Yeah. Excellent. Very nice summary. So the patient gets blood, they respond well, their heart rate comes down to a hundred systolic blood pressure goes up to one 30. What do you wanna do Now? Remember the whole time you're thinking about all these things you're thinking or or CT scan. So what do you wanna do with this [00:45:00] patient? Since he responded to our blood, we can go take him to the CT scanner to get a trauma pan scan and then a CTA neck as well. Yeah, we won't touch on the CTA neck now that's covered in, for instance, our big T trauma podcast series in detail. But we're gonna get a pan scan. So we get the scan. In this case it shows a grade three liver lac. There's active extravasation, there's a non-displaced pelvic fractures and that, and there's actually a pubic randomized fractures that are closed with your binder in place, and there's a pelvic hematoma without active extravasation. What are we gonna do next? Yeah, we're gonna wanna call our IR colleagues. We're gonna ask them if they can embolize the liver and also take a look at the pelvis to see if there's any active bleeding and consider embolization there. Right. These are two injuries that are well suited for IR in the correct patient, in the patient who is stable at a minimum, responding well to transfusion, but as it often happens, this patient, Emma, no longer responds to transfusion. You call ir, they said, yep, giddy up. We're gonna get ready. And all of a sudden, boom, [00:46:00] pressure drop, heart rate climbs. What are we doing now? Since he's not responding to our blood anymore, we get to go to the OR and do an X SLAPP with a full exploration so that we can address both the liver and then also do some pelvic packing as well. Yeah, absolutely. So those are great cases that sum up, you know, what we talked about here in this, this construct. Uh, keep your eyes out for more from behind the knife. We have a Trauma Bay Playbook series coming out soon. That we'll talk about the very practical aspects of how you manage, patients in the trauma bay. And again, we actually have a lot of great resources on behind the Knife for trauma specifically. We're gonna link all those in the show notes, so be sure to check it out. Until next time, dominate the day. And as a reminder to learn more about EPAs, including descriptions and specific competencies for each topic, you can check out the a BS website, which is linked in the show notes. And if you're interested, like we mentioned in more videos or trauma procedures in the OR and in the bay, check out our trauma video playlist on behind the knife.com and our big T trauma podcast series, [00:47:00] which also dives deeper into management of difficult trauma patients. Also, you can be prepared to dominate the day.