AAOS Comprehensive Orthopaedic Review

Section 6 - Trauma

Chapter 50. Evaluation of the Trauma Patient

I. Definition and Epidemiology

A. Definition—A major trauma victim is an individual who has potentially life- and/or limb-threatening injuries and requires hospitalization.

 

B. Epidemiology

 

1. Trauma is the fourth leading cause of death in the United States overall, but it is the leading cause of death in adults younger than 44 years. In 1999, 54 deaths per 100,000 people occurred as result of an injury; 8 of every 10 deaths in adults between the ages of 15 and 24 years result from injuries.

 

2. Worldwide, injuries cause 1 in 10 deaths.

 

3. Each year, 1.5 million individuals are admitted to hospitals and survive to discharge after an injury, representing 8% of all hospital discharges. Of emergency department visits, 38% occur for injury treatment.

 

4. The total lifetime costs for traumatic injuries that occur in 1 year have been estimated to be $260 billion; 41% of this cost is due to lost productivity of the injured individuals (1995 dollars).

 

5. The elderly (age ≥65 years) are at the highest risk for fatal or nonfatal injures requiring hospitalization. The incidence of injuries that result in death is 113 in 100,000 for patients age 65 years and older, and 169 in 100,000 for patients age 75 years and older.

 

6. Fatal injuries

 

a. Major mechanisms of injury for traumatic injury and deaths in 1999 are listed in

Table 1.

 

b. Leading causes of traumatic death

 

i. Central nervous system injuries: 40% to 50%

 

ii. Hemorrhage: 30% to 35%

 

c. Nonaccidental deaths represent 31% of traumatic deaths: of these, 63% are suicides, and 37% are homicides.

 

7. Nonfatal injuries

 

a. The leading cause of nonfatal injuries is falls (representing 39% of hospitalizations).

 

[Table 1. Mechanisms of Injury in Accidental Deaths*]

b. Injuries to the extremities are the leading reason for hospitalization (47%) and emergency department visits after nonfatal trauma. About 33% of extremity injuries that require hospitalization have an Abbreviated Injury Scale (AIS) score of 3 or above. These are moderately severe to severe injuries that may have a long recovery period and can result in permanent impairment.



II. Mortality and the Golden Hour

A. Three peak times of death after trauma

 

1. About 50% occur within minutes, from either a neurologic injury or massive hemorrhage.

 

2. Another 30% occur within the first few days after injury, most commonly from a neurologic injury.

 

3. The final 20% die days to weeks after injury as a result of infection and/or multiple organ failure.

 

B. The Golden Hour

 

1. Defined as the period of time during which life-and/or limb-threatening injuries should be treated so that the treatment results in a satisfactory outcome.

 

2. The Golden Hour can range from minutes for a compromised airway to hours for an open fracture.

 

3. Approximately 60% of preventable in-hospital deaths occur during the Golden Hour.



III. Prehospital Care and Field Triage

A. General principles

 

1. Rapid assessment to identify life-threatening injuries

 

2. Proper field triage is critical to avoid wasting resources; only 7% to 15% of trauma patients require the resources of a level I or II trauma center.

 

3. Appropriate intervention to address life-threatening conditions (airway, breathing, circulation, external hemorrhage control)

4. Rapid transport

 

B. Goals of field triage

 

1. To match a patient's needs with the resources of a particular hospital

 

2. To transport all seriously injured patients to an appropriate hospital

 

3. To determine what resources will be needed at the time of arrival of the patient

 

4. To identify whether the patient is a major trauma victim

 

5. To monitor the rates of overtriage and undertriage

 

C. Components of field triage

 

1. Rapid decision making based on physiologic, anatomic, mechanism of injury (to assess the amount of energy absorbed at the time of injury), and comorbidity factors

 

a. Physiologic criteria include assessment of vital signs such as blood pressure, heart rate, respiration rate and effort, level of consciousness, and temperature. These changes or trends may take time to see, particularly in younger patients.

 

b. Anatomic criteria include observations based on physical examination, such as penetrating injuries to the head, neck, or torso; obvious fractures; burns; and amputations. These assessments, however, can be difficult in the field, particularly in a patient with an altered level of consciousness.

 

c. Mechanisms of injury that may result in major injuries include falls of more than 15 feet; motor vehicle accidents in which a fatality has occurred, a passenger has been ejected, extrication has taken longer than 20 minutes, or a pedestrian was struck; motorcycle accidents in which the vehicle was traveling faster than 20 mph; or an obvious penetrating injury. Use of the mechanism of injury alone to assess injury severity may result in a high overtriage rate, but combining it with physiologic or anatomic data improves triage.

 

d. Comorbidity factors include increased patient age, presence of chronic disease, and acute issues such as drug and alcohol intoxication.

 

2. Numerous scoring systems have been developed for field triage that use all or parts of these data.

 

D. Components of field assessment

 

1. Goals

 

a. Should be quick and systematic

 

b. Patients with potentially life-threatening injures must be quickly transported to the closest appropriate hospital; definitive care for internal hemorrhage cannot be provided at the scene.

 

2. Primary survey (ABCDE—Airway, Breathing, Circulation, Disability, Exposure)

 

a. Performed just as in Advanced Trauma Life Support (ATLS) to establish priorities for management

 

b. Treatment is initiated as problems are identified (same as ATLS).

 

3. Indications for field intubation

 

a. Glasgow Coma Scale total score <8 (inability to maintain an airway)

 

b. Need for ventilation

 

c. Potentially threatened airway (inhalation injuries, expanding neck hematoma, etc.)

 

d. Ventilation required if respiration rate is less than 10 breaths per minute.

 

4. External bleeding is controlled with direct pressure.

 

5. Initiation of intravenous fluids in the field remains controversial. In general, transport should not be delayed just to start fluids.

 

6. Secondary survey

 

a. Performed after any acute issues have been addressed, perhaps during transport.

 

b. AMPLE history (Allergies to medications, Medications the patient is taking, Pertinent medical history, Last time eaten, Events leading to the injury)

 

c. Head-to-toe examination

 

7. Extremity trauma

 

a. Bleeding associated with fractures can be life-threatening.

 

b. External hemorrhage is controlled with direct pressure.

 

c. Immobilization of the extremity helps control internal bleeding.

 

d. For critical injuries, immobilization with a backboard is sufficient; if not, individual fractures should be splinted.

 

e. A traction splint should be used for suspected femur fractures because it stabilizes the fracture and controls pain.

 

8. Amputations

 

a. Clean the amputated parts by rinsing them with lactated Ringer solution.

 

b. Cover with sterile gauze moistened with Ringer solution and place in a plastic bag.

 

c. Label the bag and place it in another container filled with ice.

 

d. Do not allow the part to freeze.

 

e. Transport the part with the patient.



IV. Trauma Scoring Systems

A. Components of present scoring systems include physiologic data, anatomic data, a combination of the two, and specialized data.

 

B. Although no single scoring system has been universally adapted, each has advantages and disadvantages.

 

C. Types of physiologic scores

 

1. Acute Physiology and Chronic Health Evaluation (APACHE)

 

a. Combines preexisting systemic diseases with current physiologic issues

 

b. Frequently used for the evaluation of medical and surgical patients in intensive care units, but not good for patients with acute trauma

 

c. One drawback for trauma care is that it requires data obtained after 24 hours of hospitalization.

 

2. Systemic Inflammatory Response Syndrome Score (SIRS)

 

a. Scores heart and respiratory rates, temperature, and white blood cell count

 

b. Predicts mortality and length of hospital stay for trauma patients

 

D. Types of anatomic scores

 

1. Glasgow Coma Scale

 

a. An attempt to score the function (level of consciousness) of the central nervous system

 

b. Components (

Table 2)

 

2. Abbreviated Injury Scale (AIS)

 

a. Developed to accurately rate and compare injuries sustained in motor vehicle accidents.

 

b. Injuries scored from 1 (minor injuries) to 6 (fatal within 24 hours).

 

c. A total of 73 different injuries can be scored, but there is no mechanism to combine the individual injury scores into one score.

 

3. Injury Severity Score (ISS)

 

a.

The sum of the squares of the three highest AIS scores of six regions provides an overall severity score (includes head and neck, face, thorax, abdomen, pelvis, extremities).

b.

Each region is scored on a scale from 1 (minor injury) to 6 (almost always fatal).

c.

An AIS score of 6 is automatically assigned an ISS value of 75, which represents a nonsurvivable injury.

d.

A score of 15 or higher is frequently used as the definition of major trauma and correlates well with mortality.

e.

Because ISS scores only one injury per body region, it does not reflect patient morbidity associated with multiple lower extremity fractures.

 

[Table 2. Glasgow Coma Scale]

4. New Injury Severity Score (NISS)

 

a. This modification of the ISS sums the squares of the AIS scores of the three most significant injuries, even if they occur in the same anatomic area.

 

b. Better predictor of survival than the ISS

 

c. One study looking at orthopaedic blunt trauma patients found the NISS to be superior to the ISS.

 

D.

Combined systems

 

1. Trauma and Injury Severity Score (TRISS)

 

a. Tries to predict mortality based on postinjury anatomic and physiologic abnormalities

 

b. Uses age, the Revised Trauma Score (RTS) calculated in the emergency department, the ISS (calculated using discharge diagnosis), and whether the injury mechanism was blunt or penetrating.

 

c. The data from any institution can then be compared to the mortality data from the Major Trauma Outcomes Study conducted by the American College of Surgeons in 1990.

 

2. Harborview Assessment for Risk of Mortality (HARM)—Consists of 80 variables, including ICD-9 codes, comorbidities, mechanism of injury, self-inflicted versus accidental injury, combined injuries, and age.



V. Initial Hospital Workup and Resuscitation

A. Goals

 

1. Diagnosis and treatment of life-threatening injures takes priority over a sequential, detailed, definitive workup.

 

2. ATLS, which provides a systematic method to evaluate trauma patients, was developed to teach this concept and ultimately improve patient survival.

 

B. Components of ATLS

 

1. Primary survey

 

a. A systematic effort to quickly identify immediately life-threatening injuries

 

b. Treatment and resuscitation are performed simultaneously as problems are identified.

 

c. Consists of evaluation of ABCDEs, which may need to be repeated because patient reevaluation is constantly occurring during this step.

 

2. Secondary survey

 

a. Performed later as part of a head-to-toe physical examination and detailed medical history

 

b. Intended to diagnose and treat injuries that are not an immediate threat to life when the patient's vital signs are normalizing

 

c. Additional radiographs, CT, and laboratory tests are performed during this phase.

 

C. Shock

 

1. Hypovolemic shock is the most common type in trauma patients.

 

2. Signs and symptoms

 

a. Decreased peripheral or central pulses; peripheral vasoconstriction is an early compensatory mechanism for shock.

 

b. Pale and/or cool, clammy extremities; a tachycardic patient who has cool, clammy skin is in hypovolemic shock until proven otherwise.

 

c. Heart rate >120 to 130 beats/min in adult trauma patients should be assumed to be caused by shock.

 

d. Altered level of consciousness may indicate a brain injury, hypovolemic shock, or both; the key to preventing secondary brain injury is to prevent (or treat, if present) hypoxia and hypotension.

 

e. Relying on systolic blood pressure measurements alone can be misleading; because of compensatory mechanisms, up to 30% of blood volume can be lost before a patient becomes hypotensive (

Table 3).

 

f. Pulse pressures may decrease with loss of as little as 15% of blood volume.

 

g. Urine output, although useful to judge resuscitation, is not used during the primary survey.

 

D. Shock resuscitation

 

1. Initial bolus of 2 L of crystalloid that can be repeated once if vital signs are not restored to normal

 

2. Patients who respond well to fluid resuscitation likely had a 10% to 20% blood volume deficit; patients who do not respond have a higher volume deficit.

 

3. As the second bolus is being given, blood should be obtained.

 

E. Initial radiographic evaluation

 

1. Views include a chest radiograph, lateral view of the cervical spine, and AP view of the pelvis.

 

2. The AP pelvis and chest radiographs can identify potential bleeding sources.

 

3. Focused Assessment for the Sonographic Evaluation of the Trauma Patient (FAST) may be needed for patients with persistent hypotension; like a radiographic

 

[Table 3. Symptoms of Hypovolemic Shock by Hemorrhage Class]

   evaluation, FAST is quickly obtained and can be performed in the trauma bay.

 

4. FAST is accurate for detecting free intraperitoneal fluid and looking for blood in the pericardial sac and dependent regions of the abdomen, including the right and left upper quadrants and pelvis, but it cannot detect isolated bowel injuries and does not reliably detect retroperitoneal injuries.

 

F. Patient may require diagnostic peritoneal lavage.



VI. Associated Injuries

A. Neck injuries

 

1. Any patient with an injury above the clavicle who is unconscious or has a neurologic deficit is assumed to have a cervical spine injury.

 

2. Immobilize the neck until it has been proven that no injury exists.

 

B. Pelvic (retroperitoneal) versus intra-abdominal bleeding

 

1. These two injuries may coexist.

 

2. If diagnostic peritoneal lavage is performed in the presence of a pelvis fracture, it should be supraumbilical and performed early, before the pelvic hematoma can track anteriorly.

 

3. Diagnostic peritoneal lavage has a 15% false-positive rate in this setting; false-negatives are rare.

 

4. Unstable pelvis fractures should be stabilized early. Pelvic binders or bed sheets are a simple, quick, and effective means to accomplish this.

 

C. Head injuries

 

1. Autoregulation of cerebral blood flow is altered after a head injury, and blood flow may become dependent on the mean arterial blood pressure.

 

2. Secondary brain injury may develop if hypoperfusion or hypoxia occurs after the initial insult.

 

3. Whether early definitive fracture surgery has an adverse effect on neurologic outcome remains subject to debate. At least one study that used neuropsychologic testing showed that this is not the case.

 

4. Early surgery leads to more blood and fluid requirements and may require invasive monitoring to ensure that adequate cerebral blood flow is maintained during surgery.



VII. Decision to Operate: Surgical Timing

A. Early considerations

 

1. Before the 1970s, definitive fracture surgery was performed on a delayed basis.

 

2. The philosophy of early total care became accepted as it became clear that early stabilization of long bone fractures in patients with multiple trauma (ISS ≥ 18) decreased pulmonary complications and perhaps mortality in the most severely injured patients.

 

B. Current considerations

 

1. At present it is unclear which subgroups of patients might be at risk from early surgery, particularly those with femoral shaft fractures stabilized with reamed intramedullary nails.

 

2. The initial focus was on patients with thoracic injuries, but the current consensus is that the extent of the pulmonary injury is related to the severity of the initial injury to the thorax.

 

3. Although still controversial, there is evidence that patients with "occult hypotension" have higher complication rates with early definitive surgery, as do those who are clearly underresuscitated.

 

C. Damage control orthopaedics

 

1. Long bones are temporarily stabilized with external fixation and converted to definitive fixation after the patient has been resuscitated.

 

2. Complication rates with this approach are lower compared with early definitive fixation.

 

D. Hypothermia

 

1. Must be detected and corrected before definitive fracture fixation

 

2. Leads to increased mortality in trauma patients

 

3. Hypothermic: <35°C

 

4. International normalized ratio (INR) > 1.5

 

5. "Severe" head injury



VIII. Determination of Extent of Resuscitation

A. Determining which patients are in compensated shock and which patients have been fully resuscitated often is difficult.

 

B. The distinction, however, is critical because inadequate resuscitation may allow local inflammation to progress to systemic inflammation, which can cause distant organ dysfunction, including adult respiratory distress syndrome (ARDS) and/or multiple organ failure.

 

C. Patients with abnormal perfusion also may be at risk for the "second hit" phenomenon, in which a primed immune system has a supranormal response to a second insult, which may include surgical blood loss.

 

D. Vital signs including blood pressure, heart rate, and urine output are abnormal in patients with uncompensated shock but can normalize with compensated shock.

 

E. There is level 1 evidence that the base deficit or lactate level on admission is predictive of complication rates and mortality, but standard hemodynamic parameters are not.

 

F. There is level 2 evidence that following the base deficit and/or lactate (time to normalization) is predictive of survival and can be used to guide resuscitation.

 

G. Patients at risk for complications after early definitive treatment

 

1. Obvious shock: systolic blood pressure of <90 mm Hg

 

2. Abnormal base deficit or lactate level

 

a. Depends not only on the absolute value but also the trend

 

b. Normalizing is a good sign, whereas getting worse or failing to improve may indicate ongoing bleeding.



Top Testing Facts

1. A major trauma victim is an individual who has potentially life- and/or limb-threatening injuries and requires hospitalization.

 

2. The goal of prehospital care is to minimize preventable deaths.

 

3. Field triage requires rapid decisions based on physiologic, anatomic, mechanism of injury, and comorbidity factors.

 

4. During the initial treatment of a trauma patient, the diagnosis and treatment of critical injuries takes priority over a sequential, detailed, definitive workup.

 

5. The primary survey is a systematic effort to quickly identify life-threatening injuries.

 

6. The most common source of shock in a trauma patient is hypovolemic shock.

 

7. Resuscitation begins with a bolus of 2 L of crystalloid that can be repeated once if the vital signs are not restored to normal.

 

8. It is difficult to determine which patients are in compensated shock and which patients have been fully resuscitated.

 

9. Initial radiographic evaluation includes chest radiograph, lateral C-spine, and AP pelvis.

 

10. The base deficit or lactate level on admission is predictive of complication rates and mortality.



Bibliography

Balogh ZJ, Varga E, Tomka J, et al: The new injury severity score is a better predictor of extended hospitalization and intensive care admission than the injury severity score in patients with multiple orthopedic injuries. J Orthop Trauma 2003;17:508-512.

Crowl AC, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early fracture fixation. J Trauma 2000;48:260-267.

Englehart MS, Schreiber MA: Measurement of acid-base resuscitation endpoints: Lactate, base deficit, bicarbonate, or what? Curr Opin Crit Care 2006;12:569-574.

Harwood PJ, Giannoudis PV, Probst C, et al: The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma 2006;20:181-188.

Harwood PJ, Giannoudis PV, van Griensven M, et al: Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:446-454.

McKee MD, Schemitsch EH, Vincent LO, et al: The effect of a femoral fracture on concomitant closed head injury in patients with multiple fractures. J Trauma 1997;42:1041-1045.

Moore E, Feliciano DV, Mattox KL (eds): Trauma, ed 5. New York, NY, McGraw-Hill, 2004.

Moore FA, McKinley BA, Moore EE, et al: Guidelines for shock resuscitation. J Trauma 2006;61:82-89.

Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM: Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am2000;82:781-788.

Osler T, Baker SP, Long W: A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 1997;43:922-926.

Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-462.

Poole GV, Tinsley M, Tsao AK, et al: AIS scale does not reflect the added morbidity of multiple lower extremity fractures. J Trauma 1996;40:951-955.

Schulman AM, Claridge JA, Carr G, et al: Predictors of patients who will develop occult hypoperfusion following blunt trauma. J Trauma 2004;57:795-800.

Shafi S, Elliot AC, Gentilello L: Is hypothermia simply a marker of shock and injury severity or an independent risk factor for mortality in trauma patients? J Trauma 2005;59: 1081-1085.

Tisherman SA, Baie P, Bokhari F, et al: Clinical practice guideline: Endpoints of resuscitation. J Trauma 2004;57:898-912.