Resident Readiness General Surgery 1st Ed.

A 56-year-old Female Status Post Motor Vehicle Accident

Ashley Hardy, MD and Marie Crandall, MD, MPH

While on your night float rotation, you and other members of the surgical team are called to the emergency department (ED) in response to the activation of the trauma team. As the patient is being wheeled into the trauma bay, the paramedics inform you that the patient is a 56-year-old female who was a restrained driver in a motor vehicle crash (MVC). She rear-ended a stopped car going at a speed of approximately 45 mph. There was no loss of consciousness at the scene and the patient appears alert. The paramedics report that the patient has obvious deformities of her proximal upper right arm and distal left thigh. You hear your senior resident announce that she is going to begin the primary survey.

1. Why was it appropriate to initiate a trauma activation in this patient?

2. What is your role during this trauma? Where should you stand?

3. What is the goal of the trauma primary survey?

TRAUMA PRIMARY SURVEY

Answers

1. Per CDC guidelines, the trauma team should be activated if 1 or more specific anatomic, physiologic, and mechanistic criteria are met as illustrated by Table 7-1. The patient in this scenario meets criteria for trauma team activation given her involvement in a high-speed MVC and likelihood of her having at least 2 proximal long bone fractures.

Table 7-1. Anatomic, Physiologic, Mechanistic, and Other High-risk Criteria for Trauma Activation

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2. Although minor variations may exist from institution to institution, the trauma team at most academic medical centers consists of a team leader, an airway specialist, primary and secondary surveyors, and ED nurses. Note that depending on the nature of the injury, other specialized staff (ie, orthopedic surgery or neurosurgery) may also be present. It is imperative that members of the trauma team are aware of their roles to ensure that the best care possible is given to the traumatically injured patient. Trauma team members and their respective job descriptions are listed below and a diagram of their position with respect to the patient is illustrated in Figure 7-1:

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Figure 7-1. Trauma team. Diagram of the various members that comprise the trauma team and their position with respect to the traumatically injured patient.

Team leader (trauma surgery attending or the senior surgical resident until the attending arrives):

• Obtains history from Emergency Medical System (EMS) staff

• Directs team members on how and when to perform their respective tasks

• Orders the administration of drugs, fluids, or blood products

• Performs or assists with any lifesaving procedures

• Determines the patient’s disposition (ie, additional imaging, OR, ICU)

• Discusses the patient’s status with the family members

Airway specialist (2 people—anesthesiologist, ED attending, or senior residents of either specialty with 1 person serving as an assistant):

• Controls the airway, ensuring patency

• Performs any airway interventions, excluding the performance of a surgical airway

• Maintains cervical spine stabilization

Primary surveyor (surgical resident):

• Performs the primary survey, relaying all pertinent findings to the team

• May perform the secondary survey, relaying all pertinent findings to the team

• Performs or assists in the performance of any lifesaving procedures at the direction of the team leader

Secondary surveyor (surgical resident or intern—this is you!):

• Assists with the “exposure” aspect of the primary survey (see below) and applies warm blankets

• May perform the secondary survey, relaying all pertinent findings to the team

• Performs or assists in the performance of any lifesaving procedures at the direction of the team leader

ED nurses (usually 2, with 1 person performing procedures and 1 serving as a recorder):

ED nurse #1 (procedural). Obtains vital signs:

• Establishes peripheral intravenous (IV) access for the administration of drugs, fluids, or blood products

• Inserts indwelling devices (ie, nasogastric or orogastric tubes and urinary catheters) at the direction of the team leader

ED nurse #2 (scribe). Records all vital and physical exam findings obtained from the primary survey:

• Lists in chronological order any interventions performed on the patient

Note that, as a new intern, you should position yourself next to the patient, most likely next to the primary surveyor or on the patient’s left. You should expect to aid with removing clothing and getting warm blankets. You may also be called on to perform all or part of the secondary survey, perform the FAST exam, or generally be another set of hands. As you become more experienced, you may be able to move into the role of primary surveyor, especially for those trauma activations that are less acute.

3. The goal of the trauma primary survey is to identify and immediately treat any life-threatening injuries. This is in contrast to the secondary survey, the purpose of which is to ensure that no other major injuries were missed and to identify any additional, non–life-threatening injuries.

The primary survey is best accomplished in a team-oriented, standardized fashion in order to ensure the best possible outcome for the patient. The mnemonic ABCDE (A irway, B reathing, C irculation, Disability, and Exposure/E nvironment) is useful in helping one remember the order in which the primary survey should be carried out. Note that these steps should be repeated any time there is a change in the patient’s status.

The first priority should always be the airway, with the assessment focused on determining if the patient’s airway is patent or not and, if so, determining whether or not the patient can maintain an intact airway. This can be initially assessed by simply asking the patient a question such as “What is your name?” If the patient is able to speak in a clear voice, the airway is intact. However, if there is no response, speech is garbled, or it takes considerable effort to speak, intervention is required. This may simply consist of a chin lift, jaw thrust maneuver to open up the airway, suctioning if the airway is occluded by blood or vomitus, or removal of any foreign bodies. In some cases, however, placement of an endotracheal tube (ETT) is indicated. If orotracheal or nasotracheal intubation is not possible, then a surgical airway (ie, cricothyroidotomy) may be necessary. During the airway assessment, inline stabilization of the cervical spine should be maintained until a cervical injury has been ruled out.

Next, the patient’s breathing or the ability to ventilate should be assessed. An inspection of the chest and neck may identify the presence of penetrating injuries, bruising, tracheal deviation (ie, from a tension pneumothorax), and abnormal chest wall movements (ie, from a flail chest). Auscultation may reveal the absence of breath sounds or asymmetry (ie, as a result of a pneumothorax). Life-threatening injuries to the chest should be addressed at this point prior to moving on with the remainder of the survey. This is particularly the case if the patient has a suspected tension pneumothorax, in which treatment entails immediate needle decompression followed by tube thoracostomy placement.

The patient’s circulation should then be evaluated as hemorrhage is the most common cause of preventable postinjury deaths. This is assessed by looking for any evidence of external hemorrhage, palpating central pulses (most commonly the carotids or femorals), obtaining a blood pressure and heart rate, and taking note of any distended neck veins or muffled heart sounds (both of which are highly concerning for cardiac tamponade). Any external bleeding should be controlled by applying direct pressure. Cardiac tamponade should be treated immediately by a pericardiocentesis or pericardial window. In general, hypovolemia should be treated with aggressive fluid resuscitation after the establishment of 2 large-bore (14- or 16-gauge) IV catheters.

The disability of a patient can be determined by performing a quick evaluation of the pupils and by making an assessment of mental status and gross motor function in all 4 extremities. Examine the pupils for any discrepancies in size, symmetry, and reactiveness to light. Use the Glasgow Coma Scale (GCS) to quantify the degree of neurologic abnormalities and to determine if the level warrants emergent intubation (ie, if the GCS is less than 8; see Table 7-2).

Table 7-2. Glasgow Coma Scale

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Finally, the patient’s body should be completely exposed by removing all clothing. This facilitates the full head-to-toe examination that should be carried out during the secondary survey in order to look for any previously missed injuries. At this time, the patient’s back should also be examined for any signs of spinal injury in the form of tenderness or bony step-offs, and the axillae and perineum evaluated for any traumatic wounds. Be sure to cover the patient with warm blankets and be sure to maintain cervical spine stabilization when logrolling the patient to assess the back.

TIPS TO REMEMBER

Image The goal of the trauma primary survey is to identify and treat any life-threatening injuries.

Image As a trauma team member, make sure you are aware of who your leader is and what your role is during a trauma activation.

Image When performing the primary survey, use the mnemonic ABCDE to help you remember the order in which the patient should be assessed.

Image The ABCDE steps of the primary survey should be repeated with any change in patient status.

Image Use the GCS to determine a patient’s level of consciousness and any neurologic changes that might warrant an emergent intervention.

COMPREHENSION QUESTIONS

1. While in the midst of exposing the patient during the primary survey, one of the ED nurses announces that the patient’s SBP has dropped from 120 mm Hg on arrival to 70 mm Hg. The trauma team leader orders the initiation of a 2 L fluid bolus. In addition to this, the next step should be which of the following?

A. Pericardiocentesis as you weren’t sure if the heart sounds were normal during the initial assessment.

B. Take the patient to the CT scanner to determine the source of the hypotension.

C. Repeat the steps of the primary survey, starting with a reassessment of the patient’s airway.

D. Proceed with the secondary survey.

2. A patient is brought to the trauma bay after sustaining a fall from the roof of his 2-story home. When a deep sternal rub is applied to the patient, he extends his arms and legs. He lacks any eye or verbal response. What is the patient’s GCS score?

A. 4

B. 8

C. 9

D. 12

3. Which scenario meets criteria for trauma team activation?

A. A patient who “twists” her ankle after falling from a chair in her kitchen.

B. A patient who was hit by an oncoming car driving at a speed of 25 mph.

C. A patient who is rear-ended in a parking garage by a car driving at speed of 10 mph.

D. None of these scenarios meet criteria for trauma team activation.

Answers

1. C. With any change in a patient’s status, you should quickly repeat the ABCDEs of the primary survey before moving on with the rest of the assessment (secondary survey). It was okay for the trauma team leader to order a fluid bolus as this can be done concurrently with the primary survey. Pericardiocentesis is seldom performed without a high index of suspicion, such as a positive FAST or high-risk mechanism, like a stab wound to the chest. Even then it is used only as an emergent bridge to definitive therapy, which would be thoracotomy or sternotomy with cardiac repair. Finally, the patient in this scenario is too unstable to undergo a CT scan. Furthermore, determining the source of the patient’s hypotension may not require the use of CT imaging.

2. A. The absence of eye (1) or verbal responses (1) paired with decerebrate posturing (2) would give the patient a GCS score of 4.

3. B. This scenario meets criteria for trauma team activation because of the speed of >20 mph.