Panna A. Codner and Karen J. Brasel
Time is of the essence in caring for patients with multiple injuries. To emphasize the time-sensitive nature of this care, the critical period immediately following injury was historically termed the “golden hour.”1 Mortality from trauma during this crucial time was estimated to be approximately 60%. This high mortality rate has been attributed in part to inadequate assessment and resuscitation. In order to minimize morbidity and mortality for these patients, appropriate and aggressive initial care must be delivered. The “golden hour” is no longer sacred, as we know that patient outcome is directly related to the time from injury to definitive care. Rapid assessment of injuries and institution of life-preserving measures have helped to reduce the preventable death rate of 35% to <10%.2–4
In order to save time, the initial assessment and management should follow a systematic approach that can be easily learned and practiced. This approach is the foundation for the Advanced Trauma Life Support (ATLS) course.5Lack of a systematic approach to the initial assessment can result in errors from which the resuscitation team, and ultimately the patient, do not recover.6 Initial assessment and management includes the following:
• Primary survey (ABCDEs)
• Adjuncts to the primary survey and resuscitation
• Consideration of need for transfer
• Secondary survey (more detailed evaluation, diagnosis, and treatment)
• Adjuncts to the secondary survey
• Continued postresuscitation monitoring and reevaluation
• Definitive care
Initial assessment and management is a linear progression of steps that includes both the primary and secondary surveys. The name of this phase—initial assessment and management—highlights the need for evaluation and simultaneous intervention for life-threatening injury when identified. During the primary survey, remembered by the mnemonic ABCDE (airway, breathing, circulation, disability, exposure/environment), the patient is rapidly assessed for life-threatening injury. It is not always possible to dissociate diagnostic procedures from simultaneous resuscitation and treatment measures during this phase, and the treatment of life-threatening injury should not be delayed for definitive evaluation. Following the primary survey and its adjuncts, the secondary survey is performed. During the secondary survey, the patient is evaluated for potentially life-threatening and/or occult injuries. It is important to emphasize that both the primary and secondary surveys may be repeated as often as necessary. Once adjuncts to the secondary survey are completed, definitive care requirements such as type of facility and location are considered while postresuscitation monitoring is continued.
The preparatory phase is an integral component of trauma care and occurs in two different clinical settings: the prehospital and hospital settings.
The first aspect of the prehospital phase occurs before patient involvement and concerns the establishment of protocols aimed at directing the safe transport of the right patient to the appropriate trauma center at the earliest possible time using the ideal transport method. Physicians involved in trauma care should be familiar with these protocols, and should optimally be involved in their establishment, review, and revision. When an actual patient is injured, care is provided according to protocol by the personnel who receive initial notification of the trauma and are first to respond at the scene. During this phase, all events are ideally coordinated with the physicians at the receiving hospital to ensure adequate time to prepare personnel and resources in the emergency department (ED).
The treatment goals for the prehospital phase include maintenance of airway, control of external bleeding and shock, patient immobilization, and transport to the closest appropriate facility, preferably a trauma center. In addition, obtaining important information concerning the mechanism of injury, related events, and past medical history of the patient may alert the receiving team to the possibility of particular injuries and their severity to enable faster diagnosis and treatment. The National Association of Emergency Medical Technicians Prehospital Trauma Life Support course is a resource for those interested in further information about this phase of care.7
The hospital phase of preparation is initiated with advance notice of the arrival of the injured patient. There is a tiered response in place at every trauma center. Depending on the severity of injury, a level of activation is initiated. For example, patients who are hypotensive (systolic blood pressure <90 mm Hg), bradycardic or tachycardic (heart rate [HR] <50 beats/min or >130 beat/min), or intubated in the field or with respiratory compromise, meet criteria for the highest level of activation which requires the presence of the full trauma team consisting of trauma surgery faculty, surgical residents, emergency medicine faculty and residents, and ED nurses. The activation criteria are developed by each hospital and guided by published resources and take into account the needed level of expertise and resources that should be available for the patient’s circumstances. Ideally, there should be a designated arrival area with adequate space to accommodate the personnel and equipment needed to carry out a trauma resuscitation. An often overlooked part of this phase is preparation of the resuscitation team, ensuring that all personnel understand their roles and have received any information communicated by the prehospital personnel. Airway supplies such as laryngoscopes and tubes should be tested and readily available. When the patient arrives, intravenous access and fluid resuscitation should be started in conjunction with a determination of airway and breathing status. In the trauma bay, pulse oximetry and ECG monitors should be available and applied to the patient. All trauma evaluations require proper personnel.8 In addition to physicians and nurses, respiratory therapists, radiology technicians, and social workers (for family issues) should be available. Resources such as the laboratory, x-ray, and bedside diagnostic equipment such as an ultrasound machine for FAST (Focused Assessment Sonography in Trauma) examination should be present. Last but definitely not least is the safety of the hospital team caring for the patient. All personnel who will be in close contact with the patient should wear universal precautions including hair covers, facemasks, eye protection, appropriate length gowns, shoe and/or leg coverings, and gloves to minimize exposure to communicable diseases.9 As many trauma patients either do not know or are unable to communicate their personal health history due to altered mental status, it is important that strict universal precautions are observed and in place at the time of patient arrival.10
Triage is the process in which the severity of patient injuries, the number of injuries per patient, and the resources of the accepting facility determine priority of treatment. Communication between the accepting facility, other area facilities, and prehospital personnel is important prior to such an event as well as during such an event. One helpful triage scheme is based on the aforementioned ABCDE mnemonic, which is further outlined below.
There are two typical triage situations encountered: multiple casualty incidents and mass casualty events. The former involves multiple patients whose injuries do not exceed the capabilities of the receiving facility. In this situation, patients with life-threatening or multiple injuries are transported and treated first. In-hospital care is affected little, other than accessing normal surge capacity. In the latter situation, the number of patients and the severity of their injuries exceed the equipment, supplies, and personnel limitations of the receiving facility. Patients with the greatest chance of survival and requiring the least use of resources are transported and treated first. Triage continues in the hospital phase, as changing patient conditions and a variable number of patients transported may change initial estimations of survival and resource consumption.
The primary survey is a sequence of steps to identify immediately life-threatening but treatable injuries. Assessment and management proceed simultaneously, and life-threatening situations are managed as they are encountered during the course of resuscitation. This is made possible through close coordination of the trauma team, with each team member performing his or her designated role under the direction of the captain. The primary survey involves airway maintenance with cervical spine protection, breathing and ventilation, circulation with hemorrhage control, disability with respect to neurologic status, and exposure/environmental control, where the patient is completely undressed but kept warm to prevent hypothermia.
The priorities of the primary survey can be applied to all patients with certain caveats that do not alter the underlying alphabet or priorities, including pediatric patients, the elderly, pregnant women, and obese patients.
Pediatric patients: When caring for the pediatric patient, the size of the child and specific injury patterns must be kept in mind. Serious pediatric trauma is usually blunt trauma, often involving the brain. Brain injuries can lead to apnea, hypoventilation, and hypoxia, and protocols for pediatric trauma patients stress aggressive management of the airway and breathing to prevent these consequences. These physiologic derangements occur more often than hypovolemia with hypotension in seriously injured children.
Geriatric patients: The geriatric patient has overall less physiologic reserve to withstand injury. Their response may also be altered or blunted by comorbidities and chronic medication use. Resuscitation of these patients must take into account possible preexisting cardiac, pulmonary, and metabolic diseases.11 For example, minor injuries can cause serious complications due to multiple medications, especially anticoagulant use.
Pregnant women: The anatomic and physiologic changes of pregnancy can be a challenge, and the response of the pregnant patient may be modified.12 Knowledge of pregnancy and early monitoring of the fetus are important in maternal and fetal survival. Unnecessary x-ray exposure should be avoided, but treatment of the mother takes precedence.
Obese patients: The problem of obesity is on the rise.13 These patients pose a particular challenge in the trauma setting, as their anatomy can make procedures such as intubation difficult and hazardous.14 In addition, obese patients typically have cardiopulmonary disease limiting their ability to compensate for injury and stress. Treatment of these patients may exacerbate their underlying comorbidities.
Although these special populations each have their unique characteristics, the assessment and management priorities are the same. Treatment of these patients is elaborated elsewhere in this text.
Airway Maintenance with Cervical Spine Protection
Maintenance of the airway is the most important priority in caring for the trauma patient. Inadequate ventilation leads to hypoxia and inadequate oxygen delivery to tissues. Although important in all patients, this is particularly important in patients with head injury, as hypoxia contributes to secondary brain injury and hypoventilation may increase intracerebral pressure.15 Application of a pulse oximeter as an early adjunct to the primary survey in all patients helps in recognition and monitoring of hypoxemia.
In acute trauma, upper airway obstruction is the most common cause of inadequate ventilation. Structures of the upper airway such as the tongue, edematous soft tissues, blood, foreign bodies, teeth, and vomitus are common causes of obstruction. Quick assessment of the airway begins by asking the patient his or her name. A normal response implies the airway is not in immediate jeopardy, but frequent reassessment is required. Breathlessness, weak or absent voice, or hoarseness suggests airway compromise. Objective signs of potential airway problems include noisy breathing, cyanosis, and the use of accessory muscles. Unconscious and obtunded patients with a Glasgow Coma Score (GCS) of less than 8 should have their airway protected with an endotracheal tube to provide oxygenation and ventilation, and reduce the chance of aspiration. Indications for a definitive airway are listed in Table 10-1.
TABLE 10-1 Indications for Definitive Airway
A definitive airway is defined as a cuffed endotracheal tube in the trachea.5 In children under 9 years of age, an uncuffed tube should be used to prevent tracheal injury from the cuff. The most important aspect of securing the airway involves preparation. A skilled physician must be present with the necessary medication and equipment close at hand for intubation.16
When airway compromise occurs, initial maneuvers to maintain the airway are performed. The first involves opening the mouth and inspecting for foreign bodies or other obstructive causes. Either a chin lift or jaw thrust in conjunction with an oral or nasal airway can relieve obstruction caused by the tongue (Fig. 10-1). Care must be taken to protect the cervical spine during these maneuvers. The chin lift or jaw thrust can temporarily maintain oxygenation in preparation for a definitive airway. Rapid sequence intubation is employed for obtaining the definitive airway in the potentially combative trauma patient.17 An induction agent (often etomidate) is used in combination with a short-acting depolarizing agent such as succinylcholine to minimize duration of paralysis. In case of failed orotracheal intubation, the team should be ready to perform a surgical airway. Confirmation of tube placement occurs by auscultation over the epigastrium and the bilateral chest wall. There should be no breath sounds over the epigastrium and equal breath sounds heard over the chest. A CO2 monitor is attached to the endotracheal tube and confirms the presence of CO2 by color change.18 A chest x-ray is also obtained to confirm position. Once a definitive airway is established, securing by means of tape or a commercial device is imperative. In addition, frequent evaluation of tube position should be performed to prevent dislodgement of the tube and subsequent airway loss.
FIGURE 10-1 Chin lift and jaw thrust maneuvers to establish an airway. (Reproduced with permission from American College of Surgeons Committee on Trauma. Advanced Trauma Life Support For Doctors. 8th ed. Chicago, IL: American College of Surgeons Committee; 2008: p. 30.)
Breathing and Ventilation
After securing the airway, attention may be turned to breathing and ventilation. This includes both oxygenation and adequate exchange of carbon dioxide. Pulse oximetry is an effective noninvasive means of measuring arterial blood saturation by colorimetric measurement.19 Pulse oximetry may be inaccurate in the presence of peripheral vasoconstriction, carbon monoxide poisoning, or jaundice. Pulse oximetry may also be unreliable in hypothermic or severely anemic patients.20 Depending on the patient’s partial pressure of oxygen and its location on the oxyhemoglobin dissociation curve, oxygen levels may change more quickly than indicated by the pulse oximeter measurement due to limitations in instrument response time. In these situations, the partial pressure of oxygen is more accurately determined using an arterial blood gas measurement.
A patent airway does not ensure adequate ventilation.5 Evaluation of breathing begins by looking at, listening to, and feeling the chest wall. Inspection of the chest wall can reveal asymmetry in chest expansion, accessory muscle use, contusions, penetrating chest wounds, open or sucking chest wounds, and distended neck veins. Auscultation of breath sounds can help diagnose pneumo- or hemothorax by detecting differences in breath sounds between the left and right chest. Palpation of the chest wall can be used to diagnose an unstable chest wall, tenderness, crepitance, deformity, or subcutaneous air. Finally, percussion has been suggested to identify hyperesonance, dullness, or tympany. Due to an often noisy resuscitation area, it is rarely helpful in diagnosing or differentiating chest trauma. Breathing problems can be life-threatening. A tension pneumothorax develops from either blunt or penetrating injury where air continuously enters the pleural space from the trachea, bronchi, or chest wall causing the lung to collapse. Clinical signs include shifting of the mediastinum with deviation of the trachea away from the affected side, distended neck veins, respiratory distress, decreased venous return due to elevated intrathoracic pressure with low cardiac output, hypotension, and shock. Tension pneumothorax is a clinical diagnosis and a chest x-ray should be obtained after treatment by chest tube insertion. Differentiation between a tension pneumothorax and cardiac tamponade may be difficult. Neck veins may not be distended secondary to hypovolemic shock. Heart sounds are usually muffled with the latter but this may be difficult to appreciate in a noisy trauma bay. Absent breath sounds may be the only differentiating sign. A massive hemothorax can also cause mediastinal shift due to blood instead of air and circulatory compromise. Fortunately, the treatment is similar and involves tube thoracostomy.
Ultrasound may be extremely useful in the rapid detection of pneumothorax, hemothorax, and cardiac tamponade. Accuracy for diagnosis of pneumo- and hemothoraces compares favorably with portable chest radiograph, and it can be performed much more quickly. The diagnosis of cardiac tamponade is also done efficiently by ultrasound, although the presence of a left hemothorax decreases accuracy.21–23
A flail chest can also cause breathing problems. The definition of a flail segment is three or more consecutive ribs broken in at least two places each, or one or more rib fractures along with a costochrondral separation or fracture of the sternum. A flail chest is most often associated with underlying hemo- or pneumothorax and/or pulmonary contusion, which is the usual cause of associated respiratory compromise.24
An open pneumothorax is defined as a chest wall defect greater than two thirds the diameter of the trachea. This is also known as a “sucking chest wound”. In an open pneumothorax air is drawn through the defect (the path of least resistance) into the chest. Larger defects cause greater respiratory distress. Treatment involves immediate temporary coverage of the defect on three sides, ipsilateral chest tube placement, and operative closure of the defect.25
Finally, a massive hemothorax (>1,200 mL of blood evacuated initially) can cause mediastinal shift, respiratory distress, and hypovolemic shock, which must be managed immediately. This is managed with tube thoracostomy, transfusion, and immediate operation.
Circulation with Hemorrhage Control
Hemorrhage is the leading cause of preventable death after injury. Shock is the result of inadequate oxygen delivery to tissues. Although hypovolemic shock from bleeding is the most common form of shock in trauma victims, other types of shock can occur in these patients, and occasionally a combination of several types of shock are simultaneously present. Treatment for shock begins with placement of two large-bore peripheral IVs (16-gauge or larger) and appropriate isotonic fluid replacement. There are four classes of shock based on initial blood loss and presentation (Table 10-2).
TABLE 10-2 Estimated Blood Lossa Based on Patient’s Initial Presentationb
STOP THE BLEEDING!!! The most important treatment for hemorrhage is control of bleeding.26,27 Hemorrhage in the adult trauma patient comes from one of five places—the thoracic cavity, abdominal cavity, pelvic fracture, long bones, or obvious external bleeding. The rapidity with which each source is investigated depends on the degree of shock. Some sources may be excluded by physical examination (external bleeding, thigh deformity), whereas others require the radiologic adjuncts to the primary survey. Bleeding into the chest and pelvis can be difficult to determine by physical examination alone, making early radiologic examinations essential in the patient in shock. The scalp is quite vascular and profuse bleeding from scalp wounds may require suture ligation or Raney clips to stop bleeding.28 For obvious external bleeding, direct pressure on the bleeding vessel is the most effective method of hemorrhage control. For less well-defined areas of bleeding, proximal pressure over the femoral artery in the groin or the brachial artery in the upper extremity can be used. Tourniquets are effective in massive exsanguination from an extremity, but run a high risk of ischemic injury to that extremity and should only be used when direct pressure is not effective.15 However, the use of tourniquets is increasing, especially in the prehospital phase. Kragh et al. investigated tourniquet use at a combat hospital in Baghdad. They found that tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; ), that prehospital use was associated with survival, and no limbs were lost due to tourniquet use.29 Hemothorax is treated with tube thoracostomy and operative control, intra-abdominal hemorrhage in the setting of shock requires laparotomy, and bleeding from a significant pelvic fracture requires pelvic stabilization with a sheet or binder followed by angiography or pelvic packing if necessary.
The diagnosis of shock begins with a check of the patient’s pulse rate and character, skin color and temperature, and mental status. A slow, regular pulse suggests normovolemia, whereas a weak or thready pulse suggests hypovolemia. Patients with pink and warm skin and extremities are less likely to have a circulation problem. Mental status changes may be due to inadequate end organ perfusion caused by hypovolemia, brain injuries, or drug use. Blood pressure is an important indicator of response to resuscitation, but should not be relied upon during the initial evaluation for the presence of shock. Urine output and central venous monitoring may also be used later to assess volume status and response to resuscitation.
Tachycardia results from a compensatory response to intravascular volume depletion via stimulation of the sympathetic nervous system and should always raise the suspicion of hemorrhagic shock. This efferent response to low intravascular volume also results in vasoconstriction of peripheral arteries, making the skin cool and clammy to the touch. Certain medications common in the elderly may blunt the tachycardic response, including beta-blockers, calcium-channel blockers, and diuretics.
Although tachycardia is the most common compensatory response to hemorrhagic shock, paradoxical bradycardia has also been observed. Paradoxical bradycardia is associated with rapid large-volume hemorrhage. Bradycardia in hemorrhagic shock predicts a poor prognosis, and traditional teaching associates a decrease in heart rate with irreversible shock (terminal response). However, research has revealed that bradycardia as an acute response to hemorrhage is potentially reversible. The key to treatment is quick recognition that bradycardia is a sign of major bleeding requiring massive and rapid fluid loading. Administration of atropine can precipitate cardiac arrhythmias and is contraindicated.30
Traditional predictors of physiologic reserve such as age, injury severity, and lactic acidosis on admission have been criticized for lack of sensitivity and/or specificity in predicting trauma mortality. Heart rate variability (HRV) is a recently applied biomarker reflecting physiologic reserve and cardiac control and describes changes in the beat-to-beat interval rather than variations in the instantaneous heart rate. HRV may be measured using either time-domain or frequency-domain approaches. A Holter monitor or EKG may be used to measure the R-R interval in milliseconds, which can be used to derive the standard deviation of the normal RR interval (SDNN), an important and clinically useful time-domain measurement. The gold standard for time-domain measurements is to examine HRV over a 24-hour period, but a brief 5-minute assessment of HRV can also be clinically valid and meaningful. Reduced HRV reflects loss of physiologic reserve and control of the heart. This cardiac uncoupling has been used to predict severely injured patients in the prehospital setting and as a measure of a patient’s clinical course over the first 24 hours of intensive care unit (ICU) stay.31,32
Traumatic brain injury, metabolic causes such as intoxication, and shock can all cause mental status changes.33 Decreased cerebral blood flow from any cause leads to decreased cerebral perfusion and alteration of mental status. It is important to recognize and treat shock in brain-injured patients because mortality and morbidity in these patients doubles with concurrent hypotension, and there is a 3-fold increase in mortality and morbidity if both hypotension and hypoxia are present.34
Blood pressure can be a misleading sign in the shock patient. Hypotension may not be evident until 30% of blood volume is lost. The numeric difference between systolic and diastolic pressures (known as the pulse pressure) is a more sensitive indicator of blood loss. A narrowed pulse pressure is detectable after loss of as little as 15% of blood volume. In the adult trauma patient, a systolic blood pressure less than 90 mm Hg is considered shock until proven otherwise.35
Cardiogenic shock can occur as a result of cardiac tamponade or blunt myocardial injury. Cardiac tamponade may be caused by penetrating injuries to the “box,” a three-dimensional region bounded by the clavicles superiorly, the nipples inferiorly, and the mid-clavicular lines laterally. This life-threatening condition must be diagnosed and treated emergently. On clinical examination, jugular venous distension (JVD), muffled heart sounds, and hypotension are the classic signs known as Beck’s triad. Cardiac tamponade can be confused with tension pneumothorax but the latter causes diminished or absent breath sounds on the side of the pneumothorax as well as tracheal deviation. Temporary treatment of tamponade involves needle pericardiocentesis to relieve the tamponade, but definitive treatment with emergent sternotomy or thoracotomy may be necessary. Blunt myocardial injury may result from blunt chest trauma.36 Few patients with this injury have life-threatening cardiogenic shock. Blunt cardiac injury has a variable incidence depending on the method of diagnosis. It also has variable importance, ranging from clinically insignificant to life-threatening cardiac failure. In patients that sustain blunt chest trauma, a normal electrocardiogram is the only test necessary to exclude clinically significant blunt cardiac injury. Cardiac enzymes are not helpful, as troponin I and T have poor sensitivity and predictive value despite relatively high specificity.37 With no evidence of blunt cardiac injury and no respiratory distress, ICU admission for either telemetry or aggressive pulmonary therapy is also unnecessary.38 If blunt myocardial injury is present, treatment usually involves monitoring in the ICU and appropriate management of hypotension if present.39
Neurogenic shock results from spinal cord injury. It is not seen with traumatic brain injury alone unless there is imminent death from the brain injury and a state of preterminal shock. Hemorrhagic shock should be ruled out in these patients. The pathophysiology of neurogenic shock is loss of sympathetic tone due to spinal cord injury. Loss of sympathetic innervation to peripheral blood vessels and unopposed vagal stimulation of the heart lead to warm extremities and normocardia or even bradycardia with shock. This may be seen in patients with injuries at T6 or above.40 Injuries below T6 should prompt an aggressive search for alternative causes of the hemodynamic derangements. Treatment initially begins with fluid resuscitation, and vasoactive medications are usually necessary. Neurogenic shock differs from spinal shock, which refers to the temporary loss of muscle tone and reflexes occurring after total or near-total spinal cord injuries.
Septic shock is usually not seen in the acutely injured trauma patient, but may appear in hospitalized patients many hours to days after their injury due to causes such as missed hollow viscus injuries. Septic patients may be normovolemic with normal blood pressure or minimal hypotension, warm skin, and wide pulse pressure, or hypovolemic and displaying signs of shock. All patients with suspected serious injuries require the placement of two large-bore peripheral IVs. Higher flow rates are best achieved with short, large-diameter catheters. Peripheral IVs are usually placed in the upper extremities unless there is significant injury to the upper extremities or upper chest with vascular or soft tissue compromise. When peripheral IVs cannot be placed, the next preferred choice for access is a femoral central venous catheter. Use of the subclavian or jugular veins is not initially recommended because of the higher likelihood of complications such as a pneumothorax.41 Central venous catheter insertion should be performed by a physician trained in these procedures. A cutdown of the saphenous vein in the lower extremity or basilic or cephalic vein in the upper extremity can also be performed in difficult situations. In children under 6 years of age, intraosseous cannulation of the proximal tibia may be used until adequate volume resuscitation and circumstances allow venous access.42 In the out of hospital setting, intraosseous cannulation is now being used more frequently in adult patients as well (Fig. 10-2). As in the pediatric population, this access may be used in-hospital until intravenous access is obtainable.43,44 At the time of placement, blood should be drawn for basic hematologic and chemistry analysis and type-and cross-matching.
FIGURE 10-2 Demonstration of intraosseous puncture via the proximal tibial route. (Reproduced with permission from American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. 8th ed. Chicago, IL: American College of Surgeons Committee; 2008: p. 77.)
The treatment for hypovolemic shock is fluid resuscitation and hemorrhage control. Remember, STOP THE BLEEDING!!! Severely injured patients should receive a 2-L bolus of warm, isotonic fluid such as Ringer’s lactate. Patients whose blood pressure responds to this initial fluid bolus can undergo further work-up for potential injuries and continued crystalloid resuscitation. If blood pressure remains low, blood should be given. Historically, red blood cells were used alone, but recent studies have indicated that administering a combination of fresh frozen plasma and packed red blood cells during massive resuscitation is associated with improved mortality. The optimum ratio of fresh frozen plasma to packed red blood cells is still under investigation.45–47 O-negative blood should be used until type-specific blood becomes available. In hypotensive children a 20-mL/kg fluid bolus should be administered. Patient response to fluid can be categorized into three groups. Rapid responders have a return of normal vital signs after the 2-L bolus. Transient responders undergo transient normalization of blood pressure and heart rate followed by recurrence of hypotension and tachycardia. Patients who fall into the final category are referred to as minimal to no responders and their vital signs remain abnormal after the initial fluid resuscitation. These three categories correspond to minimal (10–20%), moderate and ongoing (20–40%), and severe (>40%) blood loss, respectively (Table 10-3).
TABLE 10-3 Responses to Initial Fluid Resuscitationa
For patients who present in extremis or after cardiac arrest from penetrating chest trauma, an ED thoracotomy performed by a trained surgeon may be life-saving. Resuscitation efforts may be withheld in any blunt trauma patient who is apneic, pulseless, and without organized ECG activity upon the arrival of Emergency Medical System (EMS) personnel at the scene. Termination of resuscitation efforts should be considered in blunt trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and cardiopulmonary resuscitation.48
Anticipating which patients will require blood can be challenging. In the case of patients who are hypotensive and tachycardic, the preparation is simplified by ensuring the availability of O-negative blood. However, the need for blood may be less obvious in patients with significant injury mechanisms such as high-speed crashes with prolonged extrication. These patients may initially be reported as awake and alert with minimal alterations in vital signs, but may have occult injuries. If the need for blood is not anticipated and blood is not readily available, the delay in appropriate resuscitation may affect morbidity and mortality.
Disability: Neurologic Status
Once life-threatening injuries are found and treated during the ABCs, a brief neurologic examination can be performed. The neurologic examination includes the GCS and pupil examination including size, symmetry, and reaction to light. A complete and detailed neurologic examination is not accurate or warranted until the patient is hemodynamically normal. The GCS is the sum of scores for three areas of neurologic evaluation: eye opening, verbal response, and best motor response. Abnormal pupillary size, asymmetry, or reaction to light can indicate a lateralizing brain lesion. The eye examination can be misleading if drugs, ocular prostheses, or direct injury to the globe are present.
The pupils and GCS should be frequently reevaluated to detect changes signaling deterioration of mental status. Accurate record keeping is important, particularly in those patients requiring transfer, as a change is GCS may be the earliest sign of increased intracranial pressure and worsening head injury. Computed tomography (CT) scanning should be used liberally in patients with suspected head injuries or signs or symptoms of trauma to the brain.49,50
Exposure and Environmental Control
The patient’s clothing must be completely removed for complete and adequate evaluation, while ensuring the patient does not become hypothermic. Clothing is cut when there is severe injury or risk of injury to the spine. During exposure of the patient, prevention of hypothermia with warmed air, fluids, oxygen, and blankets is necessary. The temperature of the patient should be obtained as soon as possible and reassessed frequently.51 In colder climates where the threat of hypothermia is more serious, the inaccuracy of standard thermometers below 30°C becomes an important consideration. In this situation, a temperature-sensing urinary catheter placed in the bladder is ideal. The best way to avoid hypothermia in the trauma patient is to stop bleeding. Prevention of hypothermia and rewarming of the patient are equally important parts of the primary survey and resuscitation.
Reevaluation throughout the primary survey is important to detect changes in the patient’s condition. If the patient is not responding to the treatment provided then revisiting the steps in the primary survey is crucial. In some cases, an operation is required to control circulation and the secondary survey is completed at a later time.
Adjuncts to the Primary Survey
Monitors should be placed on the trauma patient upon arrival. Heart rate, respiratory rate, temperature, and blood pressure should be checked as soon as possible. Continuous ECG monitoring of cardiac rhythm is essential. Arterial blood gas with base deficit and/or lactate measurements should be added in severely injured patients to identify presence and severity of shock.52,53
Continuous pulse oximetry provides a means to monitor the status of oxygenation and ventilation. When the patient arrives intubated, end-tidal CO2 can confirm tube position. An arterial or central venous line or pulmonary artery catheter may be useful in the seriously injured patient in the ICU, but their initial use is not indicated.
Catheters and Tubes
The main catheters and tubes are the Foley catheter and the nasogastric or orogastric tube. The Foley catheter is placed to monitor urine output. Certain injuries or signs may be a contraindication to placement of a Foley catheter.54 In the male patient, blood at the urethral meatus, a scrotal or penile hematoma, or a high-riding prostate on digital rectal examination are contraindications to placement of a Foley catheter. Placement should be deferred until a retrograde urethrogram (RUG) can be performed to rule out disruption of the urethra. If the urethrogram is normal, gentle placement of the Foley can be undertaken. If the RUG is abnormal, subspecialty consultation and placement of a suprapubic tube or definitive repair is necessary. The measurement of hourly urine output can be helpful in assessing volume status.
Decompression of the stomach is important, especially in patients where gastric distention can occur as a result of intubation. Children are especially sensitive to gastric distention, and decompression of the stomach may improve hemodynamics in this population. In the presence of severe maxillofacial trauma or the suspicion of a cribiform plate or basilar skull fracture with blood or cerebrospinal fluid (CSF) drainage from the nose or ears, placement of an orogastric tube is safer to avoid inadvertent insertion of the nasogastric tube into the brain, which is a potentially fatal injury.55 Blood return from the oro- or nasogastric tube is usually from swallowed blood but can be an indicator of traumatic injury to the upper gastrointestinal tract.
X-rays and Other Diagnostic Studies
A chest radiograph is mandatory during the primary survey/resuscitation for both blunt and penetrating trauma. The chest x-ray can be used to identify rib fractures, pneumo- or hemothorax, and a widened mediastinum possibly indicative of blunt aortic injury. In the hemodynamically abnormal blunt trauma patient, a portable pelvic x-ray is also obtained as the physical examination of the pelvis may be misleading, particularly in the obtunded patient. Significant pelvic fractures or separation of the pelvic bones can explain blood loss in the patient in shock. The results of these tests frequently alter treatment plans.
In the hemodynamically normal patient with significant mechanism for injury, CT scans of the head, cervical spine, chest, abdomen, and pelvis are obtained after completion of the primary and secondary survey. The decision of which CT scans to obtain is based on mechanism of injury as well as the findings of the primary and secondary surveys. For example, a head CT should be obtained in patients with suspected head injuries, altered GCS, or anticoagulation use. A more recently recognized injury involves the use of seat belts with a shoulder strap. Significant deceleration with the harness belt in place can cause seatbelt marks on the neck and chest. In these situations, the physician should be concerned about blunt carotid, vertebral, or aortic injuries, and a CT angiogram of the neck and chest should be performed.56 Judicious selection of CT scans is important because CT contrast agents can interfere with the sequence of tests and lead to contrast nephropathy.57 In addition, the increased use of CT scans, especially of the chest and abdomen, has been linked to a higher incidence of cancer later in life.58
If the patient’s hemodynamics do not allow safe transport to the CT scanner, the abdomen must be evaluated for blood loss not explained by chest or pelvic radiographs. A FAST59,60 examination and/or diagnostic peritoneal lavage (DPL)61,62 may be performed to identify occult abdominal blood loss.63 During the FAST examination, an experienced physician uses an ultrasound machine to look for fluid, presumed blood, in the recesses of the peritoneal cavity. The four windows examined include the spaces between the liver and the kidney (Morison’s pouch), between the spleen and the kidney (splenorenal recess), over the bladder, and at the heart to identify fluid in the pericardial sac.64In the case of a negative FAST, other sources for hemorrhage should be sought. An indeterminate result and persistent hypotension warrants a DPL as the next step. With a positive FAST, the patient is taken directly to the operating room for definitive control of hemorrhage.
Decision for Early Transfer
Early recognition of the patient that requires transfer is essential, as patient outcome is directly related to the time between injury and definitive care. The decision to transfer is based on patient injury and local resources. Once the decision is made to transfer the patient, the efforts of the team should be directed to resuscitation of the patient and restoration of normal perfusion. Any unnecessary diagnostic tests take up valuable time and should be avoided. Physician-to-physician contact should occur to relay vital information about the mechanism of injury, the injuries identified and their treatment so far, and to make arrangements for transportation, accompanying health professionals, and tasks that must be completed before and during transport. The selected mode of transport may carry its own set of risks. In recent years, the number of helicopter crashes during medical transport has risen. These crashes are often related to bad weather conditions or flight at night. Although seriously injured patients may need immediate flight transport, and “critical care” ground transport continues to evolve, older guidelines published by the National Association of EMS Physicians (consensus with American College of Surgeons) speak to the issues regarding air medical utilization. New guidelines through NAEMSP are still being drafted.65
The patient should be continuously monitored during transport. The evaluation and resuscitation of the patient continues throughout transport until safe arrival at the receiving facility. While waiting for transport, the secondary survey may be completed including a complete history, “head-to-toe” examination, laboratory tests, and only those x-ray studies that assist in treatment without adding delay. Once the patient arrives at the receiving hospital, the definitive care phase begins and treatment continues in the ED, operating room, or ICU. During direct physician-to-physician contact, arrangements are made at the receiving facility for surgical subspeciality care such as trauma surgeons, orthopedic surgeons, or neurosurgeons.
The secondary survey is a thorough history and physical examination, which begins only after the primary survey is completed and resuscitative efforts have produced some normalization of the patient’s vital signs. Reevaluation of the patient’s vital signs and response to resuscitation during the secondary survey are key. If the patient becomes hemodynamically abnormal, then the ABCDEs of the primary survey are revisited. If definitive care (e.g., in the operating room) is necessary to complete the primary survey then the secondary survey is completed after surgery.
A complete history of the mechanism of injury and the patient’s medical history are important in understanding injury patterns, in searching for occult injuries, and in identifying comorbidities and medications that may affect the physiologic response to injury. Severely injured trauma patients are usually unable to provide the history, and prehospital personnel and the patient’s family if available are consulted to obtain this history. Allowing 15–90 seconds for the prehospital personnel to provide a report before they leave may yield invaluable information. Members of the team should be silent, but not inactive, during this time to ensure adequate transfer of this information. A quick mnemonic to obtain the history is shown below:
M—Medications currently used
E—Events/Environment related to the injury
The patient’s tetanus status should also be determined.66 Allergies are important to avoid administering medications that could cause an allergic reaction. A current list of the patient’s medications can not only provide insight into the patient’s medical condition, but also help explain the patient’s physiologic response to shock. Use of anticoagulant or antiplatelet drugs suggests the need for early administration of either plasma or platelets. In patients with head injury, rapid identification of patients on chronic anticoagulation with resultant rapid reversal of coagulopathy improves outcome.67 When the patient ate his or her last meal is important for diabetic patients and also for estimating the risk of vomiting and aspiration.
The mechanism of injury is crucial to understanding injury patterns and predicting occult injuries based on the direction and amount of energy producing the injury. Injuries may be broadly characterized as blunt or penetrating. Vehicular and pedestrian impacts, falls, occupational injuries, and recreational injuries fall into the former category. Important details about car crashes include the speed of the crash, seatbelt use, air bag deployment, location of the victim in the vehicle, structural deformation, and extrication time. For example, seatbelt marks on the abdomen may be associated with “blowout” injuries of the small bowel on the antimesenteric side.68–70 Car versus pedestrian, bicycle, or motorcycle collisions have a high incidence of extremity fractures as well as brain and torso injuries.
Penetrating injuries are less predictable, particularly those due to gunshot wounds. Several factors affect the injury patterns seen with gunshot wounds, including the distance of the weapon, the mass and velocity of the missile (kinetic energy), and the location of the impact. High-velocity bullets from weapons such as rifles have the most kinetic energy and therefore the greatest potential to cause extensive injuries. The distance of shotgun blasts determines the extent of injuries. Close-range shotgun wounds are more likely to result in injury, especially to vascular structures.71
In the case of thermal or chemical burn injuries, information about the injury environment is important. There is significant potential for inhalation injury and carbon monoxide poisoning with burns.72Chemical burns can pose serious hazards to the patient and health care providers. It is important for emergency personnel to determine the possibility of chemical burns and the appropriate precautionary measures.
Head and Face
Significant bleeding can occur from the scalp and lacerations in the posterior occiput may be difficult to locate. When the patient is turned to examine the back, the back of the head should be inspected and the examiner’s gloved finger should palpate for any depressions. Scalp bleeding can result in a large volume of blood loss and hypotension, particularly with long transport times and inadequate prehospital control of hemorrhage. Quick application of direct pressure, sutures, staples, or Raney clip closure of the laceration may be necessary to control bleeding. Once active hemorrhage is controlled, the wound can be definitively managed during the secondary survey.
Facial injuries are detected by inspecting and then palpating for facial instability. Orbital fractures are the most commonly missed facial injury. In conscious patients, asking the patient if their bite feels normal can help detect any jaw fractures influencing alignment. Bleeding from the nose can usually be controlled by direct pressure. More troublesome bleeding usually occurs from the posterior nasopharynx, and nasal packing or angiography and embolization may be required. A more thorough pupillary examination should be performed, evaluating visual acuity, pupil size and reactivity, direct globe injury, hyphema, foreign body contamination including contact lenses, and extraocular movement.
Bruising around the eyes (raccoon’s eyes) or behind the ears (Battle’s sign) may indicate a basilar skull fracture. Hemotympanum or clear drainage from the nose or ears (CSF) confirms this diagnosis. If there is suspicion of a basilar skull fracture or cribriform plate fracture, an orogastric and not a nasogastric tube should be inserted and the patient should undergo a CT scan of the head. Treatment of facial fractures can be deferred unless bleeding compromises the airway.
A quick examination of the pupils and determination of GCS is performed during the primary survey. A more detailed neurologic examination is performed during the secondary survey, involving a complete motor and sensory examination. Asymmetry in the motor examination could reflect a localized intracranial injury. A CT of the head should be obtained in all patients with an abnormal neurologic examination or altered level of consciousness at any time since the trauma occurred.
Neck and Spine
All patients with a mechanism conducive to neck injuries must have a thorough examination. This includes inspection for seatbelt signs, hematomas, or a penetrating wound. A seatbelt mark across the neck or chest is associated with a 3% incidence of blunt carotid injury. A CT angiogram of the neck should be performed upon identification of a seatbelt mark or other related injuries such as cervical spine fractures, skull and facial fractures, Horner’s syndrome, or neurologic deficit.73 Penetrating neck wounds require careful investigation or surgery depending on local practices if the platysma is violated in order to rule out injury to blood vessels or other neck structures.
Patients with blunt injury and/or abnormal neurologic examination require initial cervical spine protection with a cervical collar. If the patient is thought to be alert and cooperative without distracting injuries the cervical spine may be cleared clinically. Otherwise, a CT of the spine is necessary to rule out fracture or dislocation. Plain films of the cervical spine may also be performed but obtaining adequate views can sometimes be difficult. If any spinal fracture is identified, the entire spine must be evaluated due to a 10% incidence of noncontiguous injury.
Inspection and palpation of the chest may detect pain, chest wall tenderness, or crepitance. A flail segment appears as asymmetry in the chest wall compared to the contralateral side or to another segment on the same side. Auscultation may be hard in a noisy trauma bay but is mandatory. Decreased or absent breath sounds can indicate a pneumothorax. By listening for hyperresonance or muffled heart tones and looking for JVD and symmetric chest rise in the hypotensive trauma patient, a tension pneumothorax or cardiac tamponade may be differentiated. Listening for hyperesonance is difficult because of the noisy environment, and is therefore unlikely to be helpful. Excluding the life-threatening condition of a tension pneumothorax, a chest x-ray is obtained. If the chest x-ray shows rib fractures, pneumo- or hemothorax, pulmonary contusion, or widened mediastinum, further evaluation should be performed using chest CT. Significant deceleration forces can also cause blunt aortic injury which can be evaluated with the use of chest CT.
The abdomen may be a source of occult bleeding in hemodynamically abnormal patients with normal chest and pelvic x-rays. Inspection of the abdomen may reveal a seatbelt sign, which is associated with an increased risk of small bowel injuries near the ligament of Treitz or ileocecal valve. At these locations, the bowel is fixed between two points: the ligament or ileocecal valve and the seatbelt. When there is a significant deceleration force, the bowel blows out on the antimesenteric side. Deceleration injury may also result in pancreatic trauma. Inspection may also reveal penetrating injuries. Some centers surgically explore all anterior abdominal gunshot wounds. Stab wounds to the anterior abdomen are usually managed differently. Palpation of the abdomen may elicit tenderness or masses. Obviously, if peritonitis is present, the patient should be taken to the operating room emergently.
The pelvis is included in the abdominal examination. Stability of the pelvis should be checked preferably only once by a skilled examiner. The perineum should also be examined for injuries. A mandatory rectal and/or vaginal examination is performed when a pelvic fracture is identified to rule out an open fracture. A pelvic x-ray should be obtained in the unstable patient to look for fractures that open the pelvis and increase the pelvic volume. As discussed previously, a FAST should be performed to look for hemoperitoneum. A DPL may be performed if the FAST is equivocal or is not available. With an unstable pelvic injury, a pelvic binder or sheet should be placed to help control bleeding.
Musculoskeletal and Peripheral Vascular System
The upper and lower extremities should be examined and palpated for tenderness and deformities. Each extremity is gently moved to determine range of motion. A neurovascular examination is performed. Decreased or absent pulses in one extremity must be quickly evaluated and acted upon. Arterial hemorrhage or expanding hematomas require an urgent operation. Local practice determines the course of action for a discrepancy in pulses, loss of pulses, or proximity of penetrating injuries to large vessels of the arms or legs.
An injured extremity is at risk for ischemia and compartment syndrome. The greatest risk for compartment syndrome occurs in patients with tibial fractures. The development of compartment syndrome may be insidious. A high index of suspicion is necessary, especially in unconscious patients. If the diagnosis of compartment syndrome is made, compartment pressures can be checked with a needle attached to a pressure transducer. Tissue pressures greater than 30 mm Hg require fasciotomy. Due to the catastrophic consequences of delayed response to compartment syndrome, immediate treatment with four-compartment fasciotomies is sometimes performed without measurement of pressures.
Adjuncts to the Secondary Survey
Additional tests such as x-rays of the spine or extremities, angiography, or other diagnostic procedures may be necessary. In the patient in shock, or the patient in whom transfer has already been deemed necessary, these should not be performed until the patient is at the institution that will provide definitive care due to treatment delays as well as the possible need for repeat examinations.
During the secondary survey, laboratory test results may be available depending on turnaround time. Base deficit and lactate values are important for determining the status of volume resuscitation.52,53 In critically ill patients, the severity of lactic acidosis correlates with overall oxygen debt and survival.53,74 The base deficit is part of the standard arterial blood gas panel and usually returns much sooner than the lactate level. The base deficit can be important for determining the duration and magnitude of hypoperfusion, for example, in patients who underwent prolonged extrication following a vehicular crash. If the patient has received bicarbonate for metabolic acidosis, then lactate levels (which are not influenced by bicarbonate administration) are a more useful measure of the adequacy of resuscitation.
After the secondary survey, reassessment of the patient and his or her response to treatment thus far is important. If problems are detected, the steps to the primary survey are repeated.
An injured patient’s physiologic status, anatomic injuries, mechanism of injury, and comorbidities, as well as available local resources, determine the need for transfer to a higher level of care. When the decision is made to transfer a patient, the referring physician is responsible for continued resuscitation and attempted stabilization of that patient. Physician-to-physician communication can determine urgency of transport, mode of transport, and level of care during transport. Transfer agreements and patterns of communication within regions are best established prior to patient arrival, so that individual patient transfers happen efficiently and smoothly.
The pertinent history, treatment, and potential unsolved problems must be communicated to the accepting physician and transport personnel. The level of care during transport should be commensurate with the severity of injuries, and transport personnel should be capable of continuing resuscitative efforts, including management of the ABCDEs.
Finally, the patient must be “packaged” appropriately for transport. Endotracheal tubes must be secured. At times, it is difficult to secure an airway during transport, so if there is potential for airway compromise or severe head injury requiring a definitive airway with maintenance of adequate ventilation and oxygenation, intubation should be performed prior to transport. The patient should also have two large-bore intravenous lines, crystalloid and/or blood infusing, gastric and urinary catheters in place, and continuous cardiac monitoring prior to transport.
MEDICAL RECORD DOCUMENTATION
Detailed record keeping and review of patient records and outcomes is essential in providing good patient care. Although in-person or phone communication is emphasized during the transfer process, communication also occurs via the medical record, and is facilitated with comprehensive and accurate documentation. The medical record of the trauma patient should include records of prehospital care, care in the ED, and inpatient care at all facilities in which care was provided. Minimum documentation for care provided in the emergency setting must include patient identification, how the patient arrived, care that was rendered before arrival, pertinent history, chronologic notation of the physical examination including vital signs, and the results of diagnostic and therapeutic procedures and tests. For the trauma patient, mechanism of injury, GCS, vital signs, respiratory rate, spinal immobilization, and the status of airway, breathing, and circulatory systems also must be recorded. Chronology and response to treatment are particularly important for subsequent care providers. The medical record is the legal documentation of care provided, and protects the legal interests of both patient and healthcare providers.75 When patient information is shared between facilities to provide continuity of care, the rules of the Health Insurance Portability and Accountability Act (HIPAA) do not apply.76 There are many ways that trauma resuscitations are recorded depending on the facility. The choice of which documentation form to use is up to each hospital caring for the injured patient. Review of medical records is an essential aspect of performance improvement.
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