Tintinalli's Emergency Medicine > Section 22: Trauma > Chapter 251. Initial Approach to Trauma >
Initial Approach to Trauma: Introduction
Recent cataclysmic events have made Americans more cognizant of the need for trauma systems and trauma centers. Yet, it is the everyday "unspectacular" injuries that account for nearly 150,000 deaths each year. Injury is the fourth leading killer of Americans and the single greatest cause of death before the age of 45 years.1 The predominant causes of death following trauma (i.e., head, chest, and major vascular injuries) imply that the organization of trauma centers and trauma systems should be predicated on the concepts of rapid triage, diagnosis, and therapeutic intervention.2
Trauma Systems and Timely Triage
The importance of a systems approach to trauma care becomes clear when the timing of death occurring secondary to traumatic injuries is considered.3 The pattern of mortality takes on roughly a trimodal distribution where three peak occurrences are seen. The first peak occurs in the prehospital setting, largely a result of devastating head and major vascular injuries. Efforts to reduce deaths in this setting are largely societal, complex, and multidisciplinary, and include such multifaceted activities as drunk driving laws; safe road construction; seat belt, helmet, and airbag laws; and violence-prevention activities such as counseling, education and outreach efforts, handgun control, and dissemination of conflict resolution skills.4,5 A second peak incidence of deaths as a result of traumatic injuries occurs in the early minutes and hours after a patient's arrival at the hospital. Deaths in this peak are largely a result of major head, chest, and abdominal injuries. The most important function of a trauma system is to decrease deaths in this phase by rapid transport of patients to the most appropriate facility and prompt resuscitation and identification of injuries requiring surgical intervention. The third peak in the trimodal distribution of deaths occurs in the intensive care unit, where the sequelae of organ hypoperfusion experienced in the early postinjury period are seen. Specifically, patients who have survived the initial injury, transport, and operative resuscitation die in this setting as a result of the systemic inflammatory response syndrome and multisystem organ failure.
In recognition of the need to establish a system in which injured patients are rapidly triaged to the most appropriate setting, Congress passed the Trauma Care Systems Planning and Development Act of 1991.6 This Act required the development of a Model Trauma Care System Plan to be used as a reference document for each state to develop its system. Recent appropriations for this originally unfunded mandate have allowed a growing number of states to initiate the development of a comprehensive trauma system. Ultimately, each state must determine the appropriate facility for various types of injuries, and some states have come to rely on a verification process offered by the AmericanCollege of Surgeons in order to designate certain hospitals as trauma centers.2 Table 251-1 lists examples of requirements of various levels of trauma centers. In addition to the listed essentials, a trauma center must have all the required features of lower-level trauma centers. An effective trauma program requires the teamwork of emergency medicine, trauma surgery, and trauma care subspecialists.
Table 251-1 Essential Characteristics of Levels I, II, III and IV Trauma Centers
Level I (not required of levels II, III, and IV trauma centers)
24-h availability of all surgical subspecialties (including cardiac surgery/bypass capability)
Neuroradiology, hemodialysis available 24 h
Program that establishes and monitors effect of injury prevention/education efforts
Organized trauma research program
Level II (not required of levels III and IV trauma centers)
Cardiology, ophthalmology, plastic surgery, gynecologic surgery available
Operating room ready 24 h a day
Neurosurgery department in hospital
Trauma multidisciplinary quality assurance committee
Level III (not required of level IV trauma centers)
Trauma and emergency medicine services
24-h radiology capability
Pulse oximetry, central venous and arterial catheter monitoring capability
Thermal control equipment for blood and fluids
Published on-call schedule for surgeons, subspecialists
Trauma registry
Level IV
Initial care capabilities only
Mechanism for prompt transfer
Transfer agreements and protocols
In short, trauma centers are verified on the basis of commitment of personnel and resources needed to maintain a state of readiness to receive critically injured patients. A well-functioning trauma system ensures that not only are there appropriately designated trauma centers but that there are also specific triage criteria to designate which patients should be transported to these centers (Table 251-2).
Table 251-2 Maryland Criteria for Mandatory Transport to a TraumaCenter
Abnormal vital signs (GCS <14 or systolic BP <90) (respiratory rate <10 or >29)
Multiple-system trauma
Penetrating wound to
Head, neck, or torso
Gunshot wound(s) to extremities proximal to elbow and knee
An extremity with neurovascular compromise
CNS injury (head, spine)
Suspected pelvic fracture
Mechanism of injury
Vehicular deformity
Intrusion into passenger compartment greater than 12 in
Major vehicular deformity greater than 20 in
Ejection
Entrapment
Falls greater than three times the patient's height
Fatality in same passenger compartment
Rapid deceleration
Auto–pedestrian/auto–bicycle injury with significant impact (>5 mi/h)
Vehicular rollover
Exposure to blast/explosion
Abbreviations: BP = blood pressure; CNS = central nervous system; GCS = Glasgow Coma Scale.
Source: Adapted from The Maryland Medical Protocols for Emergency Medical Services Providers. Maryland Institute for Emergency Medical Services Systems, 2003, p 121.
Primary Survey
In accordance with the principles of advanced trauma life support, injured patients are assessed and treated in a fashion that establishes priorities based on their presenting vital signs, mental status, and injury mechanism.7 The initial approach to trauma care is a process that consists of an initial primary assessment, rapid resuscitation, and a more thorough secondary survey followed by diagnostic tests and ultimate disposition constitutes (Table 251-3).
Table 251-3 A Step-by-Step Procedure for Trauma Resuscitation
1. Notification by Prehospital Personnel: The receiving emergency department should be informed about:
Airway patency
Pulse and respirations
Level of consciousness
Immobilization
Mechanism of injury and blood loss at the scene
Anatomic sites of apparent injury
2. Preparation for Receiving the Trauma Victim
Assign tasks to team members
Check and prepare vital equipment
Summon surgical consultant and other team members not present
3. Primary Survey: The most immediately lethal injuries are taken care of as they are identified.
Airway
Clear airway: chin lift, suction, finger sweep
Protect airway
Depressed level of consciousness of bleeding, tracheal intubation without neck movement
Surgical airway
Breathing
Ventilate with 100% oxygen
Check thorax and neck
Deviated trachea
Tension pneumothorax (intervention—needle decompression)
Chest wounds and chest wall motion
Sucking chest wound (intervention—occlusive dressing)
Neck and chest crepitation
Multiple broken ribs
Fractured sternum
Pneumothorax
Listen for breath sounds
Correct tracheal tube placement?
Hemopneumothorax?
Chest tube(s)—38-Fr
Collect blood for autotransfusion
Circulation
Apply pressure to sites of external exsanguination
Assure that two large-bore IVs established
Begin with rapid infusion of warm crystalloid solution
If arm sites unavailable, insert a large central line or perform a saphenous cutdown at the ankle
Assess for blood volume status
Radial and carotid pulse, BP determination
Jugular venous filling
Quality of heart tones
Beck triad present?
Pericardiocentesis or echocardiogram
Decompress tamponade
Pericardiocentesis
Thoracotomy with pericardiotomy
Hypovolemia
After 2 L of crystalloid begin blood infusion if still hypovolemic; in children use two 20-mL/kg boluses then 10-mL/kg blood boluses if still unstable
Near-term pregnant patient—place roll under right hip
Disability
Brief neurologic examination
Pupil size and reactivity
Limb movement
Glasgow Coma Scale
Exposure
Completely disrobe the patient
Logroll to inspect back
Continuing resuscitation
Monitor fluid administration
Consider central line for CVP monitoring
Use fetal heart rate as indicator in pregnant women
Record all events
4. Secondary Survey: A thorough search for injuries is carried out in order to set further priorities.
Trauma series x-rays: lateral cervical spine, supine chest, AP pelvis
Head-to-toe examination looking and feeling; quickly bring problems under control as they are discovered
Scalp wound bleeding controlled with Raney clips
Hemotympanum?
Facial stability?
Epistaxis tamponaded with balloons if severe
Avulsed teeth, broken jaw?
Penetrating injuries?
Abdominal distention and tenderness?
Pelvic stability?
Perineal laceration/hematoma?
Urethral meatus blood?
Rectal examination for tone, blood, and prostate position
Bimanual vaginal examination
Peripheral pulses
Deformities, open fractures
Reflexes, sensation
Large gastric tube 18-Fr inserted
Foley catheter inserted
Blood?
Pregnancy test
Logroll the patient to feel and see the back, flanks, and buttocks if not already done
Splint unstable fractures/dislocations
Assure that tetanus prophylaxis is given
Consult with surgeon regarding further tests or immediate need for surgery or preferred IV medications; consider:
Emergency thoracotomy to provide aortic compression of cross-clamping
Aortogram or upright chest x-ray to rule out ruptured aorta
Cystogram if pelvic fracture present or blood in urine
IVP or enhanced CT scan of the abdomen
FAST or diagnostic peritoneal lavage
Head CT scan
IV mannitol for neurologic decompensation
IV steroids for possible spinal cord injury
IV antibiotics for possible ruptured abdominal viscus
IV antibiotics for perineal, vaginal, or rectal lacerations
Pelvic arteriogram and embolization for pelvic hemorrhage
Abbreviations: CVP = central venous pressure; FAST = focused assessment with sonography for trauma; IVP = intravenous pyelography.
When available, a history obtained from a patient, witnesses, or prehospital provider may provide important information regarding circumstances of the injury (single-car accident, a fall, exposure, smoke inhalation), preexisting medical conditions (depression, cardiac disease, pregnancy), or medications (steroids, -blockers) that may suggest certain patterns of injury or the physiologic response to injury.
A primary survey is undertaken quickly with the goal of identifying and treating life-threatening conditions. Specific lethal problems (discussed in further detail below) that should be identified immediately and addressed during the primary survey are airway obstruction, tension pneumothorax, massive hemorrhage, open pneumothorax, flail chest, and cardiac tamponade. The assessment of the ABCs (airway, breathing, and circulation) is such that evidence for or against the presence of these conditions is sought. During the primary survey, the following are quickly assessed:
Airway maintenance with C-spine control
Breathing/ventilation
Circulation with hemorrhage control
Neurologic disability
Exposure, where the patient is completely undressed
Some specific points are emphasized regarding the various components of the trauma evaluation.
Airway with Cervical Spine Control
Rapid assessment for airway patency includes inspecting for foreign bodies or maxillofacial fractures that may result in airway obstruction. The chin-lift or jaw-thrust maneuver or the insertion of an oral or nasal airway is a first response for the patient making inadequate respiratory effort. A two-person technique whenever possible is suggested, where one devotes undivided attention to maintaining in-line immobilization and preventing excessive movement of the cervical spine. Comatose patients (Glasgow Coma Scale score 3 to 8; see "Disability" below) should be intubated tracheally to protect the airway and to prevent the secondary brain injury that occurs with hypoxemia. Logrolling and pharyngeal suction may be necessary to prevent aspiration if the patient vomits. Patients whose anatomy or severe maxillofacial injury precludes endotracheal intubation may require a surgical airway by means of cricothyroidotomy. Agitated trauma patients suffering from head injury, hypoxia, or drug- or alcohol-induced delirium may present a danger to themselves. In these circumstances, paralyzing agents such as succinylcholine or vecuronium, along with a small dose of diazepam or midazolam, may be necessary to enable safe airway management. See Chap. 19 for details, dosages, and techniques.
The issue of cervical spine (C-spine) clearance is one that has received much attention in the recent past. Ultimately, "clearance" of a C-spine is both a radiologic and a clinical undertaking. This implies that patients who do not demonstrate evidence of bony fractures or subluxation on x-ray may still have significant injuries that are not appreciated if they cannot cooperate with a thorough physical examination. On the other hand, precious time should not be expended on multiple views in patients who have critical head, thoracic, and abdominal injuries that may require rapid intervention. In these patients, after a cross-table lateral view of the C-spine, the cervical collar should be left in place until the patient ultimately can cooperate with the clinical examination or undergo more sophisticated studies [e.g., computed tomography (CT) scans or magnetic resonance imaging (MRI) of the spine].
Finally, the practice of obtaining multiple C-spine x-rays in awake, alert patients with normal examinations (no pain or tenderness with the neck in neutral position and rotated in all four directions) is excessive. A large multicenter study, the National Emergency X-Radiography Utilization Study (NEXUS) has helped to develop clinical screening criteria that will spare the time and expense of cervical films.8 The screening criteria that obviate need for C-spine imaging are:
1. No posterior midline C-spine tenderness
2. No evidence of intoxication
3. Alert mental status
4. No focal neurologic deficits
5. No painful distracting injuries
In a cohort of 34,069 patients with 578 clinically significant C-spine injuries, these criteria had a 99.6 percent sensitivity and 99.9 percent negative predictive value.
Breathing
With the patient breathing or now intubated and ventilated with 100 percent oxygen, the thorax and neck should be inspected, auscultated, and palpated to detect abnormalities such as a deviated trachea (tension pneumothorax); crepitus (pneumothorax); paradoxical movement of a chest wall segment (flail chest); sucking chest wound; fractured sternum; and absence of breath sounds on either side of the chest (pneumothorax, tension pneumothorax, massive pneumothorax). Possible interventions here include application of an occlusive dressing to a sucking chest wound, needle thoracostomy for tension pneumothorax, withdrawal of the endotracheal tube from the right mainstem bronchus; reintubation of the trachea if no breath sounds are heard, and insertion of large chest tubes (38-Fr) to relieve hemopneumothorax. Evacuated blood should be collected in an autotransfusion device. The volume of blood that returns should be noted immediately, because 1500 mL of hemorrhage may require a thoracotomy.
Circulation with Hemorrhage Control
Hemorrhagic shock, a common cause of postinjury death, should be assumed to be present in any hypotensive trauma patient until proven otherwise. Direct pressure should be used to control obvious external bleeding, and a rapid assessment of hemodynamic status is essential during the primary survey. This includes evaluation of level of consciousness, skin color, and presence and magnitude of peripheral pulses. Attention should be paid to the specifics of heart rate and blood pulse pressure (systolic minus diastolic blood pressure), particularly in young, previously healthy trauma patients (Table 251-4).
Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial Presentation
Class I Class II Class III Class IV
Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000
Blood loss (percent blood volume) Up to 15 15–30 30–40 40
Pulse rate <100 100–120 120–140 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg) Normal or increased Decreased Decreased Decreased
*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.
Not all hemorrhage produces hemorrhagic shock, and the unsuspecting clinician may fail to appreciate ongoing hemorrhage with blood loss of up to 30 percent of the circulating blood volume.7 While class I hemorrhage (loss of up to 15 percent of circulating blood volume) is associated with minimal symptoms in most patients and is clearly not shock, class III hemorrhage associated with gross hypotension is readily appreciated as a state of hypoperfusion. Yet consider a young, healthy male trauma victim who has lost 25 percent of circulating blood volume (class II hemorrhage) and had a preinjury blood pressure of 130/70 mm Hg and a pulse rate of 60 beats/min. If this patient experiences a 50 percent increase in his pulse rate (to a rate of 90 beats/min) and a greater than 50 percent decrement of his pulse pressure (from 130/70 mm Hg pulse pressure of 60 beats/min to 116/90 mm Hg pulse pressure of 26 beats/min), the unsuspecting clinician may assume that the patient is "hemodynamically stable." A false sense of security may lead to delays in aggressively pursuing the source of bleeding (ultrasound, peritoneal lavage, operative exploration). From this example it should be clear that the practice of omitting diastolic blood pressures (and reporting "116/palpable," thus omitting the pulse pressure) is potentially hazardous. The alert, suspicious clinician identifies hemorrhage before it reaches the class III category of obvious shock.
Two large intravenous lines should be established and blood obtained for laboratory studies. While there are varying preferences, a percutaneous large line in the groin for unstable patients in whom upper extremity veins are not available is appropriate. This is so because subclavian lines are potentially dangerous in the hypovolemic patient with upper body trauma, saphenous vein cutdown at the ankle may not be appropriate for the patient with an injured lower extremity, and complications encountered from the femoral venous line may be minimized if the line is removed quickly on completion of resuscitation in the early postoperative period. Unstable patients without an obvious indication for surgery should be assessed for their response to 2 L of rapid infusion of crystalloids. If there is not marked improvement, type O blood should be transfused (O-negative for females of childbearing age). Auscultation for breath sounds and heart sounds and inspection of neck veins are included in the assessment of circulation because two major causes of hypotension may be present in trauma patients with minimal blood loss: cardiac tamponade (hypotension, agitation, distended neck veins, muffled heart sounds) and tension pneumothorax (hypotension, distended neck veins, absent breath sounds, deviated trachea, tympanic percussion of chest wall).