Trauma

Introduction

• In trauma, assessment and resuscitation must often be performed simultaneously. The initial priority is to detect and treat rapidly fatal injuries.
• Trauma is the leading cause of death up to 44 yr of age with an estimated 57 million
  Americans injured each year and more than 150,000 people dying annually from those injuries.
• Intervention during the so-called “golden hour” is critical to patient survival since 60% of hospital deaths from trauma occur during this time.

Assessment
Primary Survey

• Goals-The goal of the primary survey is to rapidly identify treatable life-threatening emergencies during the first few minutes of the initial evaluation.
• A,B,C,D,E-The primary survey is approached in a systematic fashion using the “ABCs”:
• A-airway maintenance with C-spine stabilization
• B-breathing and ventilation
• C-circulation and hemorrhage control
• D-disability/neurological status
• E-exposure/environmental control preventing hypothermia

Airway

• The airway should be opened using the chin lift or jaw-thrust maneuver.
• The head tilt-chin lift maneuver should NEVER be performed in trauma patients with known or suspected cervical spine injury since it may cause permanent neurological injury.
• In an obtunded patient, an oral or nasopharyngeal airway may facilitate ventilation and airway patency.
• If the above measures fail to allow proper airway management endo tracheal intubation, cricothyroidotomy, or tracheotomy should be considered.

Cervical Spine Immobilization

• All trauma patients should have proper cervical spine stabilization using a hard collar or sandbags along with total body immobilization using a long board as appropriate.

Breathing

• Breathing is assessed by noting the rise and fall of the chest wall, listening for breath sounds and/or feeling for the patient’s breath.
• If breath sounds are unequal or absent, suspect possible hem thorax or pneumothorax.
• These should be immediately treated with a chest tube or needle thoracostomy, respectively.

  Table Glasgow Coma Scale

  Best Motor Response	Best Verbal Response	Eye Opening
  6-follows commands	5-oriented	4-spontaneously
  5-localizes pain	4-confused	3-to voice
  4-withdraws from pain	3-inappropriate words	2-to pain
  3-decorticates	2-incomprehensible sounds	1-none
  2-decerebrates	1-none	1-flaccid/none

  
  

• Palpate the trachea for deviation and the chest wall for fractures or subcutaneous emphysema.

Circulation

• The third step in the primary survey is to assess circulation and control any hemorrhage.
• Observe the patient’s skin for color (e.g., pale, cyanotic) and palpate for temperature.
• Peripheral pulses may be used to estimate cardiac output.
• In trauma, tachycardia (heart rate >120 beats per min in adults) is always suggestive of hypovolemic shock, often secondary to uncontrolled hemorrhage.
• A normal heart rate does not exclude the diagnosis of hypovolemic shock. Patients taking various medications (e.g., digoxin, ß-blockers or calcium channel blockers) may have a normal heart rate despite being in hypovolemic shock.
• Two large-bore intravenous lines should be placed to allow for large volume fluid resuscitation.

Disability

• The fourth step in the primary survey is to assess the patient’s disability and neurological status.
• A rapid neurological assessment is performed in order to evaluate potential intracranial injuries that might necessitate immediate surgical intervention.
• The Glasgow Coma Scale may be used to assess the patient’s level of consciousness (Table 16.1).
• Papillary responses should be documented.

Exposure/Environment

• The final step in the primary survey is exposure and environmental control.
• All of the patient’s clothing should be removed to allow thorough examination of all areas for potential injury.
• The patient should be examined paying special attention to areas where injuries are easily missed including: the head, axillae, perineum and back.
• The patient should be kept warm using blankets and warm intravenous fluids as hypothermia can induce arrhythmias, aggravate acidosis and impair platelet function.

Radiological Studies

• The three most important radiographs to obtain during the primary survey are chest, pelvis and cervical spine radiographs.

Chest X-Ray

• Allows diagnosis of a pneumothorax, hem thorax or great vessel injury.

Pelvic X-Ray

• Allows diagnosis of pelvic fractures which may be associated with significant blood loss.
• An anterior-posterior view should be obtained, and, if there is any abnormality, inlet and outlet films should be obtained.
• Inlet views delineate injuries to the sacroiliac joints or posterior displacement of the hemi pelvis.
• The outlet view allows for good visualization of the sacral foramina or cephalad displacement of the hemi pelvis.

Cervical Spine X-Ray

• Up to 90% of all significant injuries can be detected on a lateral cervical spine film which must include the C7-T1 junction.
• If any abnormality is detected an oblique view should be ordered. This view is useful in evaluating the pedicles, intervertebral foramina, facet joints, and laminae.
• The anterior-posterior view is useful in evaluating the transverse processes and rotational injuries.
• An increased distance between spinous processes suggests a flexion injury.
• The odontoid (open-mouth) view is useful to evaluate the lateral processes of C1 and the odontoid.

Life-Threatening Injuries

• During the primary survey several life-threatening injuries require immediate recognition since they are rapidly fatal if left untreated.

Cardiac Tamponade

• Occurs as a result of penetrating injuries to the chest wall (i.e., stab wounds) which results in the accumulation of fluid in the pericardial space restricting proper function of the atria and ventricles.
• As little as 150 cm3 of fluid is capable of causing tamponade.
• Approximately 33% of patients with this type of injury display the classic Beck’s triad of hypotension, distended neck trauma veins and muffled heart sounds.
• Tachycardia and pulsus paradoxus (>10 mm Hg drop in systolic blood pressure with inspiration) may also be seen.
• If this type of injury is suspected, immediate thoracotomy or pericardiocentesis should be performed.

Tension Pneumothorax

• Occurs when air escapes into the pleural space.
• Clinical findings commonly associated with this type of injury include: dyspnea, respiratory distress, diminished breath sounds on the affected side, hyper resonance to percussion on the affected side, tracheal deviation away from the side of the lesion, tachycardia, hypotension and jugular venous distension.
• Immediate needle decompression should be performed in patients suspected of having this type of injury.
• A 14 gauge intravenous catheter is inserted in the second intercostals space in the midclavicular line.
• The definitive treatment is tube thoracostomy.

Open Chest Wounds (“sucking chest wound”)

• Occurs as a result of a penetrating injury to the chest wall.
• This type of wound occurs when the chest wall communicates with the pleural space, and each breath allows air to progressively enter the pleural space.
• A three-sided dressing may be placed over the wound to prohibit air from entering and allow air to escape while obtaining supplies for definitive treatment.
• Never place an occlusive dressing over the wound as this will essentially convert an open chest wound into a tension pneumothorax.
• Immediate definitive treatment includes tube thoracostomy followed by an occlusive dressing.

Flail Chest

• Occurs due to chest wall trauma secondary to tremendous force.
• There are various criteria for a flail chest injury including:
• Two or more ribs fractured in two or more places
• Costal cartilage disarticulation associated with more than one rib fracture
• Disarticulation of the costal cartilage on both sides of the sternum
• Clinically, dyspnea and paradoxical chest wall movements may be noted.
• Treatment for flail chest is mainly supportive with supplemental oxygen and analgesics as needed.
• The clinician must assess the patient for underlying lung injuries, and intubation may be required if signs of respiratory failure become apparent.

Exsanguinating Hemorrhage

• The most common anatomic spaces for life-threatening hemorrhage are intrathoracic (hemothorax), intrabdominal (hemoperitoneum), retroperitoneal, extremity compartments (especially thigh compartments).
• External hemorrhage should be controlled with immediate direct pressure and wound management.
• Internal hemorrhage is treated with fluid and blood resuscitation and appropriate surgical intervention.

Secondary Survey

• The secondary survey should only be performed after the primary survey has been completed and resuscitation measures have been initiated. It should include a complete focused history and head-to-toe examination. The vital signs (blood pressure, heart rate, respiratory rate and temperature) should be reviewed and a focused history should be obtained.
• The pneumonic “AMPLE” can focus the questioning in order to obtain the most pertinent facts.
• A-allergies
• M-medications
• P-past medical history and illnesses
• L-last meal
• E-events surrounding the injury
• Finally, a complete head-to-toe examination should include: head, ears, eyes, nose, throat, chest, abdomen, back, rectal/vaginal, musculoskeletal, integument, and neurological status.

Laboratory Studies
Type and Cross-Match

• A type and cross should be sent immediately in all trauma patients as it takes up to 30 min to perform.
• If a patient requires an immediate blood transfusion, O/Rh negative blood can be used.
• Type-specific blood (typed but not cross-matched) can usually be ready in about 10 min.

Complete Blood Count

• A complete blood count should be sent.
• The hemoglobin and hematocrit are useful indices to determine the oxygen-carrying capacity of the blood.
• A hemoglobin of 7 mg/dL (hematocrit 21%) is usually well tolerated in trauma patients.
• In the elderly or those with cardiovascular compromise, a hemoglobin of 10 mg/dL (hematocrit 30%) may be a more appropriate goal.
• Abnormal platelet counts may herald future problems with hemostasis.

Urinalysis

• A urinalysis is a quick and easy study that can demonstrate gross or microscopic hematuria that may be indicative of a urinary tract injury.

• The PT and aPTT can help determine the presence of an underlying coagulopathy that can inhibit the patient’s ability to stop bleeding.
• It is important to remember that normothermia (>35 degrees Celsius) is crucial to correcting coagulopathies in trauma patients.