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Trauma: Optimizing Survival Outcomes

3 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Friday, August 18, 2023

AOTA Classification Code: CAT 1: Domain of OT; CAT 3: Contemporary Issurs and Tends
Education Level: Intermediate
AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9575.


FPTA Approval: CE21- 575935. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

≥92% of participants will respond correctly to patients with traumatic injury.

Objectives

After completing this course, the participant will be able to meet the following seven objectives:

  1. State the epidemiology underlying the worldwide incidence of trauma.
  2. Describe particular mechanisms which predispose patients to specific injuries.
  3. Relate the pre-arrival preparation of the trauma patient by EMS and pertinent information communicated by EMS to the receiving emergency department so that the emergency department prepares appropriately for the arrival of the trauma patient.
  4. Describe the primary evaluation and management of the adult trauma patient, including diagnostic studies deemed valuable.
  5. Describe the secondary evaluation and management of the adult trauma patient, including diagnostic studies deemed valuable.
  6. Outline various pitfalls and pearls in the care of the trauma patient.
  7. Differentiate between the primary and secondary evaluation and management of the adult trauma patient.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Pamela Downey (MSN, ARNP)

Introduction

Trauma is a leading cause of mortality globally. Traumatic injuries can range from minor isolated wounds to complex injuries involving multiple organ systems. Particular mechanisms predispose patients to specific injuries. All trauma patients require a systematic evaluation to maximize outcomes and reduce the risk of undiscovered injuries.

All trauma patients require a systematic approach to management to maximize outcomes and reduce the risk of undiscovered injuries. Optimal care requires effective and efficient communication and teamwork among clinicians.

The primary survey used in Advanced Trauma Life Support™ is organized according to the injuries that pose the most immediate threats to life. Problems are managed immediately in the order they are detected. The individual steps (including assessments of the airway, breathing, circulation, and neurologic injury) and important principles of the primary survey will be described.

A secondary survey is performed in all trauma patients determined to be stable upon completing the primary survey. The secondary survey includes a detailed history, a thorough but efficient physical examination, and targeted diagnostic studies and plays a crucial role in avoiding missed injuries.

Epidemiology (Raja & Zane, 2020)

Trauma is a leading cause of mortality globally. Worldwide, road traffic injuries are the leading cause of death between the ages of 18 and 29, while in the United States (US), trauma is the leading cause of death in young adults and accounts for 10% of all deaths among men and women. Over 45 million people globally sustain moderate to severe disability each year due to trauma. In the US alone, more than 50 million patients receive some form of trauma-related medical care annually, and trauma accounts for approximately 30% of all intensive care unit (ICU) admissions.

According to the World Health Organization (WHO), road traffic injuries accounted for 1.25 million deaths in 2014, and trauma is expected to rise to the third leading cause of disability worldwide by 2030. Outside areas of armed conflict, penetrating injuries are responsible for fewer than 15% of traumatic deaths worldwide, but these rates vary by country. For example, while homicide accounts for as many as 45% of deaths in Los Angeles, penetrating injuries account for only 13% of deaths in Norway. Approximately half of the traumatic deaths result from central nervous system (CNS) injury, while a third result from exsanguination.

Patients with serious traumatic injuries have a significantly lower likelihood of mortality or morbidity (10.4% versus 13.8%) when treated at a designated trauma center. Older age, obesity, and major comorbidities are associated with worse outcomes following trauma. In trauma patients with significant hemorrhage, a lower score on the Glasgow Coma Scale (GCS) and older age independently are associated with increased mortality. In a large retrospective study from the US National Trauma Data Bank, warfarin use was associated with an approximately 70% increased risk of mortality following trauma after adjusting for other important risk factors.

While the most common causes of mortality from trauma are hemorrhage, multiple organ dysfunction syndrome, and cardiopulmonary arrest, the most common preventable causes of morbidity are unintended extubation, technical surgical failures, missed injuries, and intravascular catheter-related complications.

Relatively few patients die after the first 24 hours following injury. Rather, most deaths occur either at the scene or within the first four hours after the patient reaches a trauma center.

The "golden hour" concept, which emphasized the increased risk of death and the need for rapid intervention during the first hour of care following major trauma, was described in early trauma studies and promulgated in textbooks and instructional courses. Undoubtedly, there are instances when rapid intervention improves the outcome of injured patients (e.g., obstructed airway, tension pneumothorax, severe hemorrhage), especially in battlefield injuries. However, the relationship between timing and mortality may be more complex than once thought. A large study using registries from multiple trauma centers across North America found no association between emergency medical services (EMS's) intervals (e.g., on scene and transport times) and trauma patient mortality.

Mechanism (Raja & Zane, 2020)

Particular mechanisms predispose patients to specific injuries. Common blunt trauma mechanisms and the most frequently associated injuries are described in the accompanying table. (Table 1)

Table 1 Blunt Trauma Mechanisms and Associated Injuries
Mechanism of InjuryAdditional ConsiderationsPotential Associated Injuries
Motor Vehicle Collisions

Head-on collision

 
  • Facial injuries
  • Lower extremity injuries
  • Aortic injuries

Rear-end collision

 
  • Hyperextension injuries of the cervical spine
  • Cervical spine fractures
  • Central cord syndrome

Lateral (T-bone) collision

 
  • Thoracic injuries
  • Abdominal injuries: spleen, liver
  • Pelvic injuries
  • Clavicle, humerus, rib fractures

Rollover

  • Greater chance of ejection
  • Significant mechanism of injury
  • Crush injuries
  • Compression fractures of the spine

Ejected from vehicle

  • Likely unrestrained
  • Significant mortality
  • Spinal injuries

Windshield damage

  • Likely unrestrained
  • Closed head injuries, coup and countercoup injuries
  • Facial fractures
  • Skull fractures
  • Cervical spine fractures

Steering wheel damage

  • Likely unrestrained

Thoracic injuries:

  • Sternal and rib fractures, flail chest
  • Cardiac contusion
  • Aortic injuries
  • Hemo/pneumothoraces

Dashboard involvement/damage

 
  • Pelvic and acetabular injuries
  • Dislocated hip
Restraint/Seat Belt Use

Proper three-point restraint

  • Decreased morbidity
  • Sternal and rib fractures Pulmonary contusions

Lap belt only

 
  • Chance fractures
  • Abdominal injuries
  • Head and facial injuries/fractures

Shoulder belt only

 
  • Cervical spine injuries/fractures
  • "Submarine" out of restraint devices (possible ejection)

Airbag deployment

  • Front-end collisions
  • Less severe head/upper torso injuries
  • Not effective for lateral impacts
  • More severe injuries in children (improper front seat placement)
  • Upper extremity soft tissue injuries/fractures
  • Lower extremity injuries/fractures
Pedestrian versus Automobile

Low speed (braking automobile

 
  • Tibia and fibula fractures
  • Knee injuries

High speed

 
  • Waddle's triad: tibia/fibula or femur fractures
  • Truncal injuries
  • Craniofacial injuries
  • "Thrown" pedestrians at risk for multisystem injuries
Bicycle

Automobile related

 

Closed head injuries:

  • "Handlebar" injuries
  • Spleen/liver lacerations
  • Additional intra-abdominal injuries
  • Consider penetrating injuries

Nonautomobile related

 
  • Extremity injuries
  • "Handlebar" injuries
Falls:36 to 60 feet (11 to 18 m)

Vertical impact

 
  • Calcaneal and lower extremity fractures
  • Pelvic fractures
  • Closed head injuries

Horizontal impact

 
  • Calcaneal and lower extremity fractures
  • Cervical spine fractures
  • Renal and renal vascular injuries
  
  • Hand and wrist fractures
  • Abdominal and thoracic visceral injuries
  • Aortic injuries

Additionally, certain high-risk blunt mechanisms, including pedestrians struck by automobiles, motorcycle accidents, severe motor vehicle accidents (MVA's) (e.g., extensive damage leading to prolonged extrication time), and falls greater than 20 feet, have been associated with morbidity and mortality.

Preparation

Pre-arrival Preparation (Raja & Zane, 2020)

Whenever possible, EMS should notify the receiving hospital that a trauma patient is en route. This report provides the receiving hospital with information and time crucial to managing the severely injured patient. Ideally, the information provided by EMS's includes:

  • Apparent injuries
  • Mechanism of injury
  • Patient age and sex
  • Vital signs (some clinicians ask for the lowest blood pressure and highest pulse)

Early notification enables the emergency department (ED) staff to do the following:

  • Notify additional personal (e.g., ED staff, trauma surgery, obstetrics, orthopedics, radiology, and interpreter services)
  • Assure resources are available (e.g., ultrasound, CT, operating room (OR) space)
  • Prepare for anticipated procedures (e.g., tracheal intubation, chest tube placement)
  • Prepare for blood transfusion(s)

Additionally, the information provided by EMS before arrival can help hospital-based clinicians focus on more likely injuries (see Table 1 above). For example, a description of a feet-first fall from great height raises suspicion for fractures of the calcaneus, lower extremity, and lumbar spine or A prolonged motor vehicle extrication report due to collapse of the driver's side compartment raises concern for injuries such as rib fractures, pulmonary contusion, and lacerations of the spleen and kidney.

Universal precautions against blood and fluid-borne diseases should be part of the trauma team’s preparation. These include:

  • Eye protection
  • Gloves
  • Gowns
  • Masks
  • Lead shields for staff should be available if portable x-rays are to be performed during resuscitation efforts.

Trauma Team (Raja & Zane, 2020)

In rural hospitals, the trauma team may be limited to one physician and a nurse. In such settings, the team might enlist help from EMS personnel or other clinicians to manage critically ill or multiple patients. Teams at major trauma centers may include ED physicians, trauma surgeons, subspecialist surgeons, other ED personnel, respiratory therapists, technicians, and social workers.

Regardless of the setting, all teams must have a designated leader who determines the overall management plan and assigns specific tasks. While leaders of smaller teams might find themselves having to perform procedures to care effectively for their patients, leaders of larger teams should avoid performing procedures. This designation allows the leader to remain focused on their supervisory responsibilities and the patient and possible changes in his/her condition.

Regardless of the setting or team composition, optimal care of a trauma patient requires effective and efficient communication and teamwork among all members. Good care begins with a pre-arrival briefing and the assignment of general roles and specific tasks. Throughout the resuscitation, the team uses closed-loop communication and maintains a common vision of the care plan. Notably, it is important to include the alert patient (or health care proxy) in this communication, keeping them informed of the care plan and any changes.

Breakdowns in the care plan and medical mismanagement typically occur due to one or more of four potential problems:

  • Communication breakdowns such as:
    • Changes in the patient’s physiologic state.
    • Critical test results not being effectively communicated.
    • Overall management plan or priority of tasks is not conveyed clearly by the team leader.
  • Failures in situational awareness such as:
    • Failure to recognize shock.
    • Failure to anticipate blood transfusion needs.
    • Failure to modify standard management for higher-risk patients.
  • Staffing or workload distribution problems such as:
    • Insufficiently trained staff conducting a procedure.
    • Inadequate staff for patient volume.
  • Unresolved conflicts such as:
    • Unresolved hostility about other team members received to be performing inadequately.
    • Disagreement about the overall management plan.
    • Disagreement among senior clinicians vying for team leadership.

Primary Evaluation and Management

Overview (Raja & Zane, 2020)

A clear, simple, and organized approach is needed when managing a severely injured patient. The primary survey promulgated in Advanced Trauma Life Support™ (ATLS™) provides such an approach. The primary survey is organized according to the injuries that pose the most immediate threats to life and is performed in the order described below. In settings with limited resources, the primary survey simplifies priorities, and any problems identified should be managed immediately before moving on to the next step of the survey. However, many capable clinicians may be present at major trauma centers, allowing the team to address multiple problems simultaneously.

The primary survey consists of the following steps:

  1. Airway assessment and protection
    1. Maintain cervical spine stabilization when appropriate.
  2. Breathing and ventilation assessment
    1. Maintain adequate oxygenation.
  3. Circulation assessment
    1. Control hemorrhage and maintain adequate end-organ perfusion.
  4. Disability assessment
    1. Perform basic neurologic evaluation.
  5. Exposure, with environmental control
    1. Undress patient and search everywhere for possible injury while preventing hypothermia.

Keep the following points in mind while performing the primary survey:

  • Airway obstruction is a major cause of death immediately following trauma. The airway may be obstructed by:
    • Aspirated material
    • Expanding hematoma
    • Foreign body
    • Tissue edema
    • Tongue
  • Definitive guidelines for tracheal intubation in trauma do not exist.
    • When in doubt, it is generally best to intubate early, particularly in patients with hemodynamic instability or those with significant injuries to the face or neck, leading to swelling and distortion of the airway.
  • Once an airway has been established, it is important to secure it well and prevent it from being dislodged any time the patient is moved.
    • Unintended extubation is the most common preventable cause of morbidity in trauma patients.
  • Unconscious patients with small pneumothoraces that are not visible or are missed on the initial chest x-ray may develop tension physiology after tracheal intubation from positive pressure ventilation.
    • It is important to auscultate the lungs of trauma patients who develop hemodynamic instability after being intubated and attentive to ventilator pressure alarms.
  • Hemorrhage is the most common preventable cause of mortality in patients with trauma.
    • Be alert for subtle signs of hemorrhagic shock, particularly in the elderly, who may be on cardiovascular medications that blunt such signs, and in young, healthy adults who may not present with obvious manifestations.
    • Hypotension is generally not manifested until at least 30% of the patient's blood volume has been lost. These patients are at high risk of death.
      • Elderly patients may be hypotensive relative to their baseline blood pressure but still have blood pressure measurements in the "normal" range.
      • A single episode of hypotension substantially increases the likelihood that a serious injury has occurred.
  • Brain injuries are common in patients who have sustained severe blunt trauma, and even a single episode of hypotension increases their risk of death.

Airway (Raja & Zane, 2020)

Within minutes severely injured patients can develop airway obstruction or inadequate ventilation leading to hypoxia and death. Observational studies suggest that airway obstruction is a major cause of preventable death among trauma patients. Therefore, airway evaluation and management remain the critical first steps in treating any severely injured patient.

Several studies suggest that checklists improve efficiency and reduce the complications associated with airway management of trauma patients. In a prospective study of 141 intubated trauma patients, implementing pre-arrival and pre-induction preparation checklists reduced intubation-related complication rates by 7.7%. A sample checklist is provided in the accompanying table (Table 2).

Table 2 Checklists for Airway Management in Adult Trauma

Pre-arrival Checklist in Preparation for Airway Management of Adult Trauma Patient

  • Oxygen mask and nasal cannula available and connected to oxygen
  • Bag-valve mask with end-tidal carbon dioxide (ETCO2) attachment available
  • Oral airways available
  • Suction available and working
  • Direct laryngoscope handle and blades available and functional (light works)
  • Tracheal tubes (multiple sizes) and stylet available; tube-shaped straight to cuff
  • Tracheal tube introducer ("bougie") available
  • Rescue airway devices available (e.g., laryngeal mask airway, King airway)
  • Cricothyrotomy kit available
  • Video laryngoscope available; monitor positioned appropriately
  • Intravenous (IV) catheters and isotonic fluids available
  • Individuals designated to provide cervical spine stabilization and airway assistance
  • Airway plan verbalized (primary plan and backup plan)
  • Respiratory therapist notified; mechanical ventilator brought to the bedside

Pre-induction Checklist for Intubation of Adult Trauma Patient

  • Pre-arrival checklist completed
  • Airway plan confirmed between trauma and ED attending physicians (if necessary)
  • IV lines functioning
  • Induction and neuromuscular blocking agent (NMBA) medications and doses confirmed and drawn up in labeled syringes
  • Cervical spine stabilization initiated (if necessary)
  • Pre-oxygenation underway: mask at 15 L/minute and nasal cannula at 5 L/minute
  • Patient positioning optimized
  • Blood pressure cuff placed on the arm opposite that of the IV line and pulse oximetry probe

Maintaining the patient's stretcher at a slight angle with the head slightly elevated (reverse Trendelenburg position) or elevating just the head to about 30 degrees if cervical spine precautions are not required, can help to decrease the risk of aspiration and improve lung capacity by reducing abdominal pressure on the chest.

Assessment

In a conscious patient, the airway assessment can be performed by first asking the patient a simple question (e.g., “What is your name?”). A clear, accurate response verifies the patient’s ability to mentate, phonate, and protect their airway, at least temporarily. Next, Observe the face, neck, chest and abdomen for signs of respiratory difficulty, including tachypnea, accessory or asymmetric muscle use, abnormal patterns of respiration, and stridor.

Inspect the oropharyngeal cavity for:

  • Blood
  • Disruption injuries to the teeth and tongue
  • Pooling secretions
  • Vomitus
  • Note if there are any obstacles to the placement of a laryngoscope and endotracheal tube

Inspect and palpate the anterior neck for:

  • Crepitus
  • Hemorrhage
  • Lacerations
  • Swelling
  • Other signs of injury

Palpation of the neck also enables the identification of the landmarks for cricothyrotomy.

The airway must be immediately protected in the unconscious patient once any obstructions (e.g., foreign body, vomitus, displaced tongue) are removed. Airway management in a trauma patient unable to protect his/her airway is completed in an expedient yet controlled fashion. When possible, a brief pre intubation assessment should be performed to gauge the potential difficulty of intubation and determine basic baseline neurologic function (e.g., pupillary light reflex, movement of extremities). The application of the LEMON mnemonic to trauma patients is described below.

L: LOOK:

Facial and neck injuries can distort external and internal structures making it difficult to visualize the glottis and insert an endotracheal tube.

E: EVALUATE 3-3-2:

These pictures refer to the intraoral, mandibular, and hyoid to thyroid notch distances.

The spatial relation ships described here are important determinates of successful direct laryngoscopy. The distance described here suggest laryngoscopy would not be difficult for this patient.

  • The Patient can open his/her mouth sufficiently to admit three of his/her fingers.

332-a

  • The distance between the mentum and the neck/mandible junction, near the hypoid bone, is equal to the width of three of the patient’s fingers.

332-b

  • The space between the superior notch of the thyroid cartilage and the neck/mandible junction, near the hyoid bone, is equal to the width of two of the patient’s fingers.

332-c

  • The cervical collar must be opened to make these assessments. The distance referred to can be narrowed by fracture, hematoma, or other anatomic distortions (e.g., soft tissue swelling)

M: MALLAMPATI:

A standard calculation of the Mallampati score cannot be performed in many trauma patients. Injured patients requiring emergency intubation often cannot open their mouths spontaneously. Nevertheless, an effort should be made to determine how much of the retropharynx can be seen and whether injuries of the oropharynx or pooled blood, vomitus, or secretions are present.

The modified Mallampati classification is a simple scoring system that relates the amount of mouth opening to the size of the tongue and provides an estimate of space available for oral intubation by direct laryngoscopy. According to the Mallampati Scale.

mallampati_scale

Class I is present when the soft palate, uvula, and pillars are visible.
Class II is when the soft palate and the uvula are visible.
Class III is when only the soft palate and base if the uvula are visible.
Class IV is when only the hard palate is visible.

O: OBSTRUCTION/OBISITY:

Either factor can interfere with visualization and management of the traumatized airway. Any number of injuries can obstruct the airway, including internal or external hematomas or soft tissue edema form smoke inhalation. Obesity complicates the performance of cricothyrotomy.

N: NECK MOBILITY:

In-line stabilization is necessary for most trauma patients. Once a second skilled provider removes the cervical collar, that provider should stabilize the spine while orotracheal intubation is performed. It is important to note that neurologic injury from hypoxemia is much greater than the risk of spinal injury due to neck extension during intubation. Judicious relaxation of immobilization may be necessary in some cases.

    Difficult Airway Devices

    Several airway tools and rescue airways can be helpful when managing a trauma patient. Devices that should be available at the bedside include:

    • Bag-valve mask attached to high flow oxygen
    • Cricothyrotomy kit
    • Endotracheal tube introducer (i.e., gum elastic bougie)
    • Endotracheal tubes in a range of sizes
    • Laryngoscopes, including a range of different sized blades and handles
    • Oral and nasal airways
    • Preferred adjunct intubating devices (e.g., lightwand)
    • Rescue airways (e.g., Combitube, laryngeal mask airway)
    • Suction (i.e., multiple pumps and tips)
    • Video laryngoscope, if available

    Direct laryngoscopy relies on direct visualization of the glottis, which is often difficult in the severely injured patient whose airway may be obstructed and whose neck cannot be manipulated. In contrast, video laryngoscopes provide an excellent view of the glottis with minimal cervical spine movement and appear to be well suited for airway management in the trauma patient. Larger studies in trauma populations are needed to confirm these initial impressions.

    The endotracheal tube introducer (or gum elastic bougie) is another invaluable tool for airway management in trauma patients, particularly when the glottic view is limited.

    Intubation

    Tracheal intubation of the injured patient is often complicated by the need to maintain cervical immobilization, the presence of obstructions such as blood, vomitus, and debris, and possibly by direct trauma to the airway. Nevertheless, many trauma patients require intubation for immediate airway protection or because of the projected disease course. Intubation improves oxygenation, thereby helping to meet increased physiologic demands and allows for testing and procedures to be performed more easily and with less patient discomfort.

    Ideally, airway managers should have a predetermined backup plan with all necessary tools at the bedside, including rescue airways and a cricothyrotomy kit, before proceeding with intubation. In crash scenarios, this may not be possible. A sample checklist to assist with airway management of the adult trauma patient was provided in Table 2 above.

    Clinicians should consider the expected course of the disease and the need for interventions when deciding to secure an airway. Patients often warrant early intubation to ensure airway protection or to allow for deeper sedation and pain control. Examples of this include the following:

    • A patient who is hemodynamically stable for the moment but at risk of deterioration and who requires a complex diagnostic study that must be performed in a remote radiology suite.
    • A patient with significant injury in imminent need of an orthopedic or other painful procedure.

    Critically ill trauma patients at risk for hypotension following sedation and paralysis for intubation should be treated aggressively before intubation. Post-intubation hypotension should be anticipated and mitigated as much as possible. In a retrospective review of 444 patients, in-hospital mortality was nearly doubled for those who had a single episode of post-intubation hypotension compared with those who did not (29.8% versus 15.9%).

    Cricothyrotomy

    Clinicians who manage trauma must be prepared to perform a cricothyrotomy when orotracheal intubation cannot be accomplished. In trauma patients with a potentially difficult airway, a double set-up, simultaneous preparation is made to perform orotracheal intubation and cricothyrotomy, may be the best approach. This approach enables the clinician to transition immediately to a cricothyrotomy if attempts at oral intubation are unsuccessful. Trauma patients may have sustained injuries to the neck that make cricothyrotomy difficult to perform, and therefore, it is important to optimize any attempt at orotracheal intubation.

    Cervical Spine Immobilization (Raja & Zane, 2020)

    Assume that an injury to the cervical spine has occurred in all blunt trauma patients until proven otherwise. Conversely, patients with isolated penetrating trauma, no secondary blunt injury, and an intact neurologic examination typically do not have an unstable spinal column injury. Routine spinal immobilization is not recommended following penetrating injury and has been associated with increased mortality. Additionally, routine spinal immobilization is unnecessary when managing the airway in patients with penetrating neck trauma.

    The anterior portion of the cervical collar should be temporarily removed and manual in-line stabilization maintained for all patients with blunt traumatic injuries receiving airway interventions, including bag-mask ventilation. Pre intubation airway interventions are associated with as much spinal column subluxation as intubation.

    Tracheal intubation should not be attempted with the anterior portion of the cervical collar in place. Intubations performed with the complete cervical collar in place are associated with greater spinal subluxation than those performed with the anterior portion removed and manual in-line stabilization.

    The safety of manual in-line stabilization for patients with blunt traumatic injuries needing intubation is well established. Few case reports describe spinal injury during intubation, and in all cases, the spine was not manually stabilized.

    Breathing and Ventilation (Raja & Zane, 2020)

    Once airway patency is ensured, assess the adequacy of oxygenation and ventilation. Chest trauma accounts for 20% to 25% of trauma-related deaths, in large part due to its harmful effects on oxygenation and ventilation.

    The clinician should:

    • Inspect the chest wall looking for signs of injury, including asymmetric or paradoxical movement (e.g., flail chest)
    • Auscultate breath sounds at the apices and axillae
    • Palpate for crepitus and deformity
    • In unstable patients, a portable chest x-ray should be obtained

    Tension pneumothorax, massive hemothorax, and cardiac tamponade are immediate threats to life that should be identified at this stage of the primary survey. Ultrasound can provide important information about all these diagnoses during this portion of the assessment.

    Presumptively treat patients exhibiting signs of tension pneumothorax, including hypotension, dyspnea, and ipsilateral decreased breath sounds, with needle decompression before obtaining imaging. Delays in obtaining a portable chest x-ray can cause significant morbidity. If confirmation is needed before treatment, ultrasound can be performed rapidly at the bedside, and it is more sensitive than a plain chest x-ray for detecting pneumothorax. Needle decompression is performed with a large-bore (14 gauge or larger) angiocatheter, either in the second intercostal space in the midclavicular line or in the fifth intercostal space in the midaxillary line. If equipment is immediately available, it is appropriate to proceed directly to chest tube insertion without intervening needle decompression.

    Of note, a standard 14-gauge angiocatheter cannot penetrate the chest wall and reach the pleural space in 10% to 33% of trauma patients. A 10-gauge, 7.5 cm (3 inches) armored angiocatheter can penetrate the pleural space in most instances. Needle decompression is followed immediately by tube thoracostomy.

    Tube thoracostomy in an unstable trauma patient is placed in anticipation of both hemothorax and pneumothorax using a size 28 to 32 French chest tube. A generous skin incision should be made in the fifth intercostal space in the midaxillary line, allowing for placement of the tube in the inferior portion of the interspace and digital guidance towards the posterior-apical portion of the hemithorax.

    Circulation (Raja & Zane, 2020)

    Recognition and Management of Hemorrhage

    Once the airway and breathing are stabilized, an initial evaluation of the patient's circulatory status should be performed by palpating central pulses. If a carotid or femoral pulse is verified and no obvious exsanguinating external injury is noted, circulation may momentarily be assumed to be intact. The determination of exact blood pressure should not delay the completion of the primary survey.

    While circulation is assessed, two large-bore (16 gauge or larger) IV catheters are placed, most often in the antecubital fossa of each arm, and blood is drawn for testing, particularly for blood typing and crossmatch. Intraosseous cannulation or central venous catheter placement (ideally under ultrasound guidance) can be performed if there is difficulty establishing peripheral IV access.

    Life-threatening hemorrhage must be controlled. A combination of manual pressure, proximal compression with either a tourniquet or a manual blood pressure cuff, and elevation are typically sufficient to control external arterial hemorrhage. When these are unsuccessful, hemostatic agents may be used, if available. Venous bleeding is controlled with direct pressure. Bleeding from severe pelvic injuries may require the application of a pelvic binder.

    Emergency thoracotomy may be needed for trauma patients without femoral or carotid pulses. The procedure is most effective for victims of stab wounds to the chest with pulses or other witnessed signs of life (e.g., voluntary movement). It is rarely beneficial in patients with blunt trauma or when performed in facilities without ready access to appropriate surgical care.

    Of note, trauma patients who require cardiopulmonary resuscitation (CPR) within one hour of hospital arrival have a low survival rate to hospital discharge (only 13% in one study), so maintaining perfusion and avoiding the need for CPR is exceptionally important.

    In patients in extremis with impending arrest, placement of a resuscitative balloon for occlusion of the aorta (REBOA) by those trained in this technique may be life-saving. This device is most effective in temporizing patients with intra-abdominal or retroperitoneal sources of hemorrhage until more definitive therapy with surgery or angioembolization is possible. So rapid transport to the OR and angiographic suite is essential. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is not appropriate for use in those with suspected thoracic sources of exsanguination or patients in cardiac arrest, in whom emergency department thoracotomy (EDT) should be performed instead.

    Most trauma patients with hypotension or signs of shock (e.g., pale, cool, moist skin) are bleeding, and patients with severe hemorrhage have significantly higher mortality.(Table 3)

    Table 3 Differential Diagnosis of Shock in Trauma

    Low CVP*

    • Hypovolemia
      • Hemorrhage
        • External (compressible)
          • Lacerations
          • Contusions
          • Fractures (partly compressible)
        • Internal (noncompressible)
          • Intrathoracic
          • Intraperitoneal
          • Retroperitoneal (partly compressible)
        • Fractures (partly compressible)
      • Third spacing (e.g., burns)
    • Neurogenic (high cervical cord injury)

    High CVP*

    • Pericardial tamponade
    • Tension pneumothorax
    • Myocardial contusion

    Other Diagnoses to Consider

    • Pharmacologic or toxicologic agents
    • Myocardial infarction (MI) (severe)
    • Diaphragmatic rupture with herniation
    • Fat or air embolism

    *CVP: central venous pressure

    Initial fluid resuscitation for these patients may consist of a bolus of IV crystalloid (e.g., 20 mL/kg isotonic saline). However, patients with obvious severe or ongoing blood loss should be transfused immediately with type O blood (women of childbearing age should be transfused with O negative blood). While mildly unstable patients may be treated with isotonic crystalloid instead of blood, the unnecessary crystalloid infusion should be avoided.

    Despite an initial fluid bolus, patients with persistent hemodynamic instability generally require blood transfusion and definitive control of the bleeding source. Significant hemorrhage occurs in any of five sites:

    • External
    • Intraperitoneal
    • Intrathoracic
    • Long bone fractures
    • Pelvic fractures
    • Retroperitoneal

    A 1:1:1 ratio of plasma, platelets, and red cells should be targeted if transfusion is required. Patients requiring transfusion may benefit from treatment with tranexamic acid (an antifibrinolytic agent) if given within three hours of injury.

    It is important to obtain manual blood pressure measurements in trauma patients with systolic blood pressures below 90 mmHg, as automated blood pressure cuffs often overestimate values significantly in these patients. Furthermore, data suggest that the traditional threshold of a systolic blood pressure below 90 mmHg to define shock is inaccurate. The appropriate systolic or mean arterial blood pressure threshold for defining shock varies by age. A significant proportion of trauma patients with hemorrhagic shock have systolic blood pressure above 90 mmHg. Using a cut-off of 110 mmHg is likely to be more appropriate in the elderly.

    Reversal of Anticoagulation (Raja & Zane, 2020)

    Some trauma patients, particularly the elderly with comorbidities, may be taking anticoagulants. Provided below are methods for reversing particular anticoagulants in cases of life-threatening bleeding.

    Warfarin - Initial emergency treatment to reverse anticoagulation due to warfarin in patients with severe hemorrhage is outlined as follows:

    • If 4-factor unactivated prothrombin complex concentrate (4F PCC*) is available (preferred approach):
      • Give 4F PCC 1500 to 2000 units** IV over 10 minutes.
        • Check international normalized ration (INR) 15 minutes after completion of the infusion. If INR is not ≤1.5. give an additional 4F PCC)
      • Give vitamin K*** 10 mg IV over 10 to 20 minutes.
    • If 3-factor unactivated prothrombin complex concentrate (3F PCC****) is available, but 4F PCC is not available:
      • Give 3F PCC 1500 to 2000 units IV over 10 minutes.
        • Check INR 15 minutes after completion of the infusion. If INR is not ≤1.5, give an additional 3F PCC.
      • Give Factor VIIa 20 mcg/kg IV OR give FFP***** 2 units IV by rapid infusion. Factor VIIa may be preferred if volume overload is a concern.
      • Give vitamin K 10 mg IV over 10 to 20 minutes.
    • If neither 3F PCC nor 4F PCC is available:
      • Give fresh frozen plasma (FFP) 2 units IV by rapid infusion.
        • Check INR 15 minutes after completion of the infusion. If INR ≥1.5, administer two additional units of FFP IV rapid infusion.
        • Repeat the process until INR ≤1.5.
        • May wish to administer loop diuretic between FFP infusions if volume overload is a concern.
      • Give Vitamin K 10 mg IV over 10 to 20 minutes.

    *4F PCC is PCC containing coagulation factors II, VII, IX, protein S, and protein C.

    **PCC doses shown are those suggested for initial treatment of emergency conditions.

    • Subsequent treatment is based on INR and patient weight, if available
    • PCC will reverse anticoagulation within minutes of administration.

    ***Vitamin K effect takes 12 to 24 hours, but Vitamin K administration is needed to counteract the long half-life of warfarin.

    • Subsequent monitoring of the PT/INR is needed to guide further therapy.

    ****3F PCC is PCC containing factors II, IX, and X and only trace factor VII.

    *****FFP administration can take hours due to the volume required.

    • It may be reasonable to thaw four units of FFP while awaiting the PT/INR.
    • The transfusion service may substitute other plasma products for FFP (e.g., Plasma Frozen with 24 hours after phlebotomy [PF24] since these products are considered clinically interchangeable.

    Initial emergency treatment to reverse anticoagulation due to direct oral anticoagulants (DOC's) such as direct thrombin inhibitors (e.g., dabigatran) and factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban) in patients with severe hemorrhage is presented below.

    Life-threatening or imminently fatal bleeding (e.g., intracranial, retroperitoneal, compartment syndrome, massive gastrointestinal).

    Dabigatran (Pradaxa®)
    Interventions Include:

    • Idarucizumab
    • Activated PCC (e.g., Factor eight inhibitor bypassing agent [FEIBA]) – use with activated PCC only if idarucizumab is unavailable
    • Antifibrinolytic agent (e.g., tranexamic acid, epsilon-aminocaproic acid)
    • Anticoagulant discontinuation
    • Oral activated charcoal (if the last dose within the prior two hours)
    • Hemodialysis
    • Red blood cell (RBC transfusions if needed for anemia
    • Platelet transfusions if needed for thrombocytopenia or impaired platelet function (e.g., due to aspirin)
    • Surgical/endoscopic intervention if appropriate

    Rivaroxaban (Xarelto®), apixaban (Eliquis®), edoxaban (Lixiana®), betrixaban (Bevyxxa®)

    Possible interventions include:

    • Andexanet alfa (AndexXa®) or 4-factor unactivated PPC (e.g., Kcentra®)
    • Antifibrinolytic agent (e.g., tranexamic acid, epsilon-aminocaproic acid)
    • Anticoagulation discontinuation
    • Oral activated charcoal (if last dose recent enough)
    • RBC transfusion if needed for anemia
    • Platelet transfusion if needed for thrombocytopenia or impaired platelet function (e.g., due to aspirin)
    • Surgical/endoscopic intervention if appropriate

    Minor Bleeding (e.g., epistaxis, uncomplicated soft tissue bleeding, minor [slow] gastrointestinal bleeding).

    Dabigatran (Pradaxa®)

    Possible interventions include:

    • Andexanet alfa (AndexXa®) or a 4-factor unactivated PCC (e.g., Kcentra®)
    • Antifibrinolytic agent (e.g., tranexamic acid, epsilon-aminocaproic acid)
    • Anticoagulant discontinuation
    • Oral activated charcoal (if last dose recent enough)
    • RBC transfusions if needed for anemia
    • Platelet transfusions if needed for thrombocytopenia or impaired platelet function (e.g., due to aspirin)
    • Surgical/endoscopic intervention if appropriate

    Rivaroxaban (Xarelto®), apixaban (Eliquis®), edoxaban (Lixiana®), betrixaban (Bevyxxa®)

    Possible interventions include:

    • Local hemostatic measures
    • Possible anticoagulant discontinuation
      • Half-lives (normal renal function*):
        • Rivaroxaban 5 to 9 hours
        • Apixaban 8 to 15 hours
        • Edoxaban 6 to 11 hours
    • Possible antifibrinolytic agent (e.g., tranexamic acid, epsilon-aminocaproic acid)

    *The anticoagulant effect of these agents (especially dabigatran) will dissipate more slowly as renal function declines. Severe hepatic failure may also prolong the half-life for rivaroxaban, apixaban, edoxaban, and betrixaban.

    Heparin and low molecular weight (LMW) heprin (Hull, Garcia & Burnett, 2019)

    Initial emergency treatment to reverse anticoagulation due to Heparin or LMW heparin in patients with severe hemorrhage is outlined below. The need for urgent heparin reversal is individualized according to the site and severity of bleeding and the degree of anticoagulation.

    Unfractionated Heparin

    Possible interventions include:

    • Heparin is discontinued
      • Protamine sulfate is administered at a dose calculated based on the dose of heparin administered and the elapsed time since the last heparin dose. It is administered by slow intravenous infusion: the infusion rate should not exceed 20 mg/minute, and the total dose should not exceed 50 mg in any 10 minutes.
      • Complete neutralization of the heparin effect is achieved with a dose of 1 mg protamine sulfate/100 units of heparin. Because of the relatively short half-life of intravenously administered heparin (approximately 30 to 60 minutes), the dose of protamine sulfate is calculated by estimating the amount of heparin remaining in the plasma at the time that reversal is required. If this information is not immediately available, administration of a single dose of 25 to 50 mg can be given, and the aPTT or anti-factor Xa activity rechecked. If heparin had been given by subcutaneous injection, repeated small doses of protamine might be required because of prolonged heparin absorption from the various subcutaneous sites.
      • Protamine is a protein derived from fish sperm. Thus, it carries a small but potential risk of anaphylaxis in individuals who have previously been exposed, including diabetic patients who have received protamine-containing insulin (e.g., NPH, PZI) and individuals with fish allergy. However, unless such an allergy is known, the benefits of protamine administration to manage bleeding are likely to outweigh this potential risk greatly.
      • Boxed Warning for Protamine includes hypotension, cardiovascular collapse, non-cardiogenic pulmonary edema, catastrophic pulmonary vasoconstriction, and pulmonary hypertension for patients who have previously received protamine sulfate or other protamine-containing drugs. Patients at increased risk who are receiving protamine should be monitored closely, and access to therapies for anaphylaxis should be available. Thrombocytopenia following protamine administration has also been reported.

    LMW heparin

    Possible Interventions include:

    • Protamine does not completely abolish the anti-Xa activity of LMW heparins. Still, it may neutralize the higher molecular weight fractions of heparin, which are thought to be most responsible for bleeding. For patients who experience bleeding while receiving LMW heparin, protamine sulfate may be used at the following doses:
      • Enoxaparin was administered in the previous eight hours: 1 mg protamine per 1 mg of enoxaparin.
      • Enoxaparin administered more than eight hours ago, or if it has been deemed that a second dose of protamine is warranted: 0.5 mg protamine per 1 mg of enoxaparin.
      • Dalteparin, tinzaparin, or nadroparin: 1 mg protamine per 100 anti-factor Xa units of LMW heparin.

    Nonhemorrhagic Cause of Shock (Raja & Zane, 2020)

    In adult trauma patients, nonhemorrhagic causes of shock include cardiac tamponade and tension pneumothorax. These injuries are best detected by physical examination or ultrasound assessment (i.e., FAST). Particularly in older patients, the clinician may need to consider medical causes of hypotension that preceded and possibly caused the trauma, such as:

    • Arrhythmia
    • Gastrointestinal Bleeding
    • Malfunctioning left ventricular assist device (LVAD)
    • Malfunctioning pacemaker
    • Myocardial Infarction (MI)

    Disability and Neurologic Evaluation (Raja & Zane, 2020)

    Once problems related to the airway, breathing, and circulation are addressed, a focused neurologic examination should be performed. This exam should include a description of the patient's level of consciousness using the Glasgow Coma Scale (GCS) score and assessments of pupillary size and reactivity, gross motor function, and sensation. (Table 4)

    Table 4 Glasgow Coma Scale (GCS)
    TestResponseScore
    Eye Opening (E)Never1
    To Pain2
    To verbal Stimuli3
    Spontaneously4
    Best Verbal Response (V)No Response1
    Incomprehensible Words2
    Inappropriate Words3
    Disoriented and Converses4
    Oriented and Converses5
    Best Motor Response (M)No Response1
    Extension Abnormal (Decerebrate Rigidity)2
    Flexion Abnormal (Decorticate Rigidity)3
    Flexion Withdrawal4
    Localizes Pain5
    Obeys Commands6
    TOTAL SCORE3-15

    The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually. For example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate brain injury, and a score of 8 or less represents severe brain injury.

    The GCS score is widely used and can be employed to follow the patient's neurologic status. Unfortunately, several studies suggest that the initial GCS score is not predictive of outcome in patients with severe brain injury, and intubation, sedatives, and alcohol or other drug intoxication may interfere with its application. During the neurologic examination, note any lateralizing signs and the level of sensation if a spinal cord injury is present.

    Maintain spinal immobilization for all patients with the potential for spinal cord injury. The presence of a motor deficit or a spinal cord sensory level indicates the need for imaging of the brain, spinal cord, and their vascular supply.

    Exposure and Environmental Control (Raja & Zane, 2020)

    The trauma patient should be completely undressed, and his/her entire body should be examined for signs of injury during the primary survey. Missed injuries pose a grave threat. Regions often neglected include the abdominal folds in obese patients, axillary folds, perineum, and scalp. Penetrating wounds may be present anywhere. Examine the patient's back while maintaining cervical spine precautions. Do not neglect examination of the gluteal fold and posterior scalp.

    Hypothermia should be prevented if possible and treated immediately once identified. Hypothermia contributes to both coagulopathy and the development of multiple organ dysfunction syndromes. During winter months and whenever a hypothermic trauma patient is treated, the resuscitation room should be heated.

    The United States Military Joint Theater Trauma System Clinical Practice Guideline on hypothermia prevention recommends ED and OR temperatures of at least 29.4°C (85°F) during the treatment of these patients. Wet clothing should be rapidly removed, make liberal use of warm blankets and active external warming devices, and warm IV fluids and blood.

    Diagnostic Studies (Raja & Zane, 2020)

    Portable Radiographs (X-rays)

    Plain x-rays play an important role in the primary evaluation of the unstable trauma patient. Screening x-rays should be obtained, either in the ED or the OR, even in hemodynamically compromised patients who are sent directly to the OR during or after their primary survey. Prompt imaging of the lateral cervical spine, chest, and pelvis can detect life-threatening injuries that might otherwise be missed. However, the sensitivity of the lateral cervical spine x-ray is only 70% to 80%, and some sacral and iliac fractures can be missed on plain pelvic x-rays.

    Clinical decision rules (e.g., NEXUS) can be used to determine the need for cervical spine imaging in hemodynamically stable trauma patients. Plain x-rays of the chest and pelvis are often obtained for trauma patients not thought to require CT imaging. The decision to obtain these images should be made based upon the injury mechanism and clinical findings.

    The evaluation of patients with penetrating trauma often includes images of the region of penetration. Even in stable patients, these x-rays can detect retained foreign bodies or fragments. However, patients with blunt trauma should undergo imaging with plain x-rays only if clinical findings suggest the presence of injury.

    Plain x-rays can be omitted altogether if there is no clinical suspicion of injury, and the studies are unlikely to alter emergency management. A plain x-ray of the chest should be obtained in patients with penetrating injuries of the chest, back, or abdomen regardless of the need for Computed Tomography (CT). Plain films may reveal foreign body/bodies, hemothorax, pneumothorax (Image 2), subdiaphragmatic free air. (Image 2)

    types_of_pneumothorax

    Image Source: Dreamstime

    Suppose the clinician determines that CT imaging is needed based upon the mechanism or clinical suspicion. In that case, there is no role for either a plain x-ray of the chest or pelvis in hemodynamically stable patients with blunt trauma.

    Ultrasound (FAST Exam)

    Focused Assessment with Sonography for Trauma (FAST) is an essential part of the primary circulation survey for unstable patients, in whom it often determines management. FAST is used primarily to detect pericardial and intraperitoneal blood, and it is more accurate than any physical examination finding for detecting signs of intra-abdominal injury. (Image 3)

    Image 3:Ultrasound

    ultrasound

    Licensed from Shutterstock
    (Fluid volumes of 200 mL have been reported to be detectable via ultrasound. Findings on a FAST examination must be placed in the appropriate clinical context because the detected fluid may be blood, ascites, urine, or peritoneal dialysate.)

    FAST can be delayed until the secondary survey in hemodynamically stable patients and is ideally performed by a second operator while the remainder of the secondary survey is completed.

    The accuracy and role of FAST may be more limited in patients with significant pelvic fractures because it is less sensitive for detecting pelvic bleeding and cannot differentiate between blood and urine. Retroperitoneal bleeding is also not reliably visualized with ultrasound. FAST is less sensitive for injury in penetrating trauma than blunt trauma, and the results of ultrasound examinations in penetrating trauma patients, particularly negative results, must be interpreted with caution.

    The Extended FAST (E-FAST) includes examinations of the thoracic cavity looking for pneumothoraces. Preliminary studies suggest the sensitivity of E-FAST is better than plain x-ray for this injury.

    Emergency Computed Tomography (CT)

    Trauma patients found to be hemodynamically unstable during the primary survey are aggressively resuscitated while clinicians attempt to determine the most likely causes of their instability. If the source of hemorrhage in an unstable trauma patient cannot be determined using diagnostic imaging studies immediately available at the bedside, or if additional information is needed to direct operative care, in most cases, the treating ED physician and surgeon must decide whether to perform emergency CT imaging first or take the patient directly to the OR. This decision is based upon the patient's response to initial resuscitation measures, their probable injuries and anticipated operative intervention, and the proximity of the CT scanner to the resuscitation bay.

    Imaging must not delay transfer in situations when patients require higher levels of care than can be provided at the initial facility. If a transfer is needed, the process should be initiated as early as possible (in some cases, immediately upon patient arrival and assessment). If CT imaging is needed and can safely and reasonably be done without delaying transfer, it may be obtained.

    In rare instances, patients may have known and potentially life-threatening allergies to IV contrast. In such cases, assessment options include:

    • Exploratory surgery
    • Magnetic resonance imaging (MRI), when patient stability and resources allow
    • Non-contrast CT
    • Radionuclide red cell scan when patient stability and resources allow
    • Ultrasound

    Diagnostic Peritoneal Tap (DPT or Lavage (DPL)

    DPT or DPL has a role similar to FAST in the unstable patient in whom a source of bleeding has not been found. It can be performed to detect intraperitoneal blood when FAST is unavailable or indeterminate in hemodynamically unstable patients, to determine the type of intraperitoneal fluid when it is important to do so (e.g., blood versus urine in the setting of a pelvic fracture), or at physician discretion.

    Electrocardiogram (ECG)

    A 12-lead ECG should be obtained for all patients injured by mechanisms with the potential to cause cardiac injury. Signs of blunt cardiac injury can include arrythmias, significant conduction delays, and ST-segment changes. Findings consistent with pericardial tamponade include electrical alternans, low voltage, and tachycardia.

    If ECG findings consistent with cardiac injury are present, formal echocardiography (in addition to the FAST examination) should be performed. Cardiac monitoring should continue throughout the trauma evaluation and resuscitation, including during diagnostic testing, as changes in heart rate and blood pressure may herald rapid clinical deterioration.

    Laboratory Tests

    The practice of obtaining routine "screening" laboratory tests on trauma patients is neither useful nor cost-effective. Testing should be performed based upon clinical suspicion and should be limited to those tests that may alter management. For example, pregnancy tests (e.g., urine hCG) should always be performed on women of childbearing age or Blood type and screen or crossmatch should be obtained for patients with significant trauma who may reasonably be expected to require transfusion.

    Clinical circumstances determine the need for further testing. For example, patients taking warfarin likely need coagulation studies (e.g., PT/INR) or patients found on the ground for an indeterminate amount of time need studies (e.g., creatine kinase) to determine if rhabdomyolysis is present.

    At the initial presentation, the need for blood transfusion blood products in the severely injured trauma patient is determined on clinical grounds and may involve massive transfusion protocols. After that, routine coagulation studies do not predict coagulopathy accurately in an acute trauma patient. Where available, thromboelastography provides a faster and more accurate means for detecting imbalances in the hemostatic system and assessing ongoing needs for treatment.

    Commonly obtained but rarely helpful tests include:

    • Metabolic panel (a fingerstick blood sugar will often suffice, provided the patient is not exhibiting signs of electrolyte abnormality or acidosis)
    • The alcohol level in a patient who is intoxicated
    • Toxicologic screen when it is not relevant to clinical care
    • Cardiac biomarkers, unless cardiac contusion or ischemia is suspected

    Elevation of both the serum lactate concentration and base deficit correlates with increased mortality in trauma patients. However, the base deficit is essentially a surrogate for lactate, and an elevated base deficit in the absence of elevated lactate is not predictive of increased mortality.

    While elevated levels should heighten suspicion for severe injury, a normal lactate and base deficit do not ensure the absence of significant injury, especially in geriatric trauma patients. Additionally, laboratory values lag behind clinical improvement after aggressive resuscitation. Thus, the patient may no longer be in shock despite elevated lactate suggesting otherwise.

    The white blood cell (WBC) count is nonspecific and of little value during the initial evaluation of the trauma patient. The positive and negative predictive value of, respectively, an elevated or normal WBC is poor. Epinephrine release from trauma can cause demargination and elevate the WBC to 12,000 to 20,000/mm3 with a moderate left shift. Solid or hollow viscus injury can cause comparable elevations.

    Patient Transfer (Raja & Zane, 2020)

    Clinicians at hospitals with limited resources to manage trauma should consult the nearest trauma center as soon as it becomes apparent that a patient has sustained injuries beyond the management capacity of their hospital. Many patients needing to be transferred for trauma evaluation are not sent. In a National Trauma Data Bank review, only 20% of patients initially taken to non-tertiary centers and meeting trauma guideline criteria for transfer were subsequently transferred. The risk-adjusted odds for mortality were higher for non-transferred patients than those treated at Level I or II Trauma Centers. Geriatric trauma patients are an important example of this phenomenon. They are frequently under-triaged, resulting in increased morbidity and mortality.

    Patients should be stabilized as well as possible without delaying the transfer. Delays are associated with increased mortality. Criteria for transfer are based upon the patient's demographics, mechanism of injury, and clinical findings. It cannot be overemphasized that a complete workup is not a requirement for transfer. Postponing transfer to obtain laboratory results or imaging studies only delays definitive treatment. Often such studies must be repeated at the receiving facility.

    CT imaging should only be obtained in patients who might otherwise be appropriately treated at the initial facility. If a negative CT allows the patient to be discharged, it should be performed, but if that patient requires transfer regardless of the results, the transfer should not be delayed. Likewise, procedures and other interventions should only be performed to treat emergency conditions or prevent possible patient deterioration during transport. Endotracheal intubation, tube thoracostomy, and pelvis fracture stabilization are common examples of necessary interventions. Laceration repair, unless it is performed to prevent exsanguination, is not a necessary intervention. For hemodynamically unstable patients, blood, if available, should be transfused. Transfusion can begin at the initial facility or be performed during transport by sending units of blood with the emergency transport team.

    Transferring an unstable patient should ideally be made by the transferring and receiving physicians collaboratively. Clear communication is critical. The transmission of vital information allows receiving clinicians to mobilize needed resources, while the inadvertent omission of such information can delay definitive care. Information should be conveyed in verbal and written (via the patient record) form. It should include the patient's identifying information, relevant medical history, prehospital course, and ED evaluation and treatment, including procedures performed and imaging obtained. The use of a transfer checklist can help to ensure that important information is not omitted.

    Secondary Evaluation and Management (Raja & Zane, 2020)

    Definitive management of a hemodynamically unstable trauma patient must not be delayed to perform a more detailed secondary evaluation. Such patients are taken directly to the OR or angiography suite or transferred to a major trauma center.

    A careful, head-to-toe secondary assessment (i.e., secondary survey) is performed in all trauma patients determined to be stable upon completing the primary survey. The secondary survey includes a:

    • Detailed history
    • Thorough but efficient physical examination
    • Targeted diagnostic studies

    The secondary survey plays a crucial role in avoiding missed injuries. Commonly missed injuries include:

    • Blunt abdominal trauma such as:
      • Diaphragmatic rupture
      • Hollow viscus injury
      • Pancreatoduodenal injuries
    • Penetrating abdominal trauma such as:
      • Rectal injuries
      • Ureteral injuries
    • Thoracic trauma such as:
      • Aortic injuries
      • Esophageal perforation
      • Pericardial tamponade
    • Extremity trauma such as:
      • Compartment syndrome
      • Fractures (especially in distal extremities)
      • Vascular disruption

    Delayed reevaluation of the trauma patient (i.e., tertiary survey) is also useful for identifying missed injuries and detecting late injuries. It is most helpful if the patient is reevaluated when fully alert. Any member of the trauma team with advanced assessment skills can perform the tertiary survey. However, it is best if the same clinician performs all serial examinations for a given patient to detect subtle changes.

    History (Raja & Zane, 2020)

    The mechanism of injury can increase suspicion for certain injuries. Prehospital personnel often know important information and should be queried regarding the mechanism and history of the injury. If this cannot be done immediately upon arrival of the patient’s status, ask the prehospital providers to remain in the ED until this can be accomplished. Often the history is conveyed while medics and hospital clinicians transfer the patient and, during this time, important information may be forgotten or missed.

    While listening to the history, remember that accidents can be chaotic, and not all information will be reliable. For example, a patient described as "found down" may have been assaulted or struck by a car.

    Mechanism-related information to be obtained from prehospital personnel includes:

    • Blunt trauma
      • Airbag deployment
      • Body part landed upon
      • Damage to the automobile (especially intrusion into the passenger compartment)
      • Direction of impact
      • Distance ejected from the vehicle
      • Height of fall
      • Seat belt use
      • Steering wheel deformation
    • Penetrating trauma
      • Type of firearm
      • Distance from firearm
      • Number of gunshots heard
      • Type of blade
      • Length of blade

    Inquire also about the patient's medications, allergies, and medical and surgical history. If this information is unknown, it can be helpful to assign someone the task of contacting family members to obtain it. The use of anticoagulant and antiplatelet medications is steadily rising and increases the risk of internal bleeding in trauma patients, and therefore these agents should specifically be discussed. As an example of the risks associated with anticoagulants, a retrospective study of 11,374 adult trauma patients reported that the use of antiplatelet drugs was associated with an increased risk of death and major morbidity among the 1,327 (11.7%) patients taking them at the time of their injury. Patients taking multiple antiplatelet medications were at greater risk than those taking a single drug.

    While such questions do not typically affect the immediate treatment of traumatic injuries, it is important to ask trauma patients about possible domestic violence. The reported prevalence of domestic violence continues to increase among both children and adults and can lead to a pattern of repeated traumatic injury.

    A history of mental illness, including thoughts or attempts at suicide, may be significant, particularly in the setting of single-car accidents or falls from a height, which may be initially unrecognized suicide attempts. A history of mental illness, including thoughts or attempts at suicide, may be significant, particularly in the setting of single-car accidents or falls from a height, which may be initially unrecognized suicide attempts.

    Knowledge of alcohol or drug abuse may help to detect or prevent withdrawal during hospital admission.

    Physical Examination (Raja & Zane, 2020)

    The goal of the secondary survey is to identify injuries. This survey includes the performance of a thorough but efficient physical examination. Standard precautions against blood or fluid-borne infection should be used.

    Head and Face

    Inspect and palpate the entire bony structure of the head and face for tenderness, deformity (e.g., step off), and bleeding. Scalp lacerations are easily missed visually but often found by palpation. Assess for foreign bodies, such as glass in the scalp after a car accident. Note any signs suggesting basilar skull fracture:

    • Hemotympanum
    • Retroauricular (Battle’s sign) generally does not appear until a least 24 hours after an inury
    • Periorbital ecchymosis (raccoon’s eyes) generally does not appear until at least 24 hours after an injury (Image 4)

    Image 4: Raccoon’s Eyes

    racoon_eyes

    Image Source: Licensed from Shutterstock

    Additionally, look for septal hematomas and perform an ocular examination, including evaluating pupillary size, shape, reactivity, and extraocular movement. Look for signs of globe rupture and intraocular hemorrhage. Point-of-care ultrasound can be used to rule out retinal detachment and other traumatic ocular injuries. Still, it should not be used to rule out injuries in those patients in whom a high clinical suspicion of injury exists. These patients should still receive emergency ophthalmologic consultation.

    Patients with mild traumatic brain injury may not have external signs of trauma. Validated decision tools, including the New Orleans Criteria and the Canadian CT Head Rule, can be used to determine the need for neuroimaging with CT.

    Neck

    Assume that all patients with blunt trauma have sustained an injury to the cervical spine. This assumption can be disproved by appropriate application of clinical decision rules, such as NEXUS or the Canadian C-Spine Rule, or by radiologic evaluation using plain x-rays or CT. Inspect and palpate the entire neck for signs of injury.

    Chest

    Inspect and palpate the entire chest wall. Pay particular attention to the sternum and clavicles. Injuries at these sites are often missed, and fractures of these bones suggest further injury, including intrathoracic structures.

    Careful auscultation can detect a previously missed small hemothorax, pneumothorax, or pericardial effusion not yet causing tamponade. The NEXUS-Chest criteria may be used to determine whether chest imaging is necessary for an adult following blunt trauma.

    Abdomen

    Inspect the abdomen and flanks for contusions, (e.g., seat belt sign), ecchymosis, and lacerations. Palpate for tenderness and rigidity. The presence of a seat belt sign, rebound tenderness, abdominal distension, or guarding all suggest intra-abdominal injury.

    Keep in mind that the abdominal examination is often unreliable and can change dramatically over time, especially in:

    • Elderly patients
    • Patients with altered mental status
    • Patients with distracting injuries
    • Patients late in pregnancy

    Rectum and Genitourinary

    Inspect the perineum of all patients for signs of injury. Traditionally, the digital rectal examination (DRE) was considered an essential part of the physical examination for all trauma patients. However, the sensitivity of the DRE for injuries of the spinal cord, pelvis, and bowel is poor, and false-positive and negative results are common. Thus, routine performance is unnecessary and generally unhelpful.

    If the examination is performed, check for Abnormal sphincter tone (sign of spinal cord injury), A high-riding prostate (sign of urethral injury), bone fragments (sign of pelvic fracture), and presence of gross blood (sign of bowel injury).

    Perform a vaginal examination on all patients at risk for vaginal injury (e.g., those with lower abdominal pain, pelvic fracture, or perineal laceration). Take care to avoid injury from bone fragments if a pelvic fracture is known or suspected.

    Musculoskeletal

    Inspect and palpate the entire length of all four extremities assessing for areas of tenderness, decreased rang of motion, deformity, and neurovascular status of each extremity.

    Manipulate all joints thought to be uninjured both passively and actively to verify their integrity. Immobilize and obtain x-rays of any area with a suspected fracture.

    Note all penetrating wounds, especially those overlying suspected fractures, suggesting an open injury. The treatment of open fractures includes application of a clean dressing, irrigation and debridement, and prophylactic antibiotics. Preliminary low-pressure wound irrigation can be performed in the trauma bay, but definitive irrigation and debridement are performed in the OR.

    Post-traumatic compartment syndrome is an important source of patient morbidity. Increasing pain, tense compartments, and pain with passive stretching of the muscles contained within the compartment should prompt immediate measurement of intracompartmental pressures.

    Inspect and palpate the pelvis. Ecchymosis over the pelvis or tenderness along with the pelvic ring warrants diagnostic imaging. Examination findings (e.g., instability) or imaging studies consistent with pelvic ring disruption indicate the need for pelvic immobilization and immediate orthopedic evaluation (Image 5). Repeat examinations to assess pelvic stability are unnecessary and likely to exacerbate bleeding

    Image 5: Pelvic Fractures

    pelvic_ring

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    Neurologic

    The trauma patient's neurologic status can change dramatically over time (e.g., from the effects of an expanding subdural hematoma). Serial examinations should be performed and carefully documented. During the secondary survey, perform a detailed assessment of the sensorimotor function of the extremities and repeat an assessment of the patient's GCS score (see table 4 above).

    Skin

    Examination of the skin may reveal abrasions, ecchymosis, hematoma, lacerations, and seroma formation. Look closely at areas where lesions may be missed, such as the scalp, axillary folds, perineum, and abdominal folds, particularly in obese patients. Do not neglect examination of the back, gluteal fold, and posterior scalp. Penetrating wounds may be present anywhere.

    Appropriate tetanus prophylaxis (Baddour & Brown, 2020) should be administered as soon as possible following a wound but should be given even to patients who present late for medical attention (Table 5). This prophylaxis is because the incubation period for tetanus is quite variable. Most cases occur within eight days, but the incubation period can be as short as three days or as long as 21 days.

    For patients who have been vaccinated against tetanus previously but are not up to date, there is likely to be little benefit in administering human tetanus immune globulin more than one week or so after the injury. However, for patients thought to be completely unvaccinated, human tetanus immune globulin should be given up to 21 days following the injury. Td or Tdap should be given concurrently to such patients.

    Table 5 Wound Management and Tetanus Prophylaxis
    Previous doses of tetanus toxoid1Clean and minor woundAll other wounds2
    Tetanus toxoid-containing vaccine3Human tetanus immune globulinTetanus toxoid-containing vaccine3Human tetanus immune globulin4
    <3 doses or unknownYes5NoYes5Yes
    ≥Three dosesOnly if the last dose was given ≥ten years agoNoOnly if the last dose is given ≥five years ago6No
    1. TT: tetanus toxoid
      1. Tetanus toxoid may have been administered as DT, DTP/DTwP (no longer available in the US), DTaP, Td, Tdap, or TT (no longer available in the US).
    2. Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva, puncture wounds, avulsions, or wounds resulting from missiles, crushing, burns, or frostbite.
    3. The preferred vaccine preparation depends upon the age and vaccination history of the patient.
    4. Two hundred fifty units intramuscularly at a different site than tetanus toxoid. Intravenous immune globulin should be administered if human tetanus immune globulin is not available. Persons with HIV infection or severe immunodeficiency who have contaminated wounds should also receive human tetanus immune globulin, regardless of their history of tetanus immunization.
    5. The vaccine series should be continued through completion as necessary.
    6. Booster doses given more frequently than every five years are not needed and can increase adverse effects.
    • DT: diphtheria-tetanus toxoids adsorbed
    • DTP/DTwP: diphtheria-tetanus whole-cell pertussis
    • DTaP: diphtheria-tetanus-acellular pertussis
    • Td: tetanus-diphtheria toxoids absorbed
    • Tdap: booster tetanus toxoid-reduced diphtheria toxoid-acellular pertussis

    Additional Imaging (Raja & Zane, 2020)

    Plain X-rays

    Plain x-rays are used during the secondary survey primarily to evaluate the spine, pelvis, and extremities for fractures, dislocations, and foreign bodies.

    CT including Total Body CT

    Multidetector computed tomography (MDCT) has become the modality of choice for imaging trauma patients because of its speed and accuracy. However, most comprehensive whole-body CT scanning ("pan scan") for all patients with significant trauma is methodologically limited and has reached contradictory conclusions. Pending further research, comprehensive CT scanning in patients without significant alterations in mental status is not advocated, and imaging studies should be performed selectively based upon clinical assessment and the mechanism of injury.

    While whole-body CT scanning may improve outcomes following certain high-risk trauma, such as explosions, high-speed motor vehicle collisions, and falls from great heights, it should not be used indiscriminately given the short-term risk of contrast-related renal injury and the long-term risk of radiation-induced cancer, as well as, the substantial costs. In an international, multi-center trial, adult trauma patients with evidence of severe injury were randomly assigned to either whole-body CT (n = 541) or selective CT imaging (n = 542). In-hospital mortality did not differ between groups (whole-body CT 86 [16%] versus selective CT 85 [16%]), nor did it differ significantly among patients with polytrauma or brain injury.

    Some authors advocate whole-body CT for severely injured patients with alterations in mental status. In a retrospective database analysis of 5,208 patients in Japan with scores on the GCS ranging from 3 to 12, decreased mortality was noted in patients who received whole-body CT scans. Although further study of the outcomes and cost-effectiveness of whole-body CT is needed, the approach may be beneficial in such patients. Examination findings are often limited or unclear.

    It should be noted that while CT may be useful in the evaluation of patients with blunt trauma, it has limited utility for evaluating the trajectory and effects of low velocity penetrating injury (e.g., stab wounds) because of the lack of tissue disruption and gas dispersion (seen with high-velocity injuries), and because injuries to luminal structures are often difficult to detect.

    Diagnostic laparoscopy may be useful in patients with penetrating injury and signs of peritoneal penetration despite negative CT imaging. Although improving, the accuracy of CT for detecting diaphragm injuries is also limited, and depending on the nature of the patient's injuries, additional diagnostic studies may be needed. Most patients should be hemodynamically stable before CT imaging is performed, and resuscitation should be sufficient to minimize the risk of decompensation while the patient is in the CT scanner. If the patient is unstable, CT imaging is usually deferred.

    Analgesia and Sedation (Raja & Zane, 2020)

    Injured patients are in pain. Appropriate analgesia and sedation should be provided if needed. Short-acting agents, such as fentanyl and midazolam, generally prefer to avoid adverse hemodynamic effects, but these require more frequent monitoring and administration. The results of a few randomized trials suggest that inhaled methoxyflurane provides effective analgesia for trauma patients, but it may not be available in many EDs.

    Victims of Crime (Raja & Zane, 2020)

    Clinical evaluation and treatment of injuries is the foremost responsibility of the clinician caring for a trauma patient. When possible, caretakers should consider and act on the need to preserve potential evidence if the trauma may be connected to a crime. For examples avoid cutting through holes in the clothing crated by penetrating injuries, careful documentation of injuries, Placing removed clothing into paper bags with carful patient identification attached.

    Pitfalls and Pearls(Raja & Zane, 2020)

    The systematic evaluation of the trauma patient outlined above is designed to help clinicians focus on life-threatening problems and minimize the risk of missed injuries. Nevertheless, one systematic review noted that up to 39% of trauma patients have injuries that are initially missed and up to 22% of these missed injuries are clinically significant (defined as injuries associated with increased mortality, requiring additional procedures or alterations in treatment, or resulting in significant pain, complications, or residual disability).

    Esophageal Intubations

    Between 0.5% and 6% of prehospital intubations are esophageal due to airway difficulty or displacement during transport. The position of all endotracheal tubes, either by direct visualization or use of an end-tidal carbon dioxide (ETCO2) detector, should be verified.

    Hemorrhagic Shock

    Approximately 30% of the circulating blood volume may be lost before the onset of hypotension. Transient response to one or more fluid boluses means the patient likely has ongoing hemorrhage and is in a persistent state of shock. A high index of suspicion should be maintained, and an aggressive search for the source of ongoing hemorrhage is warranted.

    Cardiac Tamponade

    Assume that elevated JVP in a trauma patient is caused by pericardial tamponade. However, hypovolemic patients with tamponade may not have an elevated JVP. Perform the FAST exam early in the circulation evaluation of the unstable patient and begin by looking at the heart.

    Thoracoabdominal Injury

    Assume that any penetrating wound of the thorax or abdomen involves both compartments until proven otherwise.

    Penetrating Bowel Injury

    During the initial resuscitation, injuries caused by low velocity penetrating wounds (typically stab wounds) are easily missed by ultrasound and CT because there is too little intraperitoneal blood to be detected and inadequate tissue destruction. High clinical suspicion may warrant further evaluation by DPL or laparotomy for stab wounds, despite initially negative imaging studies. Alternatively, a trauma surgeon may opt to perform serial observations of patients with abdominal stab wounds (and some extraperitoneal gunshot wounds) over a 12- to 24-hour period.

    Gunshot wounds typically require therapeutic laparotomy and should be distinguished from the stab mentioned above wounds. These high-velocity injuries are associated with much greater morbidity and mortality than their low-velocity counterparts.

    Open Book Pelvic Fractures

    The unstable pelvis should not be manipulated multiple times since additional manipulation exacerbates hemorrhage. Once suspected, open or unstable pelvic fractures should be stabilized using a pelvic binder or a sheet if no binder is available. If the patient is hemodynamically stable, CT imaging is obtained. The unstable patient requires either surgery or angiography.

    Ocular Injuries

    Periorbital swelling and ecchymosis do not preclude performing an ocular examination. Patients with such findings are at higher risk of ocular injury. Additionally, injuries such as a globe rupture or retro-orbital hematoma must be diagnosed quickly to maximize the opportunity to salvage vision.

    Older Patients

    Assume that older patients involved in trauma have sustained a significant injury, even if they appear well. The paradox of elderly trauma patients is that their physiology and medical interventions can mask and exacerbate the severity of injuries. For examples, beta-blockers may mask the effects of shock by suppressing tachycardia, and warfarin and other anticoagulants increase the risk of severe hemorrhage. Important considerations in the older trauma patient are summarized in Table 6 below.

    Table 6 Potential Pitfalls in the Management of the Elderly Trauma Patient
    What the injured elderly would tell you (if they could)Related physiology and rationale
    "I can go from normotensive to hypotensive in a heartbeat."Profound, life-threatening hypovolemia may occur in the setting of normal blood pressure. Physiologic reserve is minimal, and hemodynamic decompensation can occur quickly.
    "I respond poorly to too much or too little fluid."The therapeutic window for cardiac preload is narrow, and inadequate preload monitoring may lead to errors in volume resuscitation.
    "My subdural hematoma hasn't expanded enough yet to affect my level of consciousness."Cortical atrophy, common in the elderly, may delay the clinical manifestations of serious intracranial hemorrhage. This hemorrhage may be clinically occult.
    "Trauma is not my major problem."Stroke, MI, and seizures may result from falls or motor vehicle crashes and delayed diagnosis of the principal underlying problem.
    "I only look like I have an adequate ventilatory reserve."Ventilatory failure and respiratory arrest may occur suddenly in conjunction with chest or abdominal injuries despite a benign outward clinical appearance.
    "I get demand ischemia if I have too much pain or my hematocrit drops below 29."Myocardial (demand) ischemia may result from severe or prolonged pain or from transfusion thresholds that have not been appropriately liberalized in the setting of coronary artery disease (CAD).
    "I can't stand even a little shock or hypoxia, and neither can my myocardium."Even minor perturbations in perfusion, oxygenation, or vasoconstriction may lead to major cardiac complications.
    "My connective tissue just ain't what it used to be..."Decrease in connective tissue integrity with less "tamponade effect" for hemorrhage into soft tissues. Blood loss into soft tissue spaces, including subcutaneous loss, may be excessive and is often overlooked.
    "The sensitivity of my abdominal examination is better than flipping a coin...but not much."Clinical manifestations of serious abdominal injury in elderly patients are often minimal. Reliance on the abdominal examination often leads to missed abdominal injuries.
    "My bones are brittle...my hip bone, my shin bone, and my aortic bone!"Blunt aortic injury (BAI) may occur in the elderly in the absence of conventional signs or symptoms. A low threshold for CT imaging should exist.
    "A little medication goes a long way with me..."Failure to adjust medication dosage, particularly sedative-hypnotics and analgesics, may result in serious complications.
    "I just haven't been eating so well lately."Chronic malnutrition is common and often undiagnosed.
    "My injuries weren't accidental."Elder abuse is common and often unreported and undiagnosed.
    "Major trauma? Heck, I wouldn't even tolerate a brisk haircut..."Underestimating and undermanaging comorbidities (e.g., chronic obstructive pulmonary disease (COPD), CAD, smoking, ETOH consumption) may result in preventable morbidity/mortality.

    Common Cognitive Errors

    Several cognitive errors appear to be relatively common during the initial management of injured patients, particularly those who do not look sick initially. Among these are:

    • Premature diagnosis.
      • The hemodynamic status of trauma patients is often dynamic, and the results of their initial diagnostic studies preliminary.
      • Avoid making premature assumptions about patients' injuries and stability.
    • Overreliance upon early negative results.
      • No study is perfect and initial studies may not reveal the full extent of a patient's injuries or any injury.
      • Reassess the patient.
      • Reevaluation may include serial eFAST examinations if the patient's status has changed.
    • Attributing abnormal findings to benign causes.
      • Trauma patients, particularly young, healthy adults, may not immediately manifest signs of severe injury.
      • When abnormal findings arise, assume they reflect injury.
    • Distractions.
      • Dramatic or obvious injuries, the performance of critical procedures, and other aspects of trauma care can distract clinicians, causing them to neglect serious but less apparent injuries or changes in patient status.

    Case Study

    Scenario/Situation/Patient Description

    A 54-year-old male patient was transported by EMS to a Level 2 Trauma Center after falling off a ladder while cleaning the gutters on his one-story home. He is wearing a rigid C-collar and lying on a backboard. The patient complains of left chest wall pain and dyspnea. HR ranges from 120 – 160, cardiac rhythm remains sinus tachycardia, RR 30 - 42, O2 sat: 85 - 92%, BP 150-180/90-110, GCS is 15. He is on 2L/N.P. Upon inspection, the patient has a distinct left thoracic paradoxical movement, i.e., as the patient inspires, the left chest wall moves inwards as the rest of the chest expands, and the affected area moves outwards as the patient exhales and the rest of the chest contracts. Breath sounds are diminished over the entire left lung field.

    Interventions/Strategies

    Chest x-ray reveals that the 3rd, 4th, and 5th left ribs are fractured and separated from the sternum creating a flail chest. No other chest, abdomen, or pelvis injuries are discovered on further x-rays or CT scans.

    Discussion of Outcomes

    The patient is intubated in the Emergency Department and transported to the surgical ICU for further treatment and monitoring.

    Strengths and Weakness of the Approach Used in this Case

    Without using the ABCDE mnemonic utilized during the primary survey, specifically breathing, the patient's ability to ventilate and oxygenate could have resulted in respiratory status decline.

    Summary and Recommendations

    Trauma is a leading cause of mortality globally. All trauma patients require a systematic approach to management to maximize outcomes and reduce the risk of undiscovered injuries. Optimal care requires effective and efficient communication and teamwork among clinicians.

    Particular mechanisms predispose patients to specific injuries. Common blunt trauma mechanisms and they are most frequently associated injuries are described in Table 1 above.

    The primary survey used in Advanced Trauma Life Support™ is organized according to the injuries that pose the most immediate threats to life. Problems are managed immediately in the order they are detected. The individual steps (including assessments of the airway, breathing, circulation, and neurologic injury) and important principles of the primary survey have been described above.

    Observational studies suggest that airway obstruction is a major cause of preventable death among trauma patients. Therefore, airway evaluation and management remain the critical first steps in treating any severely injured patient.

    Hemorrhage is the most common preventable cause of mortality in trauma. Most trauma patients with signs of shock (e.g., pale, cool, moist skin) are bleeding. Be alert for subtle signs of hemorrhagic shock, particularly in the elderly and young, healthy adults who may not present with obvious manifestations. Hypotension generally does not occur until at least 30% of the patient's blood volume has been lost.

    Diagnostic testing plays an important role in trauma management. The appropriate use of studies has been described above.

    Clinicians at hospitals with limited resources for trauma management should consult the nearest trauma center as soon as it becomes apparent that a patient has sustained injuries beyond the management capacity of their hospital. It cannot be overemphasized that a complete workup is not a requirement for transfer.

    A secondary survey is performed in all trauma patients determined to be stable upon completing the primary survey. The secondary survey includes a detailed history, a thorough but efficient physical examination, and targeted diagnostic studies and plays a crucial role in avoiding missed injuries.

    Up to 39% of trauma patients have initially missed injuries, and up to 22% of these are clinically significant. Common pitfalls and guidance for avoiding missed injuries have been discussed.

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    Resources and References

    • Baddour, L., Brown, A. (2020, Jan.) Infectious complications of puncture wounds. UpToDate. Visit Source.
    • Hull, R., Garcia, D. Burnett, A. (2019, Nov.) Heparin and LMW heparin: Dosing and adverse effects. UpToDate. Visit Source.
    • Raja, A., Zane, R. (2020, Oct). Initial management of trauma in adults. UpToDate. Visit Source.