Major trauma frequently occurs in our fast-paced society. Early and frequent assessments of trauma patients allow healthcare providers to make rapid and appropriate decisions concerning each individual trauma patient from the time of injury to the point where focused, injury specific treatments can be competently carried out. As healthcare providers, we need to understand these assessments and their impact on the trauma patient's mortality and morbidity.
Upon completion of this course, the participant will be able to:
The term major trauma is used to describe events that involve sudden overwhelming injury and shock to multiple body systems. However, major trauma has no consistently accepted definition. In common usage, it is a means to convey the extreme of seriousness and extent of complex injury caused by an external force.
In general, trauma can be considered to be the result of an accident, but the term accident has become an obsolete term. Accidents can be considered avoidable and, therefore, preventable. Trauma, on the other hand, is most likely unintended. Understanding that trauma can occur at any time, the responsibility of healthcare providers is to ensure that there are adequate resources available to the victims of trauma.
Trauma can be viewed as the forgotten epidemic and the neglected disease of modern society. Trauma annually impacts hundreds of thousands of individuals and costs billions of dollars in direct expenditures and indirect losses. Trauma care has improved over the past 20 years, largely from improvements in trauma systems, assessment, triage, resuscitation and emergency care.
However, an Institute of Medicine report identified a United States crisis in access and distribution to emergency care that may impact trauma system efficiency and effectiveness. Similarly, a predicted deficit in critical care practitioners may similarly degrade the post-emergency department care of the critically injured trauma patient. The American College of Surgeons Committee on Trauma (ACS-COT) and the American Association for the Surgery of Trauma (AAST) acute care surgery initiative are designed to integrate trauma, emergency general surgery and surgical critical care and to bolster new trainee interest in this field. Its sensitivity for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders. 
Work must still be done to continuously improve trauma care nationally, regionally and institutionally. The ACS-COT applies rigorous standards to performance improvement prior to verifying United States trauma centers. For this improvement to occur, the ongoing application of the unique principles and practice of intensive care medicine is necessary.
In an effort to standardize trauma care and promote consistent data collection the Trauma Care Systems Planning and Development Act of 2007 was passed as Public Law 110-23, 121 Stat. 90-99.2 This bill provides increased trauma care nationally and, therefore, improves survival rates for victims of traumatic injuries. Seventy-five percent of the nation’s population is served by a local trauma center. The $12 million funding from this bill is disseminated throughout the 50 states to provide funding and access to improved care.
Each year trauma accounts for 41 million emergency department visits and 2.3 million hospital admissions across the nation.
Life Years Lost (LYL)3* (2014, most recent available):
* Life Years Lost: A measure to account for the age at which deaths occur, giving greater weight to deaths occurring at younger ages and lower weight to deaths occurring at older ages. The LYL (percentage of total) indicator measures the LYL due to a particular cause of death as a proportion of the total LYL lost due to premature mortality in the population.
Because trauma is a disease affecting all ages of people, the impact on life years lost is equal to the life years lost from cancer, heart disease and HIV combined.
Deaths due to injury5 (2014, most recent available):
Ranking as cause of death6
Burns7(2013, most recent available):
Falls8(2013, most recent available):
Over the past 50 years, assessment of trauma patients has evolved because of an improved understanding of the distribution of mortality and the mechanisms that contribute to morbidity and mortality in trauma.
Mortality can be grouped into immediate, early and late deaths. Immediate deaths are caused by a fatal injury to the great vessels, heart or neurologic system.9 Immediate mortality occurs at the scene of injury.
Early deaths from trauma may occur from minutes to hours after the injury. These trauma patients frequently arrive at a medical facility before death, but death usually occurs because of hemorrhage and cardiovascular collapse. Early trauma deaths result from failed oxygenation of the vital organs, massive central nervous system injury or both. The mechanisms of failed tissue oxygenation include inadequate ventilation, impaired oxygenation, circulatory collapse and insufficient end-organ perfusion. Massive central nervous system trauma leads to inadequate ventilation and/or disruption of brainstem regulatory centers. Injuries that cause early trauma mortality occur in predictable patterns based on the mechanism of injury, the patient's age, sex and body habitus or environmental conditions.
Late trauma mortality peaks from days to weeks after the injury and is primarily due to sepsis and multiple organ failure. Organized systems of trauma care are focused on the salvage of a patient from early trauma mortality, whereas critical care is designed to avert late trauma mortality.10,11
Recognition of these patterns led to the development of the Advanced Trauma Life Support (ATLS) approach by the American College of Surgeons.12 ATLS is the standard of care for trauma patients, and it is built around a consistent approach to patient evaluation. This protocol ensures that the most immediate life-threatening conditions are quickly identified and addressed in the order of their risk potential.
While definitive care of the actual injuries plays a major role in preventing these categories of disability, it must be recognized that ensuring adequate oxygen delivery to the brain and muscle groups also plays a major role, especially in the first hour or two after injury. As with death, prevention of disability is linked to specific measures.
In regions where comprehensive trauma systems have evolved patient outcomes after major trauma have improved. Crucial components of such a system should include:
Paramedics and other healthcare providers should be provided with:
It is essential to recognize that care of the significantly injured trauma patient is critical care in that critical care is a concept, not a location.
The most seriously injured trauma patients must be identified in the field and safely transported to a designated trauma center where appropriate care should be immediately available. This is the principle of triage and is subject to both under-triage and over-triage. Clearly, from a patient-centered view, over-triage is preferable, but, from a system perspective, over-triage may be problematic in an overcrowded and oversubscribed emergency department.
Trauma-receiving medical centers should receive advance communication from emergency medical services (EMS) personnel about the impending arrival of seriously injured trauma patients. The patient's mechanism of injury, vital signs, field interventions and overall status should be communicated. Advance communication allows for the in-house trauma team to be called and for the emergency department staff to make appropriate preparations.
Upon the trauma patient’s arrival, a concise transfer of the patient from EMS personnel should occur. One person should be talking, while everyone else is listening as this is crucial information for the whole team.
Most trauma centers use a system of prehospital triage that characterizes trauma patients into those with physiologic derangements and those who have a suggestive mechanism of injury. Those patients with obvious physiologic derangements should prompt a full team response, while trauma patients with less injury may be cared for by a modified team complement.
The objective of triage is to prioritize trauma patients who have a high likelihood of early clinical deterioration. Triage of trauma patients takes into consideration the patients:
Findings that lead to an accelerated workup include multiple injuries, extremes of age, evidence of severe neurologic injury, unstable vital signs and preexisting cardiac or pulmonary disease.13
When performing triage of trauma patients who have varying types of injuries, the primary survey helps to determine priorities (e.g., a patient with an obstructed airway receives greater priority for initial attention than a relatively stable patient with a traumatic amputation). In trauma centers, a team of providers evaluates trauma patients who are critically injured and simultaneously performs diagnostic procedures. This parallel processing approach can dramatically reduce the time required to assess and stabilize a trauma patient with multiple injuries.14
The team approach to trauma is resource intensive.15 Available personnel and resources can become quickly overwhelmed in nonhospital settings, in smaller institutions and in mass casualty situations. Under these conditions, additional factors affect the triage process, including:
The triage objective under conditions of limited resources becomes how to maximize the number of trauma patients who can be salvaged under the prevailing conditions.16 This process can result in bypassing seriously injured trauma patients until less critical patients have been stabilized.
Triage is the process of grouping trauma victims according to risk of death or other adverse outcomes. EMS personnel should be trained to carry out this process according to a predetermined checklist of criteria or a system of injury severity scoring. This triage of trauma patients usually depends on three simple groups of factors:
On the basis of the triage process, certain predetermined decisions are made which attempt to direct the transport of trauma patients to the most appropriate medical facility. Certain basic life support or advanced life support interventions may also be prescribed on the basis of triage criteria. Sometimes, the most appropriate medical facility is not necessarily the closest as not all medical facilities have the resources or expertise to care for all types of injuries. In this situation, the pre-hospital triage process should identify trauma patients that need to bypass the nearest medical facility for one that is better able to manage the identified injuries.
Level I Trauma Centers typically serve a large city or a population dense area and are expected to be capable of handling large numbers of injured patients. Facilities of this nature are expected to admit a minimum of 1,200 trauma patients per year. Such centers have a dedicated trauma program, trauma service, trauma team and a medical director. Centers rated as Level I possess departments or divisions of surgery, neurosurgery, orthopedic surgery, emergency medicine and anesthesia. General surgeons, anesthesiologists and emergency medicine specialists are immediately available, 24 hours a day, with immediate operative capability available at all times.
Level II Trauma Centers are able to provide support in the event of mass casualties to a Level I Trauma Center. This support is especially crucial in population dense areas, though frequently Level II Trauma Centers serve on their own in less populated areas. When there is no Level I Trauma Center readily available, the expectation exists that transfer agreements are in place to provide prearranged transport to a Level I Trauma Center. Level II Trauma Centers are expected to have similar clinical capabilities as a Level I Trauma Center. However, some specialty services such as cardiac surgery, microvascular surgery and acute in-house hemodialysis (for example) are not required. Emergency department personnel and equipment should mirror those of a Level I Trauma Center, yet operating room availability and personnel are not expected to be on duty at all times but readily available. A Level II Trauma Center, however, must be able to provide CT or
Level IV Trauma Centers should be able to provide initial evaluation, assessment and resuscitation of trauma patients. They have 24-hour physician coverage. Transport to larger facilities with more resources must be readily available if the need arises.
Trauma team members vary based on world geography but incorporate many similar elements, including representation from emergency medicine, trauma, critical care, with or without anesthesia, nursing, respiratory therapy, blood bank, radiology, social services and registration.
Victims of major trauma require a well-organized and trained team comprised of staff competent in assessing and treating the wide range of life threatening injuries commonly seen in trauma. Most Level I and Level II Trauma Centers have accepted the trauma team approach which designate specific staff members and service specialties to roles in the care of major trauma victims.
When the scene-of-event triage and injury rating assessments are received, the designated trauma team leader makes decisions as to who should be on hand for that patient’s arrival and initiate preparations. In many trauma centers, the trauma team leader is a senior or chief resident in surgery or emergency medicine, with close supervision from appropriate attending staff. Increasingly, mid-level practitioners (e.g., physician assistants, nurse practitioners) may serve in this role as well. Sometimes the emergency room physician or a senior emergency room nurse function in the role of trauma team leader.
The composition of a trauma team will differ somewhat between institutions. However, some elements remain essential:
Specialized nursing services and other essential personnel include:
Additional consultants may be engaged in response to specific injuries. In addition to the trauma team, many trauma centers also have a trauma care coordinator (usually a nurse), who follows the patient through his or her hospital course.
Regardless of the clinical setting, the trauma team should be organized before patient arrival. Leadership and unity of command are essential for directing a rapid and efficient workup. In larger institutions with dedicated trauma services, general surgeons form the core of the trauma team in close cooperation with the emergency department staff. A physician from either service who is experienced in the care of trauma patients may serve as the team leader and directs evaluation and resuscitation.
Every trauma victim must have two assessments: a primary survey and a secondary survey. It is during the primary survey when it is determined that the trauma patient requires resuscitation. These priorities follow the Advanced Cardiac Life Support protocols simultaneously with the primary survey. The secondary survey follows the primary survey with more time being spent completing this phase of the assessment. It is during the secondary survey when the medical team may determine that the trauma patient requires transfer to a different facility.
Trauma resuscitations involving simultaneous diagnosis and treatment by multiple providers demand leadership and organization to function effectively.
Additional physicians or midlevel providers are responsible for managing the airway, conducting the primary and secondary surveys and performing other procedures as needed. Nurses and technicians monitor vital signs, gain intravenous (IV) access and obtain blood samples. Respiratory therapists and radiology technologists should also be present. As consultants, neurosurgeons and orthopedic surgeons must be available immediately to the trauma team. Early consultation with a neurosurgeon is mandatory when significant central nervous system injury is present. Specific procedures performed by both neurosurgeons and orthopedists can be lifesaving.
The nature of injuries relates to the mechanisms that cause them. The severity of injuries relates to the amount of energy transferred in the injury process and the amount of the body across which the energy is transferred.
Serious injury from blunt trauma is typified by victims of traffic-related injuries or by falls from a significant height (greater than 16 feet). In these situations, large amounts of energy are often transferred across broad and multiple regions of the body without breaching the walls of the body cavities. Accordingly, certain injury patterns can only be broadly anticipated and, initially, occult injuries are not uncommon. A broader range of investigative tests are often necessary compared with penetrating trauma.
Penetrating injuries are divided into those that result from gunshot wounds and those that result from stabbings. A further small group is patients who suffer impalement. It is important to recognize that the interpersonal violence that results in gunshot wounds or stabbings often results in multiple shots being fired or multiple stab wounds or accompanying blunt injury (e.g., from a fist or boot). Possible injuries from stab wounds can often be fairly confidently predicted, and guidelines for the management of stab wounds in particular body regions are generally straightforward.
Gunshot wounds can pose additional difficulties because the missile path may not be predictable. Secondary missiles (e.g., fragments of a shattered bone) can cause gross destruction of surrounding soft tissues, and the physical features of the missile (velocity, size, mass, impact surface) contribute to the amount of energy transferred. Because of the uncertainties posed by these features and the potentially serious nature of possible injuries, a lower threshold usually exists for comprehensive investigation or surgical exploration in the presence of gunshot wounds than with stab wounds.
Good trauma management recognizes the importance of a number of key principles:
The management of a trauma patient should permit the following aims to be met:
The sequence of goals in the initial assessment of an individual trauma patient are:
The initial assessment follows a protocol of primary survey, resuscitation, secondary survey and either definitive treatment or transfer to an appropriate trauma center for definitive care.12 The term ‘definitive care’ relates to specific treatment (operative or non-operative) whose aim is to establish the optimal conditions for the healing of specific injuries. This protocol is the heart of the ATLS system, which is designed to identify life-threatening injuries and to initiate stabilizing treatment in a rapid, efficient manner. Absolute diagnostic certainty is not required to treat critical clinical conditions identified early in the process. When resources are limited (e.g., one clinician), subsequent steps in the primary survey should not be performed until after addressing life-threatening conditions in the earlier steps.
Efficient initial assessment of a trauma patient derives from the broad principles discussed in the general principles of good trauma management, a clear understanding of the patterns of death and disability i.e., causes of death from injury, prevention of death and disability and recognition of the following factors:
Principles involved in the initial assessment of a patient with major trauma are those outlined by the American College of Surgeons (ACS) in their Advanced Trauma Life Support (ATLS) guidelines or those of the Australasian College of Surgeons in the Early Management of Severe Trauma guidelines.18,19 The principals involved consist of:
The objectives of the initial assessment of the trauma patient are to:
During the primary survey, when making diagnoses and performing interventions, treatment should continue until the trauma patient's condition is stabilized, the diagnostic workup is complete and resuscitative procedures and surgeries are complete. This ongoing effort involves monitoring the trauma patients’ vital signs, protecting the airway with assisted ventilation and oxygenation as required and providing resuscitation with IV fluids and blood products.
Trauma patients with multiple injuries may require several liters of crystalloid over the first 24 hours to sustain intravascular volume, tissue and vital organ perfusion, as well as, urine output. Blood is administered for hypovolemia, which is unresponsive to crystalloid bolus.20 If ongoing blood loss is not controlled by direct pressure and transfusion with blood or blood products, surgery or imaging-based procedures may be required to attain hemostasis. The endpoints of resuscitation are normal vital signs, absence of blood loss, adequate urine output (0.5 - 1 cc/kg/h) and no evidence of end-organ dysfunction. Parameters, such as blood lactate levels and base deficit on an arterial blood gas, may be helpful with trauma patients who are severely injured.21
An abundance of standard vital sign data guides evaluation and resuscitation of the injured trauma patient.
The primary survey is the assessment process used to assist in recognition of acute life-threatening injuries and should proceed concurrently with resuscitation. An effective primary survey requires awareness of a limited number of life-threatening entities, rapid and simple systems of physiological assessment and awareness of a plethora of interventions that can be applied to correct the identified problem.
Some aspects of care during the primary survey need special emphasis. As the primary survey assessment is followed, interventions should be taken immediately to correct the problems that are identified with each step.
The primary survey aims to identify and immediately treat life-threatening injuries relying on the ABCDE mnemonic. Injuries not imminently fatal must wait. The ABCDE mnemonic prioritizes the importance of specific injuries and assists clinical performance. In medical facilities with a major trauma service and an effective trauma team response, there will be enough team members to concurrently perform some parts of the primary survey together with the necessary resuscitative interventions.
The ABCDE mnemonic comprises:
A - Airway Control with Stabilization of the Cervical Spine
The airway is the first priority. Airway assessment should proceed while maintaining the cervical spine in a neutral position. The cervical spine is best maintained in a neutral position by using a rigid cervical immobilization collar. Emphasis is given to using simple measures to protect the cervical spine when attending to the adequacy of the airway.
The airway should be assessed by determining the ability of air to pass unobstructed into the lungs. Critical findings include:
When the airway is jeopardized or when the GCS score is less than 8, an artificial airway is essential. Airway control is commonly achieved by means of rapid-sequence endotracheal intubation performed with in-line stabilization of the cervical spine. Correct placement of the endotracheal tube is confirmed by:
Several well-defined options for achieving airway control must be established if endotracheal intubation cannot be achieved. These options include:
Tracheal inspection is essential to determine if there is peritracheal crepitus or deviation from the midline indicating potential direct airway injury or intrathoracic pulmonary or major vascular injury.
|Disruption/Edema||Cyanosis||Gloved finger, light, suction|
|Foreign bodies||Voice||Oxygen, suctioning|
|Blood and Vomitus||Stridor||Chin lift/jaw thrust, suctioning|
|Soft tissue edema||Confusion||Oropharyngeal airway|
|Deteriorating Consciousness:||Respiratory Distress||Nasopharyngeal airway, Laryngeal mask airway (LMA), Intubating LMA, Fiberoptic intubation|
|Air movement||Endotracheal intubation|
|Unstable Fracture||Assume if:|
|Unconscious||Semi-rigid cervical collar|
|Face injury||Maual in-line immobilization|
B - Breathing
The adequacy of breathing should next be assessed to determine the trauma patient’s ability to ventilate and oxygenate. This assessment is most readily accomplished by:
Critical findings to assess for include:
Inadequate ventilation may result in hypoxemia, hypercarbia, cyanosis, depressed level of consciousness, bradycardia, tachycardia, hypertension or hypotension. Generally, until adequate ventilation has been achieved, high-flow oxygen should be administered by mask to all trauma patients to help prevent hypoxemia.
Classic signs of a pneumothorax, tension pneumothorax, hemothorax, combined hemopneumothorax and sucking chest wounds include:
Intrathoracic tension physiology is a clinical diagnosis and requires immediate decompression. This is initially commonly accomplished by inserting a large-bore catheter (e.g., 14 gauge or larger) into the pleural space at the second intercostal space at the mid-clavicular line (i.e., needle thoracentesis). Trauma patients treated in this way should have a tube thoracostomy (i.e., chest tubes) placed to manage simple pneumothorax and to evacuate thoracic cavity blood if present. Life-threatening hemorrhage identified when placing a tube thoracostomy may be managed with a resuscitative thoracotomy.
Initial treatment for a flail chest is mechanical ventilation which frequently is required for other injuries associated with ventilation and oxygenation deficits.
|Open pneumothorax||Confusion||Needle thoracentesis|
|Massive flail||Respiratory distress||Tube thoracentesis|
|Reduction in level of consciousness/poor respiratory effort||Shallow respiration||Tracheal intubation|
|Poor chest expansion||Cover open wound|
|High spinal cord injury|
C – Circulation/Hemorrhage Control
Emergent treatment of trauma patients with exsanguinating hemorrhage or shock can be life-saving. This assessment includes identifying and managing rapid external hemorrhage; this can often be achieved with a simple pressure dressing, but surgical intervention may be required. As more experience is gained with procoagulant dressings (used principally by the military), external hemorrhage control may gain pharmacologic support embedded in dressings.
Shock in trauma patients is defined as inadequate organ perfusion and tissue oxygenation. Causes of shock include:
Signs of shock include:
In trauma patients with hypovolemia, the neck veins may be flat. A normal mental status generally implies adequate cerebral perfusion pressure while diminished mentation may be associated with shock with or without intracranial trauma.
Treatment of hypovolemia should be initiated by rapidly infusing a lactated Ringer solution via two large-bore, peripheral IV catheters. They should be placed preferentially in the upper extremities.
The Committee on Trauma of the American College of Surgeons (ACS-COT) has long published categories of shock that allow the healthcare provider to predict the likelihood of significant blood loss and to anticipate the type and amount of fluid requirements.12
The shock classification (Table 4) allows the healthcare provider to characterize the trauma patient’s response to injury. As blood loss associated with injury progresses, mental status deteriorates, heart rate increases, blood pressure falls and oliguria becomes apparent.12 The trauma patient with persistent vital sign evaluation suggesting hypotension is at significant risk for loss of 30 - 40% of blood volume on presentation.
|Class I||Class II||Class III||Class IV|
|Blood Loss (% blood volume)||Up to 15%||15-30%||30-40%||>40%|
|Blood Pressure (mmHg)||Normal or increased||Decreased||Decreased||Decreased|
|Urine Output (mL/h)||>30||20-30||5-15||Negligible|
|CNS/Mental status||Slightly Anxious||Mildly Anxious||Anxious, Confused||Confused, Lethargic|
|Fluid Replacement (3:1 rule)||Crystalloid||Crystalloid||Crystalloid and Blood||Crystalloid and Blood|
Advanced Trauma Life Support (ATLS) also recognizes the four different classes of shock. In summary, Class I and II shock generally do not need red cell mass restoration and are well managed with asanguineous fluids for plasma volume expansion. Hypotension and disordered mentation generally indicate at least Class III shock and should prompt plasma volume expansion and red cell mass repletion if the hypotension fails to resolve after an initial 2000cc crystalloid bolus, according to ATLS.12
A systematic approach for detecting the source of hypovolemic shock should consider five sources of ongoing hemorrhage:
Fracture alignment and stabilization is essential in limiting blood loss. Pelvic fractures may be initially stabilized with a pelvic binder or a wrapped sheet secured with a towel clip as a means of reducing pelvic volume to limit hemorrhage.
|External (Scene, bed, floor)||Pale, clammy, cool||Oxygen, Direct pressure|
|Chest (chest X-ray)||Peripheral cyanosis||Intravenous access (large bore x 2)|
|Abdomen (FAST or DPL)||Confusion||Warmed crystalloid/colloid/blood|
|Pelvis (x-ray)||Tachycardia||Hemorrhage control (direct pressure or surgery)|
|Femurs (clinical exam||Low pulse volume|
|Combination||Slow capillary refill||Pressure infusion|
|Neck veins||Blood warming|
|Heart sounds (muffled)||Gastric tube|
|Surgery (urinary catheter)|
|Tension Pneumothorax||Needle/tube thoracentesis|
|Cardiac tamponade||Paricardiocentesis, Subxiphoid pericardial windo|
D - Disability
During the acute resuscitation period, a brief assessment of neurologic status should be performed. This assessment should include a global assessment of the trauma patient's level of responsiveness, as well as, the patient's posture (i.e., any asymmetry, decerebrate or decorticate posturing), pupil asymmetry and pupillary response to light.
A recommended system is the AVPU mnemonic:
The disability of the trauma patient should be assessed by determining:
|To Verbal Stimuli||3|
|BEST VERBAL||No Response||1|
|Disoriented and Converses||4|
|Oriented and Converses||5|
|BEST MOTOR||No Response||1|
|Extension Abnormal (Decerebrate Rigidity)||2|
|Flexion Abnormal (Decorticate Rigidity)||3|
Pupillary asymmetry or dilation, impaired or absent light reflexes and hemiplegia or weakness suggest impending herniation of the cerebrum through the tentorial incisura due to an expanding intracranial mass or diffuse cerebral edema.22 These findings indicate the need for emergency treatment of intracranial hypertension, including administration of IV mannitol, hypertonic saline, sedatives and muscle relaxants, after obtaining a definitive airway. Urgent neurosurgical consultation is mandatory.
The absence of a depressed level of consciousness but the presence of paraplegia or quadriplegia indicates spinal cord injury. The possibility of a spinal cord injury requires full spinal immobilization. If inspiratory efforts are weak or when a high cervical cord lesion is suspected, an endotracheal intubation should be performed.23,24
Continuous assessment using the GCS should be made at this time, during the secondary survey and at any time that the trauma patient’s mental status appears to change. A more detailed assessment of the trauma patient’s neurologic status is made during the secondary survey.
|Secondary brain injury||Alert||A, B, C|
|Intracranial hematoma||Voice Response||C-spine protection|
E – Exposure/Environment
The final step in the primary survey includes patient exposure and control of the immediate environment. Trauma patients should be completely disrobed during the primary survey for a thorough physical examination. This exam helps ensure a rapid search for hidden injuries in order to assess for emergently life-threatening damage hidden beneath garments. Practiced trauma teams often pre-designate one or more staff to the essential task of exposure. The clothes are cut off to prevent extraneous movements of the body parts.
Simultaneously, efforts should be made to prevent significant hypothermia by providing a warm ambient room (28 - 30°C). The trauma patient should be treated prophylactically with the administration of warmed IV fluids, blankets, heat lamps, overhead heating and warmed air-circulating blankets as needed. The trauma patient's temperature should be measured on arrival at the emergency department and at intervals thereafter. Strenuous efforts should be made to avoid significant hypothermia during resuscitation and therapeutic intervention.
|Concealed injuries||Prepare for secondary survey||Cut all clothes off|
|Hypothermia||Patient temperature||Warm ambient room|
Warmed IV fluids
Warmed air-circulating blankets
Several monitoring and diagnostic adjuncts are performed in concert with the primary survey.12 Monitors provide data that are critical to guiding resuscitation.
Radiographic imaging studies provide crucial diagnostic data that guide the initial evaluation. The sequence and timing of these studies are important. The imaging studies should be performed so as not to interfere with lifesaving interventions identified in the primary survey and resuscitation phases. The trauma patient should be hemodynamically stable enough for transfer to the radiology suite..
Initial imaging studies during the resuscitation effort and the primary survey should be limited to27:
Film 1: AP Chest X-ray
This chest radiograph demonstrates bilateral pulmonary contusions in a trauma patient.
Film 2: AP Pelvic x-ray
The AP pelvic X-ray quickly helps identify major pelvic fractures and joint disruptions.
* The odontoid view is an open mouth view to visualize the upper cervical spine.
Definitive clearing of the neck is managed in different ways in different institutions, but certain common features are identified:
The secondary survey is formally begun after the completion of the primary survey and after starting the resuscitation phase. The emphasis of the secondary survey is more thorough and designed to provide the information needed to establish a baseline by which progress or system decay is measured. At this time, all injuries are identified by conducting a thorough head-to-toe examination. The secondary survey might not occur until after an emergency surgery has been completed.
The secondary survey includes:
The following FGHI mnemonic can be used to guide the secondary survey:
F - Full vital signs are needed to provide tracking information as to the trauma patient’s systemic response to his/her injuries. The trauma patient's vital signs should be reviewed, and a quick repeat of the primary survey performed to assess the patients’ response to the resuscitation effort and to identify any deterioration.
G - Give comfort. During the primary survey and initial stabilization, it is easy to overlook the comfort of the trauma patient. The trauma patient will be very frightened and disoriented by what is happening.
H - Head to toe examination is the methodical, detailed inventory of injuries. Each area of the body must be examined for injury and the damage graded and categorized.
I – Inspect the trauma patient and any hidden areas.
The primary survey deals with acute, immediately life-threatening injuries. The focus of the secondary survey is the collection of the rough data that will sketch the trauma patient’s status into an overall framework. Once these two surveys are completed, assessment turns toward a detailed evaluation of each injury that was discovered during the secondary survey.
The emphasis of the detailed physical examination in the secondary survey is on identifying anatomical injuries and providing clinical information that will determine the need for further plain x-rays and other special investigations. It is a careful and methodical physical examination from head to toe. Each region of the body should be examined for signs of injury, bony instability and tenderness to palpation. It requires close inspection, careful palpation and appropriate auscultation.
Common omissions resulting in missed injuries include examination of the entire scalp, careful inspection of the back (often needing a log-roll), inspection of the perineum, inspection of the axillae and digital rectal examination.
Secondary survey: look! listen! feel! outlines a useful sequence for the execution of the secondary survey. It also indicates the common general abnormalities that may be observed and highlights some simple procedures that assist with pain relief, reduce the risk of infection and lead into the definitive-care phase of early trauma management.
The dictum "fingers or tubes in every orifice" guides this physical examination.
Photo 1: Raccoon Eyes
Periorbital ecchymosis, or "raccoon eyes," is a classic diagnostic sign of basilar skull fracture
Figure 1: Anterior and Posterior Triangles of the Neck
By Olek Remesz (wiki-pl: Orem, commons: Orem) Modified by user:madhero88 - original image File:Musculi coli base.svg, CC BY 3.0, Wikimedia.org
Figure 2: Platysma Muscles
At the completion of the physical examination, the trauma patient should be log rolled with inline stabilization of the head and neck.
During the secondary survey, the ABCDE system should be used as a guide during the constant reevaluation of the trauma patient. The ongoing diagnostic and therapeutic plan should be revised, as indicated, by the trauma patient’s response to intervention and diagnostic test results.
In general, diagnostic studies are not performed if the capability to act on the information gained is not available. For example, a patient with blunt trauma initially transported to a small rural emergency department frequently has indications for advanced imaging. If an appropriately trained surgeon is not present in the institution, then these studies are of questionable value since they may delay the transfer of the patient to a trauma center. Consequently, imaging studies are performed and prioritized based on patient stability, the practical utility of the data obtained and the imperative need for early transfer to a trauma center to obtain definitive care.
The CT scan is the definitive radiographic study in most trauma patients. CT imaging of the head, cervical spine, chest, abdomen and pelvis is the most sensitive and accurate noninvasive diagnostic tool for identifying major injury. Bedside assessment of blunt traumatic injury was recently evaluated to assess the impact of CT scans.32 Bedside evaluation was effective in ruling out serious injuries in trauma patients with low risk of serious injury. Overall diagnostic accuracy of bedside assessment was low, however, suggesting that CT is utilized in high-acuity trauma patients to avoid missing injuries.32,33
Over reliance on CT imaging can be detrimental if emergent operations are delayed. One review of trauma patients presenting with hypotension (systolic BP < 90 mm Hg) and significant abdominal injury demonstrated greater mortality if surgery was delayed by a CT scan.34 Excessive radiation exposure is also a concern.35
CT Scan 1: Head
The lenticular shape of this lesion identifies it as an epidural hematoma.
CT Scan 2: Abdomen
Several reports from major trauma centers emphasize the value of CT scanning to evaluate penetrating torso injuries. Patients requiring hospitalization or extended periods of observation in the emergency department may now be sent home with a late generation CT scan that demonstrates the benign track of a bullet wound or stabbing injury.48,49.50,51 With increasing resolution, even small bowel and mesenteric injuries are now readily identified. These injuries were previously difficult to detect and can be a source of late morbidity for patients.52
A practice of early comprehensive multislice CT is rapidly evolving in urban trauma centers. This use of advanced CT technology leads to a more accurate and faster diagnosis with a reduction in resource utilization. Whether increasing radiation exposure with the use of advanced CT technology will become a clinical and social issue is unclear.
Photo 2: Full Thickness Burn
The tertiary survey is a repeat clinical examination along the lines of the primary and secondary surveys. The goal of the tertiary survey is the identification of injuries that were missed during the initial assessments. A formal tertiary survey should be performed within 18 - 36 hours after admission. It consists of a thorough repeat physical examination proceeding from head-to-toe in conjunction with a review of all laboratory data and imaging studies obtained since admission. New laboratory and imaging studies may be requested as indicated.
While the tertiary survey does not reduce the incidence of injuries missed during the primary and secondary surveys, it decreases their morbidity and mortality by early identification and treatment. Injuries that may be missed during the primary survey and that need to be identified during the tertiary survey often have great functional importance and impact the return of the trauma patient to normal occupational, family and social functions. These injuries usually pose little threat to life but can often lead to locomotor or manipulative disability if undetected and untreated. Examples include:
Review of previous x-rays will sometimes result in a new diagnosis of pneumothorax, widened mediastinum, pelvic fracture or rib fractures that require specific management. Occult visceral injury, in particular small bowel injury, may be suspected at this stage on the basis of increasing pulse rate, increasing temperature and localized abdominal tenderness. Subtle signs of brain injury must be sought.
A sudden, unexpected deterioration of an initially stable trauma patient is a common problem encountered during the care of multiple trauma patients. This situation is especially problematic after performing thorough primary and secondary surveys and instituting a resuscitation plan. The solution to these crises lies in the ABCs (airway, breathing and circulation) of the primary survey.60
Injuries can evolve from subclinical to clinically apparent over the course of a rapid trauma workup, and even the best diagnostic workup is not perfect. It is necessary to ensure that the airway is clear, that ventilation is adequate and that the blood pressure and end-organ perfusion are sufficient. By rapidly rechecking the elements of the primary survey first, easily corrected problems (e.g., mispositioned endotracheal tubes, tension pneumothorax and unsuspected hemorrhage) can be rapidly identified and addressed.
Nevertheless, the survey may miss injuries, especially in seriously injured trauma patients who require intensive resuscitative and/or surgical procedures to stabilize. This tendency is exacerbated by the focused priorities of the primary survey and resuscitation phase. A simple remedy for this problem is frequent and thorough reassessment. A difficult aspect of treating multiple trauma patients is prioritizing between competing injuries in the same patient.
Discussion of Outcomes
Strengths and Weakness of the Approach Used in this Case
Events that produce major trauma often occur suddenly and without warning. From the time of trauma until injury-specific medical interventions can take place, a series of vital assessments must occur. On arrival, the primary survey conducted by an organized trauma team can ascertain the presence of immediate life-threatening injuries. The secondary survey can establish a framework of information about the trauma patients injuries and condition that allows formation of a plan of treatment using the objective information obtained by initial vital sign measurements, laboratory values and imaging results. The physical assessment conducted during the secondary survey focuses the trauma team to explore and begin treatment of each injury in detail starting with the most critical.
The implementation of sequential assessments beginning from the time the first trained personnel arrive at the scene of a traumatic injury and continuing to where injury-specific treatments can begin greatly increases favorable outcomes to tragic events of major trauma.
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Occupational Therapist (OT/OTA), Physical Therapist (PT/PTA), Registered Nurse (RN)
CPD: Practice Effectively, Critical Care / Emergency Care, ProCert Approved Courses