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Trauma: Optimizing Survival Outcomes

3.00 Contact Hours   -   2.00 CCUs
FPTA Approval: CE18-575935. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or sponsors.

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.

A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Pamela Downey (MSN, ARNP)

Outcomes

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.

Objectives

Upon completion of this course, the participant will be able to:

  1. Differentiate between the terms trauma and accident.
  2. Relate mortality in cases of immediate, early and late deaths.
  3. Describe four goals of assessment and resuscitation.
  4. Discriminate between the components of the Primary Survey and Resuscitation and the Secondary Survey.
  5. Differentiate the sequence of assessment in both the Primary Survey and Secondary Surveys.
  6. Identify four laboratory studies commonly ordered during the Primary Survey and Resuscitation and the Secondary Surveys to confirm or refute the presence of further injuries/problems.

OVERVIEW

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. [1]

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.

TRAUMA STATISTICS

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):

  • Trauma injury accounts for 30% of all life years lost in the U.S.
  • Cancer accounts for 16%.
  • Heart disease accounts for 12%.

* 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.

Economic Burden4:

  • $671 billion a year, including both health care costs and lost productivity.


Deaths due to injury5 (2014, most recent available):

  • 192,000

Ranking as cause of death6

  • #1 for age group 1 - 46 or 47% of all deaths in this age range.
  • #3 as leading cause of death overall, across all age groups.

Burns7(2013, most recent available):

  • 450,000 burn injuries require medical attention annually.
  • 40,000 hospitalizations related to burn injury.
  • 3,400 fire/burn/smoke inhalation deaths per year.

Falls8(2013, most recent available):

  • Each year, 2.5 million older people are treated in emergency departments for fall injuries and at least 250,000 older people are hospitalized for hip fractures.
  • Over 700,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture.

Trauma Mortality and Morbidity

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.

Death Prevention

  • General Measures
    • Optimize oxygenation (A, B)
    • Optimize perfusion acutely (C)
    • Meticulous continuing fluid management
    • Thrombosis prophylaxis
    • Adequate nutrition by appropriate route
  • Local Measures
    • Arrest or minimize bleeding (C)
    • Correct raised ICP (D)
    • Control ‘leaks’ (tracheobronchial, esophageal, abdominal hollow viscera, pancreas, urinary)
    • Decompress or revascularize ischemic tissue promptly
    • Debride dead tissue aggressively
    • Debride and clean contaminated wounds 

Disability

  • Disability principally relates to:
    • Chronic pain
    • Cognition
    • Locomotion
    • Manipulation skills

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.

Prevention of Disability

  • General Measures
    • Optimize oxygenation (A, B)
    • Optimize perfusion (C)
    • Protect spine (A and following measures)
    • Correct raised ICP (D)
  • Local Measures
    • Reduce dislocations as soon as possible
    • Re-align fractures as soon as possible
    • Correct local ischemia early
    • Diagnose and decompress compartment syndromes early
    • Prevent secondary damage to nerves (iatrogenic injury, ischemia, compression, e.g. dislocations)
    • Debride ischemic tissue early
    • Debride contaminated wounds early
    • Find the ‘minor injuries’ to ligaments, joints and small bones (tertiary survey) 

TRAUMA SYSTEM PLANNING

In regions where comprehensive trauma systems have evolved patient outcomes after major trauma have improved. Crucial components of such a system should include:

  • A coordinated approach to both prehospital care and hospital care.
  • A program for training providers in both prehospital care and hospital care areas.

Paramedics and other healthcare providers should be provided with:

  • A clear and objective framework for assessing patients
  • Establishing and engaging in treatment protocols
  • Triage guidelines
  • Engaging in transportation and communication protocols
  • Implementing ongoing performance improvement programs

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.

Triage and Organization of Care

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:

  • Vital signs
  • Prehospital clinical course
  • Mechanism of injury
  • Patient age
  • Known or suspected comorbid conditions

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:

  • Number and skill levels of available providers
  • Equipment availability
  • Provider's estimate of the clinical probability of each trauma patient's survival

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.

Pre-Hospital Triage

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:

  • Physiology:
    • Vital signs
      • Pulse > 120/min
      • Systolic blood pressure < 90 mmHg
      • Glasgow Coma Scale score [GCS] < 15)
  • Anatomy:
    • Immediately evident injuries
      • Fractured long bones
      • Penetrating injury
      • Spinal cord injury etc.
  • Mechanism of injury:
    • Fall > 16 feet
    • Injury to two or more body regions
    • Vehicle crash with ejection 

Pre-Hospital Treatment and Transport Decisions

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. 

Categorization of Hospitals

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 MRI testing at all times.

Level III Trauma Centers must have the capability to manage the initial care of the majority of injured trauma patients that might be generated in a major event or natural disaster. They also have 24-hour general surgical coverage. These facilities must also have transport readily available for patients that exceed in-house capabilities.

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 Teams

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:

  • A designated trauma team leader to coordinate and supervise the joint effort to ensure that the resuscitation proceeds in an organized and efficient manner throughout the diagnostic and therapeutic protocols.17
  • Emergency room physician
  • Trauma specialist when available
  • General surgeon
  • Anesthesiologist
  • Radiologist
  • Orthopedic surgeon
  • Other specialty surgeons such as a cardiovascular surgeon or neurosurgeon should be available on call as needed

Specialized nursing services and other essential personnel include:

  • Emergency room nurses
  • Intensive care nurses
  • Operating room personnel
  • Post-operative recovery nurses
  • Laboratory personnel
  • Radiology personnel
  • Respiratory therapists
  • Pastoral care
  • Social work personnel

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. 

BLUNT AND PENETRATING MECHANISMS OF INJURY

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. 

GENERAL PRINCIPLES OF GOOD TRAUMA MANAGEMENT

Good trauma management recognizes the importance of a number of key principles:

  • The importance of injury as a public health issue.
  • The importance of the mechanism of injury in predicting actual injuries.
  • The differing implications of blunt and penetrating injury.
  • The importance of triage.
  • The importance of the triage process of:
    • Evident injuries
    • Injury mechanism
    • Physiological status
  • The differing risk exposures and injury patterns in children, young adults and the elderly.
  • The patterns of associated injuries that are commonly observed.
  • The commonly documented deficiencies in acute injury management.
  • The importance of an integrated trauma treatment service in a hospital.
  • The importance of a triage-based team approach to acute injury assessment.
  • The value of a protocol-directed approach and practice guidelines to acute injury assessment and management.
  • The importance of regional trauma care systems that link injury prevention activities, pre-hospital care, acute care hospitals with differing roles and rehabilitation services. 

GOALS OF ASSESSMENT AND RESUSCITATION

The management of a trauma patient should permit the following aims to be met:

  1. Minimizing the time from injury to definitive care.
  2. Not allowing the obvious injury to distract from diagnosing other, less obvious injuries.
  3. Not allowing the trauma patient to leave the resuscitation area without a clear management plan.
  4. There should be no need for further clinical guesswork after 2 hours from arrival of the trauma patient. 

Specific Goals

The sequence of goals in the initial assessment of an individual trauma patient are:

  1. Save life. This requires knowledge of the causes of death.
  2. Prevent major disability. This requires knowledge of the causes of disability.
  3. Diagnose and appropriately manage all injuries.
  4. Avoid unnecessary investigations or interventions. 

INITIAL ASSESSMENT

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:

  • Trauma patient assessment is different from that of the usual patient. The traditional approach of taking a full history, performing a full physical examination, determining a provisional diagnosis and a list of differential diagnoses and deriving a logical plan for investigation and treatment should be deferred in order to first ensure a trauma patient's survival and then to ensure the smallest possible risk of major complications.
  • There is a need to minimize the time from injury to definitive care, particularly so that continued bleeding is halted.
  • Physiological responses and consequences of injury are often changing, and any static set of physiological values (e.g., pulse, respiratory rate, GCS and blood pressure) is of limited value.
  • Life-threatening injuries may be occult, multiple life-threatening injuries may coexist in different body regions and the injuries that appear most dramatic may not be those that pose the most risk.
  • The concept of the ‘golden hour’ is important i.e., a 1 – 2-hour period during which all opportunities need to be taken to discover injuries that may cause death within minutes and then to discover injuries that may cause death within hours.
  • Treating physicians can be under considerable stress and will be assisted by pre-planned protocols or evidence-based guidelines.

Assessment Principles

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:

  1. preparation and transport
  2. primary survey and resuscitation, including monitoring, urinary and nasogastric tube insertion and radiography
  3. secondary survey, including special investigations, such as CT scanning or angiography
  4. ongoing reevaluation
  5. definitive care

The objectives of the initial assessment of the trauma patient are to:

  1. Rapidly identify life-threatening injuries
  2. Initiate adequate supportive therapy
  3. Efficiently organize either definitive therapy or transfer to a medical facility that provides definitive therapy 

PRIMARY SURVEY AND RESUSCITATION

Resuscitation Phase

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.

Primary Survey and Resuscitation

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:

  • Airway control with stabilization of the cervical spine
  • Breathing (work and efficacy)
  • Circulation/Hemorrhage including the control of external hemorrhage
  • Disability or neurologic status
  • Exposure/Environment (undressing of the trauma patient while also protecting the patient from hypothermia)

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:

  • Obstruction of the airway due to direct injury, edema or foreign bodies
  • Inability to protect the airway because of a depressed level of consciousness

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:

  • The aid of an end-tidal carbon dioxide monitoring device
  • Observation of the tube passing through the vocal cords
  • Auscultation of breath sounds

Several well-defined options for achieving airway control must be established if endotracheal intubation cannot be achieved. These options include:

  • Laryngeal mask airway (LMA)
  • Intubating LMA
  • Fiberoptic intubation
  • Percutaneous cricothyroidotomy
  • Surgical cricothyroidotomy (tracheostomy in children)

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.

Table 1: Airway
ProblemAssessIntervention
Direct Trauma:
        Disruption/EdemaCyanosisGloved finger, light, suction
Obstruction:TachypneaLaryngoscope, forceps
        Foreign bodiesVoiceOxygen, suctioning
        Blood and VomitusStridorChin lift/jaw thrust, suctioning
        Soft tissue edemaConfusionOropharyngeal airway
Deteriorating Consciousness:Respiratory DistressNasopharyngeal airway, Laryngeal mask airway (LMA), Intubating LMA, Fiberoptic intubation
 Air movementEndotracheal intubation
  

Surgical Airway:
    Percutaneous cricothyroidotomy
    Surgical cricothyroidotomy
    Emergent tracheostomy

Table 2: C-Spine
ProblemAssessIntervention
Unstable Fracture    Assume if: 
     UnconsciousSemi-rigid cervical collar
     Head injurySandbags/tape
     Face injuryMaual 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:

  • Visual inspection of thoracic cage movement
  • Palpation of thoracic cage movement
  • Auscultation of gas entry (over trachea and lungs)

Critical findings to assess for include:

  • Absence of spontaneous ventilation
  • Absent or asymmetric breath sounds (consistent with either pneumothorax or endotracheal tube malposition)
  • Crepitus
  • Dyspnea
  • Hyperresonance or dullness to chest percussion (e.g., tension pneumothorax or hemothorax)
  • Gross chest wall instability or defects that compromise ventilation (e.g., flail chest, sucking chest wound)
  • Local asymmetric chest wall movement (e.g., flail chest)
  • Signs of impending respiratory failure such as uncoordinated thoracic cage and abdominal wall movement, accessory muscle use and stridor

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:

  • Tracheal deviation
  • Jugular vein distension
  • Hypoxia
  • Tachycardia
  • Hypotension

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.

Table 3: Breathing
ProblemAssessIntervention
Tension pneumothoraxCyanosisOxygen
Massive hemothoraxTachypneaVentilation
Open pneumothoraxConfusionNeedle thoracentesis
Massive flailRespiratory distressTube thoracentesis
Reduction in level of consciousness/poor respiratory effortShallow respirationTracheal intubation
Poor chest expansionCover open wound
High spinal cord injury

Asymmetric expansion
Hyperinflation
Hyper-resonance
Breath sounds
Tracheal shift
Diaphragmatic breathing

 

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:

  • Cardiac tamponade
  • Hemorrhage leading to hypovolemia (most common cause)
  • Spinal cord injury
  • Tension pneumothorax or hemothorax

Signs of shock include:

  • Decreased pulse pressure
  • Delayed capillary refill
  • Depressed level of consciousness
  • Hypotension
  • Oliguria
  • Pallor
  • Tachycardia
  • Tachypnea

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.

Table 4: Estimated Fluid and Blood Losses Based on Patient's Initial Presentation12
 Class IClass IIClass IIIClass IV
Blood Loss (% blood volume)Up to 15%15-30%30-40%>40%
Pulse Rate<100>100>120>140
Blood PressureNormalNormalDecreasedDecreased
Blood Pressure (mmHg)Normal or increasedDecreasedDecreasedDecreased
Respiratory Rate14-2020-3030-40>35
Urine Output (mL/h)>3020-305-15Negligible
CNS/Mental statusSlightly AnxiousMildly AnxiousAnxious, ConfusedConfused, Lethargic
Fluid Replacement (3:1 rule)CrystalloidCrystalloidCrystalloid and BloodCrystalloid 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:

  1. External (e.g., from the scalp, skin or nose)
  2. Long-bone fracture
  3. Pelvis/Retroperitoneum
  4. Peritoneal cavity
  5. Pleural cavities

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.

Table 5: Circulation
ProblemAssessIntervention
Bleeding:  
    External (Scene, bed, floor)Pale, clammy, coolOxygen, Direct pressure
   Chest (chest X-ray)Peripheral cyanosisIntravenous access (large bore x 2)
    Abdomen (FAST or DPL)ConfusionWarmed crystalloid/colloid/blood
     Pelvis (x-ray)TachycardiaHemorrhage control (direct pressure or surgery)
     Femurs (clinical examLow pulse volume 
    CombinationSlow capillary refillPressure infusion
Neck veinsBlood warming
Heart sounds (muffled)Gastric tube
 Surgery (urinary catheter)
Heart:  
    Tension Pneumothorax Needle/tube thoracentesis
    Cardiac tamponade Paricardiocentesis, Subxiphoid pericardial windo
    Contusion  
    Infarction  

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:

  • A = Patient is awake, alert and appropriate
  • V = Patient responds to voice
  • P = Patient responds to pain
  • U = Patient is unresponsive

The disability of the trauma patient should be assessed by determining:

  • Gross mental status and motor examinations using the Glasgow Coma Scale (GCS) (Table 6)
  • Existence of a serious head or spinal cord injury
    • Observe spontaneous movement of the extremities and spontaneous respiratory effort
  • Pupillary size, symmetry and reactiveness to light
Table 6: GCS
TESTRESPONSESCORE
Eye OpeningNever1
To Pain2
To Verbal Stimuli3
Spontaneously4
BEST VERBALNo Response1
Incomprehensible Words2
Inappropriate Words3
Disoriented and Converses4
Oriented and Converses5
BEST MOTORNo Response1
Extension Abnormal (Decerebrate Rigidity)2
Flexion Abnormal (Decorticate Rigidity)3
Flexion Withdrawal4
Localized Pain5
Obeys Commands6
TOTAL SCORE 3-15

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.

Table 7: Disability (CNS)
ProblemAssessIntervention
Secondary brain injuryAlertA, B, C
Intracranial hematomaVoice ResponseC-spine protection
BrainPain ResponseHyperventilation
CompressionUnresponsive 
ContusionLateralizing signs 
LacerationPupils 
Swelling  

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.

 

Table 8: Exposure/Environment Control
ProblemAssessIntervention
Concealed injuriesPrepare for secondary surveyCut all clothes off
HypothermiaPatient temperatureWarm ambient room
Warmed IV fluids
Warmed blankets
Warmed air-circulating blankets
Heat lamps
Overhead heating
Heating mattress

 

 

 

Monitoring and Diagnostic Adjuncts

Several monitoring and diagnostic adjuncts are performed in concert with the primary survey.12 Monitors provide data that are critical to guiding resuscitation.

  • Place ECG leads attached to a cardiac monitor to evaluate real-time heart rate and rhythm
    • If indicated and possible, an arterial line should be inserted as part of the place monitors intervention. This allows for real-time blood pressure monitoring and the frequent laboratory draws that are inevitable following major trauma.
  • Continuously monitor blood pressure, respiratory rate and temperature
  • Initiate continuous pulse oximetry in an area with sufficient blood flow to give an accurate reading to monitor oxygen saturation
  •  Nasogastric tube
    • A nasogastric tube is usually inserted towards the end of the primary survey.
    • Indications for usage include:
      • Decompression of a full stomach
      • Lessening of the likelihood of aspiration of stomach contents
      • Assessment of the aspirate for frank bleeding before it is connected to low intermittent suction
    • A nasogastric tube should be inserted into all trauma patients with major abdominal injury, major chest injury, spinal injury, brain injury, major burns and shock.
    • A nasogastric tube should be inserted orally into all trauma patients who:
      • Have a high likelihood of basilar skull fracture
      • Have a high likelihood of cribriform plate fractures
      • Require endotracheal intubation
    • Oral nasogastric tube insertion is preferred to decrease the likelihood of sinusitis from drainage pathway obstruction even in the absence of brain injury.
    • Children, in particular, are prone to gastric dilatation, which can significantly impair their respiration and lead to hemodynamic compromise.
  • Urinary drainage catheters
    • Urinary drainage catheters are commonly inserted at the end of the primary survey.
    • Indications for usage include:
      • Assessment of genitourinary system hemorrhage
      • Monitoring of hourly urine output to assess the response to intravenous fluid resuscitation
    • Urethral injury should be avoided in trauma patients with pelvic trauma and for those who have blood at the urethral meatus.
    • Placement of a Foley catheter is contraindicated if urethral injury is evident.
      • Signs of urethral injury include:
        • Blood at the meatus
        • Ecchymosis in the scrotum or labium majora
        • High-riding prostate, which can be identified during a digital rectal examination prior to catheter insertion
    • Abnormal findings from the rectal examination or concern as to the continuity of the urethra should prompt a retrograde urethrocystogram to exclude urethral injury prior to bladder catheterization. If identified, a suprapubic catheter should be inserted, and urologist should be consulted.

Laboratory Studies

  • Type and Crossmatch
    • The most important lab study.
    • This should be completed within 20 minutes of receipt of the blood sample.
  • Arterial Blood Gases
    • Useful in the initial assessment period although their use for serial monitoring has declined since the introduction of continuous pulse oximetry.
  • Baseline Hemoglobin or Hematocrit
    • Useful on arrival, with the understanding that in acute hemorrhage, a fall in hematocrit may not be apparent until autogenous mobilization of extravascular fluid or administration of IV resuscitation fluids begins.
  • Urine Drug Screens for drugs of abuse and Blood Alcohol Levels
    • Commonly ordered in trauma centers to identify correctable causes of decreased level of consciousness.
    • A recent review of the data of the National Trauma Data Bank of the United States reveals a disturbing decline in substance use screening despite the importance of substance use as a contribution to injury.25
  • Blood Glucose Levels
    • Should be drawn to identify correctable causes of decreased level of consciousness.
    • Early hyperglycemia has been linked to an increased risk of infectious complications and mortality after injury.26
  • Serum Electrolytes, Coagulation Studies, Cell Blood Counts
    • For most trauma patients, serum electrolytes, coagulation parameters, cell blood counts and other common laboratory studies are less useful during the first 1 - 2 hours than they are after stabilization and resuscitation. 

Imaging Studies

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:

  • Portable anteroposterior (AP) Chest X-ray
    • Portable AP chest x-rays should be assessed for:
      • Appropriate placement of chest tubes, endotracheal tube and other lines
        • The presence of treatable life-threatening conditions including:
        • Injuries to the thoracic cage or vertebral column
        • Lung parenchymal injuries such as:
          • Hemothorax
          • Pneumothorax
          • Pulmonary contusions (Film 1)
      • Mediastinal widening
      • Space-occupying lesions

Film 1: AP Chest X-ray

Film 1 AP Chest X-ray

By Karim - Trauma.org, CC BY-SA 3.0, Wikimedia.org

This chest radiograph demonstrates bilateral pulmonary contusions in a trauma patient.

  • Portable AP Pelvic X-ray
    • Indications for ordering an AP pelvic x-ray of the trauma patient include:
      • Involvement in a high-speed motor vehicle collision
      • Fall from a height
      • Blunt trauma
    • A high-energy pelvic fracture identified on physical examination or pelvis x-ray may substantially contribute to shock.
    • An AP pelvic x-ray helps confirm the presence of significant pelvic fractures (Film 2) which are often the sites of hemorrhage that require early operative external stabilization, operative extraperitoneal pelvic packing or angioembolization. 

Film 2: AP Pelvic x-ray

Film 2: AP Pelvic X-ray

Source: Wikipedia.org

The AP pelvic X-ray quickly helps identify major pelvic fractures and joint disruptions.

  • Portable Cervical Spine X-rays
    • Lateral cervical spine x-ray is used to screen for injuries in trauma patients where the physical examination is unreliable.
    • Prior recommendations for lateral cervical x-rays have been replaced by routine pan-cervical imaging with image reformation using CT scanning, especially if the trauma patient is to undergo a brain CT scan.
    • Plain x-ray films of the spine should be obtained in patients with high-energy blunt trauma and other trauma patients with known or suspected neurologic deficits if CT scanning is unavailable or if a complimentary image is desired.28
    • For trauma patients with a low likelihood of spinal injury, most or all of the spinal x-rays are deferred until the resuscitation phase is well underway and, if necessary, after performing a lifesaving emergent laparotomy, craniotomy or other surgeries.
    • If a greater-than-routine need to exclude cervical spine injury exists, a portable lateral cervical spine (C-spine) x-ray is performed during the resuscitation phase. An adequate lateral C-spine x-ray (e.g., visualizing from the skull base to T1) helps to identify most C-spine fractures and subluxations. Ultimately, a full C-spine series (i.e., AP, lateral and odontoid* views) must be performed to exclude injury, and virtually all trauma healthcare providers will request CT if any doubt exists.  *
    • The cervical spine x-ray can be delayed until after the completion of the primary survey or later if other injuries or unstable physiology take priority but in-line immobilization of the neck, usually with a semi-rigid cervical collar, remains paramount.

                    * 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:

  • Trauma patients with a clear sensorium and no distracting injuries may be clinically cleared providing there is no neck pain on palpation and active flexion/extension/rotation.
  • Trauma patients with a normal CT scan but an abnormal mental status should remain in a rigid cervical immobilization device until they are able to participate in a physical examination or they undergo early (< 72 hours post injury) MRI to detect the presence of ligamentous injury.

SECONDARY SURVEY

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:

  1. Detailed history
  • Critical data should be collected from the trauma patient if possible or from other information sources such as prehospital personnel, family members or other victims.
  • A detailed history should include an assessment of the following items, which can be remembered by using the AMPLE mnemonic:
    • A = Allergies
    • M = Current medications including tetanus immunization status
    • P = Past medical, surgical and social history
    • L = Time of last meal
    • E = Events leading to injury, scene findings, notable interventions and recordings en route to the hospital.
  • This critical data assists with focusing the secondary survey in identifying the mechanism of injury, the likelihood of cold or heat injury and the trauma patient's general physiologic status.
  1. Complete physical examination
  2. Additional radiologic examinations
  3. Special diagnostic studies
  • Many institutions include the Focused Assessment with Sonography in Trauma (FAST) examination as part of the primary survey rather than part of the secondary survey.

The following FGHI mnemonic can be used to guide the secondary survey:

  • Full vital signs and Five interventions
  • Give comfort
  • Head to toe examination for injury
  • Inspect the back and any areas otherwise hidden

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.

  • Speak in a slow, steady tone, giving brief, reassuring updates as to what is happening. With fading consciousness comes increased confusion.
  • Extraneous noises should be kept to a minimum with one specific team member detailed to speak to the trauma patient.

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.

IInspect 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. 

Detailed Physical Examination

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.

Neurologic Examination

  • The elements of the neurologic examination frequently are completed during the regional portions of the secondary survey.
  • A detailed neurologic examination of the trauma patient should include:
    • Recheck of the Glasgow Coma Scale (GCS)
    • Pupillary equality, size, shape, reactivity, reactions to light and accommodation (PERRLA) and extraocular movements (EOM’s)
    • Cranial nerve examination
    • Peripheral motor, sensory function and coordination
    • Reflexes
  • Any neurologic asymmetry should be identified. Trauma patients with lateralizing signs and those with an altered level of consciousness (GCS score of < 14) should undergo cranial CT scanning.
  • Patients with traumatic brain injury (TBI) are particularly susceptible to secondary brain injury, in particular from hypoperfusion, hypoxia, hypercarbia, hyperglycemia, hyperthermia and seizure activity. While primary brain injury and primary brain damage (induced apoptosis after primary brain injury) are beyond the healthcare providers control, secondary injury is a preventable complication with careful attention to detail.
  • A formal assessment of the spine is performed during the secondary survey to complete the neurologic assessment.
    • In patients with blunt trauma and patients with an unknown mechanism of injury (e.g., "found down"), full spinal precautions should be observed until injury to the spinal column is excluded.

Head and Face Examination (including Scalp, Ears, Eyes, Facial bones, Mouth)

  • Inspect and palpate the entire cranium and face for tenderness, lacerations (including entry, exit wounds), swelling (including hematomas), structural deformities (i.e., bones) and discoloration (e.g., bruising). Palpate for facial crepitus and a mobile middle third of the face as a clue to potential difficulty in airway control.
  • Evaluate the head and face for maxillofacial fractures, ocular injury and an open or closed head injury, including a basilar skull fracture. Hemotympanum and the presence of bruising around the eyes (i.e., Raccoon Eyes) (Photo 1) and mastoid process (i.e., Battle Sign) suggest basal skull fracture.

Photo 1: Raccoon Eyes

Photo 1: Raccoon Eyes

Source: Wikipedia.org

Periorbital ecchymosis, or "raccoon eyes," is a classic diagnostic sign of basilar skull fracture

Neck Examination (including C-spine, Soft tissues, Trachea)

  • Maintain strict cervical spine stabilization when removing a rigid cervical immobilization device.
  • Inspect the neck anteriorly for evidence of airway or great vessel injury and palpate posteriorly for crepitus, bony abnormality or tenderness suggestive of cervical spine injury.
  • Penetrating injuries to the neck (e.g., gunshot wounds, knife wounds, etc.) are classified according to their anatomic location.
    • The anterior and posterior triangles share a common border with the sternocleidomastoid muscle. (Figure 1) Injuries to the posterior triangle have a low chance of damaging vital structures while those of the anterior triangle carry a significant morbidity and require workup.

Figure 1: Anterior and Posterior Triangles of the Neck

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

  • Anterior neck injuries are divided into three zones (Figure 2):
    • Zone I extends from the inferior aspect of the cricoid cartilage to the thoracic outlet
    • Zone II extends from the cricoid to the angle of the mandible
    • Zone III extends from the angle of the mandible to the base of the skull
      • Zone II injuries are much more straightforward operatively, whereas Zone I and III injuries may present a formidable challenge.
  • Platysma Muscle (Figure 2)
    • Wounds that do not penetrate the platysma are considered superficial and require nothing more than primary closure. Wounds that do penetrate the platysma require appropriate diagnostic evaluation.

Figure 2: Platysma Muscles

Figure 3: Platysma Muscles

  • Penetrating injuries of the neck may require angiographic, bronchoscopic or radiologic examination depending on the level of injury (i.e., Zone I, II or III). In particular, zone II injuries that penetrate the platysma may be readily explored while those injuries in Zone I or III benefit from additional investigation because of the difficulty in identifying and controlling injuries in those zones.

Chest Examination

  • The chest should be reexamined. The chest wall should be palpated for tenderness, instability or crepitation followed by auscultation of the lungs and heart.
  • In the patient with penetrating trauma, a thorough search for additional entry or exit wounds should be performed including examining the axillae and back.
  • Chest tubes should be assessed for output and air leaks.
  • The portable chest x-ray should be examined to evaluate for bony abnormalities, persistent pneumothorax, evidence of mediastinal injury and placement of tubes and lines.
  • Further investigations should be initiated as indicated by physical examination findings or radiography results.
    • While aortography was previously identified as the criterion standard investigation to identify traumatic aortic transection, CT angiography has essentially replaced intra-arterial contrast injection.
    • Transesophageal echocardiography using an omniplane probe may be safely used but suffers from difficulty with technology access after-hours, dependence on user skill set, problematic probe insertion in trauma patients requiring cervical immobilization and blind spots at the aortic arch.

Abdomen and Pelvis Examination

  • Inspection of the abdomen may be confounded by distracting injuries and impaired consciousness from TBI, intoxicants or prescription medications.
  • The abdomen should be inspected for distension or other evidence suggesting gross intra-abdominal bleeding or injury.
    • Remember that blood is not always a peritoneal irritant, and hemoperitoneum may occur without obvious external signs.
  • Inspect for evidence of bleeding (ecchymosis) on the perineum, gross blood on vaginal and rectal examinations and urethral injury, followed by placement of a Foley catheter if appropriate.
  • In patients with penetrating trauma, low-velocity wounds should be locally explored to determine if the muscular fascia has been penetrated. High-velocity penetrating injuries should be explored in the operating room.
  • The iliac crests should be palpated once for instability to detect significant pelvic fractures.
    • A portable AP pelvic x-ray should be ordered to aid in detecting these fractures. If a fracture is diagnosed, additional manipulation of the pelvis should be avoided to prevent exacerbation of pelvic bleeding which is very difficult to control.27
  • In trauma patients with a suspected spinal cord injury, the anal sphincter motor tone should be recorded.

Extremity Examination

  • Each extremity should be inspected, palpated and manually moved to determine their anatomic and functional integrity.
  • Long bone fractures that require stabilization should be identified since they may cause vascular compromise and cause a major nerve injury.
  • The adequacy of the peripheral circulation and integrity of the nerve supply should be assessed.
    • Pulse inequality should be assessed by means of an ankle-brachial index (ABI) with diagnostic intervention reserved for those with an absolute ABI difference of 0.2 or greater comparing one side to the other. Arterial insufficiency in trauma patients with a displaced fracture or dislocation requires immediate treatment, i.e., fracture reduction and/or joint relocation. Discovery of any evidence of vascular compromise should be acted upon immediately since ischemic injury to an extremity can become irreversible in hours.
  • Plain x-ray films should be ordered to identify deformity, tenderness or instability. Liberal use of these films is essential in excluding extremity fracture in trauma patients with mixed mechanisms of injury and in those who cannot participate in an examination because of significant TBI, intoxicants or other causes.
  • Temporary splint stabilization is imperative prior to moving the trauma patient from the emergency department.

At the completion of the physical examination, the trauma patient should be log rolled with inline stabilization of the head and neck.

  • Log Roll
    • The log roll refers to the slow, controlled turning of the trauma patient from side to side to assess the dependent parts of the body. Care must be taken to avoid secondary injury from an as-yet undiagnosed unstable cervical and/or spinal fracture.
    • This examination concentrates on the back of the head, neck, back and buttocks and includes a rectal examination.
    • Inspect the entire spine from the occiput to the sacrum for bony abnormalities, deformities and tenderness. At the same time, perform a detailed survey of the back to identify penetrating injuries, ecchymoses or other injuries. Back injuries frequently are missed.
    • The log roll also provides a convenient time to remove the long immobilization board which has not been shown to prevent injury in the presence of an unstable vertebral fracture, but it is highly correlated with pressure ulceration in trauma patients who remain on the board for prolonged periods of time (i.e., until diagnostic intervention is complete).
    • The log roll should be carried out by at least four people:
      • The first person stabilizes the head and neck
      • The second and third persons slowly turn the patient
      • The fourth person examines the patient’s dorsum and performs the digital rectal examination
    • At the completion of the physical examination and, if the trauma patient is not on an x-ray film bearing stretcher, the chest x-ray plate is readily positioned behind the patient.

Reevaluation

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.

Advanced Imaging Studies

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.

Focused Assessment with Sonography in Trauma (FAST)

  • FAST complements the portable chest and pelvic x-rays.29
  • A trauma provider who has been formally trained in this technique can quickly and easily perform this portable ultrasound examination in the trauma resuscitation room.
  • The purpose of bedside ultrasound in trauma is to rapidly identify free fluid (usually blood) in the peritoneal, pericardial or pleural spaces.
  • Indications for use include:
    • Penetrating cardiac trauma: pericardial effusion, cardiac tamponade
    • Blunt cardiac trauma: pericardial effusion, cardiac rupture, global ventricular dysfunction
    • Penetrating abdominal trauma: hemoperitoneum
    • Blunt abdominal trauma: intraperitoneal bleeding
    • Chest trauma: hemothorax, pneumothorax
  • Results of FAST
    • Hemodynamically stable trauma patients with a positive FAST scan generally undergo CT scanning to establish the source of presumed hemorrhage.
    • Trauma patients with a positive FAST scan who are hemodynamically unstable generally proceed to operative intervention in the emergency department (cardiac tamponade) or the operating room (intraperitoneal hemorrhage).
  • Precautions
    • FAST scanning is not organ-based imaging, and FAST scanning should not be used to establish the presence or absence of solid organ injury.
    • FAST scanning does not evaluate the retroperitoneum. A normal FAST scan may coexist with substantial retroperitoneal hemorrhage.
    • A positive FAST scan may indicate ascites instead of blood, especially in those with renal or hepatic impairment.
  • Because of its speed, sensitivity and noninvasive character, FAST largely has supplanted other techniques for rapid assessment of unstable trauma patients. This technique requires a major commitment to attain proficiency. Therefore, it is not frequently used outside of major trauma centers.30,31
Computed Tomography (CT) Scans

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

Head CT
  • A CT scan of the head is obtained to identify intracranial bleeding (CT Scan 1) and to guide neurosurgical intervention.36
  •  A head CT scan for trauma is performed first when indicated without IV contrast and prior to the injection of an IV contrast for abdominal and pelvic scans. Many trauma centers scan the cervical spine at the same time the trauma patient is to undergo a CT scan of the head.

CT Scan 1: Head

Non-contrast CT image showing intracranial hemorrhage

The lenticular shape of this lesion identifies it as an epidural hematoma. 

Chest CT
  • A CT scan of the chest is performed to evaluate for mediastinal injuries.37
  • CT scanning is replacing aortography as the state-of-the-art study for imaging mediastinal vascular structures, particularly the aorta.38
  • CT scanning is also more sensitive than AP chest x-rays in the detection of pneumothorax, rib fractures, pulmonary contusion and hydrothorax.
  • For most patients with trauma, CT scans of the head, chest, abdomen and pelvis are sufficient to guide operative and non-operative management of injuries in their respective regions of the body.39 

 

CT of the Abdomen and/or Pelvis
  • A CT scan of the abdomen (CT Scan 2) identifies significant soft tissue injury with high sensitivity and specificity.

CT Scan 2: Abdomen

Grade 4 liver laceration


A traumatic liver laceration due to blunt trauma with rib fragment penetration into the liver parenchyma is shown.

  • CT scans of the abdomen and pelvis usually are performed together, using both IV and oral contrast.40 These scans are performed to identify injuries to abdominal and pelvic organs and to identify bleeding in the retroperitoneum and pelvis.
  • As the quality of CT scans continues to improve, the role of angiography continues to focus to a greater degree on interventions rather than on diagnosis.41
  • A growing volume of data supports the aggressive use of CT scanning in the evaluation of blunt trauma.42,43
    • Predictors of abdominal injury include:
      • Extremes of age or extremity
      • Head or spine injuries
      • Velocity changes of greater than 12 miles/h
Cervical CT and Spine CT
  • CT scanning is replacing plain x-rays in many trauma patients being evaluated for spinal injuries.44,45 Current scanners offer the capability to reconstruct spine images at the same time that scans are obtained of the chest, abdomen and pelvis.46 Many physicians will scan the cervical spine in patients with other indications for scans of the head or the head and torso. Orthopedic and neurosurgical consultants are making increased use of CT when evaluating the spine.
  • The ATLS curriculum states that, with identification of a cervical spine fracture, the likelihood of another break in the spinal column is 10%.
  • Controversy exists whether complete CT imaging is sufficient to rule out cervical spine injury. If the trauma patient cannot cooperate with a physical examination to allow an assessment of ligamentous stability, many trauma centers will perform an MRI to rule out ligamentous injury of the cervical spine, even if high-quality, multislice, multidetector CT images fail to identify this injury.
  • For trauma patients with a neurologic deficit but negative x-ray films and CT scans (formerly called spinal cord injury without radiographic abnormality), an MRI of the spinal column and nerve roots should be performed. An MRI is the most sensitive method for detecting this type of soft tissue injury, although CT scanning has become the standard for acute evaluation of the vast majority of spinal column injuries.24,31,47

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.

Angiography
  • Angiography can be both a diagnostic procedure and a therapeutic procedure, and it is valuable in selected trauma patients.
  • The most common indication for emergent angiography in trauma is to identify and control arterial bleeding from pelvic fractures or in the retroperitoneum.
  • Emergent thoracic aortic angiography should be considered when plain x-ray films or a CT scan of the chest reveals evidence of atypical mediastinal bleeding. CT is considered the diagnostic standard and stent grafting the treatment for blunt aortic injury.53,54,55 In aortic injury, angiography is the historical standard for diagnosis and operative planning.55
  • With suspected bleeding in the retroperitoneum and pelvis, an angiographic embolization often is quicker and safer than surgical approaches in these difficult-to-access areas. This is only true with arterial bleeding, while the more common case of venous bleeding remains a difficult management problem.53
  • Angiography also facilitates non-operative management of injury to the liver, spleen and kidney following blunt trauma yet specific criteria for angiography and embolization have not been agreed upon.56
  • A CT scan of the abdomen with intravenous contrast frequently demonstrates areas of active bleeding which may be targeted by the interventional radiologist in the trauma patient who is sufficiently stable to tolerate the time delay required to obtain angiography and organ-specific embolization of bleeding points.

SPECIAL INJURIES

Burns

  • Dominant priority:
    • To stop the burning process, especially in the case of chemical burns i.e., drain cleaner, bleach, battery fluid, etc. in which the continued contact of the agent with the patient's skin may not be readily apparent.
    • This process may require repeated testing of the patient's skin, specific chemical neutralization and extensive lavage of the affected areas.
  • If full thickness burns of an extremity or the thorax are suspected (Photo 2), escharotomies may be required to prevent compartment syndrome and impaired ventilation, respectively.57

Photo 2: Full Thickness Burn

Trauma: Optimizing Survival Outcomes

  • If the clinical history or the physical examination suggests that upper airway burns or inhalation injury may be present early intubation and mechanical ventilation are indicated.
  • Finally, patients with large burns require large volumes of IV crystalloid resuscitation fluids. While this resuscitation can be delayed briefly when lifesaving interventions are being performed, early commencement is beneficial.

Cold Injuries

  • The dominant priority is:
    • Rewarming, particularly in the case of systemic hypothermia, but it is equally applicable to cold injuries to the extremities (e.g., frostbite).58
    • While mild hypothermia is managed as described under environment in the primary survey, severe cold injuries should be treated with immersion in water warmed to 40°C. IV fluids should be administered only as indicated, based on the patient's physiologic status (not on the wound size).
    • In the case of severe hypothermia with cardiac arrest and/or apnea, resuscitation efforts should continue until the patient is thoroughly rewarmed.59 

High-Voltage Electrical Injuries

  • Although sometimes considered as burn injuries, high-voltage electrical injuries (e.g., lightning strikes, power lines) present a different set of problems.57
  • Much of the tissue injury from electrical injuries may not be apparent on physical examination. Massive myonecrosis and damage to both soft tissue and bone may be concealed beneath normal-appearing skin between the entrance and exit wounds. Thus, a low threshold for measurement of compartment pressures and performance of decompressive fasciotomies should be maintained.
  • The urine output should be carefully and continuously monitored for evidence of myoglobinuria which can lead to acute renal failure if untreated.
  • Continuous cardiac monitoring of the patient should continue because of the risks of direct myocardial injury and hyperkalemia arising from myonecrosis.

TERTIARY SURVEY

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:

  • Cervical spine injury without neurological deficit
  • Dislocated acromioclavicular joint
  • Fractures of small bones in the hands and feet
  • Ligamentous injuries to the knee or ankle
  • Peripheral nerve injuries

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.

PERILS, PITFALLS AND CONTROVERSIES

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.

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/NP. 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 injuries of the chest, abdomen or pelvis 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 the use of 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. 

CONCLUSION

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.

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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), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)

Topics:

CPD: Practice Effectively, Critical Care / Emergency Care, ProCert Approved Courses


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