Trauma Resuscitation

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8 Trauma Resuscitation

Epidemiology

Traumatic injury is a significant cause of death and disability worldwide, especially in the younger population. In the United States, unintentional injury is the leading cause of death in the age range between 1 and 44 years.1 Approximately half of trauma-related deaths occur at the time of injury or before the patient reaches the hospital. Another 30% of traumatic deaths may occur in the first few hours after the event. It is this severely injured, but salvageable population that should be immediately evaluated and treated with the trauma resuscitation paradigm.

Presenting Signs and Symptoms

The American College of Surgeons and many emergency medical service systems have adopted algorithms based on clinical signs and symptoms for transport to a trauma center.2 These signs and symptoms identify patients at high risk for injury and are based on early physiologic changes, anatomic criteria, or a mechanism with a high likelihood of significant injury (Box 8.2). Along with the trauma center criteria, in each of the major anatomic areas there are important clues to potentially life- and limb-threatening injures (Table 8.1).

Table 8.1 Signs of Significant Injuries in Trauma Patients

ANATOMIC AREA MOST THREATENING SIGNS
Head Cerebrospinal fluid leak
Raccoon eyes
Battle sign
Hemotympanum
Anisocoria
Neck Expanding hematoma
Thrill or murmur
Subcutaneous air
Trachea deviated from midline
Pulsatile hemorrhage
Spine Paralysis
Paresthesias
Decreased rectal tone
Chest Subcutaneous air
Multiple rib fractures
Sucking chest wound
Asymmetric chest rise
Abdomen Abdominal wall bruising
Distended abdomen
Pelvis Unstable pelvis
Large expanding hematoma
Blood at urethral meatus
Scrotal hematoma
Bone fragments in vaginal vault or rectum
High-riding prostate
Extremities Pallor
Decrease in or absence of pulses
Weakness or paralysis

Head injuries may result in a decreased level of consciousness leading to loss of airway protection or respiratory drive. Head injuries can also precipitate hemorrhagic shock as a result of the abundant vascular supply of the face and scalp. Because of their proportionally larger heads, children can lose a significant amount of blood with closed intracranial hemorrhage. For further specific evaluation and treatment of head injuries, see Chapter 73.

Injury to the face, including an unstable midface, or trauma to the oropharynx may cause direct airway compromise. Facial injuries can also lead to aspiration of blood, tissue, teeth, and bone. Early or prophylactic intubation should be considered if impending airway compromise is suspected or imminent.

High spinal injuries may lead to loss of airway control, loss of the respiratory drive, or hemodynamic instability as a result of spinal shock. Paralysis may also make evaluation of other injuries extremely difficult.

Thoracic injuries can result in direct tracheal, pulmonary, or cardiac damage and lead to significant intrathoracic hemorrhage or direct respiratory compromise.

Because the abdominal cavity can hold a large amount of blood, solid organ or vascular injury in the abdomen can easily result in hemodynamic collapse. Pelvic fractures are also a potential site of significant blood loss from uncontrolled venous bleeding.

Even isolated extremity injuries can result in arterial hemorrhage or considerable blood loss in the form of fracture-related hematomas. Fractures may cause delayed respiratory distress because of fat emboli.

A history of a significant injury mechanism, even without apparent injury, requires a thorough trauma evaluation. Examples include penetrating trauma to the head, neck, chest, abdomen, and proximal part of the extremities; significant falls; rollover or high-speed motor vehicle collisions; and cyclists or pedestrians struck by a motor vehicle.

Some patient populations are more likely to have life-threatening injuries without obvious signs and symptoms. This group includes the elderly, the very young, patients with coagulopathies, and those with reduced physiologic reserve because of chronic disease or acute intoxication.

Differential Diagnosis and Medical Decision Making

Because trauma resuscitation is a “one size fits all comers” approach to the undifferentiated patient, there is no classic differential diagnosis. It is important to remember that a patient who arrives in traumatic shock may have a concurrent acute medical condition, such as acute myocardial infarction, hypoglycemia, or intoxication, that may confound the trauma evaluation.

Primary Survey

Medical decision making for a trauma patient involves use of the ABCDEF trauma resuscitation algorithm, with consideration for the patient’s age, physiologic reserve, and underlying chronic conditions. (See the Red Flags box.)

Although performance of the primary survey should be fluid and may involve multiple individuals performing multiple actions simultaneously, the components of the primary survey can be broken down into six sequential steps: airway, breathing, circulation, disability, exposure, and fingers or Foley (ABCDEF) (see Fig. 8-1 and Priority Actions box).

If an indication for intervention is discovered during the primary survey, treatment should be initiated and the primary survey restarted from the beginning (Fig. 8.2).

The primary survey starts as the patient enters the room by questioning the patient, evaluating for airway patency, and then directly visualizing the facial structures, neck, and oropharynx (A).

Breathing or ventilatory status can then be evaluated through visual examination of the neck and thorax, auscultation of all lung fields, and palpation of the chest. Palpation can provide clues to rib injury, open or sucking chest wounds, and subcutaneous air in the neck and chest. The respiratory rate, patient report of chest pain or shortness of breath, and pulse oximetry also contribute to this phase of the resuscitation (B).

Evaluation of circulatory status (C) involves a judgment of the patient’s general appearance, heart rate and blood pressure, extremity pulses, and nail bed capillary refill. If the patient has not been connected to a continuous heart rate and blood pressure monitor, this step should be taken at this time.

The next step is a brief neurologic examination (for disability—D). At this point, assessment for disability does not include a detailed neurologic examination but instead a look at the gross motor movement of all extremities and the patient’s level of alertness. The most common tool for evaluating global neurologic function is the Glasgow Coma Scale (GCS) (Table 8.2).3 Three systems are evaluated: eye opening, verbal response, and motor response. The closer that each function is to baseline, the higher the score for each system. A GCS score of 13 or higher correlates with mild brain injury, 9 to 12 with moderate injury, and 8 or less with severe brain injury. A GCS score lower than 8 is an indication for immediate airway control. Thus, the GCS can help in evaluating the need for intubation, provide a marker for serial neurologic examinations, and promote clear communication with consultants regarding patient status.

Table 8.2 Glasgow Coma Scale Scoring*

RESPONSE SCORE
Eye Opening
No eye opening 1
Eye opening to pain 2
Eye opening to verbal command 3
Eyes open spontaneously 4
Verbal  
No verbal response 1
Incomprehensible sounds 2
Inappropriate words 3
Patient confused 4
Patient oriented 5
Motor
No motor response 1
Extension to pain 2
Flexion to pain 3
Withdrawal from pain 4
Patient localizes pain 5
Patient obeys commands 6

* The best of each response is used for the individual score; scores are added for the total Glasgow Coma Scale score.

Completion of the primary survey involves exposure of the entire patient (E) in a way that prevents hypothermia; coordinated in-line cervical spine immobilization should be maintained during this procedure.

The F (fingers and Foley) step of the primary survey involves consideration of placement of a Foley bladder catheter and orogastric tube, a rectal examination, and a bimanual vaginal examination. Even though there has been a trend away from the dogmatic approach to use of a rectal and Foley catheter for everyone who enters the trauma algorithms, these measures are still indicated in certain patients, especially those who are obtunded, have a high likelihood of bowel injury, or are hemodynamically unstable.

Secondary Survey

The secondary survey consists of an expanded history, a head-to-toe examination, focused sonography, and initiation of the standard trauma radiology and laboratory tests. If possible, the history should be taken from the patient or the prehospital personnel (e.g., emergency medical technicians) who delivered the patient to the hospital. The key points of the history can be remembered with use of the mnemonic AMPLE, which stands for allergies, medications, past medical history, last meal, and events of the injury.

The head-to-toe examination involves a second review of the airway and pulmonary examination, including an expanded physical examination to identify further injury.

In a hypotensive patient, because the abdominal cavity can conceal enough blood to be an immediate threat to life, part of the secondary survey is the focused abdominal sonography examination for trauma (FAST). FAST can be done in the resuscitation area. Because it is faster and less invasive to obtain, FAST has replaced diagnostic peritoneal lavage (Table 8.3).4,5 Likewise, the more sensitive and specific computed tomography (CT) of the abdomen should wait until the end of the secondary survey because CT scanning may be time-consuming and takes the patient out of the resuscitation area.6

Table 8.3 Diagnostic Modalities Used for Abdominal Trauma

MODALITY ADVANTAGES DISADVANTAGES
Radiographs Inexpensive
Easy to obtain and read
Good for identification of foreign objects and projectiles
May be useful as screening for free air before DPL
Very low sensitivity and specificity for injury in patients with blunt abdominal trauma
Computed tomography (CT) High sensitivity
High specificity
Patient has to leave resuscitation area
Ultrasonography (US) Easy and quick Operator dependent
Variable sensitivity and specificity for organ injury
Diagnostic peritoneal lavage (DPL) High sensitivity
High specificity
Operator dependent
Time-consuming
More invasive than CT or US
Significant complications (perforated bowel, bleeding, infection)

The advantage of a standardized approach to trauma radiology is that it can identify life-threatening injuries that may necessitate immediate attention. Significant cervical spine fractures may lead to airway compromise, loss of ventilatory drive, or spinal shock. The chest radiograph may identify a treatable condition, such as a large pneumothorax, hemo-thorax, or pulmonary contusion. Pelvic radiology can identify an open-book pelvic fracture, which may lead to hemorr-hagic shock.

For many years, standard trauma series radiographs included plain films of the cervical spine, the chest, and the pelvis. Currently, the only standard plain film is the chest radiograph. The cervical spine radiograph has been replaced by CT of the cervical spine, but a rare exception is the use of screening films for penetrating trauma (Fig. 8.3). In the majority of trauma patients, the pelvic radiograph has been replaced by CT of the abdomen and pelvis with reconstructed images of the bony pelvis. In some patients, such as those who may need immediate pelvic binding to temporize hemorrhage or penetrating injury to the pelvis, a one-view pelvic radiograph in the trauma suite is still useful. Thus, the new standard trauma radiology series involves a chest radiograph and CT scans of the head, cervical spine, and abdomen and pelvis.7 Chest CT is indicated for a widened mediastinum or if vascular injury is suspected. Early consideration of the need for CT angiography of the neck or extremities should be undertaken to minimize the load of contrast media.

Blood specimens for laboratory studies may be drawn during the initiation of intravenous (IV) access in the primary survey or can be obtained during the secondary survey. Laboratory tests should include a complete blood count, serum chemical analysis, coagulation studies (prothrombin time, partial thromboplastin time), and urinalysis. Two immediately available studies are the urine pregnancy test and fingerstick serum glucose measurement, and the results of either test can significantly change the course of the resuscitation. In the setting of altered mental status, a blood alcohol measurement and toxicology screen may also be useful. The serum lactate level can be monitored as a marker of tissue perfusion.8,9

After the primary and secondary surveys are completed and the patient is sufficiently resuscitated, the evaluation and treatment plan takes on a much more individualized course.10

Special Circumstances

Depending on the specific patient’s findings,11 injuries, underlying diseases, and age, each injury may necessitate further radiologic studies (Table 8.4), observation, or surgical intervention.

Table 8.4 Additional Studies in Trauma Patients Dictated by Special Circumstances

TRAUMA PRESENTATION ADDITIONAL STUDIES
Altered mental status, head trauma Head computed tomography (CT)
Brain magnetic resonance imaging (MRI)
CT angiography of cerebral vascular system
See also Chapter 73 for detailed evaluation of head trauma
Chest wall trauma Repeated chest radiography
Full upright posteroanterior and lateral chest radiographs
CT of the chest
Angiography
MRI of the chest
See also Chapter 78 for detailed evaluation of chest and thoracic trauma
Abdominal trauma CT of the abdomen
Focused abdominal sonographic examination for trauma (FAST)
Diagnostic peritoneal lavage
See also Chapters 79 and 80 for detailed evaluation of abdominal trauma
Pelvis Retrograde urethrography
Cystography
CT of the abdomen and pelvis
Extremity Angiography
Neck, back, spine CT or MRI of the cervical, thoracic, or lumbar spine
Obstetric Ultrasonography
Fetal heart monitoring

Treatment: Hospital

The key to maximizing the success of trauma resuscitation is early diagnosis and treatment of injuries. The extent of damage from many significant injuries can be reduced with early intervention, including cervical spine immobilization throughout the resuscitation.

For a severely injured patient, the primary airway intervention is orotracheal intubation by rapid-sequence induction. Indications for airway intervention include airway protection, expected clinical course, and the need for assisted ventilation or oxygenation (Box 8.3).

Alternative methods of orotracheal intubation include nasotracheal intubation, cricothyrotomy, laryngeal mask airway, retrograde intubation, and transtracheal jet insufflation. At a minimum, 100% oxygen should be administered via a nonrebreather mask to maximize tissue oxygenation.

After the airway is controlled, respiratory status is evaluated. Several alterations in ventilation mandate immediate intervention (Table 8.5).

Table 8.5 Indications for Respiratory Intervention in Patients with Trauma

INDICATION INTERVENTION
Tension pneumothorax Needle decompression
Pneumothorax and hemothorax Tube thoracostomy
Sucking chest wound Tube thoracostomy, petroleum jelly (Vaseline) compression dressing
Pulmonary contusion with hypoxia Intubation

After the airway and breathing are evaluated and stabilized, hemodynamic status should be evaluated. During trauma resuscitation, it is imperative that IV access be established immediately to facilitate rapid transfusion or administration of blood products (18-gauge or larger IV line). Ideal guidelines recommend a minimum of two working IV sites. Alternatives to large-bore peripheral IV access are intraosseous lines, central lines, and venous cutdown lines. In a hypotensive adult patient with trauma, an initial bolus of 2 L of warm normal saline or lactated Ringer solution is a reasonable starting point. In children, a 20-mL/kg bolus should be used. If the traumatized patient remains hypotensive after the initial bolus, transfusion of type O-negative or type-specific blood should be considered. A caveat to this statement is a patient who has sustained penetrating trauma to the chest or abdomen, in whom a short period of permissive hypotension (on the way to the operating room) may improve survivability by not disrupting an internal tamponade.5 Recent military and trauma center practice has championed aggressive blood and fresh frozen plasma resuscitation in a 1 : 1 ratio in patients in hemorrhagic shock. When possible, manual pressure or military tourniquets should be used in conjunction with fluid or blood resuscitation to temporize hemorrhage.

Once the primary survey is completed and the patient is stabilized, the secondary survey is used to unveil the remaining injuries. Patients may then require specific care of individual injuries or specialty consultation as needed.

Follow-Up, Next Steps in Care, and Patient Education

All patients requiring trauma evaluation and treatment because of anatomic or physiologic trauma center criteria (see Box 8.2) must be admitted to the hospital. Patients who meet the mechanism criteria only and in whom thorough evaluation identifies no injuries may be candidates for discharge with careful warnings and comprehensive discharge planning.

References

1 . WISQARS Leading Causes of Death Reports, 1999-2003. Available at http://webapp.cdc.gov/sasweb/ncipc/leadcaus10.html/

2 American College of Surgeons. Advanced Trauma Life Support Program for Doctors, 8th ed. Chicago: American College of Surgeons; 2008.

3 Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–94.

4 Blaivas M, Lyon M, Brannam L, et al. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. 2004;22:601–604.

5 Branney S, Moore EE, Cantrill SV, et al. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma. 1997;42:1086–1090.

6 Grieshop N, Jacobson LE, Gomez GA, et al. Selective use of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma. 1995;38:727–731.

7 Salim A, Sangthong B, Martin M, et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg. 2006;141:468–473.

8 Asimos AW, Gibbs MA, Marx JA, et al. Value of point of care blood testing in emergent trauma management. J Trauma. 2000;24:1101–1108.

9 Lavery RF, Livingston DH, Tortella BJ, et al. The utility of venous lactate to triage injured patients in the trauma center. J Am Coll Surg. 2000;190:656–664.

10 Giannoudis PV. Surgical priorities in damage control in polytrauma. J Bone Joint Surg Br. 2003;85:478–483.

11 Shah AJ, Kilcline BA. Trauma in pregnancy. Emerg Med Clin North Am. 2003;21:615–629.