Trauma Resuscitation

Published on 10/02/2015 by admin

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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.