Trauma (main)

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Background

  • The emergency clinician plays a critical role in coordinating a multi-disciplinary team to stabilize, resuscitate, and manage multiple trauma patients
  • A structured assessment, namely the ABCDE method, can be used to systematically assess the trauma patient to quickly identify and prioritize injuries, simplifying the thought process in a chaotic environment
  • Multiple trauma is defined as any trauma associated with two or more injuries, of which, one injury is classified as life threatening
    • The two most common mechanisms of multiple trauma are blunt and penetrating trauma
  • The ABCDE method is used to assess these trauma patients: airway and cervical stabilization, breathing, circulation, disability, and exposure/environmental control
  • General Approach to Multiple Trauma Patients
    • Pre-hospital and Triage
    • Primary Survey
    • Secondary Survey
    • Laboratory and Radiographic Evaluation
    • Disposition

Initial evaluation objectives

  1. Rapidly identify life-threatening injuries
  2. Initiate supportive therapy
  3. Organize definitive therapy

Locations of Possible Life-Threatening Bleeding

Classes of hemorrhagic shock[1]

Class I II III IV
Approximate blood loss <15% 15-30% 30-40% >40%
Heart rate ↔/↑ ↑↑
Blood pressure ↔/↓
Pulse Pressure (mmHg)
Respiratory Rate (per min) ↔/↑
Urine Output (mL/hr) ↓↓
Glasgow coma scale score
Base deficit^ 0 to -2 mEq/L -2 to -6 mEq/L -6 to -10 mEq/L -10 or less mEq/L
Need for blood products Monitor Possible Yes Massive transfusion protocol

^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.

Lethal Triad of Major Trauma

  1. Hypothermia
  2. Coagulopathy
  3. Acidosis

Primary Survey[2][3][4]

  • The goal of the primary survey is to immediately identify and manage life-threatening injuries
  • There are five components of ABCDE: airway and cervical stabilization, breathing, circulation, disability, exposure and environmental control
  • As critical conditions are encountered, initiate treatment without delay before continuing to the next step of the assessment
    • Often multidisciplinary team involved who can address treatment while primary survey can continue
  • After the primary survey, evaluate whether the patient needs to be transferred to a facility that can provide definitive treatment not available at the initial hospital
    • Specifically if not a level 1 trauma center
  • Continually reassess components of the primary survey

Airway and cervical spine stabilization (A)

  • Clinical Presentation
    • Patients can present with poor respiratory effort, altered mental status, inability to phonate, hypoxia, tachypnea, bradypnea, etc.
    • Look for signs of airway obstruction: blood, hematoma, edema, vomitus, facial or neck trauma, foreign bodies
  • Diagnosis and Evaluation
    • Assess airway patency, phonation, and ability to protect airway
      • If a patient can clearly phonate and protect their airway, move to “B” or Breathing, but continually reevaluate
      • If airway not patent or patient cannot phonate or protect airway, consider intubation
    • If there is any concern for a cervical spine (c-spine) injury base on history or exam, take care to limit c-spine movement and place c-collar
      • If intubation is warranted, have a second provider maintain c-spine immobilization during procedure
    • If time permits, perform a neurologic examination prior to intubation and sedation
      • The need for an emergent airway always takes priority and need not be delayed
  • Treatment
    • Although not a definitive airway, a supraglottic airway may be useful when a patient has significant facial trauma or is difficult to intubate or ventilate
      • These devices are contraindicated in awake patients and those with inability to open the mouth
    • Avoid nasal airway if suspected basilar skull fracture
    • Suction the airway of blood or emesis, and remove foreign bodies and dentures before laryngoscopy
    • Video laryngoscopy with rapid sequence intubation (RSI) is the recommended first line approach to minimize cervical spine motion and provide superior laryngeal views
    • A cricothyrotomy or another surgical airway may be necessary if endotracheal intubation fails or there is significant facial trauma or airway obstruction
    • Use capnography, auscultation and post-intubation CXR to confirm tube placement
Indications for intubation in trauma patient
A GCS equal to or less than 8 in trauma patients (inability to protect airway)
Failure to oxygenate
Failure to ventilate
Expected clinical course
Impending airway compromise (i.e. expanding hematoma)

Breathing (B)

  • Clinical Presentation
    • Awake patients may complain of difficulty breathing
    • The mechanisms of injury, such as penetrating chest trauma or blunt force trauma to the chest, may signal impending respiratory failure
    • Deviated trachea, flail chest, sucking chest wounds, asymmetric breath sounds, chest wall crepitus, etc.
    • If patient is adequately ventilating and oxygenating, then proceed to “C” or circulation
  • Diagnosis and Evaluation
    • Ventilation
      • Assess mental status, chest wall rise, respiratory rate and check end-tidal CO2 or blood gas
      • If poor ventilation identified, consider naloxone and check glucose
      • If persistent altered mental status, consider head CT, send toxicology workup, and have a second provider obtain collateral history for exposure to toxins and identify co-morbidities
      • Intubate if unable to identify or reverse cause of hypoventilation and the patient is retaining significant CO2
    • Oxygenation
      • If there is respiratory distress or hypoxia, consider flail chest, pulmonary contusion, pneumothorax or massive hemothorax
      • If unequal breath sounds, and you identify pneumothorax, hemothorax or hemopneumothorax, perform a tube thoracostomy
    • Use the Extended Focused Assessment with Sonography for Trauma (eFAST) to assess for pneumothorax and hemothorax
      • Presence of B-lines may be a sign of lung contusion
      • Lung sliding for detection of pneumothorax by absence of lung sliding
  • Treatment
    • For suspected pneumothorax/hemothorax, perform needle decompression with 14-gauge needle or tube thoracostomy at the fourth or fifth intercostal space along the mid or anterior axillary line
    • If asymmetric breath sounds or lung sliding only on one side (generally on the right) immediately following intubation, the endotracheal tube may be positioned in either mainstem bronchus
      • Measure depth on chest x-ray and reposition tube above the carina
    • Treat toxidromes appropriately when present

Circulation (C)

  • Clinical Presentation
    • Assess the patient’s level of consciousness, skin perfusion, capillary refill, blood pressure, heart rate, pulse pressure and quality of pulse
    • If the patient has good peripheral pulses, normal mental status, and adequate peripheral perfusion without obvious signs of shock, then proceed to “D” or Disability
    • Signs of shock include tachycardia, hypotension, altered mental status, rapid and thready pulse, and pale skin
    • Do not transport unstable patients to the CT scanner
    • Classes of hemorrhagic shock shown in table below
  • Diagnosis and Evaluation
    • In penetrating trauma, may use eFAST to assess for pneumothorax, free fluid in the abdomen, and cardiac tamponade
    • The FAST exam has a high specificity, but poor sensitivity for identifying clinically important hemorrhage
    • Serial FAST exams should be performed if initial FAST was negative in an unstable patient
    • Look for hemorrhage before considering other causes of shock (e.g., neurogenic)
    • For hemorrhagic shock, locate the hemorrhage using physical exam, x-rays, eFAST, CT imaging
    • For non-hemorrhagic shock, consider tension pneumothorax, cardiac tamponade, cardiogenic shock, neurogenic shock, septic shock, or hypovolemic shock from insensible fluid losses
  • Treatment
    • Identify the culprit source of hemorrhage and if possible, obtain control (may need interventional radiology, embolization, etc).
    • Establish a minimum of 2 large bore IVs 16 gauge or larger
      • Consider central venous or intraosseous access if peripheral IVs cannot be obtained quickly
    • If hemorrhagic or unclear source of shock, infuse blood products as soon as possible
      • No more than 1 liter of balanced crystalloid solution is recommended
        • More fluid may contribute to dilutional coagulopathy
        • Balanced crystalloid over normal saline is recommended to avoid non-anion gap metabolic acidosis and renal insufficiency
        • There is no advantage of giving colloids over crystalloid
      • If further resuscitation required, consider 2:1:1 or 1:1:1 infusion of packed red blood cells to platelets to plasma
    • Massive transfusion protocol (MTP) can be initiated when a patient is suspected to require more than 10 units of pRBC in the first 24 hours of admission OR more than 4 units of pRBC in one hour
      • MTP should follow the 2:1:1 or 1:1:1 ratio discussed above
    • If the patient is male or not of childbearing age, and requires emergent blood transfusion, prior to type and screen, O positive blood should be administered.
    • For women who might be of childbearing age, administer O negative blood to prevent formation of Rho antibodies
    • Consider tranexamic acid (TXA) as a 1g bolus over 10 minutes, ideally administered within 1 hour of injury, although benefit lasts up to 3 hours
      • Then infuse 1g over 8 hours if hemorrhage not controlled
    • Consider permissive hypotension, with a MAP goal of 50mmHg, unless there is concern for traumatic brain or spinal cord injury, in which the MAP goal is 80mmHg
    • Ensure adequate tissue perfusion, identified by mental status, vital signs, physical exam, urine output, lactate, and base excess
    • Avoid hypothermia from infusion of fluids
      • Use fluid warmers for infusions and external warming measures
    • Reverse known coagulopathies
      • For example, if there is a history of warfarin use or liver disease, consider PCC, FFP and vitamin K
      • Give platelets if thrombocytopenic and patient continues to hemorrhage
      • If indicated, consider administration of the reversal agents for thrombin and Xa inhibitors
        • PCC can be used for Xa inhibitors if the reversal agent is unavailable
        • Dialysis should be considered in patients on direct thrombin inhibitors with severe hemorrhage.
    • Consider Resuscitative Endovascular Occlusion of the Aorta (REBOA) if readily available and indicated (ie. pelvic hemorrhage)

Disability (D)

  • Clinical Presentation
    • Establish the patient’s level of consciousness and assess for neurologic deficits
    • The Glasgow Coma Scale (GCS) is a 15-point scale that determines the patient’s level of consciousness
    • GCS of 15 does not exclude the possibility of a traumatic brain injury
    • The GCS motor score best correlates with patient outcomes
  • Diagnosis and Evaluation
    • Altered mental status can occur from traumatic or non-traumatic causes
    • If there is a decrease in GCS, always assume there is a central nervous system injury until proven otherwise
    • Perform pupillary exam and brief motor exam of extremities as part of disability assessment
    • Perform appropriate CTs, generally non-contrast head and c-spine
Traumatic Non-traumatic
Epidural hematoma, subdural hematoma, subarachnoid hemorrhage, cerebral contusion Intoxication
Diffuse axonal injury Hypoglycemia
Poor cerebral perfusion secondary to shock Electrolyte disturbances
Mental health conditions
Previous stroke or intracranial injury
  • Treatment
    • If GCS <8, consider intubation to protect airway
    • Reverse any obvious cause of altered mental status, i.e., D50 for hypoglycemia, fluid/blood product resuscitation for hypoperfusion, oxygen for hypoxia, ventilation for hypercarbia
    • Consult a neurosurgeon when a brain or spinal cord injury is identified
    • If elevated intracranial pressure suspected, elevate the head of the bed, infuse mannitol or hypertonic saline, hyperventilate (pCO2 goal 35 mmHg)

Exposure and Environmental Control (E)

  • Clinical Presentation
    • Completely disrobe patient to assess all anatomical areas for injury
    • Hypothermia can be present on arrival or quickly develop in the emergency department and is a preventable, potentially lethal complication
  • Diagnosis and Evaluation
    • Look for signs of penetrating trauma, burns, ecchymosis (Grey-Turner, Cullen’s sign), foreign bodies (do not remove until sure it is not penetrating a vessel), open fractures, etc.
    • Logroll patients with c-spine stabilization and check back, axilla, groin and buttocks as these areas are often overlooked
    • All patients should be removed from long backboards to prevent decubitus ulcers and aspiration pneumonia
    • Continually monitor patient’s temperature
  • Treatment
    • Place blankets or external warming devices over patients to prevent hypothermia
    • Use warmed crystalloid fluids and blood products if warming transfuser available
      • Can microwave crystalloid fluids but not blood products
    • Decontaminate patient if exposed to toxic chemicals

Secondary Survey[5][6][7]

  • After the primary survey, the clinician can obtain pertinent medical history and perform a more detailed and complete physical exam to find injuries not observed on the primary survey
  • Providers can refer to the AMPLE pneumonic for a pertinent history
  • Continually reassess the components of the primary survey
AMPLE in the Secondary Survey
Allergies
Medications
Past Medical History and Pregnancy
Last meal
Events and environment surrounding the trauma

Differential Diagnosis

Head trauma

Neck Trauma

Torso Trauma

Extremity trauma

Pediatric trauma

Evaluation

Laboratory Evaluation

  • Clinical assessment and presentation should guide which diagnostic tests to order
  • Lab testing can provide a baseline assessment of metabolic derangements to guide resuscitation (e.g., base deficit and lactate)
Laboratory Test Clinical Importance
Complete blood count Hemoglobin and hematocrit (but note that value may be falsely reassuring, due to time necessary to equilibrate); thrombocytopenia
Electrolyte panel Potassium in CKD, often elevated in crush injuries; sodium in head injury or altered mental status
Liver function tests and lipase Determine blunt injury to these organs, underlying liver disease, or shock liver in setting of hypoperfusion
PT/INR and PTT Determine developing or underlying coagulopathies; provide clues to anti-coagulation use and need for reversal such as INR and coumadin
Pregnancy test in women May change medication management; may need to consult OBGYN
Blood type and screen or type and cross depending on injury severity Prevent transfusion reactions; prevent Rho antibody formation in women of childbearing age
Urine studies Gross hematuria or microscopic hematuria > 20-50 RBC in urine suggests urinary tract injury; toxicology screen may indentify cause of AMS
Lactate, arterial blood gas, base excess, anion gap Assess tissue perfusion and help guide fluid resuscitation; assess pH
Troponin Myocardial damage if concern for cardiac contusion

Radiographic Evaluation

  • Radiographic evaluation of the multiple trauma patient is crucial in identifying acute injuries that may not be elucidated on physical exam
  • Chest X-rays and pelvic X-rays are standard exams for multiple trauma patients
  • eFAST should be performed as part of the primary survey
    • eFAST is not appropriate (sensitivity is low) to assess for retroperitoneal fluid
  • Ultrasound can help to examine the inferior vena cava during the secondary survey to assess volume status
  • Although operator dependent, ultrasound is superior to chest X-ray to screen for hemothorax, pneumothorax and tamponade
  • Perform CT scans based on clinical judgment after completion of the primary and secondary survey
  • If c-spine injury is suspected, apply decision rules such as National Emergency X-Radiography Utilization Study (NEXUS) criteria or Canadian cervical spine rule (CCR) to help determine if a CT C-spine is indicated

Management

  • Decide whether to observe in the emergency department, admit to inpatient, transfer to a tertiary care facility with resources that the current facility does not have, or redline to the OR
  • Continually reassess all multiple trauma patients as their disposition is fluid and their clinical status can change rapidly
  • Massive transfusion protocol

Complications

Disposition

  • Depends on underlying injury

See Also

External Links

References

  1. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
  2. Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300
  3. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
  4. Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.
  5. Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300
  6. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
  7. Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.