Management of trauma patients

In the United States, the leading cause of death in young adults is trauma. Traumatic injuries may range from small lesions to life-threatening multi-organ injury. In order to achieve the best possible outcomes while decreasing the risk of undetected injuries, the management of trauma patients requires a highly systematic approach. Prehospital trauma care involves first aid and basic life support administered by emergency services personnel. In the hospital setting, the treatment of trauma patients is traditionally divided into primary (Advanced Trauma Life Support), secondary, and tertiary surveys. Each survey consists of an algorithm designed to diagnose and manage injuries sequentially in order of decreasing morbidity and mortality. Further steps are taken to provide analgesia and determine whether patients should be transferred to specialized trauma centers as quickly as possible.

• Prehospital care by emergency services personnel
• Transport to hospital
• Primary survey (ATLS)
• Transfer to specialized trauma center (if required)
• Secondary survey
• Tertiary survey

• Notification of an accident: 911
  • Where?
  • What (has happened)?
  • Who (number of injured people)?
  • Which (injuries or symptoms)?
  • Wait (for further questions)!
  • If necessary: When (did the accident happen)? Who is reporting the accident? Further danger?
• Life-saving emergency care by lay rescuers (see “Basic life support” in “Cardiopulmonary resuscitation”)
• Recovery position: positioning of an unconscious but breathing patient
• Rautek maneuver: Arm-to-arm drag to remove the patient from dangerous situations
  • The helper approaches the patient from behind and places his or her hands under the patient's armpits.
  • The helper grasps one of the patient's forearms (placed across the patient's chest) and pulls the patient backward to remove them from danger.

• Prehospital care of trauma patients is situation-dependent and centered on stabilization of the patient and prompt transport to a hospital.
• Nonmedical personnel trained in basic life support may provide life-saving interventions (see “Basic life support” in the article cardiopulmonary resuscitation).
• Emergency services personnel typically perform an abbreviated version of the primary survey (see ABCDE approach below)
• Low-threshold interventions that may be performed by emergency personnel prior to transport to a hospital include, but are not limited to:
  • Placement of a cervical collar (if cervical spine trauma is suspected based on primary survey or mechanism of injury)
  • Intubation or oxygen delivery via nasal cannula; (if respiratory distress or altered mental status is suspected)
  • Administration of intravenous fluid; (if hemorrhage or hypotension is suspected)
  • Administration of analgesia
  • Placement of tourniquets or pressure bandages for control of bleeding

The management of trauma patients begins with the primary survey (also commonly referred to as Advanced Trauma Life Support, or ATLS). The primary survey consists of 5 steps (ABCDE approach) that are performed in order.

1. Airway assessment (and cervical spine stabilization)
   • If appropriately answering questions, patient has a patent airway (at least for the moment)
   • Observe patient for signs of respiratory distress
   • Inspect mouth and larynx for injury or obstruction (e.g., blood, vomit, burns, soot)
   • Assume cervical spine injury in blunt trauma patients until proven otherwise
   • If patient is unconscious (and therefore unable to protect their airway) or in respiratory distress, the threshold for intubation is very low.
     • Patients may be intubated or ventilated with the anterior portion of the cervical collar removed, or with their neck manually stabilized.
   • Patients with burn injuries; and evidence of respiratory involvement (e.g., soot in the oropharynx) are often intubated out of precaution. ^[1]
   • If orotracheal intubation is difficult, perform a cricothyrotomy.
2. Breathing
   • Assess oxygenation status with pulse oximetry.
   • Inspect and auscultate chest wall for injuries (e.g., absent breath sounds, asymmetric or paradoxical movement)
   • In unstable patients, do not delay treatment of tension pneumothorax or hemothorax in favor of imaging.
3. Circulation (and hemorrhage control)
   • Assess circulatory status by palpation of central (e.g., carotid, femoral) and peripheral (e.g., radial, popliteal, posterior tibial, dorsalis pedis) pulses
     • Blood pressure should be measured if it can be done expediently, but it can be skipped if it would delay the rest of the primary survey.
   • Place two large-bore intravenous lines (at least 16 gauge) for blood typing and crossmatch, and resuscitation (if needed).
     • If intravenous line placement is not possible or difficult, intraosseus line should be used instead.
   • Control on-going hemorrhage with manual pressure or tourniquets.
   • Emergency thoracotomy; may be performed in patients with recent loss of pulses (especially in patients with stab wounds to the chest).
   • If patient is hypotensive, administer a bolus of intravenous saline.
     • If history of hemorrhage or on-going hemorrhage, transfuse type O blood.
     • If significant hemorrhage and persistent hemodynamic instability, transfuse plasma, platelets and red blood cells at 1:1:1 ratio.
   • Focused Assessment with Sonography for Trauma (FAST); exam is usually performed, especially for hemodynamically unstable patients
     • May be performed during the secondary survey in hemodynamically stable patients
   • Some patients may require emergent reversal of anticoagulation
   • Remember hypovolemic shock due to hemorrhage requires loss of ∼ 1.5 L of blood. Keep in mind the compartments where large amounts of blood may go:
     • Outside (external hemorrhage)
     • Thoracic cavity
     • Pelvic cavity
     • Abdominal cavity
     • Thighs (e.g., multiple femur fractures)
     • See Shock LC
4. Disability (and neurological evaluation)
   • Assess patient's Glasgow Coma Scale score
     • See Glasgow Coma Scale (GCS)
     • A GCS score ≤ 8 is an indication for intubation
   • Assess pupillary size
   • If patient is interactive, assess motor function and light touch sensation.
5. Exposure (and environmental control)
   • Undress patient completely.
   • Examine body for signs of occult injury, including patient's back.
   • If patient is hypothermic, cover with warm blankets and warm intravenous fluids.
   • Palpate for vertebral tenderness and rectal tone.

If the GCS is ≤ 8, you quickly have to intubate.

The specific choice of imaging modality depends on clinical judgment and mechanism of injury; . The decision to perform any diagnostic test must be based on the patient's hemodynamic stability and must be weighed against the need for urgent transfer or operative intervention.

1. Portable x-rays
   • Typically acquired after the primary survey
   • Screening x-rays of the cervical spine, chest, and pelvis are usually performed but may be skipped if a CT-scan will be performed.
     • An exception is patients with penetrating injuries to the thorax or abdomen; , in which a chest x-ray should always be acquired even if a CT-scan will be performed.
   • Good for detection of fractures, subdiaphragmatic free air, foreign bodies, pneumothorax, hemothorax
2. Focused Assessment with Sonography for Trauma (FAST) exam ^[2]
   • A rapid, standardized, bedside ultrasonographic test in trauma patients used to screen for free fluid (especially blood)
   • Typically acquired during the primary survey (especially for hemodynamically unstable patients)
   • An extended version (E-FAST); may alternatively be performed, which allows for detection of pneumothorax and hemothorax.
   • The following regions are examined:
     • Perihepatic and hepatorenal space: view of the right upper quadrant
     • Perisplenic and splenorenal space: left upper quadrant
     • Pelvis: sagittal and horizontal views of the suprapubic region
     • Pericardium: subxiphoid view with the probe pointed cranially
     • E-FAST: additional imaging of the right and left anterior hemithorax at ICS 2/3 in the midclavicular line
3. CT scans
   • Typically performed after the primary survey if the patient is hemodynamically stable (otherwise the patient may decompensate inside the scanner, which could be catastrophic)
   • Ideal imaging modality given speed and high sensitivity for injury
   • In high-energy trauma (e.g., motor vehicle collisions) or severe injuries with altered mental status, a “pan scan” of the entire body is commonly performed.
4. Diagnostic peritoneal lavage (DPL): a diagnostic test used to assess for bleeding or viscus perforation in abdominal trauma. Highly sensitive, but invasive. Performed by placing a catheter into the abdomen, aspirating, then instilling a liter of warm saline. If fecal matter or significant blood are detected, this constitutes a positive test and emergent laparotomy is indicated.
   • Typically performed after the primary survey if hemoperitoneum is suspected and FAST exam is unavailable or equivocal
   • Rarely performed given the greater sensitivity of the FAST exam
5. Laboratory tests include, but are not limited to
   1. CBC
   2. Basic chemistries
   3. Prothrombin time (given the high prevalence of patients anticoagulated on warfarin)
   4. Urinalysis
      1. Gross hematuria; should always be investigated as it may indicate urethral, bladder, or kidney injury.
      2. Microscopic hematuria after trauma is normal in adults, but should be investigated in pediatric populations.
   5. Urine pregnancy test (on all women of child-bearing age)
   6. Blood glucose
   7. Lactate (associated with hypovolemic shock)

References:^[3]

• Secondary survey
  • Performed after the primary survey has been completed and the patient is deemed stable
  • Complete history and thorough physical examination
  • Additional diagnostic tests are tailored to remaining symptoms, mechanism of injury, and patient comorbidities.
  • Main goal is to minimize the risk of missed injuries.
• Tertiary survey
  • Delayed re-examination of the patient (usually ∼ 24 hours after admission)
  • Main goal is to detect changes due to previously undetected injuries.

Certain clinical manifestations warrant immediate intervention or specific tests. Some common scenarios are:

• Penetrating wounds to the abdomen with hypovolemic shock (hypotension, pale, cold, barely detectable pulses)
  • Perform exploratory laparotomy for control of hemorrhage, then fluid resuscitation.
  • Any penetrating wound below the nipple requires an exploratory laparotomy.
  • Do not delay transfer of patient to the operating room (or to a trauma center) in favor of fluid resuscitation.
  • See Approach to penetrating abdominal trauma.
• Gunshot wounds and signs of cardiac tamponade (hypotension, barely detectable pulses, distended neck veins)
  • Perform pericardial window, thoracotomy, and then exploratory laparotomy.
  • See Pericardial effusion and cardiac tamponade and Penetrating trauma.
• Gunshot wounds to the chest and abdomen with signs of tension pneumothorax (hypotension, distended neck veins, tracheal deviation, absent breath sounds over hemithorax)
  • Place chest tube; (or perform needle thoracostomy if chest tube is not available).
  • See Approach to penetrating chest trauma.
• Allergic reaction (hypotension, tachycardia, respiratory distress, warm and swollen)
  • Administer epinephrine.
  • See Anaphylactic shock.
• High-energy trauma of the lower extremities (e.g., calcaneus fracture following a fall from a height)
  • Perform thoracolumbar spine x-rays to look for additional injuries
• High-energy trauma with widened mediastinum on x-ray
  • Perform CT Angiography for diagnosis of aortic injury and then perform surgical repair.
  • See Approach to blunt chest trauma.
• Blunt trauma with subcutaneous emphysema
  • Perform bronchoscopy for diagnosis of injury to the trachea and then perform surgical repair.
  • See Approach to blunt chest trauma .
• Blunt trauma with concern for cervical spine injury
  • Obtain cervical spine CT scan in patients with distracting injury (e.g., femoral fracture), altered mental status/intoxication, focal neurologic deficit, midline neck tenderness, or neck pain
• Signs of peritonitis (abdominal tenderness, rebound, guarding, rigid abdomen)
  • Perform exploratory laparotomy as it indicates perforated viscus.
  • See Approach to penetrating abdominal trauma.
  • See Approach to blunt abdominal trauma.
• Blood in the urinary meatus
  • Perform retrograde urethrogram (may be a bladder injury, but need to rule out urethral injury first).
  • See Traumatic injuries of the kidney and bladder.
• No blood in the urinary meatus, but hematuria through Foley catheter
  • Perform retrograde cystogram for diagnosis of bladder injury.
  • See Traumatic injuries of the kidney and bladder.
• Hematuria through Foley catheter, but normal retrograde cystogram
  • Perform CT scan for diagnosis of kidney injury.
  • See Traumatic injuries of the kidney and bladder.
• Large hematoma over the shaft of the penis
  • Perform emergent surgical repair of penile fracture.
• Human bite
  • Surgical exploration and debridement
  • See Bite wounds.
• Trauma during pregnancy
  • Examine mother in left lateral position to minimize inferior vena cava compression
  • Perform cesarean delivery if fetus > 24 weeks of gestation shows worsening signs of distress, or if mother is not responding to cardiopulmonary resuscitation.

References:^[4][5][6][7]

• Definition: two or more severe traumatic injuries to at least two areas of the body, of which at least one or the sum of all injuries is life-threatening ^[9]
• Etiology
  • Motor vehicle collisions
  • Blast injuries
  • Attempted suicide (e.g., fall from heights)
  • Physical violence (e.g., intimate partner violence, assault)
• Approach
  1. Primary survey: ABCDE approach (for further information see “Primary survey” above)
  2. In hemodynamic instability: immediate surgery
  3. Diagnostic tests (for further information, see “Urgent diagnostics for trauma patients” above)
  4. Prioritization during polytrauma management
     1. Massive hemorrhage
     2. Cerebral injury (e.g., subdural hematoma or epidural hematoma)
     3. Abdominal and/or thoracic injury (e.g., splenic rupture, pneumothorax)
     4. Pelvic ring injury
     5. Other head injuries (e.g., skull fractures)
     6. Eye and facial injuries (e.g., zygomaticomaxillary complex fractures)
     7. Spinal injuries (e.g., vertebral fractures)
     8. Other visceral injuries (e.g., renal artery rupture)
     9. Musculoskeletal injuries (e.g., open fractures of a limb)
  5. Secondary and tertiary survey (for further information, see “Secondary and tertiary surveys” above)
• Complications
  • Hemorrhagic shock
  • Neurogenic shock
  • Hypoxic shock