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transferredtoalevelItraumacenter(31).Althoughspeedisimportant,themost
important factor is transporting a patient safely to the emergency department
with all systems stabilized in order to enhance the potential for maximum
neurologicrecovery.
REFERENCES
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11
ManagementofTraumaPatientsWith
ComplexInjuries
AdamD.Fox
INTRODUCTION
The initial evaluation and treatment of the trauma patient is of paramount
importanceas it sets the basefromwhich injuries are identifiedandtreatment
prioritiesaremade.Anorganizedapproachto anytrauma patientis thekey to
performing these evaluations. In the ideal situation, a team will have been
createdwith an understanding of roles andresponsibilities.Once the team has
been activated, a choreographed “dance” willallowthe smooth assessment of
each patient, usually based on the underlying principles of Advanced Trauma
Life Support (ATLS) (1). Treatment priorities will be made and adjuncts to
physicalexaminationwillbeutilized.Athoroughunderstandingofthepotential
injuriesandneedsofthetraumapatientwilldictatesubsequentsteps.
TRIAGE
Triage, from the French “To Sort,” is the act of identifying and prioritizing
patientsaccordingtoseverityofillness.Onaday-to-daybasis,triageiscarried
outinmultiplelocationsandusuallywithonlyoneorafewpatients.Whenone
encounterslimitednumbersofpatients,thegreatestnumberofresourceswillbe
appliedto each patient. In the eventofadisaster or mass casualty-type event,
triageseekstoidentifythesickestpatientswithsurvivableinjuryandprioritize
theirtreatment.
Inamatureandresource-heavysetting,triagewilltypicallybeginwithacall
to emergency medical service (EMS). The EMS will then dispatch the
appropriate-levelEMS crew(i.e.,emergencymedicaltechnician orparamedic)
tothepatientbasedontheseverityofinjury.Onceonthescene,thenextlayerof
triageoccurs.Here,theEMScrewwilldeterminewhichtypeofhospitalcareis
neededforthetraumapatient.Theonlydifferencebetweenhospitalsshouldbe
asitrelatestoresources,notcommitment,tothebestcareoftheinjuredpatient
(2). The injured patient should be taken directly to the most appropriately
equippedcentertohandletheirneeds.Multipletriagecriteriaexisttohelpdirect
prehospitalprovidersastowhichhospitalisthemostappropriateforthepatient.
They do, however, all have some basic underlying basis, which includes
physiology (e.g., abnormal vital signs), anatomy (e.g., gunshot wound to the
torso), mechanism of injury (e.g., high-speed motor vehicle rollover), and
comorbidities (e.g., elderly patient on blood thinners). Although abnormal
physiologyisperhapsthemostsensitiveinidentifyinginjury,thecombinationof
allfourcriteriaincreasethechancethattherewillbeaninjurythatrequiresthe
servicesofthetraumateam(3,4).
Becausethecurrentdistinctionsbetweendifferentlevelsoftraumacenterare
basedonresources, including the access to and availability of specialty teams
like neurological or orthopedic surgery, advanced imaging, and rehabilitation
teams,thereissomesuggestionthatseverelyinjuredpatientsbenefitfrombeing
atlevel 1 trauma centers(5).For those patients withobvioushigh spinal cord
injuries,guidelinespromotepreferentialtriageofthesepatientstolevel1trauma
centers, even if one has to bypass a level II or III trauma center (6,7). Early
transferofthesepatientstoalevelItraumacentershouldbestronglyconsidered
oncediagnosisismadeatalower-leveltraumacenterornondesignatedhospital.
Onceinthehospital,thepatientwillbetriagedagain.Usingsimilarcriteria,
hospital triage aims to reassess and possibly revise the patients’ severity of
illnesstohelpbringtheappropriatepersonneltothebedside(8–11).
ROOMANDEQUIPMENT
Althoughthereisnospecificliteraturethatexistsregardingthetypeofroomand
equipmentneededtoevaluateandtreatatraumapatient,thebasicprinciplesin
the evaluation of the trauma patient should dictate minimums. The room and
equipmentshouldultimatelyfunctiontooptimizetraumateamperformance.The
premise of being able to identify and treat all life-threatening injury ideally
requires a dedicated space with enough room for a trauma team and their
equipment. The room should have a standard set of equipment that will be
utilized for all trauma patients. This includes a radiographically compatible
stretcher, cardiac and vital sign monitors, tools for hemorrhage control (e.g.,
tourniquets, suture material, and dressings/bandages), intravenous and
phlebotomy equipment, and basic instrumentation. Additional equipment that
may be utilized on a case-by-case basis include ultrasound machine, level 1
Transfuser,andchesttubeequipment.
TEAM
In the ideal scenario, the trauma team isamultidisciplinary group that comes
togetheratdifferenttimesduringapatient’shospitalstaytoaccomplishspecific
tasks.In the earlyphaseof thetraumapatient evaluation, thegroupshould be
maximized to perform a thorough, rapid evaluation and stabilization of the
patient.Regardlessofnumbersofpersonnelontheteam,thebasicprinciplesof
evaluationofeachtraumapatientincludeasearchforandtreatmentofalllifethreateninginjuries.Thisisfollowedbyamorein-depthsecondaryevaluation.
Collectively,theseevaluationsareknownastheprimaryandsecondarysurvey,
respectively.Therefore,assemblingateamtoincludethepersonnelnecessaryto
performthesetasksisideal.
The initial contact with a trauma patient should be designed based on a
modelofeitheraverticalorhorizontalresuscitation.Thosecenterswithlimited
personnel will employ the vertical resuscitation model in which one or two
individuals will assess a patient in a step-wise manner utilizing the basic
principles of ATLS. In this model, multiple tasks cannot be performed at the
same time, given the limitations in personnel. For those hospital centers with
large numbers of dedicated personnel, the ideal resuscitation will be in a
horizontal format in which multiple tasks are being accomplished
simultaneously,alsousinganATLSmodel(12).
Theidealizedteamforahorizontalresuscitationcanconsistofthefollowing:
Teamleader:Thisisusuallythemostseniorofpersonnelwithathorough
understandingofpotentialpathophysiology.Thisindividualactsasthe
“conductor”ofthetraumateamanddirectsallpatientcaredecisions.They
shouldhavea“30,000footview”vantagepointwheretheyarenotactually
performingdirectpatientcare.Theteamleadershouldkeeptheteamontaskandofferpromptactionanddirectionasneededtobringtheinitial
evaluationandmanagementtotheappropriateconclusion.
Primarysurveyor:Thisindividualistaskedwithperformingtheprimary
survey.Theprimarysurveyisanevaluationforalllife-threateninginjuries
utilizingtheAirway,Breathing,Circulation,Disability(ABCD’s)method
ofevaluationfromATLS.Whenaninjuryisidentifiedbytheprimary
surveyor,theteamleaderwilldictatemanagementatthattime.
Secondarysurveyor:Thisindividualwillberesponsibleforahead-to-toe
examinationofthepatientafterlife-threateninginjurieshavebeendealt
with.Thisshouldalsoincludeamedicalhistory.
Procedures:Theteamleadershouldappointanindividual(s)responsible
forperformingtheproceduresrequiredafteridentificationofinjuryduring
theprimarysurvey.
Airway:Becauseoftheimportanceofsecuringanairway,thereisoftenan
individual(s)appointedattheheadofthebedtohelpsecuretheairwayif
needed.Airwayskillssuchasendotrachealintubationisrequiredhere.In
thepatientwithsuspectedspinalcordinjury(SCI),in-lineneck
stabilizationshouldbemaintainedmanuallyduringintubationandwithaccollaratallothertimesuntilfurtherdiagnosticsareperformed.
Nursing:Nursingandtheirsupportstaffplayavaluableroleintheinitial
evaluationofthetraumapatient.Theyareoftenresponsibleforthe
placementofintravenouslinesandmonitoringaswellastheadministration
ofmedication.
Ancillarystaff:Duetothefluidnatureofatrauma,amechanismshould
existbywhichtobringinotherteammembers.Theseothermemberscan
includeextranursingpersonnel,respiratorytherapists,andx-ray
technologists.Additionally,thereneedstobeamethodforactivating
operatingroomandinterventionalradiologypersonnel.Up-to-datecontact
informationforrelevantconsultantsshouldalsobereadilyavailable.
EMSHAND-OFF
EMS plays the important role as a go-between from point of injury to the
hospitalstaff.Theycanprovidevaluableinformationregarding themechanism
ofinjury,theinitialconditionofthepatient,andresponsetotreatments.Theyare
oftenalsothearbitersofwheretheinjuredpatientwillbeseeninitially.Assuch,
they should be afforded dedicated time for hand-off that should include
importantinformationthatthetraumateammightneed.Poorhand-offhasbeen
showntoincreasemorbidityandmortality(13).
The EMS report can technically begin in the prehospital environment.
Mature systems will allow the on-scene or transporting team to contact the
receivinghospitalwith basicinformationaboutthepatient.Thiswill allowthe
traumateamtimetoprepareforthepatient.Preparationfromthisinformation,
including gathering the team and equipment, can save valuable time for the
severelyinjuredpatient.
Once in the hospital, the EMS team should provide a comprehensive but
reasonably short report of pertinent information. Although multiple templates
existfor this hand-off,one of themorecommon ones isM.I.S.T(Mechanism,
Injuries, (vital) Signs, Treatment). Utilizing the information provided in
M.I.S.T.,theEMSteamcanaccomplishthetaskwithoutbelaboringthepointor
delayingfurtherevaluationortreatmentsbythetraumateam(13–15).
PRIMARYASSESSMENT
Given that the overarching goal in trauma care is to minimize mortality and
improve outcomes, the primary survey is designed to optimize outcomes. Its
design is not only an evaluation but rather the identification and treatment of
life-threatening injury as well. Utilizing the ABCDE formula, the primary
surveyor is going to be able to rapidly assessfor injuryand allowthe trauma
teamtobegintreatmentfortheseinjuries.
TheAirwayexaminationbeginswiththeassessmentofpatency.Ingeneral,
the verbal patient with a normal voicedoes nothave an airway pathology.If,
however,thepatientisnotspeakingspontaneously,furtherexplorationisneeded
todetermineifthereisaproblemwiththemouth,oropharynx,orneck.Asearch
forintraoralbleedingormandibularmalocclusionshouldbemade.Inthepatient
with oropharyngeal bleeding after penetrating trauma, the patient without SCI
should be allowed to sit up and self-suction. Airway stabilization with an
endotrachealtubeshouldbeperformedinthosepatientswithairwaypathology
orwithalteredmentalstatusandGlasgowComaScore(GCS)lessthan9.
While the majority of airways can be secured using rapid sequence
intubationand standard techniques,one must alsobeprepared with alternative
methods (e.g., video laryngoscopy), rescue (e.g., King airway), or surgical
airway,shoulditbecomenecessary.
TheBreathingexaminationisasearchfor life-threateningpathologyinthe
chest. These injuries can include pneumo- and hemothoraces. Patient
hemodynamics will dictate the invasiveness of this examination. For those
patientswithouthemodynamicinstability,theprimarysurveyorwillbeginwith
anausculatoryexaminationassessingforabsenceorpresenceofbreathsounds.
In the intubated patient, absent breath sounds on the left should prompt
withdrawaloftheendotrachealtubeacentimeterortwopriortootherinvasive
interventions. Other assessment tools are to look for tachypnea, oxygen
saturations, or crepitus. The chest x-ray is a useful adjunct to the breathing
assessment.Ultrasoundhasbeenshowntobemoresensitivetothechestx-ray;
however,itisunclearwhattodowithfindingsofpathologyonultrasoundinthe
hemodynamicallynormalpatient.
In those patients with hemodynamic instability, the time frame in which
diagnosisneedsto be made is narrowed and as such the team will need tobe
moreinvasiveintheirassessment.Triageofthechestcavitiescanbedonewith
chesttubesorwithathoracotomy.
The general approach to the patient with a chest pathology (i.e.,
pneumothoraxandhemothorax)istheplacementofachesttube.
Circulation can be assessed by palpating for pulses and searching for
hemorrhage.Anyexternalhemorrhageshouldbecontrolledwithdirectpressure,
wound packing, or tourniquet use. Other interventions for the treatment of
circulatory compromise include placing the patient on a monitor and
establishmentofintravenousaccess.Adjunctstocirculatoryexaminationinclude
a rapid search for intracavitary bleeding using chest and pelvic radiography,
focused assessment with sonography for trauma (FAST) examination, and
diagnostic peritoneal aspirate/lavage. Identification of intrathoracic or intraabdominalinjuryinunstablepatientsshouldpromptatriptotheoperatingroom.
The Disability examination focuses on the patient’s neurologicstatus. The
GCSandpupillaryresponseshouldbeassessed.Interventionsforalteredmental
status with lateralizing signs can include osmotherapy and rapid surgical
decompressionalongwithbloodpressuresupport.
Thekeyto eachexamination isafullExposureofthepatient.Allclothing
shouldberemovedfromthepatienttohelpcompleteatotalexamination.Once
the examination is completed, care should be made to cover and warm the
patient.WarmIVfluidsandblanketscanbeutilized.
SECONDARYASSESSMENT
Thesecondarysurveyshouldbeginassoonastheprimarysurvey/treatmentsare
completed. This examination can be performed by the same or different
individualastheprimarysurveyor.Thissurveyisamorethoroughanddetailed
examinationofeachbodyregion.Thiscompletehistoryandphysicalwillhelp
identifycomorbiditiesaswellothernon-life-threateninginjuries.
Afterobtainingafullsetofvitals,amedicalhistoryshouldbeobtainedusing
a tool such as AMPLE (Allergies, Medications, Past Illnesses, Last meal,
Events/Environment/Mechanism). The provider will then perform a complete
head-to-toe examination following an inspection and palpation model. For
patients with SCI, it is important that a full neurologic examination by
experiencedpersonnel(e.g.,physiatristwithSCIexperience)takesplaceassoon
asreasonablypossibletodeterminethelevelandseverityoftheinjuryaswellas
to make general care recommendations. Further details of the neurological
examinationcanbefoundinChapters5and12.
ADJUNCTSTOSURVEY
Limitationsinthephysicalexaminationofthetraumapatient,requireadjunctsto
helpidentifyinjury(16–19).Thesetests/studieswillhelpidentifyseriousinjury.
Theseexaminationsshouldberapid,reliable,mobile,andprovideahighdegree
of specificity. Adjuncts to the primary survey include chest and pelvic
radiography, FAST (focused assessment with sonography for trauma)
examination, and diagnostic peritoneal aspirate/lavage. These studies help
identifylife-threateninginjury,especiallyinthose patientswithquestionsasto
why there is hemodynamic instability. While the CT scan has revolutionized
traumacare,itshouldnotbeusedinthepatientwithhemodynamicinstability.
HEMODYNAMICINSTABILITY
Those trauma patients arriving with physiologic derangements should have a
promptevaluationforthesourceoftheirhemodynamicinstability.Whentrauma
istheunderlyingmechanismin a hemodynamically unstable patient, it is said
thatthethreemostcommoncausesoftheirshockarehemorrhage,hemorrhage,
and hemorrhage. While this “trauma saying” is a bit tongue-in-cheek, it
underlies the basic premise that mortality from a trauma mechanism is from
hemorrhageaboveallelse.
Given the importance of hemorrhage as a cause of mortality, the initial
search for the source is paramount to improving survival. Hemorrhagic shock
should be addressed as soon as possible by controlling the source and
replacementoflostbloodwithbloodandbloodproducts.Itshouldbenotedthat
a specific threshold of systolic blood pressure (SBP) shouldnot defineshock,
but certain values have traditionally beenused to label these patients.For the
adult patient, any SBP below 90 mmHg can be used. Recent literature has
identifiedaneedtoredefinethisvalueinthegeriatrictraumapatienttobelow
110mmHg(20).Byitself,life-threateningbleedingcanoccurfromonlyafew
sources. This includes the chest, abdomen, pelvis, long bone injury, and
externally.Assuch,theevaluationofeachpatientwillincludeasearchofthese
cavitiesasfollows:
Chest:Whilebreathsoundsprovidesomebasicinformation,thechestx-ray
istrulytheworkhorseofthiscavitiestriage.Identificationofahemothorax
providesasourceforhemodynamicchangesandcanbefurthermonitored
withtubethoracostomy.Returnedvolumesthroughthechesttubeofgreater
than1,200to1,500mLimmediatelyareanindicationforoperative
intervention.Considerationshouldbemadetoreturningthepatients’blood
fromthecollectionchamberifable.
Abdomen:Thiscavityistriagedusingbedsideultrasound.TheFASTisa
portablereproduciblestudythatcanidentifyfreefluidintheabdomen.A
positivestudyinthefaceofinstabilityisanindicationforanexploratory
laparotomy.Intheabsenceofanultrasoundmachineoraproviderwith
knowledgeofitsuse,adiagnosticperitoneallavageoraspiratecanbe
utilizedtoassesstheabdominalcavity.
Pelvis:This“cavity”istriagedusingapelvicx-ray.Thepresenceof
significantdisruptionofthepelvicringisindicativeofseriousinjurywitha
sourceforbleeding.Restorationofthenormalanatomyandstabilizationis
theidealbedsideprimarytreatmentforthisdisruption.
Longbone:Inisolation,afemurfracturecanresultinseveralunitsofblood
loss.Otherlongbonesfractures,especiallywhenmultiple,canalsoleadto
multipleunitsofbloodlossandhemodynamicderangements.Extremities
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