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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_885_Библиотеки_им_академика_М_И_Перельмана.pdf
8 E. E. Moore and H. B. Moore
Fig. 3. U.S. healthcare system wastes.
Fig. 4. U.S. population health expenditures.
Critical Care Responsibility in Healthcare Reform 9
Review of Current Literature with References
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Yoshimura, S, The anatomy of health care in the United States. JAMA
2013; 310: 1947–1963.
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acute care spending to total spending for high cost Medicare patients. JAMA
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Chapter 2
Initial Approach to the Trauma Patient
C. N. Eisenhauer, MD* and Gregory J. Jurkovich, MD
*Surgical Resident, University of Colorado School of Medicine
†
Chief of Surgery and Trauma Services, Denver Health Medical Center
†
Take Home Points
• The initial evaluation of trauma patients should happen in an organized,
systematic approach by a coordinated team of healthcare providers. This
should include surgeons, emergency medicine physicians, nurses, respiratory
therapists, and a variety of specialized technicians.
• Pre-arrival planning is essential for effective care.
• Communication, team work, and a calm and assured disposition among all
healthcare providers is essential during this period of care for the acutely
injured patients.
• The initial goal of care in the Emergency Department should be completion
of the primary survey, recognition of life- or limb-threatening injuries, and a
determination of appropriately diagnostic imaging and/or procedures.
• Procedures or tests that will not immediately provide diagnostic data that are
critical to the care of the patient should not interfere with necessary care
(i.e. do not stop cardiopulmonary resuscitation to place an arterial line).
Contact information: (C. N. Eisenhauer) 12631 East 17th Ave, MSC313, Aurora, CO
80045; (Gregory J. Jurkovich) 777 Bannock St., MC 0206, Denver, CO 80204; Email:
Charles.Eisenhauer@ucdenver.edu; Jerry@dhha.org
11
12 C. N. Eisenhauer and G. J. Jurkovich
• Always remember the ABC’s ( airway, breathing, circulation). This is the
foundation of the primary survey and providers should re-evaluate these
points if at any time the patient becomes unstable.
• NEVER leave an unstable patient unsupervised, even if they are on cardiopul-
monary monitoring. This is true regardless of the patient’s location (i.e. ED,
radiology, transport, etc.).
Background
• Trauma is the leading cause of death globally, accounting for 5.8 million
deaths per year. Each year there are over 31 million trauma patients evaluated
by hospitals in the U.S. It is the leading cause of death among Americans
under the age of 45 years, the fifth leading cause of death among the elderly,
and accounts for 10% of all mortality in this country.
• In 2010, 180,811 people died from trauma. Originally described by Donald
Trunkey in 1983, trauma-related deaths usually occur in a trimodal distribution.
{ Death within minutes of an accident is caused by fatal injuries with the
only effective intervention being injury prevention.
{ Death within hours of an accident is usually from severe injuries, and their
survival is dependent on access to a medical facility and the quality of
care received.
{ Death occurring weeks after an accident is usually caused by sepsis and
multisystem organ failure. Recent data have shown a marked decrease in
mortality among patients admitted to the hospital for > 24 hours, which is
likely a result of improved critical care management.
• The CDC estimates that in 2005, over $63 billion was spent on the care of
trauma patients.
{ Patients that were evaluated in the ED and release accounted for $21.4 billion
with an average cost of $800 per patient.
{ Patients that were hospitalized and survived to discharge accounted for
$40.4 billion with an average cost of $20,162 per patient.
{ Trauma related deaths accounted for $1.6 billion with an average cost of
$9,323 per patient.
Main Body
• The American College of Surgeons Advanced Trauma Life Support is the
internationally recognized and standard of practice guide to management of
Initial Approach to the Trauma Patient 13
patients with traumatic injuries. This highly organized algorithmic approach
to a trauma patient has been designed to: (1) maximize the survival of patients
who have been critically injured through early recognition and treatment of
life-threatening conditions and (2) ensure a thorough evaluation that minimizes missed injuries in patients who can undergo a full workup. The
fundamental aspects of this approach include the primary survey, resuscitation, and secondary survey.
{ While it is possible to complete the ATLS approach in a controlled step-
wise manner in most trauma patients, it is absolutely critical to recognize
the following:
If at any time a patient deteriorates for an unknown reason, the algo-
rithm of primary survey, resuscitation, and secondary survey should be
stopped and healthcare providers should restart the entire evaluation
from the beginning.
Emergent operative intervention for treatment of life- or limb-threat-
ening injuries should take precedence over completing the entire
evaluation. When a patient is dying from a condition that can only be
corrected surgically, the place for that patient to be is in the operating
room and not the trauma bay. The only notable exception to this is the
case of a resuscitative thoracotomy, where surgical intervention must
be undertaken in the Emergency Department in order to stabilize the
patient for transport to the operating room. This is, arguably, just a part
of the “C” of the primary survey of stopping the bleeding.
It is fundamentally important to recognize that the primary survey
requires that life-threatening problems identified within each step
must be corrected before moving on to the next step. It is not appropriate to do the steps of the primary survey as such: identify a series of
life-threatening issues, catalogue them, and go on with the survey with
plans to return to each problem. Solve them as you find them.
• Primary Survey
{ Airway Management and Cervical Spine Protection
Being the first issue that must be addressed in any trauma patient, a
secure and protected airway is of utmost importance.
Patients can usually protect their own airway if they are awake and
talking.
Indications for immediate intubation include Glasgow Coma Score
≤ 8 or non-purposeful motor activity, obvious respiratory distress, and
14 C. N. Eisenhauer and G. J. Jurkovich
cardiopulmonary arrest. The importance of airway control with
significant head injury is to prevent hypoxia, hyper- and hypocarbia,
and aspiration.
If prehospital personnel performed an intubation, its position should
always be verified. The gold standard for this is to do so by direct
laryngoscopy but end tidal capnography, moisture inside the ET tube,
and bronchoscopy can all be used as well. Familiarity of the different
airway devices used by prehospital personnel is essential, as several of
these devices are adequate for emergency transport to the hospital but
do not ensure a definitive, protected airway.
Cervical spine collars or another immobilizing device should be
placed on all patients whose mechanism of injury could cause damage
to bony and ligamentous structures of the spine. Always assume that
victims of multisystem trauma, especially if the patient’s neurological
status is altered or if there has been blunt injury above the torso.
{ Breathing and Ventilation
Once a patent and protected airway has been verified or established,
assurance of oxygenation and ventilation is the next crucial step.
Look at the patient’s chest to make sure that it symmetrically rises. If
a color changing capnography device is used after an intubation, look
at it to ensure good color change for at least five consecutive breaths.
Always remember that if an esophageal intubation has been performed
on a patient that has recently consumed carbonated beverages,
capnography may be falsely positive on the first few breaths.
Listen to breath sounds on both sides to ensure adequate gas exchange.
The absence of breath sounds unilaterally suggests a main-stem intubation or a pneumothorax. Absence of breath sounds bilaterally
suggests an esophageal intubation. If an esophageal intubation is
suspected, auscultate the epigastric area to detect gas flow into the
stomach.
Feel both sides of the chest for gaseous or bony crepitus. Gaseous
crepitus over either side of the thorax suggests a pneumothorax.
Gaseous crepitus over the neck suggest an aerodigestive injury. Bony
crepitus suggest underlying fractures. In a conscious patient, gaseous
crepitus is painless while bony crepitus is usually very painful.
Remember that pulse oximiter devices have a 30 second delay in
reporting oxygen saturations. Falsely elevated readings can be caused
by carbon monoxide poisoning. Hypoperfusion, hypothermia, and
Initial Approach to the Trauma Patient 15
the presence of nail polish may render the device unable to
determine the oxygen saturation. Methemoglobinemia, whether
genetic or the result of chemical exposure, also make pulse oximeter
readings inaccurate.
{ Circulation and Hemorrhage Control
The key components of “C” in the ATLS protocol are: Stop the bleed-
ing; Assess circulation; IV-IO Access; Resuscitation fluids.
Stop all obvious bleeding with manual pressure, a tourniquet, or a
clamp.
A manual blood pressure should be checked once before an automated
blood pressure cuff is applied because automated cuffs can be inaccurate in the setting of hypotension.
Always remember that in trauma patients, the etiology of hypotension
is hemorrhage until proven otherwise. Adult patients must lose 30% of
their total circulatory volume (~2L depending on body size) before
hypotension occurs; Children become hypotensive only from more
severe blood loss and at a near terminal event time.
Hypotension from hemorrhage is usually associated with tachycardia.
However, elderly patients who are heavily beta-blocked or whose
cardiac rhythm is pacemaker dependent may not become so. Also,
neurogenic shock will produce hypotension without tachycardia so
this scenario should prompt attention to the exam of the cervical and
high thoracic spines.
After determination of the patient’s blood pressure, all extremities
should be checked for palpable pulses. The lack of a pulse in an
extremity should prompt a thorough evaluation for arterial injury.
Equally diminished or absent pulses in all extremities is a sign of
profound hypoperfusion or cardiac arrest.
External hemorrhage should be controlled during the primary survey
and the most effective way to do so is manual compression. If a tourniquet was applied by prehospital personnel, it should be taken down
in a controlled manner after all necessary physicians are present in
order to determine the nature and severity of the hemorrhage.
If external hemorrhage is not obvious in a hypotensive trauma patient,
sources of occult bleeding include the thorax (hemothorax, great
vessel injury), abdomen (solid organ injury, mesenteric injury), retroperitoneum (pelvic fracture, renal injury, penetrating wound), and
long bone fractures.
16 C. N. Eisenhauer and G. J. Jurkovich
{ Disability
A brief neurological exam should be performed on every patient
during the primary survey and should include level of consciousness,
pupil size and re-activity, and movement of all extremities.
Ideally these can be examined before the administration of sedative or
paralytic medications. If these medications were administered by
prehospital personnel, always remember to ask what the results of
their physical exam were en route to the hospital.
While intoxication is a frequent cause of altered mental stats, more
serious etiologies include hypoperfusion of the brain, hypoxemia, and
traumatic intracranial injuries. Deterioration of a patient’s level of
consciousness first demands re-evaluation of the ABCs but should
also raise awareness of a potential head injury.
{ Exposure and Environmental Control
In order to properly evaluate a trauma patient, all of their clothes and
belongings should be removed. Hospital personnel should then
securely store these for the patient.
Environmental exposure, large volume hemorrhage, and both colloid
and crystalloid resuscitation can cause hypothermia in a trauma
patient. Consequences of hypothermia include cardiac arrhythmias,
alterations in blood flow, decreased delivery of oxygen to tissues
through increased affinity for hemoglobin, and an increased susceptibility to infection.
At the completion of the primary survey, the patient should quickly be
covered with warm blankets. Other steps to correct or prevent hypothermia include increasing the ambient temperature of the trauma bay,
administration of warmed IV fluids (maximum temperature of 40°C),
and using active warming devices.
• Initial Resuscitation
{ Remember: life-threatening problems identified during the steps of the
primary survey must be solved before moving on to the next step. With
enough expert assistance these can be done in parallel, but do not forget
the principle of step-wise management.
{ Airway
Adjunctive devices such as nasal trumpets and oral airways, along
with maneuvers such as the jaw thrust may suffice in establishing an
airway for a patient. Never perform a chin tilt maneuver on a patient
Initial Approach to the Trauma Patient 17
with a possible cervical spine injury. If there is any doubt about a
patient’s ability to maintain or protect their airway, the patient should
be intubated.
When dealing with a patient whose cervical spine requires immobilization
that needs to be intubated, there has not been any significant difference
shown between direct laryngoscopy and videoscopic approaches in
achieving oral intubation. The physician’s experience and comfort level
with each of these techniques should dictate which is chosen.
Patients with obvious oropharyngeal, laryngeal, or tracheal injuries
should be intubated with extreme caution. Never hesitate to involve
other providers who have additional experience in these circumstances
(i.e. anesthesiologists, CRNAs, etc.).
Emergency surgical airways should not be considered a failure of
airway management but should be reserved only for the most extreme
of circumstances (direct contraindication to or inability to achieve oral
or nasal intubation).
If a patient is going to require intubation in the immediate future for
an emergent procedure, it is not mandatory to do so in the ED before
transport. Often times, this will delay the emergent procedure and can
easily be addressed in the operating room.
{ Ventilation and Oxygenation
As a general rule, all trauma patients should receive supplemental
oxygen. The route of delivery should be determined based on the
patient’s overall condition and oxygenation status.
A tension pneumothorax may produce profound respiratory distress
and hypotension from mediastinal shift. It must be urgently alleviated
during the primary survey by immediate chest decompression. If
attempting needle decompression, remember to account for the thickness of the patient’s chest wall when selecting a needle for use. Tube
thoracostomy is definitive.
Massive hemothorax should be recognized during the primary survey
and tube thoracostomy performed to evacuate, monitor blood loss, and
get the lung inflated.
After endotracheal intubation or establishment of a surgical airway,
bag ventilation of the patient is effective at rapid correction of hypoxia
and hypercapnia. However, once improved and stable, the patient
should be placed on a mechanical ventilator to ensure consistent
oxygenation and ventilation.