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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_885_Библиотеки_им_академика_М_И_Перельмана.pdf
18 C. N. Eisenhauer and G. J. Jurkovich
{ Circulation
Stop the bleeding; Assess circulation; IV or IO access; Resuscitate.
As mentioned previously, manual compression is the most effective
treatment of external hemorrhage and should be initiated upon recognition of the source of bleeding.
A minimum of two large bore peripheral IV catheters (14–18 gauge)
should be established in every trauma patient. If there are obvious
fractures of an extremity then it should not be used for access.
If peripheral IVs cannot be established in a patient, intraosseous
catheters are safe and effective for resuscitation. They are relatively
easy to establish but should not be placed in extremities with obvious
fractures. Primary sites in an adult are the tibial plateau (antero-medial
aspect) and the proximal (head) humerus. Sternal IO and iliac crest IO
are alternatives. Some reports suggest IO to be a superior site for
rapidity of access in children.
Central venous catheters should be placed by experienced personnel if
peripheral IVs and intraosseous catheters cannot be established. Good
sterile technique should be practiced. The default placement location
should be the femoral vein, as insertion here is not associated with the
risk of carotid artery puncture or iatrogenic pneumothorax. Remember
though that large bore single lumen catheters are preferred to triple
lumen catheters, as triple lumen catheters have small diameters and
relatively high resistance owing to their length. These lines should be
removed as early as possible during the hospital course as they are
often times placed under less than ideal circumstances in terms of
sterility.
Initial fluid boluses should be proportionate to the patient’s estimated
volume deficiency based on vital signs. Response to initial fluid bolus
of 10–20 cc per kg should direct further fluid resuscitation needs. For
example, adults (70–80 kg) should be treated with 1–1.5 L crystalloid
for initial volume resuscitation. If tachycardia and or hypotension do
not resolve, a second bolus of similar volume should be administered,
and blood transfusion initiated for subsequent transfusion, while a
diligent search for ongoing blood loss continues. Remember: volume
is the treatment of bleeding — occluding the open blood vessel is the
treatment.
Lactated Ringer’s Solution should be considered the preferred fluid for
initial boluses given its chemical similarity to serum, but normal saline
is also acceptable. Remember that in patients with severe liver failure,
Initial Approach to the Trauma Patient 19
LR will produce a lactic acidosis that may confound your clinical picture. Excessive administration of NS (> 10L) over a short time can
cause a metabolic acidosis that can be very difficult to correct.
Patients presenting with hemorrhagic shock should be transfused
blood products as quickly as possible. All Level 1 trauma centers are
required to have a massive transfusion protocol that is reserved for
such scenarios. These products should be utilized initially, until a
crossmatch for the patient can be completed. It is generally agreed
upon that packed red blood cells, fresh frozen plasma, and platelets
should all be administered to a patient in this situation, although there
is ongoing debate as to the ideal ratio of these products (i.e. 1:1:1,
1:2:1, etc.).
Vasopressive medications should never be used until the patient is
adequately volume resuscitated. Failure to do so can result in catastrophic ischemic sequelae such as myocardial infarction, intestinal
necrosis, and renal failure.
The primary method of operative hemorrhage control is surgical repair
or ligation performed in the operating room, hybrid room or intervention radiology suite. Volume resuscitation is temporizing, and can be
harmful if overdone.
• Adjuncts to the Primary Survey and Resuscitation
{ Pulse Oximetry
Pulse oximetry monitor should be attached to an ear lobe or fin-
gertip, but without polish or tattoos. A pair of small light-emitting
diodes (LEDs) emit two waveforms: one LED is red, with wavelength
of 660 nm, and the other is infrared with a wavelength of 940 nm.
Absorption of light at these wavelengths differs significantly between
blood loaded with oxygen and blood lacking oxygen. The ratio of the
red light measurement to the infrared light measurement is then calculated by the processor (which represents the ratio of oxygenated
hemoglobin to deoxygenated hemoglobin), and this ratio is then converted to SpO
by the processor via a lookup table.
2
Remember that pulse oximiter devices have a 30 second delay in
reporting oxygen saturations. Carbon monoxide poisoning can cause
falsely elevated readings. Hypoperfusion, hypothermia, and 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.
20 C. N. Eisenhauer and G. J. Jurkovich
{ ECG Monitoring
As quickly as possible, all trauma patients should be placed on an
ECG monitor. This provides a real-time monitor of both heart rate and
cardiac rhythm.
Cardiac arrhythmias can be signs of underlying traumatic injuries.
Ö Cardiac contusion caused by blunt trauma most frequently mani-
fests as sinus tachycardia, but can also cause atrial fibrillation,
premature ventricular contractions, and ST segment elevation
indicative of ongoing ischemia.
Ö Conditions causing inadequate preload (tension pneumothorax,
extreme hypovolemia, cardiac tamponade) can manifest as pulseless electrical activity, or PEA.
Ö Sinus bradycardia and hypertension can be a sign of cerebral
herniation (Cushing’s reflex).
{ FAST Exam
The focused assessment with sonography for trauma (FAST) exam is
a useful adjunct to the primary survey to detect internal hemorrhage.
The four “windows” that are routinely imaged are the hepatorenal
recess (Morrison’s pouch), the bladder and surrounding pelvic space,
the perisplenic space, and the pericardium.
The reported sensitivity and specificity of the FAST exam in detecting
intraabdominal free fluid after blunt trauma are ~30% and ~99%,
respectively. As the sensitivity is so low, a FAST exam should never
be referred to as “negative.” A more appropriate term would be “indeterminate,” “inconclusive,” or “useless” if it is not positive for blood.
Repeating the exam within 24 hours of admission increases the sensitivity to ~70%, although most occult injuries are detected before this
time period (Blackbourne LH et al., J Trauma 2004;57:934–938).
Secondary ultrasound examination within an hour increases the sensitivity of the FAST exam in blunt trauma, and should be considered
best practice.
The sensitivity and specificity of FAST in penetrating abdominal
trauma are about the same as that for blunt trauma, although the indications for laparotomy or thoracotomy are uniquely different based on
mechanism.
Recently, the exam has been extended to include examination of the
anterior thorax bilateral to detect the presence of pneumothorax. This
is referred to as an extended FAST or eFAST. The reported sensitivity
Initial Approach to the Trauma Patient 21
and specficicty in detecting the presence of a pneumothorax are
~60% and ~99%, respectively (Kirkpatrick AW, Sirois M, Laupland
KB et al., J Trauma 2004; 57: 288–295).
Drawbacks to the FAST exam is that its accuracy is dependent on the
body habitus of the patient, the experience level of the healthcare professional performing the exam, and low accuracy in patients who are
severely injured due to the higher incidence of ultrasound-occult injuries among these patients. Pelvic fracture-related hematomas also
make interpretation difficult.
{ Urinary and Gastric Catheters
Urinary catheters are necessary during resuscitation to have real-time
data about urine production. It also facilitates uncontaminated collection of urine for a urinalysis, which should be a routine lab sent on all
trauma patients. If there is any sign of urethral trauma (blood at the
meatus, a high riding prostate, perineal or scrotal ecchymosis, or fractures of the pubic ramii), a retrograde urethrogram should be obtained
before placing a urinary catheter.
Gastric catheters allow for quick decompression of stomach contents
and help to decrease the chance of aspiration. They do not, however,
prevent aspiration and should be used with caution in patients with
head and neck trauma. Never place a nasogastric tube in a patient with
a suspected skull base fracture.
{ Plain Films
While X-rays obtained in the trauma bay can afford valuable diagnos-
tic information, they should never delay the primary survey or
resuscitation of a patient.
The typical X-ray workup in the trauma bay consists of a chest film
(portable AP) and a pelvic film (portable AP). Together, these are
commonly referred to as “The Big Two.”
Chest X-ray provides valuable diagnostic information about the
presence of a pneumothorax, hemothorax, fractured ribs, and positioning of an endotracheal tube and gastric catheter. It can also be
helpful in locating missiles and other foreign bodies in penetrating
trauma, which can sometimes influence operative approaches when
emergency surgery is indicated. Since the chest X-ray is obtained
with the patient supine, its sensitivity in detecting pneumothoraces is
less than an upright film and hence is inadequate in making the diagnosis of an occult pneumothorax. If there is any question of a
22 C. N. Eisenhauer and G. J. Jurkovich
possible pneumothorax, never transport a patient without first
viewing the portable XR — a large pneumothorax should be treated
with tube thoracostomy prior to leaving the trauma bay to prevent the
development of tension physiology.
The utility of pelvic X-rays is less straightforward. In conscious
patients, there is less than 10% chance of missing a pelvic fracture
when complaints of pelvic pain are absent and the physical exam is
negative; furthermore these missed fractures are usually clinically
insignificant. Conversely, routine pelvic X-ray is advocated in patients
with severe blunt trauma who are unconscious or neurologically
altered given the higher incidence of pelvic fractures in these patients
and inability to obtain an accurate exam.
{ Diagnostic Peritoneal Lavage/Diagnostic Peritoneal Aspirate
Once a common diagnostic procedure in the evaluation of critically
injured trauma patients, diagnostic peritoneal lavage has become relatively uncommon due to the increased use of FAST examination and
the accessibility of quality CT scanners.
DPL is a lavage technique, where 1 liter of fluid is instilled into the
abdomen, and as much fluid as possible withdrawn and analyzed for
red blood cells, white blood cells, amylase, bacteria and food fibers.
Generally, >300 ml needs to be returned to be considered adequate
sampling. DPA is a simple aspirate, whereby 10 cc of blood or succus
entericus aspirated is positive for injury requiring laparotomy.
The most common use of DPL/DPA today is in the hemodynamically
unstable blunt trauma patient who has an indeterminate (not clearly
positive) FAST exam. In this scenario, it is not safe to transport the
patient to the CT scanner and a grossly positive result would mandate
emergent surgical exploration. A good example is the blunt trauma/
pelvic fracture patient who is unstable, and help is needed with the
decision to go to the operating room for laparotomy, or to the angio
suite for pelvic arterial embolization. In this scenario, a supra-pubic
DPA will quickly assess for intra-peritoneal bleeding vs. retroperitoneal/pelvic bleeding as the source.
DPL also has a role in the stable patient with a penetrating abdominal
wound. In this circumstance, a local wound exploration that shows
peritoneal violation and a DPL result of >100,000 RBCs has a high
predictive value in detecting an injury that will eventually lead to
peritonitis or shock and should warrant emergent exploration. If there
is question of peritoneal violation or a diaphragmatic injury, many
Initial Approach to the Trauma Patient 23
authors advocate for using > 10,000 RBCs as indicating a positive
result.
The drawbacks of DPL are that many physicians lack familiarity with
the technique and supplies are often not readily available in the trauma
bay. The only direct contraindication to DPL is previous abdominal
surgery, as adhesions may prevent total peritoneal content sampling,
in addition the risk of injury during insertion is higher.
• Consideration of the Need for Patient Transfer
{ In the U.S., there are 400 designated trauma centers that are verified by
the American College of Surgeons Committee on Trauma. They are
designated by different levels (I–IV) based on availability of clinical and
academic resources. One hundred fifty-four of these centers carry the
highest designation (Level I), having the personnel and resources to care
for any aspect of a trauma patient 24 hours a day.
{ There is a growing body of evidence that shows lower in-hospital as well
as one-year mortality for trauma patients that are treated at Level I centers
when compared to patients cared for at hospitals lacking a trauma center
designation.
{ If a trauma patient is being cared for at a hospital that lacks a trauma
center designation, consideration should always be given to the necessity
for transfer to a trauma center. This is especially true if a patient presents
with injuries that would require resources that are unavailable at the initial
hospital, or if caring for the patient would overwhelm the hospital’s
resources.
• Secondary Survey
{ Once the primary survey is complete, life- or limb-threatening injuries
have been identified, and reasonable resuscitation has been delivered, it is
appropriate to do a more comprehensive evaluation of the patient.
{ Remember that if at any time the patient’s condition deteriorates and becomes
unstable, return immediately to the primary survey and resuscitation.
{ The history obtained from the patient should start with the AMPLE tem-
plate — allergies, medications, past history (medical, surgical, and
obstetrical), last meal, and the events of the injury. The last point is especially important as the mechanism of injury defines the likelihood of
related injuries.
For penetrating injuries, the most important detail is the type of
weapon used to inflict the injury. In the case of stab wounds, details of
24 C. N. Eisenhauer and G. J. Jurkovich
the knife can help determine the potential for intracavitary injuries.
For gunshot wounds, low velocity missiles have a much more localized pattern of tissue destruction whereas high powered missiles cause
much more injury related to blast effect.
Most blunt injuries are the result of either motor vehicle or motor
cycle crashes. Important details in these cases include the type of
vehicle involved, the mechanism of the crash, the speed at which the
patient was traveling, and any use of safety devices such as helmets or
restraints. Many recreational and sporting activities can also result in
blunt injuries, and the same details of these injuries should be documented as well. The prehospital triage criteria advocated by the ACS
COT and the CDC provide important mechanisms with higher probability of significant injury.
Remember that many details of a trauma are conveyed to providers by the
prehospital personnel upon arrival to the trauma bay. This information
should be documented early on so that if a patient is noncommunicative,
there will be at least some data regarding what happened to the patient.
{ A more thorough examination of the patient should be performed once
their history has been recorded. The purpose of this secondary survey is
to detect any injuries that were not readily apparent on arrival to the
trauma bay or revealed by the primary survey or patient history. It is
important to remember that this examination is not definitive — up to
50% of non-life-threatening injuries are not detected during the secondary
survey, especially in unconscious blunt trauma patient. However, every
effort should be made at this stage to detect damage to internal organs and
musculoskeletal structures to avoid delays in diagnosis.
Head — External examination of the head should focus on detection
of lacerations, hematomae, and bony crepitus. The presence of these
findings should raise awareness for the possibility of a potential traumatic brain injury. Remember that due to the abundant vascular supply
to the scalp, large lacerations can be the source of significant hemorrhage and should be washed out and closed as quickly as it is
appropriate to do so. The preferred method of closure of a scalp
laceration that is the source of significant bleeding is not stapling;
instead, these wounds should be closed with a running locked stitch
using monofilament suture in order to assure hemostasis.
Maxillofacial — It is important to identify any injuries to the eyes,
ears, nose, facial structures, and oropharynx. When examining the
Initial Approach to the Trauma Patient 25
eyes, look for conjunctival hemorrhage and abnormalities of movement. A pupillary exam should always be performed to detect
asymmetry or nonreactivity. Otoscopic examination should be performed to evaluate for otorrhea or blood in the ear canal as these can
be signs of a skull base fracture. The nose should be examined for
obvious deformity or rhinorrhea. The mouth should be examined for
blood, debris, or damaged teeth as all these things pose significant
aspiration risk.
Neck and Cervical Spine — In general, only patients who are alert,
cooperative, and lack distracting injuries should have their cervical
spine examined at this point. More importantly, ensure that patients
have a properly positioned cervical spine immobilization device in
place and defer the examination until the above criteria are met. If a
patient is appropriate to undergo examination of their cervical spine,
look for midline tenderness to palpation and pain with range of motion;
the presence of these findings should prompt radiographic workup and
re-examination. The neck should always be inspected for any external
signs of trauma as well. Blunt injury to the neck can cause not only
skeletal damage but also injury to neck vessels and penetrating injuries
should be worked up and treated according to an organized algorithm.
Chest — The examination of the chest at this point should be the same
as done during the primary survey: look for equal chest rise bilaterally,
listen for breath sounds, and feel for bony or gaseous crepitus. Also
auscultate the heart to detect any possibly undiagnosed structural
abnormalities of the heart. The management of chest trauma is too
expansive to be covered here but physicians should be well-versed in
the potential life-threatening nature of many of these injuries and what
injuries warrant operative treatment.
Back and Thoracic/Lumbar Spine — The examination of a patient’s
back is incredibly important but can sometimes be overlooked in the
busy environment of a trauma bay. After log-rolling the patient onto
their side, the entirety of the thoracic, lumbar, and sacral spine should
be inspected for tenderness to palpation, bony crepitus, or step off
deformities. The presence of these findings should raise awareness for
a spine injury and spinal precautions should be strictly observed. Note
should also be made of any evidence of blunt or penetrating trauma
just as it is with the anterior structures. A rectal exam should also be
performed at this point, paying specific attention to the location of the
patient’s prostate, the presence of blood, and strength of rectal tone.
26 C. N. Eisenhauer and G. J. Jurkovich
Abdomen — As mentioned above, the sensitivity of a FAST exam is
not high enough to rely upon solely to exclude abdominal trauma. Any
penetrating injury should be thoroughly explored under local anesthesia to rule evaluate fascial penetration. Notes should be made of any
signs of blunt trauma, such as an ecchymosis across the lower abdomen in a seat belt distribution, as these give clues to the force of the
traumatic mechanism and raise the possibility of occult intraabdominal injury. The presence of tenderness to palpation or peritoneal signs
should prompt further workup of intraabdominal injury.
Pelvis — A thorough but gentle pelvic examination of the bony pelvis
should be performed in every blunt trauma patient. The anterior superior iliac spine, pubic symphysis, and lateral femoral trochanters
should all be examined for crepitus and tenderness to palpation. If any
of these structures are unusually mobile, the examination should be
stopped as excessive force or movement can cause further injury to the
patient. One important note to remember is that if you suspect a pelvic
fracture based on mechanism or physical exam and the patient is
hemodynamically unstable, immediately apply some form of pelvic
binder in order to reduce the pelvic volume and limit further hemorrhage.
Genitourinary — This portion of the exam is often accomplished dur-
ing the placement of a urinary catheter but can be deferred until the
secondary survey if that procedure was not performed. However, all
patients should have at a minimum the external orifices of their genitourinary structures evaluated for ecchymoses or frank blood. Also,
examine the perineum for signs of injury as well. Finding signs of
injury to these structures should raise suspicion for damage to the
urethra, pelvis, testicles, and vagina.
Extremities — Examination of a patient’s extremities after trauma
should start with visual inspection for obvious deformities, swelling,
ecchymosis, or bleeding. All extremities should be palpated in an
organized fashion so as to detect any points of tenderness or crepitus. All joints should also be flexed and/or extended to examine for
tenderness or crepitus. Any abnormalities should be worked up radiographically to evaluate for a fracture. Joints should also be examined
for instability as a traumatic dislocation often will cause injury to surrounding neurovascular structures. If a displaced fracture of an
extremity is detected, a manual BP cuff and a Doppler ultrasound
device should be used to compare the systolic blood pressure in the
Initial Approach to the Trauma Patient 27
extremity’s terminal artery (i.e. radial, dorsalis pedis, or posterior
tibial) to the contralateral limb as this has been shown to predict arterial injury.
Neurologic — In addition to examination of the pupils and spine, a
detailed neurologic exam should be performed. Detection of either
sensory or motor deficits should raise the possibility of injury to either
the central or peripheral nervous system, especially the spinal cord.
Carefully document these findings so that the progression of symptoms can be monitored closely during the patient’s care.
• Diagnostic Imaging
{ CT Head
When evaluating for traumatic injury, CT of the head should be per-
formed without IV contrast. It can be rapidly obtained once the patient
is positioned in the CT scanner and will provide invaluable data about
the presence, type, and severity of intracranial hemorrhage, the presence of skull fractures and pneumocephaly, and can show signs of
elevated intracranial pressure or herniation.
Any patient who presents with signs of hard signs of neurological
deficits, has significant alterations of consciousness, or who is intubated should undergo CT scan of the head. In addition, findings on
physical examination that suggest the presence of a skull fracture or
traumatic brain injury should also undergo a head CT.
In the setting of minor head trauma, there are two tools that have been
developed to determine the need for head CT — the Canadian CT
Head Rule and the New Orleans Criteria. Both of these tools have
been shown to reduce the need for head CT among these patients and
are reported to have 100% sensitivity in detecting patients with injuries requiring neurosurgical intervention. When compared to one
another, the CCHR has been shown to be less sensitive in detecting
non-operative traumatic head injuries but has a greater reduction in the
need for CT scans.
{ Cervical Spine — X-rays, CT, and MRI
Bony elements of the cervical spine can be imaged by both CT scan
and plain X-ray. Despite the lack of a randomized controlled trial
comparing the two directly, most experts agree that CT scan is far
more sensitive and specific for identification of fractures than are plain
films.