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28 C. N. Eisenhauer and G. J. Jurkovich
Any patient that has sustained blunt trauma who cannot be examined
because of their level of consciousness, has obvious neurological
deficits or concerning physical exam findings, or has significant
distracting injuries that prohibit a thorough examination should
undergo cervical spine CT. Notice that these guidelines are similar to
those pertaining to head CT, and often times a blunt trauma patient
should undergo both tests.
Two predictive tools have been designed to predict which patients
should undergo cervical spine CT — the Canadian C-Spine Rule and
the NEXUS Criteria. Prospective data has shown that the CCSR has
higher sensitivity and specificity in predicting cervical spine fractures
and has been accepted as the standard tool at most trauma centers.
Unfortunately, cervical spine CT is limited in its ability to detect liga-
mentous injury or damage to the spinal cord. Remember that
ligamentous injury alone can produce an unstable cervical spine so a
negative CT cervical spine is not a definitive test. In patients who have
a suspected ligamentous or spinal cord injury, an MRI is warranted to
determine the presence and severity of such injuries.
{ CT Chest
Portable chest X-rays that are obtained in the trauma bay are usually
of such low quality that they should be regarded as a screening tool.
While formal chest radiography with PA and lateral chest X-rays is
very useful for detecting the presence of a pneumothorax, pleural effusion/hemothorax, rib fractures, or widened mediastinum, the portable
trauma bay films are not sensitive enough to definitively rule out these
conditions in most patients.
For this reason, a trauma patient should undergo chest CT if there is
any question of thoracic trauma after the completion of the primary
and secondary surveys. This study should always be performed with
IV contrast so that the great vessels can also be evaluated for injury.
For patients who have been in a motor vehicle collision, it is important
to remember that a velocity of 30 mph imparts enough kinetic injury to
potentially cause blunt aortic injury if the rate of deceleration is significant enough. These injuries cannot be reliably excluded with plain films
alone and these patients should have a chest CT for definitive diagnosis.
The diagnosis of an occult pneumothorax, which is a pneumothorax
that is present on chest CT but not chest X-ray and does not need to
be treated with immediate tube thoracostomy, is that the comparison
Initial Approach to the Trauma Patient 29
X-ray must be an upright film. A pneumothorax usually rises to the
highest area of the chest and as such can move depending on a
patient’s position. A relatively large pneumothorax can be missed on
a portable supine chest X-ray since they are often located anterior to
the lung parenchyma, but will be easily detected on an upright film.
{ CT Abdomen/Pelvis
The early detection of intraabdominal injuries is incredibly important
for both operative and nonoperative conditions, and in some instances
has been related to the overall mortality of trauma patients. This is
especially true of hemodynamically stable patients with hollow
viscous injuries.
Although the FAST exam is reliable in diagnosis of intraabdominal
injury when it detects free fluid, the sensitivity is low enough that it
should not be relied upon solely to rule out intraabdominal injury.
Instead, patients who have injury mechanisms or physical exam findings that are suggestive of abdominal trauma should undergo CT of
the abdomen and pelvis with IV contrast.
While abdomen/pelvis CT has nearly 100% sensitivity for solid organ
injury, it has been well-documented that the sensitivity for hollow
organ injury is poor. Thus, the finding of intraabdominal fluid in the
absence of a solid organ injury should give rise to a high suspicion of
bowel injury and the patient should be followed closely with serial
abdominal exams.
{ CT Arteriogram
As mentioned above, the finding of a displaced extremity fracture war-
rants a comparison of the terminal blood pressure of that limb to the
contralateral limb (A:A). A ratio of < 0.9 has high sensitivity in detecting acute arterial injury and should undergo imaging to diagnose this.
Before the advent of CT scanners, arteriograms were both time and
labor intensive and carried the risk of iatrogenic vascular injury.
However, CT arteriogram has been widely accepted as the gold standard for detection of acute arterial injury in trauma patients.
Given the need for urgent intervention in acute arterial injuries, CT
arteriograms are often obtained at the same time as other traumarelated CT scans. Two things must be kept in mind when this is the
case — the first is that the CTA is an additional contrast load in
addition to the other scans requiring IV contrast, and the second is that
30 C. N. Eisenhauer and G. J. Jurkovich
it can be difficult to synchronize the timing of the contrast load and
image acquisition when other images protocols are being obtained.
If there is ever a question as to the accuracy of a CT arteriogram, the
patient should undergo formal angiography. It is preferable to perform
this in a hybrid style operating room, where open or endovascular
intervention can immediately be performed after definitive diagnosis
has been established.
Review of Current Literature with References
• Stiell IG et al. “The Canadian C-spine rule versus the NEXUS low-risk crite-
ria in patients with trauma.” N Engl J Med 2003; 349: 2510–2518.
This prospective cohort study was designed to evaluate the accuracy of the
Canadian C-spine rule (CCR) and the National Emergency X-Radiography
Utilization Study (NEXUS) algorithms in predicting significant cervical spine
injury in alert trauma patients. The data showed that the CCR was both more
sensitive and specific than NEXUS in predicting significant injuries. The
authors concluded that the widespread use of CCR would lead to a decreased
need for cervical spine radiographs in trauma evaluations.
• Smits M et al. “External validation of the Canadian CT Head Rule and the
New Orleans Criteria for CT scanning in patients with minor head injury.”
JAMA 2005; 294: 1519–1525.
This prospective multicenter study conducted in the Netherlands was
designed to validate and compare the Canadian CT Head Rule (CCHR) and
the New Orleans Criteria (NOC), two algorithms designed to predict the need
for head CT among trauma patients. Only patients with a GCS ≥ 13 were
included in the study. The data showed that both algorithms identified every
patient with an intracranial injury severe enough to warrant neurosurgical
intervention, although the NOC had a higher sensitivity for clinically important findings. The authors concluded that the CCHR was the superior tool
given that it would not miss any injuries requiring surgical intervention and
that its widespread use would reduce the need for head CT in these patients
by 37.3%, although they did not speculate as to the repercussions of the
potential for increased incidence of missed clinically-important findings.
• Johansen K et al. “Objective criteria accurately predict amputation following
lower extremity trauma.” J Trauma 1990; 30: 568–572.
The mangled extremity severity score (MESS) is a tool used to evaluate the
severity of lower extremity trauma based on skeletal and soft tissue damage,
Initial Approach to the Trauma Patient 31
limb ischemia, shock, and age. This review of early data for the MESS showed
that there was indeed a correlation between MESS value and the need for amputation of traumatic limbs. Salvaged limbs had an average MESS of 4–5 and
doomed limbs had an average MESS of 8–9 on initial assessment. A MESS
value > 7 was found to be 100% sensitive for predicting the need for amputation.
• Kortbeek JB et al. “Advanced trauma life support, 8th edition, the evidence
for change.” J Trauma 2008; 64: 1638–1650.
In 1976, Dr. Jim Styner came to the realization that the care for trauma
patients in the U.S. needed systematic improvements after he and his family
were involved in an airplane crash in rural Nebraska. That tragedy led to the
development of the Advanced Trauma and Life Support course in 1978. Since
then, the ATLS has been the quintessential tool for the education and training
of surgeons in the initial assessment and management of trauma victims. The
most recent update to this course, the 8
th
edition, has made many evidence
based changes to the longstanding course and uses graded levels of evidence
to evaluate and approve course material.
• MacKenzie EJ et al. “A national evaluation of the effect of trauma-center care
on mortality.” N Engl J Med 2006; 354: 366–378.
The purpose of this retrospective review was to determine the impact of
hospitals with a Level 1 trauma designation in lowering mortality after
trauma. To do so, the authors examined survival data from 18 Level 1 hospitals and 51 non-trauma hospitals in 14 states and included 5,191 patients aged
18 to 84 years with moderate to severe injuries. Data analysis showed a
significant difference favoring patients treated at Level 1 facilities for both
in-house mortality (7.6% vs. 9.5%, 95% CI 0.66–0.98) and 1 year mortality
(10.4% vs. 13.8%, 96% CI 0.60–0.95), with the greatest differences seen
among patients with more severe injuries. Accordingly, the authors recommended further efforts directed at regionalization of trauma care.
• Baker SP et al. “The injury severity score: a method for describing patients with
multiple injuries and evaluating emergency care.” J Trauma 1974; 14: 187–196.
Now a common tool in trauma care, the injury severity score was first developed
and documented in this paper by Dr. Susan P Baker as a method of determining
the impact of multiple injuries on the overall survival of trauma patients. The
tool is based on assessment of injury to six body regions (head & neck, face,
chest, abdomen, extremity, and external) and utilizes the three most significant
injuries to calculate an overall score. This scoring system has proven itself as
being an accurate predictor of trauma-related mortality and is one of the most
invaluable variables that can be collected and analyzed in trauma research.
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Chapter 3
Systems-based Approach to the Critically Ill Surgical Patient
Fredric M. Pieracci, MD, MPH*
*Acute Care Surgeon, Denver Health Medical Center
Take Home Points
• Most critically ill surgical patients present with complex, multi-system
pathology.
• Using a standardized, systems-based approach to data collection, data presen-
tation, assessment, and plans will minimize confusion, omission of important
information, and medical errors.
• Using this approach entails creation and implementation of a standardized
data collection tool, or “ progress note,” that is organized by systems (Fig. 1).
• This daily progress note can be supplemented with a “problem list” that is
included in the front of the chart (or electronic medical record), which is
continually updated as problems both arise and are solved.
• Adoption of the aforementioned approach has been associated with improved
patient outcomes, as well as physician and nurse satisfaction.
Contact information: Denver Health Medical Center, 777 Bannock Street, MC 0206,
A388, Denver, CO 80206; Email: Fredric.Pieracci@dhha.org
33
34 F. M. Pieracci
• Modern surgical critical care benefits from a multi-disciplinary approach,
involving physicians, nurses, respiratory therapists, pharmacists, physical and
occupational therapists, registered dieticians, and social workers.
Representatives from these disciplines should be involved in daily rounds
whenever possible.
Main Body
• The complex pathophysiology observed in critically ill surgical patients
is simplified by using a “ systems-based approach.” Whenever the patient is
considered, data are organized “by system,” or presented “from head to toe.”
There are multiple ways to group information; the important point is that all
relevant systems are included, and that the form is standardized such that each
system is discussed every time. Our system grouping is discussed below.
• General (overnight events): Major interval events since the last presentation
are disclosed. One should avoid summarizing relatively mundane information
that will otherwise be discussed in other systems (e.g., the patient had a fever
overnight and a lower respiratory tract culture was obtained). Rather, major
changes in clinical status are discussed, such as new shock, new pressor
requirement, return to the operating room, and major bedside procedures
(e.g., laparotomy).
• Neurologic: Neurologic diagnoses are reviewed. For trauma patients, the
Glasgow Coma Score is reported. The RASS and CAM scores are also
reported. The remainder of the neurologic exam is reviewed, including
movement, cognition, and alertness. For severely injured patients, brainstem
reflexes are reviewed. Any intracranial pressure monitors and their values are
reported, including ventriculostomy, bolt, and other operative drains.
Strategies for elevated intracranial pressures are discussed [Chapter 4-(ii)].
Current medications, including anaglesics, sedatives, anti-pyschotics, and
anti-epileptics are reviewed. A daily assessment of the ability to decrease the
medications, or at least attempt a sedation holiday, is made [Chapter 5-(vi)].
Spine clearance and mobility status is reviewed [Chapter 5-(v)].
• Respiratory: Pulmonary diagnoses are reviewed. Ventilator settings are
listed, including discussions of (1) appropriateness for ventilator liberation
and (2) appropriateness for extubation. For patients with either acute lung
injury or acute respiratory distress syndrome, additional ventilator variables
are reported, such as the peak and plateau airway pressures, compliance, and
P:F ratio. Presence and character of tracheal secretions are noted (this is often
Systems-based Approach to the Critically Ill Surgical Patient 35
a good time to touch base with the patient’s respiratory therapist). The arterial
blood gas is interpreted. Presence of pleural drains is noted, including type,
drainage mode (water seal, suction at 20 cm H2O, etc.), drainage amount,
respiratory variation (tidal), and air leakage. If available, the daily chest
X-ray is reviewed.
• Cardiovascular: The heart rate, rhythm, and blood pressure are reported. For
patients in shock, secondary markers of preload responsiveness, cardiac
output, oxygen delivery and oxygen consumption are reported. The diagnosis
of shock, its etiologies, and use of vasoactive medications are noted. Markers
of end organ perfusion and resuscitative progress are addressed (pH, base
deficit, lactate). Other cardiac medications are reviewed. For patients with
active vascular pathology (e.g., blunt carotid or vertebral artery injuries), the
relevant physical exam findings, radiographic findings, and medications are
reviewed. Assessment for compartment syndrome is included in this portion
of the presentation.
• Gastrointestinal: Intra-abdominal injuries and their management are reviewed.
The route, formulation, and caloric amounts of nutrition is reported. Patients
who are intolerant of enteral medications should have the workup presented,
including physical exam, laboratory values, and radiology studies [Chapter
8-(iii)]. Intra-abdominal pathology, including liver, biliary, and pancreatic
disease [Chapter 8-(v)] are discussed.
• Renal: The urine output, as well as the total inputs and outputs over the last
predetermined period, are reported. Laboratory values such as the blood urea
nitrogen and creatinine are reviewed. The workup for oliguria and/or rising
creatinine is reported [Chapter 7-(iii)]. Any urinary drains, their output
amount and character, are presented.
• Hematologic: Anemia is reported and characterized. Indication for pRBCs
transfusions are addressed [Chapter 9-(i)]. Coagulation status is reported,
including platelet count, coagulations markers, and thromboelastograms.
Anti-coagulant medications, their indications, and therapeutic ranges are
reviewed.
• Infectious Disease: Each infection site, microbiology, and therapy is reviewed
in turn. Some standard verbiage for reporting antibiotics is shown in the
examples below. Note that each has (1) the infection site; (2) the microbiology;
(3) the indication for therapy (i.e. prophylactic, empiric, or definitive);
(4) the duration of therapy; and (5) drug dosage:
{ “The patient is on cefazolin 1 gram IV q8H, day one of one of prophylactic
therapy for an open femur fracture.”
36 F. M. Pieracci
{ “The patient is on vancomycin 1 gram IV q12H and cefepime 2 grams IV
q12H, day 2 of empiric therapy for ventilator associated pneumonia.
Cultures are pending.”
{ “The patient is on cefepime 2 grams IV q12H, day 4 of 8 of definitive
therapy for pseudomonas ventilator-associated pneumonia.”
Workup for new infections (usually in the setting of a fever) is reported in
terms of site investigated, tests performed, and cultures drawn, including pulmonary [Chapter 10-(iv)], blood [Chapter 10-(viii)], urine [Chapter 10-(v)],
abdominal [Chapter 10-(vi)], central nervous system [Chapter 10-(vii)], central
venous catheter [Chapter 10-(viii)], and wounds.
• Electrolytes/Metabolism: Electrolyte disturbances, their workup, etiologies,
and treatments are reviewed. Glycemic control is assessed [Chapter 11-(iii)].
Total parenteral nutrition formulation and contents are reviewed.
• Prophylaxis: Indications for venous thromboembolism, stress ulcer, antimi-
crobial prophylaxis are reviewed, and prophylactic agents specified. For
patients in whom VTE prophylaxis is current being withheld, the plan for
beginning such prophylaxis is discussed (e.g., 72 hours from craniotomy)
[Chapters 9-(ii) and 9-(iii)]. Duration of indwelling central venous catheters
is reported.
Systems-based Approach to the Critically Ill Surgical Patient 37
Practical Algorithm(s)/ Diagrams
Fig. 1. Denver health medical center surgical intensive care unit daily progress note.
Review of Current Literature with References
• Thornton et al. documented the high frequency of copied, redundant informa-
tion throughout the medical record of critically ill patients (Crit Care Med
2013; 41: 382).
• Dodek and Raboud reported improved communication and provider satis-
faction after implementing a standardized, systems-based approach to patient
presentation on ICU rounds (Intensive Care Med 2003; 29: 1584).