2 Albert Einstein Medical Center, Philadelphia, PA, USA
Background
Definition of disease
Trauma is injury due to an often sudden external force that affects one or many aspects of the body. Injury can be minor or it can be fatal.
Incidence/prevalence
Trauma is the fifth leading cause of death in the USA and the leading cause of death in people aged 1–44 years.
A fatal injury occurs nearly every 5 minutes.
By 2020, it is estimated that one in 10 people worldwide will die as a result of trauma.
Economic impact
In recent years, annual medical costs associated with injury and consequent loss of civilian work productivity in the USA has totaled over $500 billion.
Etiology
Blunt injury comprises about 75% of all trauma; penetrating injury accounts for the majority of the remainder; with blast, thermal, caustic, electrical, and radiation injuries comprising a small portion.
Approximately 70% of traumas are unintentional.
Traumatic brain injury (TBI) is the most common ultimate cause of death in the USA with over 2 million TBIs occurring annually.
Motor vehicle crashes are the leading mechanism of traumatic death.
Firearm‐related deaths are rising, and comprise the third leading cause of death in children between the ages of 10 and 19 years in the USA.
Falls are responsible for the majority of all deaths in people older than 65, and are the leading cause of non‐fatal injuries in all age groups.
Pathology/pathogenesis
Trauma is a heterogeneous process with variable manifestations depending on mechanism and energy of injury, location of injury, and the patient’s degree of physiologic plasticity.
Broadly speaking, mortality following trauma follows a trimodal distribution:
50% of people die immediately, 30% within the first few hours (a potentially salvageable period with appropriate interventions), and 20% die 1–3 weeks following the injury (often due to sepsis and multiorgan system failure).
Advanced trauma and life support initiatives mainly target the second peak where specific early interventions can prevent morbidity or mortality
Predictive/risk factors
Lower socioeconomic status is associated with a higher proportion of overall trauma as well as interpersonal and domestic violence.
Men are nearly three times as likely as women to become victims of trauma and are more likely to engage in violence.
People at extremes of age suffer proportionally higher fatality due to trauma.
Elderly have the highest rates of suicide.
Children are most likely to drown.
Prevention
Screening
Factors that predispose to trauma are more easily determined retroactively and are difficult to predict.
Implementation of alcohol abuse screening programs has been shown to reduce recidivism. The American College of Surgeons Committee on Trauma has mandated brief intervention initiatives in trauma patients testing positive for alcohol.
Primary prevention
As trauma mechanisms are distinct in different groups of people, preventive initiatives target different age groups and different sources of injury.
In general, unintentional trauma is more easily preventable than intentional because of the multiple social, economic, and psychological factors involved in the latter.
Use of automobile seat belts has been shown to reduce injuries and fatalities.
Injury prevention counseling in families with children and among the elderly has been shown to reduce unintentional trauma.
Gun safety initiatives in public service announcements and primary care settings may reduce firearm‐related injuries.
Secondary prevention
Secondary prevention follows the same basic strategy as primary prevention.
Victims of trauma are often more prone to subsequent trauma than the general population. Targeted behavior modification and education may reduce the risk of recurrence.
Diagnosis
Typical presentation
Presentation of the trauma patient is highly variable.
Individual trauma centers often have guidelines that specify criteria for activating different levels of trauma management. Different types of trauma are specific to geographic regions (e.g. an urban location may encounter proportionally higher penetrating traumas).
Generally speaking, a level 1 trauma center is the best equipped and receives patients with blunt and penetrating trauma in all age groups. It should have all the necessary resources to manage a critically ill patient including 24 hour surgical staffing, immediate access to imaging modalities and the operating room, and available surgical specialists (e.g. neurosurgery, orthopedic surgery).
Clinical diagnosis
History
History in a trauma patient may sometimes be suboptimal due to the patient’s mental status and a lack of bystanders familiar with the patient.
A thorough trauma history should be specific and limited to information pertinent to the circumstance; it should be detailed enough to help guide differential diagnoses but not so drawn out to delay necessary evaluations or interventions.
The examiner should first inquire about circumstances of the injury to set a context, often provided at time of presentation, as mechanism of injury can provide clues.
AMPLE questions should be ascertained:
Allergies.
Medication.
Past medical history including tetanus status.
Last meal.
Events leading to injury.
Physical examination
The examination should begin with rapid assessment of the most critical potential sources of early mortality, the patient’s airway, breathing, and circulation (‘ABCs’), while the patient’s clothing is removed to provide complete exposure.
Ask the patient to speak, visualizing the work of breathing, assessing jugular venous distension and tracheal position, and listening for breath sounds to quickly evaluate airway patency and respiratory compromise.
Heart rate and blood pressure in conjunction with a pulse examination provide information on the circulatory system.
Disability or the patient’s neurologic status should also be assessed by speaking to the patient and assessing responsiveness, evaluating pupillary response, and monitoring extremity movement (patient history is useful, as abnormalities could signify stable baseline or traumatic brain injury with impending intracranial herniation).
If ABCs are intact, a secondary survey should proceed with a thorough head‐to‐toe examination.
This should include inspection and palpation and a neurologic assessment.
It is crucial to log roll the patient to examine all areas (while maintaining cervical spine precautions if there is concern for a neck injury).
Following initial treatment, a tertiary survey must be conducted including a thorough review of the patient’s medical record and pertinent comorbidities and thorough repeat examination to search for missed injuries.
Useful clinical decision rules and calculators
A patient with diminished neurologic function, equal to or less than a Glasgow Coma Scale (GCS) score of 8 should be considered for intubation for airway control.
If a patient is intubated for respiratory distress, a CXR should be obtained as soon as possible to rule out a pneumothorax which could be exacerbated by intubation.
Emergency department thoracotomy should be considered in a penetrating injury with signs of life (SOL) at the scene of injury and loss of SOL 5 minutes prior to ED arrival, or blunt injury in which SOL were lost on arrival to the ED.
Disease severity classification
A multitude of trauma scoring systems have been developed over the past 30 years, but none have been universally accepted by all trauma authorities.
While many provide useful information for prognostication and management, their main utility is in research and comparison of hospital outcomes.
Scoring systems can generally be divided into anatomic and physiologic scores.
The Injury Severity Score (ISS), calculated based on degree of injury to one of six body regions, has been shown to predict mortality, and is probably the most widely use anatomic method (www.mdcalc.com/injury‐severity‐score‐iss).
The Revised Trauma Score (RTS) is the most widely used physiologic measure. It incorporates GCS score, a 15 point assessment of neurologic function, as well as respiratory rate and blood pressure (www.mdcalc.com/revised‐trauma‐score). It has similarly been shown to correlate well with survival and is a useful adjunct in triage decision making.
Laboratory diagnosis
List of diagnostic tests
Many laboratory tests are patient specific and may not be of initial use in an unstable patient needing urgent intervention.
Typical initial tests include:
Complete blood count (CBC) to establish a baseline hemoglobin and platelet count.
Basic metabolic profile (BMP) to determine kidney function, electrolyte abnormalities, and blood glucose level.
Lactate level as an indicator of hypoperfusion.
Alcohol and urine drug screen.
Beta‐human chorionic gonadotropin (β‐HCG) to diagnose pregnancy in a woman of child‐bearing age.
Arterial blood gas (ABG) if concern exists for acid–base abnormality or pulmonary dysfunction.
Prothrombin time (PT) or international normalized ratio (INR) in a patient taking warfarin.
Blood type and cross in a patient likely to need blood product transfusions.
Urinalysis or urine dipstick if possible genitourinary trauma occurred and if there is concern for rhabdomyolysis or infection.
List of imaging techniques
Radiologic studies should similarly be guided by mechanism of injury and examination.
If other diagnostic methods are present, time‐intensive imaging studies should be avoided in unstable patients.
Common initial tests include the following (list is not comprehensive):
Typically all patients undergo electrocardiogram.
Chest X‐rays are often routine, except in patients with isolated extremity penetrating injury.
Pelvic X‐rays are used to evaluate blunt injuries.
Focused assessment using sonography for trauma (FAST): indicated for hypotension, chest or abdominal trauma, impaired consciousness, and pulseless electrical activity (may be obviated by diagnostic peritoneal lavage in abdominal trauma).
CT head: penetrating trauma to the head, or blunt trauma to the head with high energy mechanism, altered mental status or focal neurologic defect, headaches, or presence of anticoagulation.
CT spine: spine tenderness or new motor or sensory neurologic defects.
MRI spine: new motor or sensory deficits or persistent pain without bone disruption.
CT abdomen: abdominal tenderness or stable patients with blunt trauma and positive FAST, presence of macroscopic or microscopic hematuria, and low rib fractures.
Angiography neck: blunt neck trauma with new neurologic defect, penetrating neck trauma, first rib fractures.
Retrograde urethrogram: concern for urethral injury.
Extremity film: extremity tenderness.
Doppler arterial exam and arterial to brachial indices: abnormal or differential in pulse exam.
Diagnostic algorithms
As trauma is a rather broad field, algorithms have been developed for many different types of injuries (see Guidelines section).
Following initial resuscitation and FAST exam, clinicians assess stability and decide on whether abdominal imaging or laparotomy is necessary.
Potential pitfalls/common errors made regarding diagnosis of disease
Sole focus on one specific site of injury can lead to delay in or failure to recognize concurrent life‐threatening injuries.
Patients at extremes of age, trained athletes, pregnant patients, and those taking medications may have altered physiologic responses, which can confound degree of illness.
A normal hemoglobin level in the setting of blood loss may not be accurate as whole blood is lost.
In a hemodynamically unstable patient with obvious head trauma, the temptation to image the head should be avoided in search of other sources as the head is rarely a source of hypotension and is less likely to cause imminent death.
Blast and firearm injuries may cause more extensive damage at the cellular level than can initially be recognized grossly.
Treatment
Treatment rationale
Treatment should begin as soon as the patient presents and should occur in concert with evaluation.
Initial steps include placement of two preferably large bore IVs (or central venous access) and initiation of oxygen by nasal cannula or facemask.
In patients with blunt trauma, a cervical collar should be placed for cervical spine immobilization until the extent of injury is determined.
As with triage and diagnosis, treatment should be individualized.
Initial management is guided by ABCs, which will sequentially identify the earliest and most threatening potential sources of mortality.
After airway and breathing have been deemed intact, focus should shift to causes of circulatory compromise, as hemorrhage is the predominant cause of preventable death.
Other causes of hypotension including cardiogenic, obstructive, and neurogenic shock should be ruled out.
Initiation of warmed isotonic IV fluids should begin on any patient with a systolic blood pressure <110 mmHg and a heart rate >100 beats/min with a rapid search to identify the origin of blood loss
Due to cost and its potential deleterious effects, colloids should be avoided.
Frequent reassessment of resuscitation should occur (with clinical assessment, urinary output, laboratory values) to avoid under‐ or over‐resuscitation.
Initiation of blood product transfusion should be based on clinical judgment.
In general, if an adult patient does not respond or transiently responds to 2 L of fluids and has a mechanism of injury concerning for possible hemorrhage, initiation of blood products should begin with a 1:1:1 blood product ratio (PRBC : FFP : PLT) to avoid coagulopathy.
Blood products should ideally be limited to maintain hemoglobin above 7 g/dl.
When to hospitalize
Transfer to a level 1 trauma facility should be considered in the following conditions:
GCS ≤13, SBP <90, RR<10 or >20 in an adult.
Two or more long bone fractures, mangled extremity or amputation, pelvic fracture, new paralysis.
Penetrating injuries to the head, neck, torso, or proximal extremities.
Falls in adults of ≥2 stories, or in children 2–3 times height.
Significant blunt mechanism including automobile versus pedestrian or motorcycle accident >20 mph, ejection from vehicle, significant destruction to vehicle.
Traumatic injury in a woman >20 weeks pregnant, burns in patients with traumatic mechanisms, and children and elderly with a significant mechanism and unreliable examination.
Managing the hospitalized patient
Two important concepts to consider in the critically ill patient include definitive airway control and damage control surgery.
Airway control
Some indications for airway control include apnea, depressed consciousness (typically GCS ≤8), respiratory distress or respiratory compromise, airway obstruction or facial or neck injury with potential to compromise airway, combativeness or risk for deterioration with continued need for diagnostic or therapeutic interventions, cyanosis.
Definitive airway control includes nasotracheal intubation, orotracheal intubation, and a surgical airway.
Nasotracheal intubation is contraindicated in apnea, basal skull fracture, and some facial fractures.
If accessible, endotracheal is the preferred route of intubation.
If endotracheal intubation fails, a surgical airway must be placed.
In adults, cricothyroidotomy is preferable to tracheostomy because it is easier, quicker, and causes less bleeding.
Endotracheal intubation is temporary and may be converted to a tracheostomy as a definitive airway after 14 days if the patient is unable to be weaned from mechanical ventilation.
If prolonged intubation is anticipated, consideration should be given to performing an early tracheostomy between days 3 and 7, which may reduce upper airway trauma, overall mortality, and length of hospital stay.
Damage control
Damage control is a method of rapidly accomplishing the minimum necessary to stabilize the critically ill patient. It begins with resuscitation in the trauma bay, continues to the OR, followed by transport to the ICU for continued resuscitation. More definitive procedures (e.g. abdominal closure, bowel anastomosis) are performed after the patient is stable.
Prevention of the lethal triad of hypothermia, acidosis, and coagulopathy is crucial.
A damage control technique should be considered in patients requiring massive resuscitation (>10 units PRBC or >12 L fluids), continued acidosis (pH <7.2), hypothermia (<34°C), inaccessible vascular injuries or need to return to the OR for an additional reassessment, and patients with high peak airway pressure or difficulty closing the abdomen.
An abdominal operation should identify and abolish hemorrhage and minimize intra‐abdominal contamination.
Temporary abdominal closure should be achieved with a vacuum‐assisted device, which places tension on the abdominal fascia and does not harm visceral structures.
Morbidity and mortality decreases proportionately with shorter duration of OR time until the abdomen is closed. As soon as the patient is hemodynamically stable and well resuscitated, abdominal closure should occur.
Similar damage control concepts can be applied to management of thoracic, vascular, and orthopedic injuries.
Prevention/management of complications
The third wave of trauma‐related mortality is most often due to sepsis and multiorgan dysfunction syndrome (MODS).
MODS is a complex process due to inflammatory or immune dysregulation with deleterious systemic effects.
Prevention of MODS and sepsis begins in the initial stages of treatment.
Management includes rapid identification of the cause, appropriate use of antibiotics when indicated, aggressive nutritional support, prevention of hypoxemia and hypotension, avoidance of nephrotoxic agents, use of lung protective ventilation strategies, limitation of blood product transfusions, and maintenance of euglycemia.
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