Approach to the Trauma Patient

Chapter 95


Approach to the Trauma Patient image



Trauma is the leading cause of death in people under the age of 45 and represents a significant public health problem in the United States. In addition to the profound effect on public health, the implications from traumatic injuries consume a substantial amount of medical and economic resources. Medical expenditures attributed to injury exceeded $117 billion in 2000 with nearly 10% of total U.S. medical spending going toward the care and rehabilitation of the injured patients.



Patterns of Mortality from Trauma


In 1983 Donald Trunkey described, in what has now become a classic paper in trauma literature, the trimodal distribution of trauma deaths. The first time period occurred within 1 to 2 hours of the injury and was defined as “immediate.” The lethal injuries in this “immediate” period were usually due to lacerations of the brain stem, spinal cord, heart, aorta, or other large blood vessels and accounted for 45% of all trauma deaths. “Early” deaths (Trunkey’s second time period) were those that occurred within 4 hours of injury. Thirty-four percent of deaths occurred in this time period and were due to subdural and epidural hematomas, tension hemo- or pneumothoraces, splenic rupture, liver lacerations, pelvic fractures, or multiple injuries with major blood loss. Injuries occurring in this time period were found to benefit most from expeditious interventions such as decompressive craniectomy, tube thoracostomy or splenectomy. The third peak, termed “late deaths,” occurred days to weeks after the injury and accounted for 20% of all trauma-related mortality. These deaths were secondary to infection, the acute respiratory distress syndrome (ARDS), and multiple organ system failure (MOSF). Since this description of trimodal trauma-related mortality, there have been significant advances in injury and safety prevention as well as the development of regionalized trauma systems and implementation of rapid prehospital transportation networks. As a result of these developments and further maturation of trauma systems, more recent reports question the validity of the classical trimodal mortality model.


The development of the current Advanced Trauma Life Support (ATLS) has also had a significant impact on trauma-related mortality. Injuries are addressed in a systematic fashion (the classic “ABCs” of resuscitation) such that the airway is secured first, followed by treatments to improve breathing (e.g., decompression of a pneumothorax), and finally circulation is restored by cessation of hemorrhage and fluid resuscitation. image


The ATLS system was originally founded after the pilot of a crashed airplane, Dr. James Styner (also an orthopedic surgeon), witnessed firsthand the flawed “system” of trauma care that existed in the 1970s. Based on this experience, he and others revolutionized the initial treatment of the injured patient by developing a standardized, systematic approach to the initial assessment.


In 1978, the first ATLS course incorporating these initial ABC’s of patient management was taught, and in 1979 the course was formally adopted by the American College of Surgeons, Committee on Trauma. It is now taught throughout the United States and in 46 other countries. ATLS gives practitioners a standardized, systematic approach to the injured patient. These advancements in pre-hospital care have led to the timely delivery of patients with life-threatening injuries to emergency departments within the “golden hour” and have saved many of their lives as a result of the rapid assessment and treatment set forth by the ATLS guidelines.



Initial Management of the Trauma Patient


The primary survey (Table 95.1) is used to quickly identify and treat life-threatening injuries and includes securing the airway, assuring adequate ventilation and oxygenation, and resuscitating with intravenous fluids. Fluid resuscitation is initiated with crystalloid, preferably 0.9% normal saline, or blood products. Transfusing packed red blood cells (pRBCs) in the face of active hemorrhage is traditionally preferred because it not only restores intravascular volume but also improves the oxygen-carrying capacity (see Chapters 9 and 19 for more details about recommendations for the transfusion of blood products).



Following the primary survey, the patient is examined from head to toe in a detailed yet expeditious fashion in order to identify other injuries. This comprises the secondary survey. Adjuncts to the secondary survey include radiographs, ultrasound, and computed tomography.


The ATLS course recommends obtaining an anterior-posterior (AP) chest radiograph and a pelvic film. The chest radiograph is an excellent way to identify pneumothoraces, hemothoraces, rib fractures, and, if intubated, the position of the endotracheal tube. The pelvis radiograph is strongly indicated if the patient is unable to be examined because of obtundation or sedation, has a pelvic deformity, is experiencing pain, or is hemodynamically unstable. image


Prior to the widespread utilization of computed tomography, a lateral cervical spine radiograph was done to identify malalignment of neck vertebrae. This was routinely followed with an anterior cervical and odontoid view to complete the evaluation.


Focused abdominal sonography for trauma (FAST) is a commonly used diagnostic tool to evaluate blunt abdominal trauma. The sensitivity and specificity of this modality range between 73% to 88% and 98% to 100%, respectively. FAST has several advantages over other imaging modalities. It is rapid (usually performed in a matter of minutes), non-invasive, and easily performed in the trauma bay in concert with the ongoing resuscitation. Ultrasound machines are also portable and allow the study to be repeated easily whether the patient remains in the trauma bay or is moved to the intensive care unit (ICU). The FAST is helpful in identifying intra-abdominal hemorrhage and in helping to triage the unstable patient with multiple injuries. It can also be used to triage the pregnant patient, thereby limiting the amount of radiation exposure to the fetus. image


One drawback to the FAST exam is that it is user dependent. With experience, however, an operator may detect as little as 200 mL of intra-abdominal fluid. Additionally, the FAST exam is less reliable at identifying injuries not typically associated with a large amount of intra-abdominal fluid early in their presentation (e.g., hollow viscous, pancreatic injury, retroperitoneal injuries). However, the FAST is an excellent tool for helping to triage patients with blunt mechanisms. Unstable patients with a positive FAST require emergent laparotomy, whereas stable patients with a positive FAST may be assessed with other imaging modalities including computed tomography scans to better evaluate the extent of their injuries.


Other imaging, which may be indicated in the stable patient, includes computed tomography (CT) scans of the head, c-spine, chest, abdomen, and pelvis. CT scans of the head without contrast are essential for identifying intracranial injuries that may require neurosurgical intervention such as subarachnoid, subdural, and epidural hemorrhages. A CT scan of the cervical spine, also without contrast, allows excellent visualization of bony abnormalities, malalignment of vertebrae, or vertebral retropulsion into the spinal canal. These images may be reconstructed in sagittal and coronal dimensions in addition to the standard axial planes. Although CT scans of the cervical spine are very sensitive for fractures and malalignment, they are not adequate to diagnose ligamentous injury.


CT scans of the chest, abdomen, and pelvis will identify great vessel injuries, pulmonary contusions, pneumothoraces, solid organ injuries to the spleen, liver, and kidneys, as well as free fluid suggestive of hollow viscous injuries. However, a CT scan of the abdomen and pelvis immediately after the injury is unable to reliably diagnose hollow viscous or pancreatic injuries as there may be no or minimal free fluid within the abdomen. To make this diagnosis, one must rely on physical exam and clinical suspicion.


It must be emphasized that hemodynamically unstable patients who have sustained an injury via a blunt mechanism should not be evaluated by CT. Rather, they should undergo FAST exam or diagnostic peritoneal lavage (DPL) and, if appropriate, they should be taken to the operating room for surgical exploration. image


Patients with multiple injuries frequently require specialized care. Patients with traumatic brain injuries, for example, may require intracranial pressure monitoring and associated treatment (see Chapters 41 and 99). Those with chest trauma may require mechanical ventilator support (see Chapter 100), whereas patients with solid organ injuries or pelvic fractures may need aggressive fluid resuscitation and hemodynamic monitoring. These treatment modalities and procedures are best served in the surgical intensive care unit (SICU).



Evaluation of the Trauma Patient upon Arrival to the Intensive Care Unit


Upon arrival to the SICU, the trauma patient should undergo another complete evaluation by the critical care team. The details of the patient’s trauma event and clinical condition should be reviewed and a detailed account of any performed procedures should be communicated. Past medical history including medications, allergies, and social habits must be obtained, often from the patient’s family members and friends. A complete physical exam must be performed. All laboratory tests should be reviewed in detail and additional tests should be obtained as necessary such as lactate, arterial blood gases, hemoglobin, and creatine phosphokinase (CPK). The trends of these values is often more important than a single measurement. The ICU physician should reexamine all previously obtained radiographs, including CT scans, to look for injuries that may have been missed. It is helpful to make a list of all lab tests and radiographs that remain outstanding or need an official interpretation by a radiologist to ensure that nothing is missed (Box 95.1).



BOX 95.1   Trauma Patient Evaluation upon Arrival to the Intensive Care Unit

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Approach to the Trauma Patient

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