Resuscitation of the adult patient is an intense period of medical care in which initial and continuous patient assessment guides concurrent diagnostic and therapeutic procedures. As a dynamic period, resuscitation requires the trauma team to rapidly develop a differential diagnosis based on effectiveness of treatment and results of available diagnostic studies. When possible, the surgeon and emergency physician should direct this crucial activity. The supervising physician must ensure that the optimal resuscitation space, personnel, and equipment are present.

Resuscitation of the trauma patient requires an organized, systematic approach utilizing a well-rehearsed protocol. Advanced Trauma Life Support (ATLS) is a single-physician resuscitation course of the American College of Surgeons that prescribes an initial approach to an unstable patient with life-threatening injury (Table 4-1). The principles of ATLS resuscitation are also applicable to the Trauma Center environment and should be supplemented by a team approach to the trauma patient. The approach of a trauma team should be multispecialty and protocol driven based on patient “stability” and mechanism of injury (blunt vs. penetrating) (Fig. 4-1). This chapter presents a team-oriented approach for initial assessment and resuscitation.

The term “unstable” has classically referred to physiologic parameters such as vital signs (pulse, blood pressure, and respiratory rate). Patients with abnormalities of these vital signs are usually sending out a clear distress signal. However, in the context of trauma resuscitation, the definition of unstable can be expanded to include patients who are considered metastable (the capacity to change at any time). These patients exhibit subjective, objective, or anatomical findings that may predict need for specialized trauma care in the Trauma Center. These expanded criteria for instability (and metastability) are liberal and refer to the potential need for operative intervention or the intensive care unit (ICU) (Table 4-2). Patients who meet these expanded criteria usually have injuries that are life- or limb-threatening. A subcategory of unstable patients, those who present in extremis (sometimes referred to as “agonal”), requires a tailored approach.

Blood pressure response to initial fluid challenge is also a measure of stability. Hypotensive patients who sustain a normotensive response to the first 1 to 2 L of fluid are responders and considered stable. Transient responders and non-responders are unstable (generally from ongoing bleeding) and should be treated accordingly.

Significant injury may also be suspected from interpretation of key phrases verbalized by patients.

Assess for airway, breathing, circulation, and neurologic disability.

Immobilize cervical spine.

Administer O₂ nasally or by mask.

Insert at least one peripheral intravenous (IV) (18 gauge or larger).

Perform “stable patient” laboratory studies.

Splint deformed extremities.

Assess for occult injury.

Consider Insertion of a nasogastric tube (unnecessary in most stable patients).

Insert urinary catheter (if patient unable to void or pelvic fracture).

Limit IV fluid (e.g., 1 L in first 30 minutes).

Perform Select radiologic studies as indicated by mechanism of injury and physical examination.

Assess airway (with C-spine immobilization).