Initial Assessment of the Multiple Trauma Patient
TRIAGE
Triage is defined as the planning for care to patients on the basis of need or severity of illness. Although clear exceptions occur, patients with compromise of the airway should be seen and treated first because if the airway is inadequate, then survival is most immediately threatened. Second, breathing, or the adequacy of air exchange within the chest and oxygenation, must be ensured. Third, the circulation must be evaluated and restored and bleeding arrested. For most patients, these three priorities provide a reasonable initial basis for the determination of the urgency of care.
ASSESSMENT
Perhaps in no other clinical setting is the importance of a well-defined, rigorous strategy for patient evaluation more apparent than in the patient with multiple injuries. Begin the assessment with an initial evaluation using the mnemonic ABCDE; during this time, specific critical functions are sequentially evaluated, resuscitation is instituted, and life-threatening conditions are corrected. After the initial assessment and resuscitation, a more detailed secondary survey and a definitive care phase follow.
Primary Survey and Resuscitation
During the initial assessment, as one moves sequentially through the mnemonic, ABCDE, life-threatening conditions are diagnosed and corrected at each stage. This hierarchy of assessment and treatment should be strictly followed.
A: Upper airway is established and maintained with cervical spine control.
B: Breathing (or the adequacy of air exchange) is evaluated and established.
C: Circulation-blood pressure is evaluated and corrected, and bleeding is arrested.
D: Deficits of neurologic function are identified, and treatment is initiated.
E: Exposure is obtained by completely undressing the patient.
A: Upper airway is established and maintained along with cervical spine control. All patients presenting with head, neck, or facial trauma, or neurologic symptoms, such as weakness or abnormalities of mental status after trauma, however subtle, must be assumed to have injuries to the cervical spine, and strict attention given to immobilization of the neck must be maintained. This is undertaken with a combination of a spine board, to which the patient’s head must be secured, with the application of a rigid or semirigid cervical collar (not a soft collar) and manual maintenance of the head and neck in the neutral position.
Airway intervention, if required, must proceed rapidly. Begin the assessment of the airway by determining whether the patient can speak normally; if so, a reasonable airway probably exists, and other priorities can be assessed. Patients without inspiratory effort and those with a Glasgow Coma Scale score of 8 or less require intubation to establish and secure a functional airway; while the neck remains immobilized, oral intubation should be undertaken as soon as possible. Patients with inspiratory effort but without adequate ventilation require a rapid and directed assessment of the pharynx to exclude local obstruction related to posterior movement of the tongue or the presence of swelling, bleeding, secretions, or gastric contents. Rigid suction and manual extraction should be used to clear the pharynx of any foreign material. Obstruction of the airway caused by posterior movement of the tongue is particularly common in lethargic or obtunded patients and may be quickly corrected by the insertion of an oral or nasal airway and/or the chin-lift or jaw-thrust maneuvers. Contraindications to the insertion of a nasal airway should be noted and include the suspicion or demonstration of a basilar skull fracture, cerebrospinal fluid otorrhea or rhinorrhea, or significant maxillofacial or perinasal injuries. The chin-lift and jaw-thrust maneuvers simply involve grasping the chin and angle of the jaw, respectively, and moving these structures anteriorly or upward in such a way that the tongue is displaced forward. Patients with extensive facial or neck injuries in whom intubation of the trachea is impossible require needle or surgical cricothyrotomy to secure the airway. When these techniques are unsuccessful, Ambu-bag-assisted ventilation with 100% oxygen and an oral or a nasopharyngeal airway may provide temporary oxygenation.
There are a number of common, rapidly reversible causes of central nervous system or respiratory depression that commonly precipitate trauma by interfering with consciousness; these include hypoglycemia, opiate overdose, and Wernicke encephalopathy. These disorders must be considered and presumptively treated in all patients presenting with abnormalities of mental status after trauma, even when other explanations seem both obvious and adequate to explain the clinical presentation (e.g., head injury, alcohol ingestion, severe hypotension). Treatment includes the rapid intravenous administration of 1 ampule of 50% dextrose, 0.4 to 2.0 mg of naloxone, and 100 mg of thiamine; any response to the various agents should be carefully recorded. When improvement does occur, a variety of problems related to establishing or maintaining the airway, circulation, or both may be avoided.
B: Breathing (or the adequacy of air exchange) is evaluated and established. After an airway is secured and ventilation with oxygen initiated, the adequacy of air exchange must be assessed. Bilateral and symmetric breath sounds (best heard in the axilla) should be present immediately after intubation or other airway establishment. Placement of the endotracheal tube in the esophagus is the most common
cause of failure to ventilate the patient adequately after intubation, and this may be diagnosed by bedside capnography and auscultation over the stomach during ventilation. Failure to appreciate breath sounds on the left or reduced breath sounds on the left is often explained by the presence of the endotracheal tube in the right mainstem bronchus; this is easily corrected by deflating the cuff and then slowly pulling the tube back until bilateral breath sounds are heard. When these problems are excluded and ventilation or oxygenation remains inadequate, hemothorax, simple pneumothorax, and tension pneumothorax must then be considered and corrected if present. Flail chest, pulmonary contusion, and aspiration are additional diagnoses that may explain persisting hypoxia in the traumatized patient but initially remain diagnoses of exclusion.
C: Circulation-blood pressure is evaluated and bleeding arrested. Evaluating the patient’s pulse, skin color, and level of consciousness can be performed very quickly and provide a rapid bedside assessment of the adequacy of circulation.
Control of bleeding. External bleeding should be controlled by direct pressure. If an extremity is involved and direct pressure is unsuccessful, then elevation followed by the application of a proximal blood pressure cuff inflated above systolic pressure may be used temporarily while other care is rendered.
Intravenous access should be established with two 14- or 16-gauge short peripheral lines and normal saline or Ringer lactate solution and then rapidly infused.
Central lines should not be used for initial fluid resuscitation because their placement, even in experienced hands, is more time-consuming, is associated with a higher rate of complications, and, most importantly, results in a dramatically reduced rate of fluid delivery as a function of catheter-induced resistance; a 16-gauge, 8-inch line, for example, delivers approximately half the fluid of a 16-gauge, 2-inch catheter per any unit of time.
Initial fluid challenge. Adults presenting with significant blood loss or established or evolving shock should be treated initially with 2 L of normal saline or Ringer lactate solution; this may be administered as rapidly as possible, usually over 5 to 10 minutes; and children may be administered 20 mL/kg over a similar interval.
Blood replacement. Although subsequent therapy will be dictated by the patient’s response to the initial fluid challenge, most patients presenting with significant hypotension will require blood replacement, and a minimum of 4 U of packed cells should rapidly be made available. Although cross-matched blood is clearly preferable, its preparation requires between 50 and 70 minutes, and in many patients presenting with exsanguinating hemorrhage or severe hypotension, an abbreviated type and cross-match (which requires 15-20 minutes), type-specific blood (which requires approximately 10 minutes), or O-negative blood (which should be available immediately) should be transfused. Blood should be administered through macropore (160-μm) filters and, if possible, should be warmed before or during transfusion; warming is often impractical, however, because of the urgency of transfusion.
Pressors have no role in the routine management of hemorrhagic shock; aggressive reexpansion of intravascular volume with crystalloid and/or blood remains the mainstay of initial treatment. Similarly, colloid solutions, including albumin, dextran, hetastarch, fresh frozen plasma, and plasma protein fraction (Plasmanate, Plasmatein), offer no particular advantage over normal saline or Ringer lactate in the initial management of the shock/trauma patient. The use of colloid solutions
is also associated with markedly increased expense and some other disadvantages, that is, the risk of hepatitis with fresh frozen plasma and allergic reactions, renal damage, and increased bleeding tendency caused by decreased platelet adhesiveness with dextran.
Assessment of response to initial fluid challenge. In general, patients who rapidly respond to the initial fluid challenge with a normal blood pressure and who remain stable may be assumed to have lost relatively little blood (<15%-20%) and will generally not require additional fluid challenges or blood replacement. Hospital admission for observation is required, and a minimum of 4 U of packed cells should remain available for emergency transfusion. Patients in whom only a transient increase in blood pressure is noted require rechallenge with normal saline or Ringer lactate solution and rapid blood replacement. If patients exhibit little or no response to the initial fluid challenge, then blood loss was either extensive or continuing, or the diagnosis of hypovolemic shock was in error. If the initial diagnosis is correct, then blood replacement must be aggressively undertaken and plans for possible surgical intervention pursued. Evidence of elevated right-sided pressures associated with systemic hypotension suggests that hypovolemic shock may have been at least an incomplete if not an incorrect diagnosis; one should immediately consider cardiac tamponade, tension pneumothorax, massive hemothorax, and congestive heart failure in these patients. These two groups may be differentiated by physical examination and by measurement of central venous pressure: If the diagnosis of hypovolemic shock is correct, then central venous pressure will be low, whereas if any of the other conditions exist, central venous pressures will be elevated.
Implications associated with massive blood transfusion. Massive transfusion is defined as the replacement of half the patient’s blood volume in a single hour or total blood volume replacement in less than 24 hours. Massive transfusion of packed red blood cells may result in hypothermia and occasionally both hypocalcemia and abnormalities of hemostasis. Hypothermia causes an increased affinity between oxygen and hemoglobin and interferes with the body’s normal response to adequate resuscitation; efforts should be taken to prevent the development of hypothermia and to institute rewarming measures as early as possible. Coagulation factor depletion and thrombocytopenia secondary to dilution are typically not problems in the first hour of resuscitation but can become significant over the next 24 to 48 hours. Clotting factor replacement therapy should be considered in patients with 1.5 × total blood volume replaced, presenting hypothermia, liver dysfunction, or transfusion-induced hypothermia. One unit of fresh frozen plasma can be empirically administered for every 4 U of packed red blood cells and may prevent abnormalities of hemostasis caused by dilution. Alternatively, the need for treatment may be determined by frequent measurement of clotting parameters.
Hypocalcemia is caused by chelation of intravascular calcium by the citrate preservative, and abnormalities of hemostasis are secondary to dilution of clotting factors. If more than 1 U of blood is transfused every 5 minutes, or in association with severe liver dysfunction, then hypocalcemia may become a problem; supplemental calcium can be administered slowly by separate intravenous line, if evidence of hypocalcemia (tetany, EKG changes) is noted.
Hyperkalemia is usually seen only in patients massively transfused over a very short period of time. Transfused red blood cells take up potassium after becoming active, and hypokalemia can then occur. As with other electrolyte abnormalities in this setting, management, including replacement, is based on clinical evidence (e.g., EKG changes).
D: Deficits of neurologic function are identified, and treatment is initiated. In general, during the initial assessment, the patient’s overall neurologic status is grossly assessed and may simply be characterized as alert, responsive to verbal stimuli, responsive to painful stimuli, or unresponsive to all stimuli.
Rapidly reversible causes of central nervous system depression, including hypoglycemia, opiate overdose, and Wernicke encephalopathy, must be considered and prophylactically treated. Similarly, seizure may have precipitated trauma, and the postictal state may produce persisting abnormalities of consciousness as well as focal neurologic findings. Persisting abnormalities of mental status at a time when blood pressure is normal or relatively normal should suggest cerebral injury.
