I. INTRODUCTION: Trauma remains a major cause of morbidity and mortality in the United States, as well as a major source of patients requiring intensive care unit (ICU) admission. The most recent data from the Centers for Disease Control lists “unintentional injury” as the leading cause of death for patients aged 1 to 44. Suicide and homicide are in the top five causes of death for patients between the ages of 10 and 44. The bulk of the critical care of trauma patients is similar to the care of other critically ill patients, but a few aspects are unique. This chapter will explain the initial evaluation of trauma patients, highlight some aspects of critical care unique to trauma patients, and address the care of specific commonly encountered injuries.
II. INITIAL EVALUATION AND PRIMARY SURVEY, THE ABCs: The initial evaluation of the trauma patient begins in the emergency department and should be complete by the time of transfer to the ICU, but the ICU provider should have some familiarity with this evaluation process. This standardized evaluation, promulgated through courses such as the American College of Surgeons’ Advanced Trauma Life Support, is remarkably similar at different institutions. Hemorrhage and respiratory compromise are the most common causes of preventable trauma deaths, and the initial evaluation is aimed at rapid identification of these entities. Clinical evaluation is based on history, physical exam, and portable diagnostic adjuncts such as x-ray or ultrasound, which are immediately available in the trauma bay.
A. Airway. An awake, talking patient has a stable airway, unless there are other reasons to worry about the durability of that airway (e.g., bleeding, expanding neck hematoma, subcutaneous emphysema). Please see Chapter 4 for an excellent review and details of airway management, including rapid sequence intubation. Specific indications for securing the airway and considerations for managing the airway in trauma patients are described below:
1. Indications for endotracheal intubation
a. Glasgow Coma Scale (GCS) ≤8.
b. Respiratory distress with signs of potential impending airway collapse such as stridor or crepitus, expanding neck hematoma, or severe facial injury.
2. Special situations
a. Head injury—In these cases, it is important to minimize the intracranial hypertension associated with laryngeal stimulation, the hypotension sometimes associated with induction regimens, and hypoxemia, as all of these can worsen outcome in head injury. No specific pharmacologic adjuncts have been proven effective.
b. Basilar skull fracture—Nasotracheal intubation should be avoided to prevent inadvertent passage of foreign bodies into the cranial vault.
c. Suspected laryngotracheal injury—Consider awake fiber-optic intubation in the operating room for awake patients who are controlling their airway. Paralysis and direct laryngoscopy can precipitate an emergency. Whenever possible, surgical assistance should be available in case tracheostomy is required.
d. Maxillofacial injury—In cases of severe maxillofacial injury, consider early placement of a surgical airway if orotracheal intubation fails.
B. Breathing. Victims of trauma can present with varied pathology that will affect their breathing including pneumothorax, hemothorax, aspiration, flail chest, and diaphragmatic rupture. Initial evaluation begins with a physical exam including auscultation of breath sounds bilaterally and palpation of the thorax to feel for crepitus or flail segments. Additional adjuncts include portable chest x-ray and chest ultrasonography. The most common initial interventions affecting breathing are tube thoracostomy and endotracheal intubation. In unstable patients with absent breath sounds, radiographic confirmation of pneumothorax or hemothorax is not necessary and only delays treatment; place a chest tube immediately. In cases of suspected pneumothorax or hemothorax without obvious signs on physical exam, either ultrasound or chest x-ray performed in the trauma bay can be used for immediate further evaluation. See the sections on pneumothorax, hemothorax, and pulmonary contusion below regarding further management of these injuries.
C. Circulation. Hemorrhage is the most common cause of circulatory compromise in trauma. Hemodynamically significant bleeding can occur in five locations, which are evaluated as noted below:
1. External—physical exam
2. Thoracic cavity—chest x-ray, ultrasound, empiric chest tube placement
3. Abdominal cavity—ultrasound (focused abdominal sonography for trauma [FAST exam]), diagnostic peritoneal aspiration
4. Extraperitoneal pelvis—physical exam, pelvic x-ray
5. Thighs—physical exam, x-ray
D. Other less common but important causes of circulatory compromise in trauma include tension pneumothorax, pericardial tamponade, and neurogenic shock. Pericardial tamponade is most frequently diagnosed by ultrasound. Neurogenic shock from spinal cord injury is identified by the combination of bradycardia and hypotension and findings of lower body paralysis.
E. Once the “ABCs” have been reviewed, the patient should undergo a complete history and physical exam (the secondary survey) and will typically either travel for a therapeutic procedure (e.g., to the operating room or angiography suite) or to undergo further diagnostic imaging (usually computed tomography [CT]).
III. TRAUMA RESUSCITATION
A. Goals of Resuscitation. These are determined by the patient and the suspected injuries. Young healthy patients with suspected bleeding can undergo “permissive hypotension” while en route to definitive control of the bleeding source. If they are awake and mentating, they have an acceptable blood pressure. If they are sedated, we select an arbitrary but relatively low systolic pressure goal of 90 mmHg. Patients with suspected head injury or older patients who are more likely to have a higher baseline systolic pressure may not be candidates for this type of resuscitation strategy and have more standard resuscitation goals.
B. Choice of Resuscitation Fluid. Hypovolemia secondary to bleeding should be treated with blood products. The optimum ratio of packed red cells, plasma, and platelets remains an area of controversy. We favor a ratio of one unit of FFP for every two units of PRBC given, and consider platelets after the fourth unit of PRBC. We never consider colloid (albumin) in patients with head injuries or burns and rarely use it in the initial resuscitation of any patient.
IV. SPECIFIC INJURIES:
A. Head Injuries—For the critically ill head injured patient, a checklist approach to physiologic management goals may improve outcomes. Invasive intracranial pressure monitoring is typically utilized when the GCS is ≤8. Standard parameters include the following:
1. SBP >90—control with fluid boluses and/or vasopressor use
2. PaCO2 35 to 40—control with mechanical ventilation
3. PaO2 >60, SaO2 >90%—control with supplemental oxygen
4.
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