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Key Points

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  • Assess all trauma patients with a rapid primary survey followed by a more comprehensive secondary evaluation.

  • Address all emergent life threats in a stepwise manner during the primary survey before progressing to the next stage.

  • Treat hemodynamically unstable patients as hemorrhagic shock until proven otherwise.

  • Initiate aggressive volume resuscitation in all unstable patients while concurrently searching for active sources of hemorrhage.

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Introduction

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Trauma is currently the fourth leading cause of death in the United States across all age groups and the leading cause of death in patients under the age of 44 years. It is responsible for more deaths in patients under the age of 19 years than all other causes combined. Approximately 40% of all emergency department (ED) visits are for trauma-related complaints, and the annual costs exceed $400 billion. Adding to these costs, permanent disability is actually 3 times more likely than death in this cohort.

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Trauma is broadly classified by mechanism into blunt and penetrating varieties, with the former more than twice as common as the latter. Regardless of mechanism, victims of significant trauma present with a wide range of complex problems, and their proper care necessitates a multidisciplinary approach, including emergency physicians, trauma surgeons, and the appropriate subspecialties. Most trauma care delivery systems follow the Advanced Trauma Life Support guidelines developed and maintained by the American College of Surgeons.

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The mortality rates for traumatic injuries typically follow a trimodal distribution. Certain injury patterns including major vascular injuries and high cervical cord disruption with secondary apnea result in near immediate death. The second cohort of injuries, including conditions such as pneumothorax and pericardial tamponade, typically evolve over a duration of minutes to hours and are generally responsive to aggressive emergent intervention. Septicemia and multisystem organ failure account for the third peak of fatalities and typically occur weeks to months after injury.

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Clinical Presentation

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History

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Attempt to identify the severity of mechanism, as this will predict the patterns of injury. For example, determine the approximate speed of a motor vehicle collision (MVC) and whether or not the patient was restrained. Emergency medical service personnel can be an invaluable resource, especially in amnestic and nonverbal patients. In assault patients, inquire if they can recall exactly what they were struck with and the number of times. Ask if there was any loss of consciousness, as this may portend to a significant head injury. For penetrating trauma, ask about the number of shots heard and how many times the patient felt himself or herself get shot.

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Obtain a brief medical history using the AMPLE mnemonic. Ask about any known drug allergies, current medication use, past medical history, last oral intake, and the immediate events leading up to the injury. Keep in mind that regardless of past history, elderly patients have less physiologic ...

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