Prior to the patient's arrival at the hospital, EMS providers should inform the receiving ED about the mechanism of trauma, suspected injuries, vital signs, clinical symptoms, examination findings, and treatments provided. In preparation for the patient's arrival, ED staff should assign tasks to team members, prepare resuscitation and procedural equipment, and ensure the presence of surgical consultants and other care team members. For patients transported to EDs that are not trauma centers, consider immediately whether transfer to a trauma center is appropriate and what resuscitation or stabilization can or should be performed prior to transfer.
A focused history obtained from the patient, family members, witnesses, or prehospital providers may provide important information regarding circumstances of the injury (e.g., single-vehicle crash, fall from height, environmental exposure, smoke inhalation), ingestion of intoxicants, preexisting medical conditions (e.g., diabetes, depression, cardiac disease, pregnancy), and medication use (e.g., steroids, β-blockers, anticoagulants) that may suggest certain patterns of injury or the physiologic response to injury.
ED care of the trauma patient begins with an initial assessment for potentially serious injuries. A primary survey is undertaken quickly to identify and treat immediately life-threatening conditions, with simultaneous resuscitation and treatment. Specific injuries that should be immediately identified and addressed during the primary survey include airway obstruction, tension pneumothorax, massive internal or external hemorrhage, open pneumothorax, flail chest, and cardiac tamponade. After assessing the patient's airway, breathing, and circulation, perform a more thorough head-to-toe examination (the secondary survey) (Table 254-3). Follow the secondary survey with appropriate diagnostic testing, further therapeutic interventions, and disposition. When derangements are identified in any of the systems assessed in the primary survey, undertake treatment immediately.
TABLE 254-3Primary and Secondary Survey in Trauma Resuscitation ||Download (.pdf) TABLE 254-3 Primary and Secondary Survey in Trauma Resuscitation
Primary Survey (rapid identification and management of immediately life-threatening injuries)
A. Airway and cervical spine
Assess, clear, and protect airway: jaw thrust/chin lift, suctioning.
Perform endotracheal intubation with in-line stabilization for patient with depressed level of consciousness or inability to protect airway.
Create surgical airway if there is significant bleeding or obstruction or laryngoscopy cannot be performed.
Ventilate with 100% oxygen; monitor oxygen saturation.
Auscultate for breath sounds.
Inspect thorax and neck for deviated trachea, open chest wounds, abnormal chest wall motion, and crepitus at neck or chest.
Consider immediate needle thoracostomy for suspected tension pneumothorax.
Consider tube thoracostomy for suspected hemopneumothorax.
Assess for blood volume status: skin color, capillary refill, radial/femoral/carotid pulse, and blood pressure.
Place two large-bore peripheral IV catheters.
Begin rapid infusion of warm crystalloid solution, if indicated.
Apply direct pressure to sites of brisk external bleeding.
Consider central venous or interosseous access if peripheral sites are unavailable.
Consider pericardiocentesis for suspected pericardial tamponade.
Consider left lateral decubitus position in late-trimester pregnancy.
Perform screening neurologic and mental status examination, assessing:
Pupil size and reactivity
Limb strength and movement, grip strength
Orientation, Glasgow coma scale score
Consider measurement of capillary blood glucose level in patients with altered mental status.
Completely disrobe the patient, and inspect for burns and toxic exposures.
Logroll patient, maintaining neutral position and in-line neck stabilization, to inspect and palpate thoracic spine, flank, back, and buttocks.
Secondary Survey (head-to-toe examination for rapid identification and control of injuries or potential instability)
Identify and control scalp wound bleeding with direct pressure, sutures, or surgical clips.
Identify facial instability and potential for airway instability.
Identify epistaxis or septal hematoma; consider tamponade or airway control if bleeding is profuse.
Identify avulsed teeth or jaw instability.
Evaluate for abdominal distention and tenderness.
Identify penetrating chest, back, flank, or abdominal injuries.
Assess for pelvic stability; consider pelvic wrap or sling.
Inspect perineum for laceration or hematoma.
Inspect urethral meatus for blood.
Consider rectal examination for sphincter tone and gross blood.
Assess peripheral pulses for vascular compromise.
Identify extremity deformities, and immobilize open and closed fractures and dislocations.
AIRWAY MANAGEMENT WITH CERVICAL SPINE CONTROL
Determine airway patency by inspecting for foreign bodies or maxillofacial fractures that may result in airway obstruction. Perform a jaw thrust maneuver (simultaneously with in-line stabilization of the head and neck) and insert an oral or nasal airway as part of the first response to a patient with inadequate respiratory effort. Insertion of an oral airway may be difficult in patients with an active gag reflex. Avoid nasal airway insertion in patients with suspected basilar skull fractures. Whenever possible, use a two-person spinal stabilization technique in which one provider devotes undivided attention to maintaining in-line immobilization and preventing excessive movement of the cervical spine while the other manages the airway. If the patient vomits, logroll the patient and provide pharyngeal suction to prevent aspiration. Perform endotracheal intubation in comatose patients (Glasgow coma scale score between 3 and 8) to protect the airway and to prevent secondary brain injury from hypoxemia. Agitated trauma patients with head injury, hypoxia, or drug- or alcohol-induced delirium may be at risk for self-injury. Trauma patients are frequently difficult to intubate due to the need for neck immobilization, the presence of blood or vomitus, or upper airway injury. Video laryngoscopy devices are beneficial because they aid in vocal cord visualization while minimizing cervical spine manipulation. If anatomy or severe maxillofacial injury precludes endotracheal intubation, cricothyroidotomy may be needed. Use a rapid-sequence intubation technique for intubation (see chapter 29, "Intubation and Mechanical Ventilation").
Clearance of the cervical spine from serious injury involves careful clinical assessment, with or without radiologic imaging. Not all patients require cervical spine radiographs. The National Emergency X-Radiography Utilization Study (NEXUS) criteria (Table 254-4)5 and the Canadian cervical spine rule (Table 254-5)6 are useful only in awake and alert patients and are not a substitute for good clinical judgment. Patients meeting NEXUS or Canadian criteria for low risk of cervical spine injury should undergo full examination of the cervical spine, including active range-of-motion testing in all directions along with a thorough neurologic examination.
TABLE 254-4NEXUS (National Emergency X-Radiography Utilization Study) Criteria for Omitting Cervical Spinal Imaging* ||Download (.pdf) TABLE 254-4 NEXUS (National Emergency X-Radiography Utilization Study) Criteria for Omitting Cervical Spinal Imaging*
No posterior midline cervical spine tenderness
No evidence of intoxication
Alert mental status
No focal neurologic deficits
No painful distracting injuries
TABLE 254-5Canadian Cervical Spine Rule ||Download (.pdf) TABLE 254-5 Canadian Cervical Spine Rule
Any high-risk factor that mandates radiography?
(Age >64 y or dangerous mechanism or paresthesias in extremities)
|If Yes, radiography indicated |
Any low-risk factor that allows safe assessment of range of motion?
(Simple rear-end collision or sitting position in the ED or ambulatory at any time or delayed onset of neck pain or absence of midline cervical spine tenderness)
|If No, radiography indicated |
Able to rotate neck actively?
(45 degrees left and right)
|If No, radiography indicated |
|No radiography indicated || |
If the patient is obtunded, assume a cervical spine injury until proven otherwise. Even when plain radiographs or CT images show normal findings, it is possible for a patient to have unstable ligamentous injuries. Therefore, maintain spinal immobilization during the resuscitation. Imaging of the spine should not delay urgent operative procedures because imaging results will not change the immediate management. CT of the cervical spine is the preferred initial imaging modality. For full discussion of cervical spine imaging and management in trauma, see chapter 258, "Spine Trauma."
Once the airway is controlled, inspect, auscultate, and palpate the thorax and neck to detect abnormalities such as a deviated trachea (tension pneumothorax); crepitus (pneumothorax); paradoxical movement of a chest wall segment (flail chest); sucking chest wound; fractured sternum; and absence of breath sounds on either side of the chest (simple or tension pneumothorax, massive hemothorax, or right mainstem intubation). Any of these findings warrants immediate intervention, including needle thoracostomy for tension pneumothorax (see the section "Needle Decompression" in chapter 68, "Pneumothorax"); insertion of large-bore chest tubes (36-F) to relieve hemopneumothorax (see chapter 261, "Pulmonary Trauma"); and application of an occlusive dressing to a sucking chest wound. For asymmetric or absent breath sounds in the intubated patient, partially withdraw the endotracheal tube from the right mainstem bronchus or reintubate. If no breath sounds are heard, and if massive hemothorax or vascular injury is suspected (initial chest tube output of >1000 mL, or >200 mL/h), a thoracotomy or video-assisted thoracic surgery is indicated to identify and control the source of bleeding.
CIRCULATION AND HEMORRHAGE CONTROL
Assessment of the patient's overall hemodynamic status is critical. This assessment includes evaluation of level of consciousness, skin color, and presence and magnitude of peripheral pulses. Note the heart rate and pulse pressure (systolic minus diastolic blood pressure), particularly in young, previously healthy trauma patients.
As part of the primary survey in the prehospital and hospital settings, identify and control external hemorrhage. Apply direct pressure, a compression bandage, or a hemostatic dressing to control active external bleeding. QuikClot Combat Gauze is a kaolin-impregnated rayon and polyester hemostatic dressing that is safe and effective for arterial or venous bleeding.2,7 For exsanguinating extremity injury, apply a tourniquet (see "Tourniquets"). Prehospital use of tourniquets on the battlefield has become commonplace. With aggressive tourniquet use, death rates from isolated limb exsanguination in Iraq dropped to 2% compared to 9% in the Vietnam War.8
Robert L. Mabry
More than a decade of combat operations in Afghanistan and Iraq have provided the opportunity to evaluate methods for minimizing morbidity and mortality from traumatic injury. One of the greatest advances in the prevention of death on the modern battlefield is the rediscovery of the tourniquet.9 During the war in Vietnam, tourniquet application was generally felt to be a technique of last resort.10 The myth arguing against tourniquet use was primarily based on World War I and II experiences when evacuation to definitive care took many hours, and tourniquets were felt to increase ischemia in an already vulnerable extremity.
However, proper tourniquet application, coupled with rapid transport times to definitive care, can be life- and limb-saving in military and civilian settings.7 Tourniquets saved lives at the Boston Marathon bombing, and as a result, the Boston Police Department and Boston EMS now carry tourniquets.11,12,13
Civilian tourniquet use is based on the military Tactical Combat Casualty Care guidelines for first responder care in the battlefield. Tourniquet use is a key component to Tactical Combat Casualty Care.
The Tactical Combat Casualty Care guidelines currently recommend three different tourniquets14: the Combat Application Tourniquet (C-A-T®), the SOF Tactical Tourniquet (SOF TT®), and the Emergency and Military Tourniquet (EMT®). The C-A-T® (Figure 1) is a lightweight windlass tourniquet, which can be applied with one hand. The SOF TT® (Figure 2) is another windlass tourniquet. The EMT® (Figure 3) is a pneumatic device, which carries the disadvantage of potential tourniquet failure if it were to be damaged or punctured by debris. Do not use narrow, elastic, or bungee-type tourniquets.7
If direct pressure is ineffective or impractical in controlling external bleeding, apply the tourniquet directly to the skin or over clothing, 2 to 3 inches above the wound. Tighten the tourniquet to eliminate the distal pulse. Do not release the tourniquet until the patient reaches definitive care and there is a positive response to resuscitation efforts.
The Tactical Combat Casualty Care guidelines recommend the application of a junctional tourniquet (SAM JT®) (Figure 4) if the bleeding site is appropriate (groin or axilla, where the torso meets the extremities) and the application of a hemostatic dressing with pressure has no effect.14 However, as of this writing, the American College of Surgeons Committee on Trauma has not provided recommendations for the application of junctional tourniquets in the civilian environment.7
SAM-JT junctional tourniquet (internal view).
Any hypotensive trauma patient is at risk for development of hemorrhagic shock, a common cause of postinjury death. One system is commonly used for classifying the degree of hemorrhage (Table 254-6), although it has not been validated and there is wide variability in individual patient response to hypovolemia. Hemorrhage and shock are on a continuum, and some patients can compensate for significant blood loss better than others. Hemorrhage of up to 30% of total blood volume may be associated with only mild tachycardia and a decrease in pulse pressure, but may quickly progress to profound hypoperfusion and decompensated shock if not recognized early. Be aware that medications, such as β-blockers, can mask early hemodynamic indicators of shock.
TABLE 254-6Classification of Hemorrhage Based on Estimated Blood Loss at Initial Presentation ||Download (.pdf) TABLE 254-6 Classification of Hemorrhage Based on Estimated Blood Loss at Initial Presentation
| ||Class I ||Class II ||Class III ||Class IV |
|Blood loss (mL)* ||Up to 750 ||750–1500 ||1500–2000 ||>2000 |
|Blood loss (% blood volume) ||Up to 15 ||15–30 ||30–40 ||40 |
|Pulse rate (beats/min) ||<100 ||100–120 ||120–140 ||>140 |
|Blood pressure ||Normal ||Normal ||Decreased ||Decreased |
|Pulse pressure ||Normal or increased ||Decreased ||Decreased ||Decreased |
Establish two large-bore IV lines (18 gauge or larger), infuse lactated Ringer's or normal saline, and obtain blood samples or specimens for laboratory studies, particularly blood type and screen. In patients who are in unstable condition or in whom upper extremity peripheral veins are not easily cannulated, establish central venous access via the subclavian, internal jugular, or femoral vein. Avoid placement of a central venous line distal to a potential venous injury. Intraosseous access is an alternative technique for providing rapid vascular access in difficult clinical situations. Most medications including blood products can be administered through the interosseous route. Use a pressure bag to maximize flow rates. Decades of study have failed to demonstrate an advantage of colloid therapy over crystalloid infusion. Therefore, a balanced salt crystalloid (normal saline or lactated Ringer's) is the fluid of choice for initial resuscitation. There is some theoretical advantage of lactated Ringer's over saline when large volumes are given in order to avoid hyperchloremic acidosis, although this is unlikely to be significant for most patients during initial resuscitation.
Reassess hypotensive patients without an obvious indication for surgery after rapid infusion of 2 L of crystalloid solution (lactated Ringer's or normal saline). If there is no marked improvement, then transfuse type O blood (O-negative for females of childbearing age). Aggressive volume resuscitation is not a substitute for definitive hemorrhage control. A full discussion of the long-standing controversies over volume, timing, and composition of fluid resuscitation is beyond the scope of this chapter. One major study demonstrated higher mortality in patients receiving immediate IV fluid resuscitation than in those from whom fluid was withheld until operative intervention. The study speculated that aggressive fluid resuscitation before operative control of bleeding was harmful.15
Patients requiring massive transfusions generally require urgent surgical intervention to control hemorrhage. A well-defined source of bleeding may be evident on external examination, assessment of chest tube output, extended FAST examination (Figure 254-3), or conventional or CT imaging of the chest or abdomen. There may also be considerable blood loss from blunt trauma to the pelvis and limbs without a discrete source. Immobilize open pelvic fractures in a pelvic wrap or sling and reduce and immobilize limb fractures to tamponade bleeding from fractured bone ends.
Positive extended FAST exam with blood identified in Morison's pouch. [Photo contributed by Barry Knapp, MD.]
Major trauma patients may develop a bleeding diathesis almost from the time of injury, which results in defective clotting and platelet function. Data from both military and civilian experience reveal that patients receiving >10 units of packed red blood cells showed decreased mortality when they simultaneously receive fresh frozen plasma in a ratio of packed red blood cells to fresh frozen plasma of 1:1 rather than 1:4 (26% vs 87.5% mortality, respectively).16 Another consensus article examining use of blood products worldwide supported the administration of platelets in massive transfusion protocol in a 1:1:1 ratio with packed red blood cells and fresh frozen plasma.17 Both acidosis and hypothermia contribute to the coagulopathy and should be corrected as quickly as possible.
Tranexamic acid is an antifibrinolytic agent that reduces blood loss after surgery and may reduce blood loss after traumatic injury. It prevents cleavage of plasmin and degradation of fibrin. It is on the World Health Organization list of essential medications affecting coagulation.18 Studies involving >20,000 patients reported a risk reduction of death from bleeding of 10% to 15%. There was no reported difference in risk of death from myocardial infarction, vascular occlusion, stroke, pulmonary embolism, mutiorgan failure, or head injury.19 Criticism of CRASH-2 was that the patient populations studied were heterogeneous in terms of injury and were in low- to middle-income countries with basic and very limited resources for major trauma management.20 For these and other reasons, major Western nation trauma centers have not rushed to adopt the use of tranexamic acid in trauma management algorithms.21 Nevertheless, the evidence to date indicates that tranexamic acid may reduce mortality without significant adverse side effects when given as early as possible after injury, with administration within 1 hour of injury reported to decrease the relative risk of death from bleeding by 32% and within 1 to 3 hours by 21%.22 Administration of tranexamic acid more than 3 hours after injury is less effective and potentially harmful.19 Tranexamic acid must be given before transfer/arrival to a trauma center in order to meet the time requirement of early administration.20 The dose is 1 gram of tranexamic acid IV bolus over 10 minutes, followed by 1 gram IV over 8 hours.
Once airway, breathing, and circulation have been addressed and stabilized, perform a focused neurologic evaluation to assess level of consciousness, pupillary size and reactivity, and motor function. Assess the Glasgow coma scale (see chapter 257, "Head Trauma"). A search for the cause of depressed level of consciousness should include measurement of capillary blood glucose level and consideration of possible intoxicants. Despite the concomitant use of drugs and alcohol in many trauma patients, do not simply attribute altered mental status in the setting of trauma to intoxication. Assume that a patient with an appropriate mechanism for head trauma and with altered mental status or a Glasgow coma scale score of <15 has a significant head injury until proven otherwise. The Glasgow coma scale assessment can be insensitive in patients with normal or near-normal scores, and a Glasgow coma scale score of 15 does not completely exclude the presence of traumatic brain injury. However, patients with a persistent Glasgow coma scale score of ≤8 generally have a graver prognosis; secure a definitive airway to protect against aspiration or asphyxia. Direct efforts toward resuscitating brain-injured patients in order to maintain normal cerebral perfusion. Monitor serum glucose levels and maintain euglycemia. Mild hyperventilation may reduce intracranial pressure, although at the expense of cerebral vasoconstriction and hypoperfusion. Avoid hyperventilation during the first 24 hours after injury when cerebral blood flow is often critically reduced. Prophylactic hyperventilation (partial pressure of arterial carbon dioxide of 25 mm Hg or less) is not recommended.23
No primary survey is complete without completely disrobing the patient and examining carefully for occult bruising, lacerations, impaled foreign bodies, and open fractures. After completing the primary survey, logroll the patient, with one team member assigned to maintain in-line cervical stabilization. Palpate the spinous processes of the thoracic and lumbar spine for tenderness or deformity, and then carefully logroll the patient back to a neutral position. The utility of routine rectal examination is debated, but it is useful to identify gross rectal bleeding or loss of rectal tone in patients with suspected spinal injury. Examine the perineum for bruising, laceration, or bleeding. Cover the patient with warm blankets to prevent heat loss. Some have advocated the use of hypothermia in cases of severe brain injury. However, as of this writing, there is no conclusive evidence in favor of this therapy. Potential therapeutic benefits must be weighed against the coagulopathy and increased bleeding that hypothermia also causes in trauma patients.