+++
INITIAL TRAUMA—STABILIZATION AND RESUSCITATION
++
Injuries remain the leading cause of death among persons 1-44 years of age.
++
KEY FACT
Head injury and hemorrhage are the two most common causes of death in trauma patients.
+++
EXAMINATION/DIAGNOSIS
++
As with any critically ill patient, the initial assessment of a trauma patient begins with ABCs. Further assessment and treatment should be directed to specific complaints or injuries. In a patient with multiple injuries, the ABCDE approach described by the Advanced Trauma Life Support (ATLS) guidelines provides a methodical approach to patient assessment and treatment. The goal of the primary survey is to identify immediate life threats, with the emphasis on simultaneous assessment and intervention (eg, intubating a patient airway for protection) at each step.
++
Do not move onto the next step unless the first step is secure. If the patient’s clinical status worsens or changes during your assessment, restart at Airway.
++
Airway, with C-spine stabilization
Breathing and ventilation
Circulation and control of bleeding
Disability (mental status)
Environment/Exposure of patient
++
KEY FACT
Glasgow Coma Scale (GCS) of 8? Intubate! Avoid both hypoxia and extreme hyperoxia in the head injured patient.
++
Examine face/oropharynx/neck for signs of trauma or obstruction.
Administer O2 to maintain PaO2 > 60 mm Hg.
Perform airway maneuvers (chin-lift/jaw-thrust, nasopharyngeal airway, suction, etc).
Maintain C-spine immobilization during intubation
Intubate for:
Glasgow Coma Scale (GCS) ≤ 8 (see Table 3.2)
Loss of airway reflexes in setting of intoxication
Severe facial or airway trauma, burns or smoke inhalation with potential for swelling and obstruction Intubate early!
++
KEY FACT
Before intubation, perform a brief neurologic examination consisting of GCS, pupils, and motor function of extremities.
++
Look for adequate chest rise and external signs of trauma.
Listen to breath sounds bilaterally to assess symmetry and an appropriate volume of air movement.
Feel for crepitus and tracheal deviation.
Look for prominent neck veins.
Life-threatening injuries that should be identified and treated here include:
++
KEY FACT
Five types of shock in trauma:
Hypovolemic (hemorrhage)
Neurogenic (spinal cord injury)
Cardiogenic (direct cardiac injury)
Obstructive (tamponade, tension pneumothorax)
Dissociative (CO or CN)
++
Evaluate circulation, including level of consciousness, skin color, pulses, capillary refill, blood pressure, and heart rate.
ATLS guidelines separate hemorrhage into 4 classes based on physiologic parameters (Table 3.1). It is important to keep in mind that increased age, medication use (eg, β-blockers), comorbidities, and type of injury (eg, blunt cardiac injury, tension pneumothorax) can alter these parameters causing misleading ...