Chapter 156. Trauma in Adults

Trauma care should be guided by the concepts of rapid assessment, triage, resuscitation, serial reassessment, diagnosis, and therapeutic intervention.

Trauma patients can sustain a multitude of injuries. Many will present with abnormal vital signs, neurologic deficits, or other gross evidence of injury. These signs must prompt both a thorough search for the specific underlying injuries and rapid interventions to correct the abnormalities. Nonspecific signs such as tachycardia, tachypnea, or mild alterations in consciousness must similarly be presumed to signify serious injury until proven otherwise. Further, without signs of significant trauma, the mechanism of injury may suggest potential problems, and these also should be pursued diligently.

The assessment of trauma patients begins with a focused history from the patient, family members, witnesses, or prehospital providers. Patterns of injuries, and expected physiologic responses to these injuries, can be ascertained by collecting history regarding the circumstances of the event (eg, single vehicle crash, fall from height, smoke inhalation, or environmental exposures), ingestion of intoxicants, preexisting medical conditions, and medications.

To facilitate an organized approach to the trauma patient, the examination is divided into primary and secondary surveys (Table 156-1). The goal of the primary survey is to identify and immediately treat life-threatening conditions. To do so, the acronym ABCDE encourages the clinician to examine the patient's airway, breathing, circulation, and disability (mental status, Glasgow Coma Scale (GCS), and neurologic examination), and to completely expose each patient so that occult injuries or exposures are visualized. After this initial primary survey, perform a thorough head-to-toe examination (the secondary survey, Table 156-1), then proceed with appropriate diagnostic testing and further therapeutic interventions.

1. The ED management of trauma patients begins prior to the patient's arrival. EMS providers inform the receiving ED about the mechanism of trauma, vital sign values, suspected injuries, and treatments provided.

2. Airway patency is confirmed at the outset of the primary survey. In patients making inadequate respiratory efforts, perform a jaw thrust, then insert an oral or nasal airway. Avoid nasal airway placement in patients with suspected basilar skull fractures. Endotracheal intubation is indicated in comatose patients (GCS < 8) to protect the airway and prevent secondary brain injury from hypoxemia. Agitated trauma patients who need further diagnostic or therapeutic interventions or patients whose expected course necessitates immediate operative management are also candidates for intubation. Whenever possible, use a two-person spinal stabilization technique, in which one caregiver provides in-line immobilization of the cervical spine while the other manages the airway. Trauma patients are often difficult to intubate due to associated facial trauma, cervical spine immobilization, or the presence of blood or vomitus. In virtually all trauma patients requiring urgent intubation, a rapid sequence intubation technique should be used. In cases of extensive facial trauma or when endotracheal intubation is not possible, cricothyrotomy or another advanced airway technique may be used to secure the airway.

3. Once the airway is secured, examine the neck and thorax 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, or the absence of breath sounds on either side of the chest (simple or tension pneumothorax, massive hemothorax, or right mainstem intubation). Treat tension pneumothorax immediately with needle decompression followed by tube thoracostomy.

4. Rapidly assess the patient's hemodynamic status during the primary survey by noting the level of consciousness, skin color, and the presence and magnitude of peripheral pulses. Note the heart rate, blood pressure, and pulse pressure (systolic minus diastolic blood pressure). 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 shock if not recognized early. Establish 2 large-bore peripheral IV lines, and obtain blood samples for laboratory studies, particularly the blood type and screen. Establish a central line in patients who are unstable or in whom upper extremity peripheral veins are not easily cannulated.

5. Reassess hemodynamically unstable patients without an obvious indication for surgery after infusion of 2 L of warm crystalloid solution. If there is no marked improvement, consider the need to transfuse type O blood (O-negative for females of childbearing age). A focused assessment with sonography for trauma (FAST) examination screens for causes of shock immediately after the primary survey. If a patient is hemodynamically stable, definitive imaging can be performed with a CT scan of the abdomen and pelvis with IV contrast. In patients with penetrating abdominal trauma who are in shock, early operative intervention results in better outcomes.

6. Major trauma patients may develop a bleeding diathesis, which results in defective clotting and platelet function. If patients require >10 units of packed red blood cells (PRBC), patients should receive PRBC in a 1:1 ratio with fresh frozen plasma. Both acidosis and hypothermia contribute to the coagulopathy and should be corrected as soon as possible.

7. After the primary survey and stabilization, perform an abbreviated neurologic examination, including an assessment of the patient's level of consciousness, GCS, pupillary size and reactivity, and motor function. A search for the cause of depressed level of consciousness includes the measurement of capillary blood glucose levels and the consideration of possible intoxicants, though one should begin with the assumption this is due to significant traumatic brain injury (TBI). In order to quickly identify potentially operative intracranial injuries among patients with suspected traumatic brain injury and coma (GCS of 3 to 8), defer any procedures that do not correct a specific problem during the primary survey until after the CT scan of the head is performed. Intubated patients should undergo continuous capnography. GCS assessment can be insensitive in patients with normal or near-normal scores, and a GCS score of 15 does not exclude the presence of TBI.

8. Once the patient is hemodynamically stable and the airway is secured, log-roll 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. Consider performing a rectal examination to assess for gross blood, displaced prostate, or determining rectal tone in the setting of a suspected spinal injury.

9. Certain conditions, such as injuries to the esophagus, diaphragm, and small bowel, often remain undiagnosed even with diligent examination, and further imaging and hospital observation for delayed presentation may be required. The most frequently missed injuries are orthopedic.

10. Expeditiously transport patients with hemodynamic instability and ongoing bleeding to the operating room or transfer them to another facility with appropriate surgical or critical care resources. Serial examinations are essential in patients without obvious indications for surgery identified on the initial assessment. These examinations may be performed in the inpatient or, in some cases, the ED observation unit settings.