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.
Table 156-1 Primary and Secondary Survey in Trauma Resuscitation ||Download (.pdf)
Table 156-1 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, 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, blood pressure.
- Place 2 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 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 ...