Jonathan S. Ilgen
CLINICAL FEATURES
Trauma patients who present with obviously abnormal vital signs must prompt a thorough search for the specific underlying injuries.
Nonspecific signs such as tachycardia, tachypnea, or mild alterations in consciousness must similarly be presumed to signify serious injury until proven otherwise. These findings should be aggressively evaluated and treated.
Even without significant physical examination findings, the mechanism of trauma may suggest potential injury patterns that should be pursued diligently.
DIAGNOSIS AND DIFFERENTIAL
Obtain the history from the patient, witnesses, or paramedics, and include the mechanism of injury, sites of injury, blood loss at the scene, degree of damage to any vehicles, and descriptions of weapons used.
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, environmental exposures), ingestion of intoxicants, preexisting medical conditions, and medications.
The primary survey (ABCDE), including a complete set of vital signs, is characterized by the orderly identification and immediate treatment of life-threatening conditions.
Assess airway patency and breathing by examining for a gag reflex, pooling of secretions, airway obstruction, tracheal deviation, presence and quality of breath sounds, flail chest, chest or neck crepitus, sucking chest wounds, and fractures of the sternum.
In the appropriate clinical setting, ensure cervical spine immobilization during the airway assessment.
Problems such as tension pneumothorax, pneumothorax, hemothorax, and malpositioned endotracheal tube should be remedied before proceeding further in the primary survey.
Circulatory status is evaluated via vital signs, level of consciousness, skin color, and the presence and magnitude of peripheral pulses. Sites of obvious bleeding, indications of shock, and signs of cardiac tamponade (Beck’s triad of hypotension, jugular venous distention, and muffled heart sounds) should be identified.
The primary survey concludes with a brief neurologic examination for disability using the Glasgow Coma Scale (GCS), pupil size and reactivity, and motor function assessment. The 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 traumatic brain injury.
The patient is then completely exposed in order to identify other injuries.
The focused assessment with sonography for trauma (FAST) examination is a screening tool that should be used to identify causes of shock immediately after the primary survey. Among patients with hypotension, diagnostic peritoneal lavage (DPL) is an alternative method of identifying intraperitoneal blood in lieu of a FAST examination. If a patient is hemodynamically stable, definitive imaging can be performed with a CT scan of the abdomen and pelvis with IV contrast.
The secondary survey is a rapid but thorough head-to-toe examination aimed toward the identification of all injuries and thereby set priorities for care. Resuscitation and frequent monitoring of vital signs continue throughout this process. Do not start the secondary survey until basic functions under the primary survey have been corrected and resuscitation has been initiated.
Assess for evidence of significant head injury (eg, skull and facial fractures) and recheck the pupils. Complete the neck, chest, and abdominal examinations and assess the stability of the pelvis.
Evaluate the genitourinary system by external inspection and rectal examination. If there is blood at the urethral meatus or a displaced prostate on rectal examination, perform a retrograde urethrogram to evaluate for urethral injury. Otherwise, place a Foley catheter and check the urine for blood. Order a pregnancy test for female patients of childbearing age.
Vaginal blood on a bimanual examination raises concern for a vaginal laceration from a pelvic fracture, and is an indication for a speculum examination.
Check the extremities for soft tissue injury, fractures, and pulses.
Complete a more thorough neurologic examination, carefully checking motor and sensory function.
After the secondary survey, laboratory and imaging studies (plain radiographs and CT scans) should be considered. In younger patients in whom the clinical indication for CT scan may be equivocal, avoid the use of ionizing radiation if possible.
Certain conditions, such as injuries to the esophagus, diaphragm, and small bowel, often remain undiagnosed even after thorough serial examinations and imaging. Prolonged observation for delayed presentations may be required in the appropriate clinical settings.
The most frequently missed injuries are orthopedic. A tertiary survey has been recommended in patients with multisystem trauma within the first 24 hours to lessen the risk of missed injuries.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Confirm airway patency at the outset of the primary survey.
A jaw thrust may initially help in opening the airway; suctioning may remove foreign material, blood, loose tissue, or avulsed teeth.
Endotracheal intubation via a rapid sequence technique is indicated for airway management. Whenever possible, use of a two-person spinal stabilization technique is suggested in which one provider provides in-line immobilization of the cervical spine while the other manages the airway.
Endotracheal intubation is indicated in comatose patients (GCS <8) to protect the airway and prevent secondary brain injury from hypoxemia.
In cases of extensive facial trauma or when endotracheal intubation is not possible, cricothyrotomy or another advanced airway technique should be employed to secure the airway. Avoid nasal airway insertion in patients with suspected basilar skull fractures.
Treat clinically suspected tension pneumothorax immediately with needle decompression followed by tube thoracostomy. Treat large or open pneumothoraces identified during the primary survey with a tube thoracostomy.
The presence of a flail chest may mandate endotracheal intubation to ventilate patients adequately.
Reassess hypotensive patients without an obvious indication for surgery after infusion of 2 L of warm crystalloid solution (LR or normal saline). If there is no marked improvement, type O blood should be transfused (O-negative for females of childbearing age).
If patients require >10 units of packed red blood cells (PRBCs), they should receive PRBCs in a 1:1 ratio with fresh frozen plasma. Both acidosis and hypothermia contribute to coagulopathy and should be corrected as soon as possible.
In patients with penetrating abdominal trauma who are in shock, early operative intervention results in better outcomes.
Manage severe external hemorrhage with compression at the bleeding site.
Tamponade of severe epistaxis may be achieved with balloon compression devices or nasal packing.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 250, “Trauma in Adults,” by Patrick H. Brunett and Peter A. Cameron.