Management of trauma patients

Last updated: February 22, 2022

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In the United States, the leading cause of death in young adults is trauma. Traumatic injuries may range from small lesions to life-threatening multi-organ injury. In order to achieve the best possible outcomes while decreasing the risk of undetected injuries, the management of trauma patients requires a highly systematic approach. Prehospital trauma care involves first aid and basic life support administered by emergency services personnel. In the hospital setting, the treatment of trauma patients is traditionally divided into primary (Advanced Trauma Life Support), secondary, and tertiary surveys. Each survey consists of an algorithm designed to diagnose and manage injuries sequentially in order of decreasing morbidity and mortality. Further steps are taken to provide analgesia and determine whether patients should be transferred to specialized trauma centers as quickly as possible.

  • Notification of an accident: 911
    • Where?
    • What (has happened)?
    • Who (number of injured people)?
    • Which (injuries or symptoms)?
    • Wait (for further questions)!
    • If necessary: When (did the accident happen)? Who is reporting the accident? Further danger?
  • Life-saving emergency care by lay rescuers (see “Basic life support” in “Cardiopulmonary resuscitation”)
  • Recovery position: positioning of an unconscious but breathing patient
  • Rautek maneuver: Arm-to-arm drag to remove the patient from dangerous situations
    • The helper approaches the patient from behind and places his or her hands under the patient's armpits.
    • The helper grasps one of the patient's forearms (placed across the patient's chest) and pulls the patient backward to remove them from danger.

The management of trauma patients begins with the primary survey (also commonly referred to as Advanced Trauma Life Support, or ATLS). The primary survey consists of 5 steps (ABCDE approach) that are performed in order.

  1. Airway assessment (and cervical spine stabilization)
    • If appropriately answering questions, patient has a patent airway (at least for the moment)
    • Observe patient for signs of respiratory distress
    • Inspect mouth and larynx for injury or obstruction (e.g., blood, vomit, burns, soot)
    • Assume cervical spine injury in blunt trauma patients until proven otherwise
    • If patient is unconscious (and therefore unable to protect their airway) or in respiratory distress, the threshold for intubation is very low.
      • Patients may be intubated or ventilated with the anterior portion of the cervical collar removed, or with their neck manually stabilized.
    • Patients with burn injuries; and evidence of respiratory involvement (e.g., soot in the oropharynx) are often intubated out of precaution. [1]
    • If orotracheal intubation is difficult, perform a cricothyrotomy.
  2. Breathing
  3. Circulation (and hemorrhage control)
    • Assess circulatory status by palpation of central (e.g., carotid, femoral) and peripheral (e.g., radial, popliteal, posterior tibial, dorsalis pedis) pulses
      • Blood pressure should be measured if it can be done expediently, but it can be skipped if it would delay the rest of the primary survey.
    • Place two large-bore intravenous lines (at least 16 gauge) for blood typing and crossmatch, and resuscitation (if needed).
      • If intravenous line placement is not possible or difficult, intraosseus line should be used instead.
    • Control on-going hemorrhage with manual pressure or tourniquets.
    • Emergency thoracotomy; may be performed in patients with recent loss of pulses (especially in patients with stab wounds to the chest).
    • If patient is hypotensive, administer a bolus of intravenous saline.
    • Focused Assessment with Sonography for Trauma (FAST); exam is usually performed, especially for hemodynamically unstable patients
      • May be performed during the secondary survey in hemodynamically stable patients
    • Some patients may require emergent reversal of anticoagulation
    • Remember hypovolemic shock due to hemorrhage requires loss of ∼ 1.5 L of blood. Keep in mind the compartments where large amounts of blood may go:
  4. Disability (and neurological evaluation)
  5. Exposure (and environmental control)
    • Undress patient completely.
    • Examine body for signs of occult injury, including patient's back.
    • If patient is hypothermic, cover with warm blankets and warm intravenous fluids.
    • Palpate for vertebral tenderness and rectal tone.

If the GCS is ≤ 8, you quickly have to intubate.

  • Secondary survey
    • Performed after the primary survey has been completed and the patient is deemed stable
    • Complete history and thorough physical examination
    • Additional diagnostic tests are tailored to remaining symptoms, mechanism of injury, and patient comorbidities.
    • Main goal is to minimize the risk of missed injuries.
  • Tertiary survey
    • Delayed re-examination of the patient (usually ∼ 24 hours after admission)
    • Main goal is to detect changes due to previously undetected injuries.

The specific choice of imaging modality depends on clinical judgment and mechanism of injury; . The decision to perform any diagnostic test must be based on the patient's hemodynamic stability and must be weighed against the need for urgent transfer or operative intervention.

  1. Portable x-rays
  2. Focused Assessment with Sonography for Trauma (FAST) exam [2]
  3. CT scans
    • Typically performed after the primary survey if the patient is hemodynamically stable (otherwise the patient may decompensate inside the scanner, which could be catastrophic)
    • Ideal imaging modality given speed and high sensitivity for injury
    • In high-energy trauma (e.g., motor vehicle collisions) or severe injuries with altered mental status, a “pan scan” of the entire body is commonly performed.
  4. Diagnostic peritoneal lavage (DPL): a diagnostic test used to assess for bleeding or viscus perforation in abdominal trauma. Highly sensitive, but invasive. Performed by placing a catheter into the abdomen, aspirating, then instilling a liter of warm saline. If fecal matter or significant blood are detected, this constitutes a positive test and emergent laparotomy is indicated.
  5. Laboratory tests include, but are not limited to
    1. CBC
    2. Basic chemistries
    3. Prothrombin time (given the high prevalence of patients anticoagulated on warfarin)
    4. Urinalysis
      1. Gross hematuria; should always be investigated as it may indicate urethral, bladder, or kidney injury.
      2. Microscopic hematuria after trauma is normal in adults, but should be investigated in pediatric populations.
    5. Urine pregnancy test (on all women of child-bearing age)
    6. Blood glucose
    7. Lactate (associated with hypovolemic shock)

References:[3]

Certain clinical manifestations warrant immediate intervention or specific tests. Some common scenarios are:

References:[4][5][6][7]

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  3. Pestana C. Dr. Pestana's Surgery Notes: Top 180 Vignettes for the Surgical Wards. Kaplan ; 2015
  4. Munera F, Rivas LA, Nunez DB Jr, Quencer RM. Imaging evaluation of adult spinal injuries: emphasis on multidetector CT in cervical spine trauma. Radiology. 2012; 263 (3): p.645-660. doi: 10.1148/radiol.12110526 . | Open in Read by QxMD
  5. American College of Radiology ACR Appropriateness Criteria, Suspected Spine Trauma.
  6. Iflazoglu N, Ureyen O, Oner OZ, Tusat M, Akcal MA. Complications and risk factors for mortality in penetrating abdominal firearm injuries: analysis of 120 cases. Int J Clin Exp Med. 2015; 8 (4): p.6154-62.
  7. Krettek C, Simon RG, Tscherne H. Management priorities in patients with polytrauma. Langenbeck's Archives of Surgery. 1998; 383 (3-4): p.220-227. doi: 10.1007/s004230050122 . | Open in Read by QxMD
  8. Kroupa J. [Definition of "polytrauma" and "polytraumatism"].. Acta Chir Orthop Traumatol Cech. 1990; 57 (4): p.347-60.
  9. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  10. E. Brooke Lerner, Ronald M. Moscati. The Golden Hour: Scientific Fact or Medical "Urban Legend"?. Academic Emergency Medicine. 2001; 8 (7): p.758-760. doi: 10.1111/j.1553-2712.2001.tb00201.x . | Open in Read by QxMD
  11. Rogers FB, Rittenhouse KJ, Gross BW. The golden hour in trauma: Dogma or medical folklore?. Injury. 2015; 46 (4): p.525-527. doi: 10.1016/j.injury.2014.08.043 . | Open in Read by QxMD
  12. Bittner EA, Shank E, Woodson L, Martyn JAJ. Acute and perioperative care of the burn-injured patient. Anesthesiology. 2015; 122 (2): p.448-464. doi: 10.1097/aln.0000000000000559 . | Open in Read by QxMD
  13. Siewert JR. Chirurgie. Springer Verlag (2006)
  14. Tactical Combat Casualty Care Handbook, version 5. https://usacac.army.mil/sites/default/files/publications/17493.pdf. Updated: May 1, 2017. Accessed: November 3, 2020.
  15. TCCC Guidelines for Medical Personnel.

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