- Clinical science
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.
- Pre-hospital care by emergency services personnel
- Transport to hospital
- Primary survey (ATLS)
- Transfer to specialized trauma center (if required)
- Secondary survey
- Tertiary survey
- Notification of an accident: 911
Where? What (has happened)? Who (number of injured people)? What (which injuries or symptoms)? Wait (for further questions)!
- If necessary: When (did the accident happen)? Who is reporting the accident? Further danger?
- Where? What (has happened)? Who (number of injured people)? What (which injuries or symptoms)? Wait (for further questions)!
- Life-saving emergency care by lay rescuers (see “Basic life support” in the learning card )
- Unconscious but breathing patients may be placed in the recovery position.
- Initial position: With the unconscious person lying flat on their back, the helper kneels on the floor at their left side.
- Place the left arm at a right angle (between the shoulder and elbow joint) to the patient's body.
- Place the right hand on top of the left shoulder, with the right arm crossing the chest.
- Bend the right knee and use it as a lever to roll the unconscious person onto their left side. At the same time, hold the right hand tight to the person's left shoulder, supporting the head while rolling the person over.
- The right thigh comes to rest at a right angle to the hip.
- Overstretch the head gently and tuck the unconscious person's right hand under their head to support the mouth in a slightly open position (head lowest point of the body).
- Keep on checking respiration and blood circulation after the patient has been placed in the recovery position!
- Rautek maneuver
- Prehospital care of trauma patients is situation-dependent and centered on stabilization of the patient and prompt transport to a hospital.
- Nonmedical personnel trained in basic life support may provide life-saving interventions (see “Basic life support” in the learning card ).
- Emergency services personnel typically perform an abbreviated version of the primary survey (see below)
Low-threshold interventions that may be performed by emergency personnel prior to transport to a hospital include, but are not limited to:
- Placement of a cervical collar (if cervical spine trauma is suspected based on primary survey or mechanism of injury)
- Intubation or oxygen delivery via nasal cannula; (if respiratory distress or altered mental status is suspected)
- Administration of intravenous fluid; (if hemorrhage or hypotension is suspected)
- Administration of analgesia
- Placement of tourniquets or pressure bandages for control of bleeding
- Ground transport
- Patient transport vehicle: Only patients with unimpaired vital functions may be transported in this kind of vehicle.
- Emergency ambulance
- Mobile intensive care unit (MICU, emergency physician aboard, space for patients), emergency response vehicle (vehicle for emergency physician, no space for patients)
- Airborne transport: rescue helicopter
- Sea rescue
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 () that are performed in order.
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
- 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 are often intubated out of precaution.
- If orotracheal intubation is difficult, perform a .
- Circulation (and hemorrhage control)
Assess circulatory status by palpation of central and peripheral 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:
- Assess circulatory status by palpation of central and peripheral pulses
- Disability (and neurological evaluation)
- 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.
- Polytrauma: Injuries affecting several bodily regions at the same time. At least one of the injuries or their combination is life-threatening.
Phases of treatment:
- Operative phase I: treatment of acute life-threatening injuries, simultaneously if necessary (e.g., laparotomy, thoracotomy, craniotomy, pelvic C-clamp, if necessary directly in the shock room)
- Stabilization: treatment of e.g., blood coagulation disorders, hypothermia
- With severe : slow warming of the patient “from the inside out,” e.g., administration of warm infusion solutions
- Operative phase II: surgeries, e.g., on open fractures, compartment syndrome, spinal cord compression, injuries of the urogenital tract
- Further operations: Further surgical interventions may be performed after ongoing stabilization of the patient.
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.
- Portable x-rays
- Typically acquired after the primary survey
Screening x-rays of the cervical spine, chest, and pelvis are usually performed but may be skipped if a CT-scan will be performed.
- An exception is patients with penetrating injuries to the thorax or abdomen; , in which a chest x-ray should always be acquired even if a CT-scan will be performed.
- Good for detection of fractures, subdiaphragmatic free air, foreign bodies, pneumothorax, hemothorax
- Focused Assessment with Sonography for Trauma () exam
- 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.
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.
- Typically performed after the primary survey if hemoperitoneum is suspected and FAST exam is unavailable or equivocal
- Rarely performed given the greater sensitivity of the FAST exam
Laboratory tests include, but are not limited to
- Basic chemistries
- Prothrombin time (given the high prevalence of patients anticoagulated on warfarin)
- Urine pregnancy test (on all women of child-bearing age)
- Blood glucose
- Lactate (associated with hypovolemic shock)
- 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.
Certain clinical manifestations warrant immediate intervention or specific tests. Some common scenarios are:
- Penetrating wounds to the abdomen with hypovolemic shock (hypotension, pale, cold, barely detectable pulses)
- Gunshot wounds and signs of cardiac tamponade (hypotension, barely detectable pulses, distended neck veins)
- Perform pericardial window, thoracotomy, and then exploratory laparotomy.
- See and .
- Gunshot wounds to the chest and abdomen with signs of tension pneumothorax (hypotension, distended neck veins, tracheal deviation, absent breath sounds over hemithorax)
Allergic reaction (hypotension, tachycardia, respiratory distress, warm and swollen)
- Administer epinephrine.
- See .
High-energy trauma of the lower extremities (e.g., calcaneus fracture following a fall from a height)
- Perform thoracolumbar spine x-rays to look for additional injuries
High-energy trauma with widened mediastinum on x-ray
- Perform CT Angiography for diagnosis of aortic injury and then perform surgical repair.
- See .
Blunt trauma with subcutaneous emphysema
- Perform bronchoscopy for diagnosis of injury to the trachea and then perform surgical repair.
- Blunt trauma with concern for cervical spine injury
- Signs of peritonitis (abdominal tenderness, rebound, guarding, rigid abdomen)
- Perform exploratory laparotomy as it indicates perforated viscus.
- See .
- See .
- Blood in the urinary meatus
- Perform retrograde urethrogram (may be a bladder injury, but need to rule out urethral injury first).
- See .
- No blood in the urinary meatus, but hematuria through Foley catheter
- Perform retrograde cystogram for diagnosis of bladder injury.
- See .
Hematuria through Foley catheter, but normal retrograde cystogram
- Perform CT scan for diagnosis of kidney injury.
- See .
- Large hematoma over the shaft of the penis
- Perform emergent surgical repair of penile fracture.
- Human bite
- Surgical exploration and debridement
- See .
- Trauma during pregnancy
- Most common cause of nonobstetric maternal death
- Inferior vena cava compression → reduced maternal cardiac output → reduced placental perfusion
- Increased risk of placental abruption
- Increased risk of gastrointestinal injury in upper abdominal or chest trauma. The intestine is displaced by the uterus.
- Penetrating injury: high fetal mortality rate (80%)
- Assess hemodynamic stability of the mother and stabilize if necessary.
- Examine mother in left lateral position to minimize inferior vena cava compression.
- The mother should be examined before the fetus.
- Obstetric examination
- Cesarean section: fetus > 24 weeks of gestation with signs of distress or if mother is not responding to cardiopulmonary resuscitation