• Clinical science

Management of trauma patients

Summary

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.

Order of events

  • Pre-hospital care by emergency services personnel
  • Transport to hospital
  • Primary survey (ATLS)
  • Transfer to specialized trauma center (if required)
  • Secondary survey
  • Tertiary survey

References:[1]

Prehospital trauma care

  • 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 cardiopulmonary resuscitation).
  • Emergency services personnel typically perform an abbreviated version of the primary survey (see ABCDE approach 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

References:[1]

Primary survey (Advanced Trauma Life Support)

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
    • 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 cricothyrotomy.
  2. Breathing
  3. 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.
      • If history of hemorrhage or on-going hemorrhage, transfuse type O blood.
      • If significant hemorrhage and persistent hemodynamic instability, transfuse plasma, platelets and red blood cells at 1:1:1 ratio.
    • 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.

References:[1][2]

Diagnostic tests

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
    • 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
  2. Focused Assessment with Sonography for Trauma (FAST) exam
    • Typically acquired during the primary survey (especially for hemodynamically unstable patients)
    • An extended version (E-FAST); may alternatively be performed, which allows for detection of pneumothorax and hemothorax.
  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.
    • 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
  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:[1][3]

Secondary and tertiary surveys

  • 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.

References:[1]

Special cases

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

References:[4][1][5][6][7][8][9]

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  • 2. Bittner EA, Shank E, Woodson L, Martyn JAJ. Acute and perioperative care of the burn-injured patient. Anesthesiology. 2015; 122(2): pp. 448–464. doi: 10.1097/aln.0000000000000559.
  • 3. Saunders F, Argall J. Investigating microscopic haematuria in blunt abdominal trauma. Emerg. Med. J. 2002; 19(4). doi: 10.1136/emj.19.4.322-a.
  • 4. Pestana C. Dr. Pestana's Surgery Notes: Top 180 Vignettes for the Surgical Wards. Kaplan; 2015.
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  • 6. 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): pp. 645–660. doi: 10.1148/radiol.12110526.
  • 7. Daffner RH, Weissman BN, Wippold FJ et al. American College of Radiology ACR Appropriateness Criteria, Suspected Spine Trauma. url: https://acsearch.acr.org/docs/69359/Narrative/ Accessed March 9, 2017.
  • 8. 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): pp. 6154–62. pmid: 26131219.
  • 9. Kilpatrick SJ. Initial Evaluation and Management of Pregnant Women with Major Trauma. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/initial-evaluation-and-management-of-pregnant-women-with-major-trauma. Last updated September 26, 2017. Accessed March 8, 2018.
  • Siewert JR. Chirurgie. Springer Verlag (2006).
  • Offner P. Penetrating Abdominal Trauma. In: Penetrating Abdominal Trauma. New York, NY: WebMD. http://emedicine.medscape.com/article/2036859-overview#a5. Updated January 13, 2017. Accessed February 16, 2017.
last updated 09/01/2019
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