Initial Assessment and Management

Panna A. Codner and Karen J. Brasel

INTRODUCTION

Time is of the essence in caring for patients with multiple injuries. To emphasize the time-sensitive nature of this care, the critical period immediately following injury was historically termed the “golden hour.”¹ Mortality from trauma during this crucial time was estimated to be approximately 60%. This high mortality rate has been attributed in part to inadequate assessment and resuscitation. In order to minimize morbidity and mortality for these patients, appropriate and aggressive initial care must be delivered. The “golden hour” is no longer sacred, as we know that patient outcome is directly related to the time from injury to definitive care. Rapid assessment of injuries and institution of life-preserving measures have helped to reduce the preventable death rate of 35% to <10%.^2–4

In order to save time, the initial assessment and management should follow a systematic approach that can be easily learned and practiced. This approach is the foundation for the Advanced Trauma Life Support (ATLS) course.⁵ Lack of a systematic approach to the initial assessment can result in errors from which the resuscitation team, and ultimately the patient, do not recover.⁶ Initial assessment and management includes the following:

• Preparation

• Triage

• Primary survey (ABCDEs)

• Resuscitation

• Adjuncts to the primary survey and resuscitation

• Consideration of need for transfer

• Secondary survey (more detailed evaluation, diagnosis, and treatment)

• Adjuncts to the secondary survey

• Continued postresuscitation monitoring and reevaluation

• Definitive care

Initial assessment and management is a linear progression of steps that includes both the primary and secondary surveys. The name of this phase—initial assessment and management—highlights the need for evaluation and simultaneous intervention for life-threatening injury when identified. During the primary survey, remembered by the mnemonic ABCDE (airway, breathing, circulation, disability, exposure/environment), the patient is rapidly assessed for life-threatening injury. It is not always possible to dissociate diagnostic procedures from simultaneous resuscitation and treatment measures during this phase, and the treatment of life-threatening injury should not be delayed for definitive evaluation. Following the primary survey and its adjuncts, the secondary survey is performed. During the secondary survey, the patient is evaluated for potentially life-threatening and/or occult injuries. It is important to emphasize that both the primary and secondary surveys may be repeated as often as necessary. Once adjuncts to the secondary survey are completed, definitive care requirements such as type of facility and location are considered while postresuscitation monitoring is continued.

PREPARATION

The preparatory phase is an integral component of trauma care and occurs in two different clinical settings: the prehospital and hospital settings.

Prehospital Phase

The first aspect of the prehospital phase occurs before patient involvement and concerns the establishment of protocols aimed at directing the safe transport of the right patient to the appropriate trauma center at the earliest possible time using the ideal transport method. Physicians involved in trauma care should be familiar with these protocols, and should optimally be involved in their establishment, review, and revision. When an actual patient is injured, care is provided according to protocol by the personnel who receive initial notification of the trauma and are first to respond at the scene. During this phase, all events are ideally coordinated with the physicians at the receiving hospital to ensure adequate time to prepare personnel and resources in the emergency department (ED).

The treatment goals for the prehospital phase include maintenance of airway, control of external bleeding and shock, patient immobilization, and transport to the closest appropriate facility, preferably a trauma center. In addition, obtaining important information concerning the mechanism of injury, related events, and past medical history of the patient may alert the receiving team to the possibility of particular injuries and their severity to enable faster diagnosis and treatment. The National Association of Emergency Medical Technicians Prehospital Trauma Life Support course is a resource for those interested in further information about this phase of care.⁷

Hospital Phase

The hospital phase of preparation is initiated with advance notice of the arrival of the injured patient. There is a tiered response in place at every trauma center. Depending on the severity of injury, a level of activation is initiated. For example, patients who are hypotensive (systolic blood pressure <90 mm Hg), bradycardic or tachycardic (heart rate [HR] <50 beats/min or >130 beat/min), or intubated in the field or with respiratory compromise, meet criteria for the highest level of activation which requires the presence of the full trauma team consisting of trauma surgery faculty, surgical residents, emergency medicine faculty and residents, and ED nurses. The activation criteria are developed by each hospital and guided by published resources and take into account the needed level of expertise and resources that should be available for the patient’s circumstances. Ideally, there should be a designated arrival area with adequate space to accommodate the personnel and equipment needed to carry out a trauma resuscitation. An often overlooked part of this phase is preparation of the resuscitation team, ensuring that all personnel understand their roles and have received any information communicated by the prehospital personnel. Airway supplies such as laryngoscopes and tubes should be tested and readily available. When the patient arrives, intravenous access and fluid resuscitation should be started in conjunction with a determination of airway and breathing status. In the trauma bay, pulse oximetry and ECG monitors should be available and applied to the patient. All trauma evaluations require proper personnel.⁸ In addition to physicians and nurses, respiratory therapists, radiology technicians, and social workers (for family issues) should be available. Resources such as the laboratory, x-ray, and bedside diagnostic equipment such as an ultrasound machine for FAST (Focused Assessment Sonography in Trauma) examination should be present. Last but definitely not least is the safety of the hospital team caring for the patient. All personnel who will be in close contact with the patient should wear universal precautions including hair covers, facemasks, eye protection, appropriate length gowns, shoe and/or leg coverings, and gloves to minimize exposure to communicable diseases.⁹ As many trauma patients either do not know or are unable to communicate their personal health history due to altered mental status, it is important that strict universal precautions are observed and in place at the time of patient arrival.¹⁰

TRIAGE

Triage is the process in which the severity of patient injuries, the number of injuries per patient, and the resources of the accepting facility determine priority of treatment. Communication between the accepting facility, other area facilities, and prehospital personnel is important prior to such an event as well as during such an event. One helpful triage scheme is based on the aforementioned ABCDE mnemonic, which is further outlined below.

There are two typical triage situations encountered: multiple casualty incidents and mass casualty events. The former involves multiple patients whose injuries do not exceed the capabilities of the receiving facility. In this situation, patients with life-threatening or multiple injuries are transported and treated first. In-hospital care is affected little, other than accessing normal surge capacity. In the latter situation, the number of patients and the severity of their injuries exceed the equipment, supplies, and personnel limitations of the receiving facility. Patients with the greatest chance of survival and requiring the least use of resources are transported and treated first. Triage continues in the hospital phase, as changing patient conditions and a variable number of patients transported may change initial estimations of survival and resource consumption.

PRIMARY SURVEY

The primary survey is a sequence of steps to identify immediately life-threatening but treatable injuries. Assessment and management proceed simultaneously, and life-threatening situations are managed as they are encountered during the course of resuscitation. This is made possible through close coordination of the trauma team, with each team member performing his or her designated role under the direction of the captain. The primary survey involves airway maintenance with cervical spine protection, breathing and ventilation, circulation with hemorrhage control, disability with respect to neurologic status, and exposure/environmental control, where the patient is completely undressed but kept warm to prevent hypothermia.

The priorities of the primary survey can be applied to all patients with certain caveats that do not alter the underlying alphabet or priorities, including pediatric patients, the elderly, pregnant women, and obese patients.

Pediatric patients: When caring for the pediatric patient, the size of the child and specific injury patterns must be kept in mind. Serious pediatric trauma is usually blunt trauma, often involving the brain. Brain injuries can lead to apnea, hypoventilation, and hypoxia, and protocols for pediatric trauma patients stress aggressive management of the airway and breathing to prevent these consequences. These physiologic derangements occur more often than hypovolemia with hypotension in seriously injured children.

Geriatric patients: The geriatric patient has overall less physiologic reserve to withstand injury. Their response may also be altered or blunted by comorbidities and chronic medication use. Resuscitation of these patients must take into account possible preexisting cardiac, pulmonary, and metabolic diseases.¹¹ For example, minor injuries can cause serious complications due to multiple medications, especially anticoagulant use.

Pregnant women: The anatomic and physiologic changes of pregnancy can be a challenge, and the response of the pregnant patient may be modified.¹² Knowledge of pregnancy and early monitoring of the fetus are important in maternal and fetal survival. Unnecessary x-ray exposure should be avoided, but treatment of the mother takes precedence.

Obese patients: The problem of obesity is on the rise.¹³ These patients pose a particular challenge in the trauma setting, as their anatomy can make procedures such as intubation difficult and hazardous.¹⁴ In addition, obese patients typically have cardiopulmonary disease limiting their ability to compensate for injury and stress. Treatment of these patients may exacerbate their underlying comorbidities.

Although these special populations each have their unique characteristics, the assessment and management priorities are the same. Treatment of these patients is elaborated elsewhere in this text.

Airway Maintenance with Cervical Spine Protection

Maintenance of the airway is the most important priority in caring for the trauma patient. Inadequate ventilation leads to hypoxia and inadequate oxygen delivery to tissues. Although important in all patients, this is particularly important in patients with head injury, as hypoxia contributes to secondary brain injury and hypoventilation may increase intracerebral pressure.¹⁵ Application of a pulse oximeter as an early adjunct to the primary survey in all patients helps in recognition and monitoring of hypoxemia.

In acute trauma, upper airway obstruction is the most common cause of inadequate ventilation. Structures of the upper airway such as the tongue, edematous soft tissues, blood, foreign bodies, teeth, and vomitus are common causes of obstruction. Quick assessment of the airway begins by asking the patient his or her name. A normal response implies the airway is not in immediate jeopardy, but frequent reassessment is required. Breathlessness, weak or absent voice, or hoarseness suggests airway compromise. Objective signs of potential airway problems include noisy breathing, cyanosis, and the use of accessory muscles. Unconscious and obtunded patients with a Glasgow Coma Score (GCS) of less than 8 should have their airway protected with an endotracheal tube to provide oxygenation and ventilation, and reduce the chance of aspiration. Indications for a definitive airway are listed in Table 10-1.

TABLE 10-1 Indications for Definitive Airway

A definitive airway is defined as a cuffed endotracheal tube in the trachea.⁵ In children under 9 years of age, an uncuffed tube should be used to prevent tracheal injury from the cuff. The most important aspect of securing the airway involves preparation. A skilled physician must be present with the necessary medication and equipment close at hand for intubation.¹⁶

When airway compromise occurs, initial maneuvers to maintain the airway are performed. The first involves opening the mouth and inspecting for foreign bodies or other obstructive causes. Either a chin lift or jaw thrust in conjunction with an oral or nasal airway can relieve obstruction caused by the tongue (Fig. 10-1). Care must be taken to protect the cervical spine during these maneuvers. The chin lift or jaw thrust can temporarily maintain oxygenation in preparation for a definitive airway. Rapid sequence intubation is employed for obtaining the definitive airway in the potentially combative trauma patient.¹⁷ An induction agent (often etomidate) is used in combination with a short-acting depolarizing agent such as succinylcholine to minimize duration of paralysis. In case of failed orotracheal intubation, the team should be ready to perform a surgical airway. Confirmation of tube placement occurs by auscultation over the epigastrium and the bilateral chest wall. There should be no breath sounds over the epigastrium and equal breath sounds heard over the chest. A CO₂ monitor is attached to the endotracheal tube and confirms the presence of CO₂ by color change.¹⁸ A chest x-ray is also obtained to confirm position. Once a definitive airway is established, securing by means of tape or a commercial device is imperative. In addition, frequent evaluation of tube position should be performed to prevent dislodgement of the tube and subsequent airway loss.

FIGURE 10-1 Chin lift and jaw thrust maneuvers to establish an airway. (Reproduced with permission from American College of Surgeons Committee on Trauma. Advanced Trauma Life Support For Doctors. 8th ed. Chicago, IL: American College of Surgeons Committee; 2008: p. 30.)

Breathing and Ventilation

After securing the airway, attention may be turned to breathing and ventilation. This includes both oxygenation and adequate exchange of carbon dioxide. Pulse oximetry is an effective noninvasive means of measuring arterial blood saturation by colorimetric measurement.¹⁹ Pulse oximetry may be inaccurate in the presence of peripheral vasoconstriction, carbon monoxide poisoning, or jaundice. Pulse oximetry may also be unreliable in hypothermic or severely anemic patients.²⁰ Depending on the patient’s partial pressure of oxygen and its location on the oxyhemoglobin dissociation curve, oxygen levels may change more quickly than indicated by the pulse oximeter measurement due to limitations in instrument response time. In these situations, the partial pressure of oxygen is more accurately determined using an arterial blood gas measurement.

A patent airway does not ensure adequate ventilation.⁵ Evaluation of breathing begins by looking at, listening to, and feeling the chest wall. Inspection of the chest wall can reveal asymmetry in chest expansion, accessory muscle use, contusions, penetrating chest wounds, open or sucking chest wounds, and distended neck veins. Auscultation of breath sounds can help diagnose pneumo- or hemothorax by detecting differences in breath sounds between the left and right chest. Palpation of the chest wall can be used to diagnose an unstable chest wall, tenderness, crepitance, deformity, or subcutaneous air. Finally, percussion has been suggested to identify hyperesonance, dullness, or tympany. Due to an often noisy resuscitation area, it is rarely helpful in diagnosing or differentiating chest trauma. Breathing problems can be life-threatening. A tension pneumothorax develops from either blunt or penetrating injury where air continuously enters the pleural space from the trachea, bronchi, or chest wall causing the lung to collapse. Clinical signs include shifting of the mediastinum with deviation of the trachea away from the affected side, distended neck veins, respiratory distress, decreased venous return due to elevated intrathoracic pressure with low cardiac output, hypotension, and shock. Tension pneumothorax is a clinical diagnosis and a chest x-ray should be obtained after treatment by chest tube insertion. Differentiation between a tension pneumothorax and cardiac tamponade may be difficult. Neck veins may not be distended secondary to hypovolemic shock. Heart sounds are usually muffled with the latter but this may be difficult to appreciate in a noisy trauma bay. Absent breath sounds may be the only differentiating sign. A massive hemothorax can also cause mediastinal shift due to blood instead of air and circulatory compromise. Fortunately, the treatment is similar and involves tube thoracostomy.

Ultrasound may be extremely useful in the rapid detection of pneumothorax, hemothorax, and cardiac tamponade. Accuracy for diagnosis of pneumo- and hemothoraces compares favorably with portable chest radiograph, and it can be performed much more quickly. The diagnosis of cardiac tamponade is also done efficiently by ultrasound, although the presence of a left hemothorax decreases accuracy.^21–23

A flail chest can also cause breathing problems. The definition of a flail segment is three or more consecutive ribs broken in at least two places each, or one or more rib fractures along with a costochrondral separation or fracture of the sternum. A flail chest is most often associated with underlying hemo- or pneumothorax and/or pulmonary contusion, which is the usual cause of associated respiratory compromise.²⁴

An open pneumothorax is defined as a chest wall defect greater than two thirds the diameter of the trachea. This is also known as a “sucking chest wound”. In an open pneumothorax air is drawn through the defect (the path of least resistance) into the chest. Larger defects cause greater respiratory distress. Treatment involves immediate temporary coverage of the defect on three sides, ipsilateral chest tube placement, and operative closure of the defect.²⁵

Finally, a massive hemothorax (>1,200 mL of blood evacuated initially) can cause mediastinal shift, respiratory distress, and hypovolemic shock, which must be managed immediately. This is managed with tube thoracostomy, transfusion, and immediate operation.

Circulation with Hemorrhage Control

Hemorrhage is the leading cause of preventable death after injury. Shock is the result of inadequate oxygen delivery to tissues. Although hypovolemic shock from bleeding is the most common form of shock in trauma victims, other types of shock can occur in these patients, and occasionally a combination of several types of shock are simultaneously present. Treatment for shock begins with placement of two large-bore peripheral IVs (16-gauge or larger) and appropriate isotonic fluid replacement. There are four classes of shock based on initial blood loss and presentation (Table 10-2).

TABLE 10-2 Estimated Blood Loss^a Based on Patient’s Initial Presentation^b

STOP THE BLEEDING!!! The most important treatment for hemorrhage is control of bleeding.^26,27 Hemorrhage in the adult trauma patient comes from one of five places—the thoracic cavity, abdominal cavity, pelvic fracture, long bones, or obvious external bleeding. The rapidity with which each source is investigated depends on the degree of shock. Some sources may be excluded by physical examination (external bleeding, thigh deformity), whereas others require the radiologic adjuncts to the primary survey. Bleeding into the chest and pelvis can be difficult to determine by physical examination alone, making early radiologic examinations essential in the patient in shock. The scalp is quite vascular and profuse bleeding from scalp wounds may require suture ligation or Raney clips to stop bleeding.²⁸ For obvious external bleeding, direct pressure on the bleeding vessel is the most effective method of hemorrhage control. For less well-defined areas of bleeding, proximal pressure over the femoral artery in the groin or the brachial artery in the upper extremity can be used. Tourniquets are effective in massive exsanguination from an extremity, but run a high risk of ischemic injury to that extremity and should only be used when direct pressure is not effective.¹⁵ However, the use of tourniquets is increasing, especially in the prehospital phase. Kragh et al. investigated tourniquet use at a combat hospital in Baghdad. They found that tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; ), that prehospital use was associated with survival, and no limbs were lost due to tourniquet use.²⁹ Hemothorax is treated with tube thoracostomy and operative control, intra-abdominal hemorrhage in the setting of shock requires laparotomy, and bleeding from a significant pelvic fracture requires pelvic stabilization with a sheet or binder followed by angiography or pelvic packing if necessary.

The diagnosis of shock begins with a check of the patient’s pulse rate and character, skin color and temperature, and mental status. A slow, regular pulse suggests normovolemia, whereas a weak or thready pulse suggests hypovolemia. Patients with pink and warm skin and extremities are less likely to have a circulation problem. Mental status changes may be due to inadequate end organ perfusion caused by hypovolemia, brain injuries, or drug use. Blood pressure is an important indicator of response to resuscitation, but should not be relied upon during the initial evaluation for the presence of shock. Urine output and central venous monitoring may also be used later to assess volume status and response to resuscitation.

Tachycardia results from a compensatory response to intravascular volume depletion via stimulation of the sympathetic nervous system and should always raise the suspicion of hemorrhagic shock. This efferent response to low intravascular volume also results in vasoconstriction of peripheral arteries, making the skin cool and clammy to the touch. Certain medications common in the elderly may blunt the tachycardic response, including beta-blockers, calcium-channel blockers, and diuretics.

Although tachycardia is the most common compensatory response to hemorrhagic shock, paradoxical bradycardia has also been observed. Paradoxical bradycardia is associated with rapid large-volume hemorrhage. Bradycardia in hemorrhagic shock predicts a poor prognosis, and traditional teaching associates a decrease in heart rate with irreversible shock (terminal response). However, research has revealed that bradycardia as an acute response to hemorrhage is potentially reversible. The key to treatment is quick recognition that bradycardia is a sign of major bleeding requiring massive and rapid fluid loading. Administration of atropine can precipitate cardiac arrhythmias and is contraindicated.³⁰

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