Primary and Secondary Survey

A

Mortality

Trauma is the third leading cause of death in the United States for all ages and the leading cause of deaths in persons younger than 45 years.

• 1.

  A total of 50% of deaths occur within minutes after injury.

• 2.

  A total of 30% of deaths occur within 24 hours of injury.

• 3.

  The remainder of deaths occur days to weeks after injury.

B

Mechanisms of Injury

• 1.

  Motor vehicle crash or collision (MVC)

  • a.

    It is the leading cause of death.

  • b.

    Adolescents and young adults are at greatest risk for fatal MVCs.

  • c.

    Alcohol intoxication is a major factor in fatal MVCs in adolescents and young adults.

• 2.

  Firearms

  • a.

    Approximately 33,000 deaths occur secondary to firearms annually.

• 3.

  Falls

  • a.

    Falls are the leading cause of nonfatal injury in children younger than 14 years.

  • b.

    A total of 27% of adults older than 65 years will fall each year.

• 4.

  Industrial accidents and burns are also significant.

A

Primary Survey

Initial evaluation of the trauma patient

• 1.

  Brief history—mechanism of injury, time of injury, vital signs in the field, and medical history

• 2.

  ABCDEs

  • a.

    A irway: If the patient is alert and answers the questions with a clear voice, the airway is intact. If the patient’s airway is not secure, rapid sequence endotracheal intubation or a definitive surgical airway should be established. Repeated assessment of airway patency is crucial. Special considerations include:

    • (1)

      Mental status: Glasgow Coma Scale (GCS) ( Table 15.1 ) score of less than 8 usually requires intubation for airway protection. Agitation or combativeness may be signs of hypoxia or profound shock.

      TABLE 15.1

      Glasgow Coma Scale

      Eye Opening
      Opens spontaneously	4
      Opens to command	3
      Opens to pain	2
      No response	1
      Verbal
      Oriented	5
      Confused	4
      Inappropriate words	3
      Incomprehensible sounds	2
      No response	1
      Motor
      Follows commands	6
      Localizes pain	5
      Withdraws from pain	4
      Flexion with pain (decorticate)	3
      Extension with pain (decerebrate)	2
      No response	1

    • (2)

      Facial trauma: Upper airway landmarks can be distorted by soft tissue damage or blood.

    • (3)

      Protect cervical spine.

    • (4)

      A surgical airway (i.e., cricothyroidotomy) is established when edema of the glottis, fracture of the larynx, or severe oropharyngeal hemorrhage obstructs the airway or an endotracheal tube (ET) cannot be placed through the vocal cords. Surgical cricothyroidotomy is performed by making a skin incision that extends through the cricothyroid membrane, dilating, and inserting a small ET or tracheostomy tube.

  • b.

    B reathing: Assess oxygen saturation via pulse oximetry. Anemia, hypotension, and hypothermia can affect the reliability of the pulse oximeter. Palpation, percussion, auscultation, and inspection of chest cavity should be performed. Injuries that severely impair ventilation include: tension pneumothorax, flail chest with pulmonary contusion, massive hemothorax, and open pneumothorax.

  • c.

    C irculation and hemorrhage control: Shock is defined as inadequate tissue perfusion to support metabolic demands. The trauma patient can present with hypovolemic, cardiogenic, or neurogenic shock, or a combination of all three. Two large-bore (16–18 gauge) peripheral intravenous lines should be established.

    • (1)

      Vital signs: Tachycardia can be the first sign of hypovolemic shock. Blood pressure can be misleading because in hypovolemic shock, hypotension is not seen until 30%–40% of the blood volume is lost. Absence of tachycardia may be present in patients taking beta-blockers or digoxin, those in spinal shock, or in older adults.

    • (2)

      Physical examination: Level of consciousness, skin color, capillary refill, and pulses must be assessed.

    • (3)

      Hypovolemic shock: This is caused by loss of blood volume ( Table 15.2 for classes of shock). Major areas of internal hemorrhage include: chest, abdomen, retroperitoneum, pelvis, and long bones. Source of bleeding can be identified via physical examination and imaging (chest x-ray, pelvic x-ray, or focused assessment sonography in trauma [FAST]). One to 2 L of isotonic fluids are given initially unless the patient has predictors for requiring a massive transfusion. Predictors for massive transfusion include a penetrating mechanism of injury, a systolic blood pressure (SBP) <90 mm Hg, heart rate >120, and a positive FAST examination. If a massive transfusion is anticipated, resuscitation should be done with a balanced 1:1:1 (packed red blood cells [PRBC]:fresh frozen plasma [FFP]:platelets) transfusion strategy to mimic whole blood.

      TABLE 15.2

      Classification of Hemorrhage

      Parameter	I	II	III	IV
      Blood loss (mL)	<750	750–1500	1500–2000	>2000
      Blood loss (%)	<15	15–30	30–40	>40
      Pulse rate	<100	>100	>120	>140
      Blood pressure	Normal	Normal	Decreased	Deceased
      Respiratory rate	14–20	20–30	30–40	>35
      Urine output (mL/h)	>30	20–30	5–15	Negligible
      Central nervous system symptoms	Normal	Anxious	Confused	Lethargic
      Fluid	Crystalloid	Crystalloid	Blood	Blood

    • (4)

      Cardiogenic shock: This is caused by blunt or penetrating cardiac injury; it can also be caused by tension pneumothorax, which is treated with needle decompression and subsequent chest tube placement. Patients in cardiogenic shock may have cardiac tamponade, which is associated with Beck triad: hypotension, muffled heart sounds, and distended neck veins. Cardiac tamponade can be initially managed with pericardiocentesis.

    • (5)

      Neurogenic shock: This is caused by injuries to the spinal cord that result in loss of sympathetic tone, vasodilatation, and inability to mount a tachycardic response. Neurogenic shock is treated with fluid resuscitation and vasopressors.

  • d.

    D isability: After the airway, breathing, and circulation are assessed, the mental status and neurologic function are evaluated. The GCS is a standardized method of classifying level of consciousness.

  • e.

    E xposure: All clothing should be completely removed to perform a thorough assessment. Warm blankets and warmed fluid should be used to decrease hypothermia.

B

Further Evaluation and Transfer

• 1.

  Transfer of trauma patients: Some trauma facilities do not have the resources to deal with certain injuries. The patient should be stabilized and transferred by air or ground depending on the distance and injury severity.

• 2.

  Additional studies/diagnostics

  • a.

    Foley catheter to monitor urine output. Contraindicated if blood is present at urethral meatus, scrotal or penile hematoma, or high-riding prostate on rectal examination. If any contraindications, perform retrograde urethrogram to determine whether urethral injury is present. If no extravasation, a Foley catheter may be safely inserted.

  • b.

    Nasogastric tubes can be helpful for decompression. Massive gastric distension can contribute to nausea, vomiting, aspiration, tachycardia, and hypotension. Intubated patients should receive a nasogastric tube. Orogastric tubes are preferred over nasogastric tubes in patients with midface trauma.

  • c.

    Radiographic studies: In patients who are critically ill, it is important to obtain only studies that will affect management. A portable chest and pelvic radiograph can provide valuable information in the unstable patient. Patients being transported for studies or procedures must have an established airway, be hemodynamically stable, and be on a cardiopulmonary monitor.

  • d.

    Laboratory evaluation: Draw a standard trauma laboratory panel while establishing intravenous access. Recommend: type and screen, complete blood cell count, electrolyte panel, and coagulation tests. Lactic acid and base deficit are helpful to monitor the degree of shock. Thromboelastography (TEG) may guide resuscitation and blood product use.

C