Evaluation and Treatment of the Multi-Injured Trauma Patient

Prehospital Personnel

The on-scene evaluation and treatment of trauma patients can be widely variable and are dependent on the level of training of the provider, local standards and protocols, and available resources. Although local protocols often follow nationally accepted standards, there may be variations for each specific protocol based on regional need or the local medical director's preference. In general, more densely populated areas have a greater number of EMS providers and resources. Unfortunately, as the population density decreases, EMS resources often decrease. In rural areas, only one ambulance and a basic EMT team may be available for a large geographic area.

Each EMS system has a unique structure, but in general, there are five levels of providers: first responder, emergency medical technician (EMT) basic and advanced, paramedic, and prehospital critical care provider. Each level of prehospital provider has specific required training that increases in conjunction with the number and complexity of the available protocols and interventions to be performed ( Table 10.1 ). The US Department of Transportation (DOT) establishes the National Standard Curricula (NSC) as the minimum standards for each level and recommends the range of required training hours.

Prehospital critical care providers include critical care–trained paramedics, nurses, respiratory therapists, and physicians. These providers operate in ground and air transport systems and are often required to have a certain amount of in-hospital critical care experience before joining a transport team. Commonly, they receive further training, both didactic and practical, as part of an orientation to the transport program; most advanced teams receive 2 to 6 months of training after joining the transport team. This group of practitioners provides the highest level of care outside of the hospital setting. The assessment of a trauma patient is generally the same as done by other prehospital medics but involves more attention to detail. The interventions follow the same general principles but are often more aggressive, including intravenous (IV) fluid resuscitation and administration of analgesia. The same principles for immobilization are used, and the patient is transported to the hospital.

Prehospital Care: Airway Control

The first objective is to evaluate, manage, and secure the airway. Inspection of the airway for foreign bodies such as broken teeth, foodstuff, emesis, and clotted blood is essential before an artificial airway is placed. In all Basic Life Support courses, the emphasis on chin lift and jaw thrust cannot be overemphasized as the initial treatment. This simple maneuver moves the tongue away from the back of the throat and often reestablishes a patent airway. At this point, an oral or nasopharyngeal airway may need to be placed to prevent the tongue from occluding the airway.

In the event that this maneuver does not restore spontaneous breathing, assisted ventilation may be required, and a wide range of breathing assist devices is currently available. The use of SteriShields or more sophisticated mouth-to-mask breathing devices has introduced an element of safety for the resuscitator ( Fig. 10.1A ). These devices are small and are found in first responder mobile units as a standard approach to resuscitation. Some of these devices allow for supplemental oxygen to be used in the resuscitation. Hyperoxygenation is essential for cardiopulmonary stabilization and resuscitation.

After this maneuver has been performed, the airway may need to be definitively controlled in patients who are unresponsive or have an altered mental status (Glasgow Coma Scale [GCS] score <8), are hemodynamically unstable, or have multiple injuries involving the head and neck. Thermal injuries to the airway also warrant consideration for early airway control. The presence of singed hair, soot, or burns around the air passages suggests significant thermal injury, and early placement of an endotracheal tube before significant edema and swelling develop is important.

Prehospital endotracheal intubation remains a controversial intervention because of the success rate and amount of time required to secure the airway. The EMS systems with the highest endotracheal intubations rate have very stringent requirements for certification (i.e., 20 live intubation or a minimum of 12 field intubations annually). Neuromuscular blockade increases the success rate (97%), but the current use is limited to a few ground EMS systems and aeromedical agencies under direct medical control.

Whenever the decision is made to emergently secure an airway, it must be accomplished as quickly and safely as possible. Pharmacologic agents must be chosen that allow the procedure to be performed safely while minimizing the risk to the patient. The most rapidly acting agents with the shortest duration (i.e., etomidate for sedation and succinylcholine for paralysis) along with an acceptable side-effect profile should be chosen. In the case of the standard rapid-sequence induction, the patient should be preoxygenated, and a hypnotic agent should be given and immediately followed by the paralytic agent. Mask ventilation is not attempted (it may induce aspiration), and it is hoped that the immediate successful placement of the endotracheal tube will follow. Proper placement is verified by auscultation of the lungs bilaterally, lack of gastric sounds with ventilation, and the presence of end-tidal carbon dioxide at the proximal end of the endotracheal tube.

As the anesthetic induction is begun, an assistant should apply enough pressure to the cricoid cartilage to occlude the esophagus, which lies directly posterior (although this maneuver is controversial). Trauma, pain, and the use of narcotics may all delay gastric emptying, so release of cricoid pressure occurs only after proper positioning of the endotracheal tube has been verified. In-line cervical spine stabilization must be maintained to minimize iatrogenic injuries to the spine and spinal cord during the process of definitive airway control.

Besides direct endotracheal intubation, other airway adjuncts are available (see Fig. 10.1 ). The use of the laryngeal mask airway (LMA) has gained popularity because of the relative ease of placement and relatively low cardiovascular stress that the patient undergoes compared with standard endotracheal intubation. The LMA was designed for use in spontaneously breathing patients and does not technically protect the airway from aspiration. It may be used emergently for a patient to whom a paralytic agent has been given but for whom successful intubation has not been achieved or before the injection of the paralytic agent if mask ventilation is not adequate.

The King LT is a commonly used rescue technique to manage the airway in the prehospital setting. The King LT is a single-use supraglottic airway that uses two cuffs to create a ventilation seal at the pharynx and esophagus. It has a single ventilation port and a single valve and pilot balloon that go to both the pharyngeal balloon and the esophageal balloon. Although it is possible to insert the distal tip of the King LT directly into the trachea instead of the esophagus, its overall short length and preformed curve make this very unlikely. Several studies have shown the King LT to have a higher rate of success for airway control in the prehospital setting compared with other supraglottic airways or endotracheal intubation.

Prehospital Care: Resuscitation

A primary goal of prehospital providers in conjunction with airway and hemorrhage control is the restoration of perfusion. Prompt and appropriate access to the intravascular space is critical, and the placement of large-bore peripheral catheters is still the standard. However, rapid access is not always easily achievable, and an alternative approach with placement of intraosseous (IO) devices has become routine in our trauma system ( Fig. 10.2 ). These devices can be placed in both children and adults in a variety of locations (sternal vs. tibia vs. humerus), but caution must be used because each IO device is specifically designed for a specific age group and specific anatomic location.

The traditional prehospital resuscitation treatment regimen of 2 L of crystalloid fluid to achieve a minimum systolic blood pressure of 90 mm Hg has been reduced to 1 L of crystalloid with the 9th edition of the ATLS course based on growing evidence that aggressive crystalloid resuscitation may be harmful. The concept of withholding resuscitation and allowing “permissive hypotension” with ongoing hemorrhage dates back to World War I and has been uniformly adopted in the current management of gastrointestinal (GI) hemorrhage and aortic aneurysm rupture. In selected groups of trauma patients, it has also been shown to increase survival. This concept of controlled resuscitation has already been adopted by the military with limited administration of fluids (maximum of two 500-mL boluses of Hextend a minimum of 30 minutes apart). The rationale for this recommendation is based on limited resources on the battlefield and the cumulative literature regarding limited resuscitation.

The prehospital administration of blood components and fresh whole blood (FWB) is becoming more frequent, particularly with prehospital critical care providers on both rotary-wing and ground transports. Currently, several air services carry packed red blood cells (pRBCs), and a few carry plasma. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used since the 1960s to control bleeding from blood dyscrasias, heavy menstrual bleeding, and GI bleeding and is now also being evaluated in trauma patients as part of the resuscitation. In a very large multicenter, randomized, double-blind, placebo-controlled trial, trauma patients who received TXA had a significant reduction in all-cause mortality and an overall reduction in death secondary to hemorrhage. Those patients who benefited the most received TXA within 3 hours of injury. The military recently retrospectively compared combat-injured patients who received TXA with those who did not, demonstrating improved survival in the group that received TXA. Current efforts are under way to study the use of TXA in the prehospital setting to assess if earlier administration of the drug would extend the benefits previously seen in the hospital treatment. Over the next several years, we anticipate increased use of blood, plasma, and TXA in the prehospital setting.

Trauma Team

The configuration of the trauma team receiving patients is variable but includes emergency medicine physicians, nurses, allied health personnel, and the trauma surgeon as the team leader. Various subspecialists in surgery, orthopaedics, neurosurgery, cardiothoracic surgery, anesthesia, and pediatrics are readily available at a level I center. The receiving facility should have a dedicated area for the resuscitation of trauma patients as well as a dedicated operating room (OR) available 24 hours a day. A resuscitation room should be well equipped with devices for the warming of fluids, rapid infusers, and appropriate surgical supplies for the performance of lifesaving procedures. Permanently fixed radiographic equipment expedites the evaluation of injured patients in the resuscitation room. Staffing in the trauma room should be limited to those individuals with experience in trauma resuscitation, and their duties should follow the guidelines outlined in the ACS Committee on Trauma Resources for Optimal Care of the Trauma Patient.

After the acute phase of resuscitation and operative intervention, a level I trauma facility maintains a highly trained staff of surgical intensivists. The staff provides 24-hour coverage of the intensive care unit (ICU). ICU patients are susceptible to complications such as sepsis, acute respiratory distress syndrome (ARDS), and multisystem organ failure, which require the technical support and resources provided by a level I center. Intermediate care units provide intensive supervision of the patient before placement on the trauma floor, which is critical for optimal recovery. During this time, patients receive rehabilitation to prepare them for dealing with disabilities and limitations that have changed their lives secondary to injury. The patient's physical and emotional health are assessed, and treatment is initiated. Those patients with significant injuries will have special nutritional needs given their increased caloric demands, and an assessment by nutritional services helps guide optimal nutritional support. As the patient nears discharge, arrangements for home needs and potential placement are made by social services and case care coordinators. The availability of and relationships with rehabilitation centers and chronic nursing facilities are essential for injured patients.

Hospital Resuscitation

After the trauma patient has reached the trauma center, resuscitation is continued according to the principles of primary, secondary, and tertiary surveys as established by the ACS Committee on Trauma. The primary survey encompasses the ABCs, disability, and exposure. The goal is to identify and treat immediate threats to life. The focus of the primary survey is to restore normal physiology in an unstable patient. Realize that this may require operative intervention or interventional radiology to control hemorrhage. Thus the primary survey is a physiologic concept and not a temporal one. The primary survey and resuscitation phase occur simultaneously rather than sequentially, with clear assignment of tasks to team members. The team leader must coordinate this process. The team does not move to the secondary survey until immediate threats to life have been addressed. The secondary survey involves a head-to-toe evaluation of the patient's injuries and the implementation of appropriate interventions ( Box 10.1 ). The tertiary survey involves a serial reevaluation of the patient's status during his or her hospital course. This section reviews the process of trauma resuscitation and diagnostic modalities and treatment options for specific injuries.