Initial Evaluation and Resuscitation

Primary Survey

Initial assessment and management of the injured patient are guided by prioritized steps defined by the Advanced Trauma Life Support (ATLS) program. Although described sequentially, these steps must be accomplished rapidly and often simultaneously. The first series of steps, the primary survey, is intended to identify and treat immediately life-threatening conditions and follows the acronym ABCDE:

• Airway: Ensure patency.

• Breathing: Rule out pneumo- and hemothoraces.

• Circulation: Assess vital signs and peripheral pulses. Obtain intravenous (IV) access.

• Disability: Perform brief neurologic examination.

• Exposure: Remove patient's clothing. Cover with warm blankets to prevent hypothermia.

If the patient needs to be intubated, a brief neurologic examination should be performed before administering sedative or paralytic medications. If the patient arrives in extremis or with life-threatening external hemorrhage, circulation should precede the airway.

Adjuncts

Although the primary and secondary surveys focus on physical examination, adjuncts may be used to assist with identifying injuries and guiding resuscitation. These adjuncts include plain radiographs (especially chest and pelvic x-rays), focused assessment with sonography in trauma (FAST), and gastric and urinary catheters.

Assess Need for Resuscitation

The need for resuscitation is determined during the circulation component of the primary survey based on initial vital signs and injury characteristics. New understandings of physiologic, coagulation, and inflammatory perturbations after injury have resulted in the development of multiple rules, scoring systems, and physiologic tests to assist with this determination. Hemodynamic instability in the field or upon arrival [systolic blood pressure (SBP) <70 mm Hg or 71–90 mm Hg with heart rate >100 bpm], penetrating torso injury, major pelvic fracture, or positive FAST indicate that the patient will likely require resuscitation. In these circumstances, transfusion should be initiated with a balanced ratio of red blood cells (RBCs) and fresh frozen plasma (FFP), often via a pre-established massive transfusion protocol that ensures rapid delivery of blood products from the blood bank. As soon as IV access has been obtained, laboratory tests should be sent including a type and screen, complete blood count (CBC), thromboelastography (TEG), arterial blood gas (ABG), and lactate. Base excess < –6 and/or lactic acidosis >4 suggest severe metabolic derangements, and repeat measurements can be used to guide the effectiveness of ongoing resuscitation.