Key Concepts

  • Immediately after a trauma patient arrives the emergency department (ED), the primary survey should be performed in a standardized fashion. The goal of the primary survey is to rapidly identify and initiate the treatment of critical, and life-threatening injuries.

  • The extended Focused Assessment with Sonography for Trauma (eFAST) examination should be performed early in the evaluation of the trauma patient (ideally as part of the primary survey). Thoracic examination of the trauma patient by ultrasound is more accurate than plain radiography.

  • Any patient with potentially life-threatening injuries should have blood typing and screening performed. When transfusion is indicated, blood products should be transfused in a 1:1:1 or 1:1:2 ratio of plasma to platelets to packed red blood cells.

  • Tranexamic acid (TXA) is indicated for patients with evidence of significant hemorrhage or shock and is given as a 1-g intravenous bolus followed by a 1-g infusion over 8 h. Results are best if started within an hour of injury but benefit may occur when it is given within 3 h.

  • Special consideration should be given to the elderly who demonstrate increased morbidity and mortality in settings where traumatic injury initially appear less concerning. Patients over the age 65 with one or more of the following comorbid conditions (coagulopathy, cirrhosis, COPD, CAD, or DM) have more than twice the mortality risk than younger patients.

Foundations

Background and Importance

Unintentional injury remains the leading cause of death in persons 1 to 44 years of age. , Each day, approximately 9 people are killed and more than 1000 injured by distracted drivers that have led to new laws prohibiting texting while driving. Firearm-related deaths are a significant concern, especially in the United States. , The economic cost of traumatic injuries and death (medical costs and lost productivity) is estimated in the hundreds of billions of dollars. ,

Stabilization, evaluation, and treatment of trauma patients are central to the practice of emergency medicine. Effective management of critically ill trauma patients requires decisiveness, technical skill, and effective leadership. A methodical, team-based approach is necessary, capitalizing on a strong clinical partnership between emergency medicine and surgery. Coordination with emergency medical services (EMS) providers, nursing, radiology, and other trauma-related specialties is needed to optimize outcomes. Prompt and safe transfer to the operating room requires collaboration and effective communication with other specialists such as surgeons, and anesthesiologists.

Anatomy, Physiology, and Pathophysiology

In blunt trauma victims, the mechanism of injury can be associated with particular injury patterns. These are listed in Table 32.1 . Knowledge of these associations can help the clinician evaluate for injuries that may not be readily identified by initial examination.

TABLE 32.1
Blunt Trauma Mechanisms and Associated Injuries
Mechanism of Injury Additional Considerations Potential Associated Injuries
Motor Vehicle Collisions
Head-on collision Facial injuries
Lower extremity injuries
Aortic injuries
Rear end collision Hyperextension injuries of cervical spine
Cervical spine fractures
Central cord syndrome
Lateral (T-bone) collision Thoracic injuries
Abdominal injuries—spleen, liver
Pelvic injuries
Clavicle, humerus, rib fractures
Rollover Greater chance of ejection Crush injuries
Significant mechanism of injury Compression fractures of spine
Ejected from vehicle Likely unrestrained Spinal injuries
Significant mortality
Windshield damage Likely unrestrained Closed head injuries, coup and countercoup injuries
Facial fractures
Skull fractures
Cervical spine fractures
Steering wheel damage Likely unrestrained Thoracic injuries
Sternal and rib fractures, flail chest
Cardiac contusion
Aortic injuries
Hemothorax, pneumothorax
Dashboard involvement or damage Pelvic and acetabular injuries
Dislocated hip
Restraint or seat belt use
Proper three-point restraint

  • Lap belt only

  • Shoulder belt only

Decreased morbidity Sternal and rib fractures, pulmonary contusions
Chance fractures, abdominal injuries, head and facial injuries and fractures
Cervical spine injuries and fractures, “submarine” out of restraint devices (possible ejection)
Air bag deployment Front end collisions
Less severe head and upper torso injuries
Not effective for lateral impacts
More severe injuries in children (improper front seat placement)
Upper extremity soft tissue injuries and fractures
Lower extremity injuries and fractures
Pedestrian Versus Automobile
Low speed (braking automobile) Tibia and fibula fractures, knee injuries
High speed Waddel’s triad—tibia and fibula or femur fractures, truncal injuries, craniofacial injuries
Thrown pedestrians at risk for multisystem injuries
Bicycle
  • Automobile-related

Closed head injuries
Handlebar injuries
  • Spleen or liver lacerations

  • Additional intra-abdominal injuries

  • Consider penetrating injuries

  • Non–automobile-related

Extremity injuries
Handlebar injuries
Falls LD 50 , 36–60 ft.
Vertical impact Calcaneal and lower extremity fractures
Pelvic fractures
Closed head injuries
Cervical spine fractures
Renal and renal vascular injuries
Horizontal impact Craniofacial fractures
Hand and wrist fractures
Abdominal and thoracic visceral injuries
Aortic injuries
LD 50 , Height of fall that would be fatal for 50% of those falling.

Older patients commonly sustain extremity, craniofacial, and closed head injuries. Most of these occur as a result of a fall or motor vehicle collision (MVC). Thirty million older adults fall each year, resulting in about 30,000 deaths. Older trauma patients typically have comorbid illnesses, usually on medications (especially anticoagulants), and also have age-related changes in organ-system function. These factors can increase susceptibility to injury, morbidity, and mortality. Obese patients are also at risk for increased morbidity and mortality from trauma.

In penetrating trauma from knife wounds or injuries from low-velocity sharp objects, tissue damage can be expected to occur primarily along the track of the object. However, the type and severity of injuries inflicted by gunshot wounds depend on several factors. The amount of tissue damage is related to the kinetic energy of the bullet, which is a factor of the bullet weight (caliber) and velocity. Gunshot wounds cause trauma to the surrounding tissue by direct laceration, crush injury, shock waves, and cavitation—the displacement of tissue forward and radially. Owing to these dynamic forces, high-velocity weapons, such as rifles, cause more widespread injuries than low-velocity weapons (handguns). Similar to knives, handgun bullets and shotgun pellets (from long range) generally cause injury based on direct laceration and crush generated by the missile along its track. Shotgun wounds from close range are characterized by massive tissue injury.

Clinical Features

Primary Survey

A focused and methodical primary survey should be initiated immediately in the emergency department (ED). The goal of the primary survey is to diagnose critical, life-threatening injuries rapidly, and begin treatment at the time of diagnosis. Figs. 32.1, 32.2, and 32.3 show the recommended algorithms for the evaluation of airway, breathing, and circulation. Fig. 32.4 highlights special considerations between blunt and penetrating mechanisms that should be considered during the primary survey.

Fig. 32.1, Airway Assessment Algorithm.

Fig. 32.2, Breathing Assessment Algorithm.

Fig. 32.3, Circulation With Hemorrhage Control Algorithm.

Fig. 32.4, Special Considerations of the Primary Survey.

In the absence of obvious direct trauma involving the airway, management decisions are based on the overall patient condition and potential for deterioration. Following initial airway assessment, decisions surrounding airway management should focus on the ability of the patient to protect their airway, adequacy of ventilation and oxygenation, and anticipated clinical course.

Inadequate ventilation, which may lead to respiratory acidosis, can be noted by the rate and quality of respirations and can be monitored using end-tidal carbon dioxide monitoring. Pulse oximetry will detect inadequate oxygenation, which may manifest clinically as agitation and restlessness, as opposed to hypercapnia which usually manifests as somnolence. Assessment of injuries that may compromise oxygenation or ventilation requires careful inspection and auscultation of the chest and may be augmented by use of point-of-care ultrasound. Signs of such compromising injury include increased work of breathing, tachypnea, penetrating wounds, subcutaneous emphysema, chest wall instability, flail segments, tracheal deviation, and distended neck veins. See Fig. 32.2 .

Assessment of hemodynamic and circulatory status (see Fig. 32.3 ) follows evaluation of the airway and ventilation. Clinical indicators of adequate perfusion include normal mental status, skin color and temperature, heart rate, blood pressure, and capillary refill. However, a normal finding for any single sign does not rule out significant hemorrhage or even shock. Mental status changes associated with hypoperfusion can include anxiety, agitation, and depressed consciousness. Cool pale skin or extremities with delayed capillary refill suggest inadequate perfusion and shock. Vital signs can be misleading in well-conditioned athletes and children. Medications may also blunt expected physiologic responses. A normal heart rate, blood pressure, or both can be present, despite significant hemorrhage. Conversely, tachycardia could be seen without significant volume loss.

Traditionally, direct pressure to external bleeding sites was advocated, while the use of tourniquets was discouraged. While direct pressure remains first-line therapy, there is good evidence to support the early use of tourniquets for massive extremity hemorrhage that is not otherwise easily controlled. Similarly, studies of newer hemostatic agents have shown potential application in combat and out-of-hospital settings. ,

Early intravenous (IV) access is required in the assessment of circulation. Two short, large-bore (14- or 16-gauge) IV catheters are preferred. Routine IV access may be difficult or unobtainable in certain cases. Intraosseous (IO) vascular access can be obtained rapidly in pediatric and adult patients, and this allows the safe infusion of large amounts of fluid or blood products. , Battery operated drills are widely available and can facilitate IO placement. Ultrasound-guided peripheral venous access by nurses and emergency clinicians should be considered in patients with challenging peripheral vascular anatomy. Central venous access may also be indicated in the appropriate clinical scenario or based on the emergency clinician’s discretion. The use of ultrasound has been shown to increase successful vein cannulation and decrease complications in the placement of central venous lines. , A straight leg raise test or real-time ultrasound of the vena cava can be performed to determine adequacy or response to resuscitation. An extended, focused, abdominal sonography in trauma (eFAST) examination should be performed on all patients during transition from the primary to secondary survey.

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