Principles of Trauma

1

Describe the primary assessment of the trauma patient (ABCs).

• Airway: Assess the patient’s airway by observing and listening. Assess for bleeding, loose teeth, inhalation injury (in case of burn), and level of consciousness. A decreased level of consciousness (GCS ≤8) is an indication of the potential inability to protect the airway and need for elective intubation. Orotracheal intubation with in-line cervical stabilization is the method of choice; however, orofacial trauma or a difficult airway may require a surgical airway (see Chapter 77 ). In the setting of blunt or penetrating tracheal injury, intubation should ideally be performed in the OR. This is performed with adequate equipment for a surgical airway open and readily available and with the neck prepped and draped prior to intubation attempts. Manipulation of the traumatically injured airway during intubation attempts may lead to critical decompensation, which requires immediate emergency surgical airway.

• Breathing: Assess by looking, listening, and feeling. Look for equal chest rise bilaterally. Auscultation can be difficult in the trauma bay but should be performed to evaluate for absence of breath sounds suggesting pneumothorax or hemothorax. Palpate for crepitus of the chest wall, suggesting rib fracture with potential underlying pneumothorax. Evaluate for “flail chest” – three or more ribs with fractures in two or more locations. Paradoxical respiration of this segment and impaired pulmonary mechanics can lead to both life-threatening hypoxia and hypercapnia. Additionally, this substantial injury mechanism is often associated with refractory, life-threatening hypoxia, even with mechanical ventilator support.

• Circulation: Assess circulation with frequent vital sign assessments, pulse examination (all extremities), skin color/capillary refill, and mentation. Circulatory assessment may be challenging in the extremes of age, with concomitant heart disease, in athletes and pregnant women, and with medications, hypothermia, and pacemakers.

• Disability: A brief neurologic exam and assessment based on the Glasgow Coma Scale is essential, particularly if the patient requires therapeutic paralysis for intubation (recognize if patient is moving extremities and document facial nerve function prior to administering paralytic agents).

• Exposure/Environmental Control: Perform a full physical examination for injury, especially in the non-alert patient, while minimizing hypothermia.

2

What is an AMPLE history?

An AMPLE history involves the key elements that can be rapidly obtained by the patient or patient’s friends or family when the patient has a limited ability to provide medical history. It consists of: A llergies, M edications, P ast Medical History, L ast PO Intake, and the E vents leading to the trauma.

3

What are the methods of verifying a secure airway after intubation or surgical airway procedure?

A secured airway must always be verified, including patients who are intubated in the field. The intubation itself should involve direct visualization of the vocal cords. An equal chest rise/fall should be observed. Auscultate for bilateral breath sounds, with consideration of the possibility of right mainstem intubation. Capnography should be rapidly used to assess the proper position; a small plastic insert is placed onto the endotracheal tube and assessed over the duration of several breaths. The return of CO ₂ confirms endotracheal positioning and is indicated by a color change from purple to yellow on the capnography insert. Persistent purple coloration indicates no CO ₂ return (yellow = mellow, purple = problem) ( Fig. 69.1 ). A chest radiograph can demonstrate the position of the endotracheal tube above the carina but does not necessarily rule out the possibility of esophageal intubation. Bronchoscopic confirmation of endotracheal tube placement is generally not feasible in the trauma bay setting.

4

What are the indications for chest tube placement?

A patient with hypotension and decreased breath sounds in the trauma bay should be presumed to have tension pneumothorax. Decompression should be performed immediately. Needle decompression can rapidly be performed with a 14-gauge needle catheter; recent updates to ATLS recommend needle decompression in the 4th or 5th intercostal space and mid-axillary line for adults (for children, the recommendation is the 2nd intercostal space, mid-clavicular line). Rapid decompression can also be performed with an incision in the anterior axillary 5th intercostal space (generally at the level of the nipple). Entry into the pleural space decompresses the tension pneumothorax; the chest tube can then be placed through this incision (immediate intervention involves the incision; do not wait for a chest tube to be ready if tension pneumothorax is suspected). A chest tube is also placed when hemothorax is suspected on examination or imaging. The initial chest tube output will dictate further management; greater than 1500 cc of blood is an indication for exploratory thoracotomy. Follow-up chest radiography should be performed after chest tube placement. Open chest wounds (“sucking chest wounds”) occur where the pleural space/pulmonary circuit directly communicates with the external environment. Large tidal volumes are lost through this open pulmonary wound. Initial management can include “three-sided” occlusive dressing. However, optimal initial management would include chest tube placement on that side of the thorax with a three-sided occlusive dressing to allow decompression and prevent tension pneumothorax.

5

What are the five locations of blood loss in a trauma patient?

• Scalp/street: The scalp and face are highly vascularized areas, and scalp bleeding should promptly be addressed with pressure, sutures, clips, or staples in the significantly injured patient. Prehospital care should include a rapid report that describes any significant blood loss at the scene of the trauma or en route.

• Chest: Rib fractures (up to 100 mL each), lung laceration, or injury to the great vessels or heart can result in significant thoracic hemorrhage and should be assessed for by examination (observation, palpation, auscultation) and imaging (radiography, ultrasound, computed tomography).

• Abdomen: Solid organ or mesenteric injury may result in hemoperitoneum and should be assessed for by examination (observation, palpation) and imaging (ultrasound, CT).

• Pelvis/retroperitoneum: Bleeding may occur from pelvic fractures, vascular injury, or solid organ injury (kidney, pancreas) and can be assessed for by examination, pelvic radiography, and CT.

• Bones: Blood loss from a pelvic fracture can be as much as 2000 mL; femur fracture, 1000 mL; tibia fracture, 250 to 500 mL; and rib fracture, 100 mL each. Evaluate by physical examination and imaging (radiographs) when injury is suspected.

6

Define shock.

Shock simply means inadequate tissue perfusion. In trauma, the most common cause is hemorrhagic shock, which requires immediate hemorrhage control and resuscitation with blood products and/or intravenous fluids. Shock may also result from spinal cord injury (spinal shock or neurogenic shock). Cardiogenic shock may occur due to tension physiology such as tension pneumothorax or cardiac tamponade. Cardiogenic shock from direct myocardial injury is less common in the trauma setting but should be considered for patients with a history of heart disease (i.e., syncopal episode leading to motor vehicle collision), significant anterior chest wall trauma, or sternal fractures. Septic shock should be considered for patients with a significantly delayed presentation such as extremely prolonged extrication or time-consuming transfer from remote locations.

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