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Initial Evaluation of the Trauma Patient

April 29, 2022 - read ≈ 11 min

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Authors

Annabelle Jones, MD

Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

Authors

Paige Newell, MD

Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

Nakul Raykar, MD, MPH

Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

Content

Introduction

Advanced Trauma Life Support (ATLS) was first developed in 1976 and is used globally as a framework for the systematic evaluation of trauma patients to optimize outcomes and reduce the risk of unidentified injuries(1). ATLS provides an easy-to-remember, algorithmic approach to the evaluation and initial management of the trauma patient, focusing on the greatest threat to life first, with the “ABCDE” approach to trauma management: Airway (with restriction of cervical spine motion), Breathing, Circulation (stop bleeding), Disability of neurologic status, and Exposure (undress) / Environment (temperature control). This chapter will outline the initial evaluation of the trauma patient using the ABCDE approach.

Pre-Arrival Phase

Preparation is critical and an area for resuscitation should be designated prior to the patient’s arrival. Preparation includes ensuring availability and proper functioning of equipment potentially required for the rapid resuscitation of the trauma patient (Table 1). The equipment detailed in Table 1 represents an ideal set of equipment, which should be adapted to local context based on resource availability. Intravenous crystalloid solutions should be warmed and readily available. Team roles should be established, including team leader and those who will oversee and intervene at the behest of the team leader on the securing the airway, intravenous access, laboratory collection, and medication administration. A designated individual to document can be critical to quality improvement efforts.   Other medical providers that may be required in the care of the trauma patient, such as orthopedic surgeons or neurosurgeons, should be notified of the arrival of a trauma patient. Rapid lines of communication should be available to laboratory and radiology personnel.

Table 1- Suggested Trauma Bay Equipment By Anatomic Region

Instrument TrayHemostats / Clamps, Retractors, Pickups/Needle Drivers, Sutures/Staplers
Head/NeckIntracranial Pressure Kits, Light Source, Cervical Collars
AirwayAirway Kit (Endotracheal Tube, Stylets, Bougies, Capnography)Video Laryngoscope, Suction, Ventilator, Arterial Blood Gas Kits, Emergency surgical airway kit
ThoraxChest Tubes / Pneumovac, Thoracotomy Kit
Abdomen/PelvisUltrasound, Nasogastric Tubes, Foleys, Pelvic Binders
ExtremitiesTourniquets, Doppler Probe
ShockIntravenous Fluids, Fluid Warming Devices, Rapid Infusers Central Lines, Arterial Lines, Intraosseous Line Kits

Primary Survey

The goal of the primary survey, or the ABCDE system, is the rapid assessment of vital functions and injuries with the goal of addressing life-threatening injuries that can kill within seconds to minutes and to establish treatment priorities. Much of the primary survey should be completed within two minutes, and any life-threatening injury identified should prompt a pause for intervention. Throughout the entirety of the initial evaluation of the trauma patient, patients should be continually reevaluated, and any alteration in vital functions should prompt repeat of the primary survey.

Table 2 – The ABCDE System of the Primary Survey

ABCDE Focus AreaPotential Life Threatening Injuries
Airway maintenance with restriction of cervical spine motionHypoxia from airway obstruction, misplaced endotracheal tube, or significantly depressed mental status with inability to protect airway
Breathing and ventilationTension pneumohemothorax
Circulation with hemorrhage controlBleeding, bleeding, bleeding
Disability (assessment of neurologic status)Catastrophic spinal cord injury with hypotension or inability to support breathing
Exposure / Environmental ControlMissed injuries leading to hemorrhage

Airway with Restriction of Cervical Spine Motion

The initial priority in the evaluation of the trauma patient is the airway. Airway patency must be assessed and need for definitive airway placement established. The cervical spine should be kept immobilized throughout the primary survey, and providers should assume a spinal injury exists. Asking a patient what their name is can be an efficient method of assessing for airway patency. In general, a patient able to speak in their normal voice does not have an airway obstruction.  Obstructions to the airway, including foreign bodies, excessive bleeding, expanding hematomas, and laryngeal/tracheal disruption, must be identified and addressed, often with establishment of an airway either through endotracheal intubation or surgical airway (cricothyroidotomy). Signs of impending airway compromise include significant bleeding in the oropharynx, alteration in voice or phonation, dyspnea, hematoma in neck or face, and subcutaneous air in neck or chest. It may be prudent to evaluate risk of difficult intubation during airway assessment. Predictive factors of a difficult intubation, and potential need for surgical airway placement, include facial trauma, large incisors, beards, large tongues, incisor distance <3 finger-breadths, distance between hyoid and mental process <3 finger-breadths, distance between thyroid and mouth <2 finger-breadths, high Mallampati score, obesity, and poor neck mobility(2).

If there is any concern about the patient’s ability to maintain their airway a definitive airway should be established (typically a cuffed, secured tube in the trachea via intubation or surgical cricothyroidotomy). The Eastern Society for the Surgery of Trauma (EAST) guidelines for intubation include: airway obstruction, hypoventilation, persistent hypoxemia (SaO2 less than or equal to 90%) despite supplemental oxygen, Glasgow Coma Score less than or equal to 8, severe hemorrhagic shock, cardiac arrest, and major burn burden ( greater than or equal to 40% total body surface area) (3). The technique for cricothyroidotomy is discussed separately. 

Potential Interventions: Endotracheal intubation, surgical cricothyroidotomy

Adjuncts: pulse oximetry, continuous electrocardiography, end-tidal carbon dioxide measurement, ABG

Any intervention should prompt full, rapid, reassessment of the primary survey, starting with airway.

Breathing and Ventilation

After establishment of a patent airway, it must be ensured that the patient is adequately oxygenating and ventilating. All patients should be provided with supplemental oxygen, and oxygen saturation should be monitored with pulse oximetry. Assessment of breathing includes exposing the chest, neck, and axilla to reveal evidence of trauma, evaluation of chest wall mechanics, jugular venous distension, the position of the trachea, respiratory rate, and oxygen saturation. The bilateral lungs should be auscultated. Major injuries that may compromise ventilation that should be identified during the primary survey include tension pneumothorax, hemothorax, open pneumothorax, and tracheobronchial injuries. These injuries often require immediate intervention to ensure effective ventilation, such as tube thoracostomy for decompression. A portable anteroposterior CXR can be a useful adjunct to diagnose thoracic pathology but should not interrupt the resuscitation process.

Potential Interventions: Tube thoracostomy, needle decompression of thorax

Adjuncts: Anteroposterior CXR, ABG, pulse oximetry, continuous electrocardiography

Any intervention should prompt full, rapid, reassessment of the primary survey, starting with airway.

Circulation with Hemorrhage Control

Hemorrhage is the largest cause of preventable deaths after trauma and should be addressed immediately and, if human resources permit, concomitantly with airway. Shock should be rapidly identified, and resuscitation should be initiated. Administration of medications for intubation such as etomidate and rocuronium in a patient with severe, unaddressed hypovolemia can push the patient into cardiac arrest. As such, rapid initiation of fluid or blood should be performed first or concomitantly, if the securing the airway can permit a small delay(4). A brief physical exam, including patient level of consciousness, skin perfusion, pulse (rate and presence in distal extremities), and blood pressure, can alert the provider to shock states. Once tension pneumothorax has been excluded during the breathing assessment, hypotension is due to blood loss until proven otherwise. Areas of bleeding that can result in shock states in the trauma patient include the chest, abdomen (including the retroperitoneum), pelvis, long bones, and externally. Sources of bleeding should be identified as able and external hemorrhage should be rapidly controlled during the primary survey. External hemorrhage can be managed through manual pressure on the wound, packing the wound, or if those methods are ineffective and hemorrhage is from a limb, tourniquet application. Adjuncts to the primary survey, including Focused Assessment by Sonography in Trauma (FAST), chest x-ray, and pelvic x-ray, can be utilized to identify internal sources of hemorrhage and guide future management. The technique to perform the FAST exam is discussed separately.

Adequate vascular access should be established, ideally at least two large bore (18 gauge or larger diameter) intravenous lines in the upper extremities, to allow for resuscitation. Alternative methods of venous access, including intraosseus access, are discussed separately. Fluid resuscitation should be initiated – preferably with blood if the patient is believed to be hypotensive from bleeding. Transfusion  can begin with type O blood (and preferably type O negative blood in women of childbearing age, though this is not an absolute). Given significant morbidity with coagulopathy in the trauma patient transfusion should be in a 1:1:1 ratio of packed red blood cells, plasma, and platelets if you anticipate transfusing >4 units of red blood cells. The administration of 1 gram of tranexamic acid within three hours of injury has been associated with improved survival(5). The priority in this section should be controlling hemorrhage; aggressive resuscitation before control of bleeding has been demonstrated to increase morbidity and mortality(6).

Potential Interventions: Intravenous access placement, crystalloid infusion, blood product, transfusion, urinary catheter placement

Adjuncts: Blood pressure monitoring, Anteroposterior CXR, Abdominal XR, Pelvic XR, FAST, hematologic laboratory analysis 

Any intervention should prompt full, rapid, reassessment of the primary survey, starting with airway.

Disability

A rapid neurologic evaluation should be undertaken to assess for life-threatening neurologic injury. Components of the physical exam include assessment of level of consciousness, pupillary size and reaction, identification of lateralizing signs, and determination of level of spinal cord injury if present. The Glasgow Coma Scale (GCS) can be a fast and objective method of determining a patient’s level of consciousness. Alteration in level of consciousness should prompt re-evaluation of oxygenation, ventilation, and perfusion, as well as presence of hypoglycemia, alcohol, narcotics or other substances. A GCS score of less than eight should prompt definitive airway placement. Once intracranial injury is identified efforts should be undertaken to prevent secondary injury through maintenance of adequate oxygenation and perfusion.

Potential Interventions: Endotracheal intubation

Adjuncts: pulse oximetry, continuous electrocardiography, blood pressure monitoring

Any intervention should prompt full, rapid, reassessment of the primary survey, starting with airway.

Exposure / Environmental Control

The last component of the ABCDE system is the complete exposure of the patient to facilitate thorough examination and assessment. The patient should be log-rolled to assess for posterior injuries; cervical, thoracic, or lumbar spine tenderness or deformities; and intact rectal tone. At this time a thorough physical exam of the patient should be performed taking care to remove all clothing and check less visible areas (under cervical spine collar, scalp, axilla, and perineum) to ensure that all injuries are accounted for. Patients should then be covered with warming blankets, or an external warming device, to prevent hypothermia, a potentially lethal complication in the injured patient. All fluids should be warmed to 39°C if feasible.

Potential Interventions: External heating device, warmed intravenous fluids 

Adjuncts: Temperature monitoring

Any intervention should prompt full, rapid, reassessment of the primary survey, starting with airway.

Secondary Survey

The secondary survey is a complete and thorough history and physical exam to identify previously unidentified injuries, or potential injuries that require attention. The secondary survey is a secondary priority and does not begin until the primary survey is completed, life-threatening injuries have been identified and addressed, resuscitation is occurring, and the patient has demonstrated improvement in vital functions.

The secondary survey includes an abbreviated medical history including allergies, medications, past medical and surgical history, last meal, and events leading to the injury. The mechanism of the injury may alert providers to potential occult injuries- for example, a fall from height may result in abdominal visceral injuries, spinal injuries, or lower extremity fractures. A thorough head-to-toe physical exam should occur, and include the head, maxillofacial structures, cervical spine, neck, chest, abdomen, pelvis, perineum, rectum, genitalia, musculoskeletal system, and neurological system. Based on the results of the secondary survey and patient status, further diagnostic tests may be pursued including CT scan of head, cervical spine, chest, abdomen, and pelvis.

As a reminder, it is imperative to continually reevaluate patients throughout the initial evaluation, and any change in vital functions should prompt reassessment of the primary survey.


References

  1. American College of Surgeons. Advanced Trauma Life Support: Student course manual. 10th ed. Trauma C on, editor. 2018.
  2. Reed MJ, Dunn MJG, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J. 2005 Feb;22(2):99–102.
  3. Mayglothling J, Duane TM, Gibbs M, McCunn M, Legome E, Eastman AL, et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S333-40.
  4. Ferrada P, Callcut RA, Skarupa DJ, Duane TM, Garcia A, Inaba K, et al. Circulation first – the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial. World J Emerg Surg. 2018 Feb 5;13:8.
  5. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military application of tranexamic acid in trauma emergency resuscitation (matters) study. Arch Surg. 2012 Feb;147(2):113–9.
  6. Tran A, Yates J, Lau A, Lampron J, Matar M. Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2018 May;84(5):802–8.

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