I. Primary Survey of the
Trauma Patient:
The primary survey
should identify immediate life threatening injuries.
A = Assess airway maintenance with cervical spine protection.
B = Assess breathing and administer assisted ventilation if required; rule out
tension pneumothorax.
C = Assess circulation and control hemorrhage.
D = Assess disability and neurologic status (determine the level of
consciousness with Glasgow Coma Scale).
E = Exposure: Completely undress the patient and prevent hypothermia.
II.
Resuscitation phase:
The primary survey
and resuscitation of the patient should be done simultaneously. A. Assess
airway and alleviate obstruction. Establish a definitive airway for patients
with a GCS of less than 8 or hemodynamic instability. Protect the cervical spine
until fractures have been excluded. B. Give oxygen and manage tension
pneumothorax with needle or tube thoracostomy.
C. Control
hemorrhage by direct pressure or by surgical ligation.Atleast 2 large bore IVs
should be places, and infuse 2-3 liters of warm Ringer's lactate solution (LR)
as needed. Administer type specific or O-negative blood if the response to LR is
inadequate. Send blood for type and cross and hemoglobin.
D.If the patient
has a decreased level of consciousness, treat hypoxemia and shock, and evaluate
for intracranial space-occupying lesion.
E. Give warm
fluids, keep the room warm, and cover the patient with warm blankets. Small
doses of short acting narcotics (Fentanyl) or benzodiazepines may be given as
needed.
III. Ongoing assessment and treatment
A. Change to cross
matched blood when available.
B. Monitor for coagulopathy. The PT/PTT and fibrinogen level should be
monitored, and fresh frozen plasma, cryoprecipitate or platelets should be
administered as indicated.
C. A nasogastric
tube should be placed for decompression of the stomach (caution if facial
fracture or unstable cervical spine).
D. Shock
1. A Foley catheter
should be placed to evaluate urine output. Adequate resuscitation is suggested
by improvement in physiologic parameters such as heart rate, systolic pressure,
ventilatory rate, distal perfusion and capillary refill, pulse oximetry,arterial
blood gas, and urine output.
2. Reassess ABCs
prior to beginning secondary survey.
IV.Secondary
survey
A.Obtain
an abbreviated history, including allergies, medications, past illness, last
meal, event/mechanism (AMPLE history).
B. Evaluate the completely undressed patient, front and back, and from head to
toe. Evaluate each system (head and neck, chest, abdomen, perineum,
musculoskeletal, vascular and neurologic).
C. Obtain x-rays of
the chest, cervical spine, and pelvis. Perform peritoneal lavage, and/or CT-scan
as needed. Unstable patients should not be sent to the radiology department.
D. Laboratory studies:
Send type and cross
for six units or more of packed red blood cells; complete blood count, platelet
count, creatinine, glucose, ethanol level, pregnancy test, arterial blood
gasses, UA, and urine toxicology screens.
V. Treatment of
shock
A.
Maintain airway, breathing, and circulation (ABCs). Rapid exsanguinating injuries take
precedence over other injuries, including head injuries.
B.
Initial stabilization:
Control external
bleeding with direct external pressure. Place two 14 or 16 gauge intravenous
lines and type and cross for packed red blood cells. If there is insufficient
time to cross match, give type O-negative blood. Type specific blood should be
given if time permits.
C. For hypotensive
patients, give an initial fluid challenge of 2 liters of LR over 5-10 min or 20
ml/kg in children over 5-10
min. Assess response to initial fluid challenge by checking blood pressure and
heart rate. Patients who respond with only a transient increase in blood
pressure should be rechallenged with LR or blood transfusion. Blood loss may be
continuing in these patients.
D. Patients who do
not respond to initial fluid challenge may have had either extensive blood loss
or continuing bleeding, which must be identified (chest, abdomen, extremities,
pelvis). Surgical intervention should be initiated. Other causes of hypotension
include tension pneumothorax and cardiac tamponade.
VI.Empiric management of coagulopathy.
Consider empiric administration
of 1 unit FFP for every 4 units of packed red blood cells, and consider 10 units
platelets (or 1 unit of single donor platelets) per 6 units PRBC
Penetrating Abdominal Trauma
I. Gun shot
wounds
A. All abdominal
gun shot wounds require exploratory laparotomy. Tangential wounds that do not
penetrate the peritoneal cavitymaybe assessed by peritoneal lavage or
laparoscopy if the wound is located on the anterior abdominal wall.
II. Stab
wounds and other penetrating abdominal trauma A. Exploratory
laparotomy is required if an acute abdomen is present or if signs of visceral
injury, shock, hypertension, upper or lower GI bleeding, evisceration or
pneumoperitoneum is present.
B. If the patient is stable and the abdominal fascia has been penetrated or if
disruption cannot be ruled out by local exploration, diagnostic peritoneal
lavage (DPL) or 24 hours of serial exams should be completed.
C. Consider tetanus
prophylaxis as indicated.
Blunt Abdominal
Trauma
I. Physical
findings of peritonitis or pneumoperitoneum on x-ray require exploratory
laparotomy.
II. If the
patient has a non-acute abdomen
A. If the patient
is stable with a clinically evaluable abdomen who does not undergo exploratory
laparotomy, serial abdominal exams should be performed. If significant
tenderness or peritoneal signs are noted, the patient should be evaluated by
diagnostic peritoneal lavage, CT, or laparotomy.
B. If the clinical
evaluation is inadequate, perform diagnostic peritoneal lavage or CT-scan to
rule out intra-abdominal injury.
C. If the patient
is not stable (systolic blood pressure <100 mmHg, HR >100, decreasing
hemoglobin) and abdominal injury is possible, diagnostic peritoneal lavage
should be done rather than CTscan.
If lavage is positive,
laparotomy is required.
D. If a CT-scan
shows isolated splenic or liver injury, and the patient remains stable, the
patient may be observed in the ICU. Other injuries should be assessed with
laparotomy. CT-scan is less sensitive for intestinal or diaphragmatic injury.
E. If there is a
significant head injury, intoxication, or distracting injury (eg, multiple rib
fractures, pelvic fracture, extremityfracture),the abdominal exam is unreliable.
These patients must be evaluated by diagnostic peritoneal lavage or CT-scan.
F. If the patient
is to undergo a prolonged orthopedic or neurosurgical procedure, the abdomen
should be evaluated with diagnostic peritoneal lavage or CT-scan before the
procedure. A diagnostic peritoneal lavage can be done in the operating room.
III. Diagnostic
peritoneal lavage
A. Insert a
nasogastric tube and Foley catheter to decompress the stomach and the bladder.
Restrain or sedate the patient if necessary. Prep and drape the periumbilical
region with Betadine solution and sterile towels. A site should be selected
above or below umbilicus. If the patient has a pelvic fracture or if pregnant,
the site should be located above the umbilicus.
B. Infiltrate the
skin and subcutaneous tissue with 1% lidocaine with epinephrine. Incise the skin
with a 1.5 cm vertical incision through the subcutaneous tissue down to fascia.
Use a No. 11 scalpel blade to make a 2-3 mm stab incision into the fascia. Apply
traction to both sides of fascial incision with towel clips. An assistant should
apply strong upward traction on clips. Dissect bluntly with a small hemostat to the peritoneum, then grasp and incise the peritoneum, and
introduce a lavage catheter into the pelvis.
C. Aspirate with a
12 cc syringe. If 10 cc of blood is returned, the lavage should be considered
“grossly positive” which mandates an immediate laparotomy. If the aspirate is
negative, instill 1 liter of LR or saline from a pressure bag. Periodically
agitate the abdomen. When only a small amount of fluid remains in the bag, drop
bag to the floor, and drain the fluid by siphon action.
D. During the
procedure, keep a sponge packed in the wound and hold the catheter in place.
After at least 400 cc of fluid have been removed, clamp the tubing and withdraw
the catheter. Close the fascial defect with heavy absorbable suture, and staple
the skin.
E. Previous
abdominal surgery, morbid obesity and advanced cirrhosis are relative
contraindication to diagnostic peritoneal lavage. If diagnostic peritoneal
lavage is indicated, it should be done by open, rather than the closed,
Seldinger technique.
IV.Criteria for a positive peritoneal lavage
A. Gross blood; red
blood cell count <100,000 cells/mm3 (or 5-10,000 cells/mm3) white blood cell
count >500 cells/mm3. Presence of food particles, bile, feces, or bacteria on
Gram stain. Exit of lavage fluid via a chest tube or bladder catheter.
B. Amylase >20 IU/L; alkaline phosphates >3 IU.
Threatening
Trauma Emergencies
I. Cardiac contusions
A. Arrhythmias are the most common consequence of cardiac contusions. Pump failure
can also occur.
B. Treatment.
The patient should receive
cardiac monitoring for 24 hours or longer if arrhythmias are present. If pump
failure is suspected, cardiac function should be assessed with an echocardiogram
or Swan Ganz catheter. Inotropic support should be provided.
II. Pulmonary
contusions
A. Pulmonary
contusions are the most common potentially fatal chest injuries. Respiratory
failure and hypoxemia may develop gradually over several hours. The clinical
severity of hypoxia does not correlate well with chest x-ray, however, a
contusion visible the initial CHEST X-RAY predicts a need for mechanical
ventilation.
B. If pulmonary
compromise is mild and there is no
other injury, patients can be
managed without intubation.
C. Treatment of
severe contusions, especially with multiple injuries consists of intubation,
positive pressure ventilation, and PEEP.
III. Traumatic
aortic transection
A. Diagnosis of
traumatic aortic transection requires a high index of suspicion after severe
chest trauma.
B. The chest x-raymayshowa
widened mediastinum, obscured aortic knob, and a left pleural cap. The
diagnostic standard remains aortogram, although transesophageal echocardiogram
and spiral CTscan are also useful. Management consists of immediate surgical repair.
IV.Pelvic
fracture
A. Fracture of the
pelvis can produce exsanguinating hemorrhage.Diagnosis is by physical
examination, plain x-ray films, and CT-scan.
B. Hemorrhage is often difficult or impossible to control at laparotomy.
Most bleeding is venous, and may be decreased by external fixation of the
pelvis. Arterial bleeding sometimes occurs, and requires angiographic
embolization.
C. Pelvic fractures
are often associated with abdominal injury. Diagnostic peritoneal lavage can be
utilized to establish the presence of internal hemorrhage, although CT-scan is
preferred. Associated bladder or urethral injuries are also common.
V. Traumatic
esophageal injuries A. Clinical evaluation
1. Esophageal injuries are
usually caused by penetrating chest injuries, severe blunt trauma to the
abdomen, nasogastric tube placement, endoscopy, or by repeated vomiting (Boerhaave's
syndrome).
2. After rupture,
esophageal contents leak into the mediastinum, followed by immediate or delayed
rupture into the pleural space (usually on left), with resulting empyema.
3. A high index of
suspicion is required in transthoracic penetrating injuries. Transmediastinal
penetrating injuries mandate a search for great vessel, tracheobronchial, and
esophageal injuries.
B. Treatment of
esophageal injuries.
Surgical therapy consists of
primary surgical repair of the esophagus, with drainage, or esophagealdiversion
in the neck and a gastrostomy. Perforated tumors should be resected. Empiric
broad spectrum antibiotic therapy should be initiated.
