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Assessment of acute trauma patient
History taking and examination
Assessment of acute trauma patient
intracranial pressure may follow spine stabilization using head blocks and tape. Breathing with ventilation Assessment of breathing must exclude simple or tension pneumothorax, flail chest, pulmonary contusion and haemothorax. Needle decompression is a temporary measure for tension pneumothorax; tube thoracocentesis is the definitive therapy. Inadequate ventilation should be assisted.
Richard Thomas Charles D Deakin
Circulation with haemorrhage control The degree of hypovolaemia should be assessed using capillary refill, peripheral temperature, blood pressure and the conscious level. Blood pressure cannot be predicted accurately merely by the presence or absence of particular peripheral pulses. The most common aetiology of shock in trauma is haemor rhagic hypovolaemia. External haemorrhage should be managed by direct manual pressure and elevation of the affected part. If peripheral intravenous access is impossible, femoral vein cannulation or surgical cut-down can be life saving. Limited evidence suggests that crystalloid solutions may be better than colloids; whichever are chosen, they are best administered warm. O negative blood should be available immediately to maintain the haemoglobin level above 8.0 g/dl, but full crossmatching should also be undertaken. Non-haemorrhagic causes for shock should be identified and treated. For instance, cardiac tamponade requires pericardiocentesis or pericardiotomy. Specific manoeuvres may be required for pregnant trauma patients. For instance, the gravid uterus should be displaced laterally, using a wedge or blankets under the left hip, to avoid hypotension associated with aorto-caval compression. If the patient requires immobilization on a spinal board, the wedge should be placed underneath the board. Occasionally the patient has to undergo salvage surgery (i.e. laparotomy for exsanguinating abdominal haemorrhage) as part of the primary survey.
Since the introduction of the Advanced Trauma Life Support (ATLS) programme in the UK in 1988, there have been major improvements in educating healthcare professionals in the principles of assessment and management of the traumatized patient. In-hospital preparation: each hospital should ensure that an adequately equipped area is available to receive the patient. A ‘trauma team’, including members of the accident and emergency, anaesthetic/ICU, orthopaedic and surgical departments, should attend all major trauma cases and team members should be aware of their roles. When arriving at the accident and emergency department with the patient, paramedics should give a detailed handover to hospital staff. This should include the mechanism of injury, because this is important in anticipating likely injuries.
Primary survey: assessment and resuscitation Life-threatening injuries must be identified and treated simultaneously in order of clinical priority using the ABCDE sequence. Airway maintenance with cervical spine control Recognizing the high risk of cervical spine injury associated with multisystem trauma (especially in patients with blunt trauma or altered consciousness), airway patency should be confirmed while the cervical spine is immobilized manually or using a correctly sized hard collar, lateral supports and fixation (see page 282). Interventions such as removing foreign bodies, chin lift or jaw thrust or the institution of a definitive airway (tracheal intubation or surgical airway) may be required. High concentration oxygen should be administered to all traumatized patients. Loosening the cervical collar to avoid rises in
Disability A rapid assessment of neurological status, using the AVPU (see Anaesthesia and Intensive Care Medicine 3:7: 235) or Glasgow Coma Score (GCS; see Anaesthesia and Intensive Care Medicine 3:4: 132) systems, capillary size and reaction should be performed as part of the primary survey. An altered conscious level may indicate hypoxaemia or shock. Therefore, the ‘ABCs’ should be re-evaluated before ascribing the neurological state to CNS trauma. Regular re-evaluation of disability is essential to monitor trends. A comatose patient (GCS < 8) requires intubation. Secondary brain injury is minimized by ensuring adequate oxygenation (patent airway), adequate ventilation (to prevent cerebral vasodilation caused by hypercapnia) and normotension to ensure adequate cerebral perfusion. Timely consultation with a neurosurgeon is recommended, particularly in patients who have clinical or radiographic evidence of expanding space-occupying lesions.
Richard Thomas is Specialist Registrar in Anaesthesia. He graduated from St Mary’s Hospital, Paddington, London, and is now training with the Wessex School of Anaesthesia. He has a clinical interest in trauma and is an ATLS instructor. Charles D Deakin BChir FRCA is Eponymous Professor at the Royal College of Anaesthetists. He qualified from Cambridge University and King’s College Hospital, London, and trained in London and Southampton. His interests include cardiac anaesthesia, pre-hospital care and resuscitation.
THE FOUNDATION YEARS 3:1
Exposure and environment control The patient’s clothing should be removed to allow a complete examination. Log roll the patient and examine the back.
© 2006 Elsevier Ltd. All rights reserved.
History taking and examination
ypothermia is common and can be minimized by warming H the room, warming inspired gases and intravenous fluids, using blankets and warmed-air devices (e.g. BairHugger®).
injury. Immobilization should continue until the spine has been cleared of bony, ligamentous and neurological injury. Patients who have suspected trauma to neck vasculature may require angiographic examination. Thoracic and lumbar spine – examine for deformity, tenderness and neurological signs. The mechanisms of injury are important clues. Chest – repeated evaluation is required to ensure a patent airway and adequate ventilation. Any deterioration of the patient should trigger a repeat of the primary survey. Positive-pressure ventilation may rapidly convert a small simple pneumothorax into a life-threatening tension pneumothorax. Plain chest radio graphy does not always detect rib fractures. An apparently widened mediastinum is common in portable, supine chest radiographs, but should trigger suspicion of an aortic injury; contrast aortography is required to exclude the diagnosis. Abdomen – early surgical assessment is vital to identify and manage covert intra-abdominal injury. Bleeding from the liver and spleen can be predicted from the mechanism of injury and bruising patterns, but remains under-recognized, especially in unconscious patients who are unable to complain of pain. Diagnostic peritoneal lavage and ultrasonography can be performed at the bedside; more complex radiological evaluation (e.g. angio graphy) should be reserved for stable patients. Exploratory laparotomy may be required as a diagnostic procedure in some patients. Perineum (including rectal and vaginal examination) – rectal examination is required before urethral catheterization and may provide information about pelvic fractures, integrity of the rectal wall and anal tone (spinal injury). A pregnancy test should be undertaken in women of childbearing age. Musculoskeletal – a ‘look, feel, move’ approach is required for every bone and joint. Neurovascular assessment of extremities should be performed and repeated after any manipulation. Pelvic mobility should be assessed once only. Injuries to the extremities are often overlooked, but remain a major source of litigation; the secondary survey is the time to discover them. Neurological – early consultation with a neurosurgeon is required in all patients with neurological injury. The most important measures to minimize secondary brain injury are the maintenance of adequate oxygenation, ventilation and cerebral perfusion. The management of acutely raised intracranial pressure and convulsions is best discussed locally, because neuro surgical preferences differ.
Adjuncts to the primary survey • All trauma patients should be monitored using ECG, blood pressure, pulse oximetry, temperature and capnography. • A gastric tube should be placed in all patients with life- threatening injuries, but the nasal route is contraindicated in those with basal skull fracture (risks of intracerebral migration via fractured cribriform plate). • Urinary catheters permit accurate measurement of urine output, but urethral injury should be excluded before catheterization (suspected by blood at penile meatus, perineal bruising, scrotal haematoma or a high-riding prostate on rectal examination). • Plain anteroposterior radiographs of chest, pelvis and lateral cervical spine should be taken in the resuscitation area. They may provide information to guide resuscitative efforts (e.g. pelvic fracture can explain hypotension resistant to fluid infusion). • Diagnostic peritoneal lavage and abdominal ultrasonography may reveal occult abdominal haemorrhage. Transfer: depending on the patient’s injuries and the local f acilities, intra- or inter-hospital transfer may be required. This can be facilitated by administrative staff, but the patient should be stable before being moved. Occasionally, transfer of a patient to salvage surgery (i.e. laparotomy for exsanguinating abdominal haemorrhage) may form part of the primary survey.
Secondary survey The secondary survey, a meticulous head-to-toe evaluation (including log-roll), should not commence until the primary survey is complete. It is also a useful time to re-evaluate injuries identified in the primary survey and to arrange targeted radiological and laboratory tests. History: the important aspects of patient history are covered by the mnemonic AMPLE (Allergies, Medications, Past illness/ pregnancy, Last meal and Events/environment related to injury). Physical examination: clinical examination should be systematic. All injuries should be documented for clinical and medicolegal reasons. Head and skull – the entire head and scalp should be examined for lacerations, contusions and fractures. Eyes should be examined early, in case eyelid oedema precludes subsequent examination. Auditory canals should be examined for CSF leak, tympanic membrane integrity and haemotympanum. Maxillofacial – facial burns and trauma can lead to airway obstruction or major blood loss. Patients with mid-face fractures should be assessed for nasal CSF leak and ocular mobility (entrapment of extraocular muscles may occur with orbital fractures). Cervical spine and neck – patients with injuries above the clavicles should be assumed to have an unstable cervical spine
THE FOUNDATION YEARS 3:1
Adjuncts to the secondary survey The specialized diagnostic tests indicated by the findings of the secondary survey (e.g. CT, angiography, bronchoscopy) involve transfer of the patient away from the resuscitation area. As a general rule, the patient should be stable and should be accompanied by a team and equipment that permits continuing resuscitation. Post-resuscitation monitoring and re-evaluation The successful management of trauma depends on frequent re-evaluation. Invasive blood pressure monitoring may be a useful adjunct to the monitoring previously described.
© 2006 Elsevier Ltd. All rights reserved.
History taking and examination
Intravenous opiates (e.g. morphine, 2 mg increments) should be titrated to effect. An anti-emetic should also be administered.
Further reading American College of Surgeons. Advanced Trauma Life Support Course Manual, 6th ed, 1997. Mattox KL, Feliciano DV, Moore EE, eds. Trauma. McGraw-Hill, 1999. Driscoll P, Skinner D, Earlam R. ABC of Major Trauma, 3rd ed. London: BMJ Books, 2000.
Definitive care Definitive care usually involves early surgery or admission to ICU. Control of haemorrhage and optimization of oxygen delivery to all organs is vital in minimizing mortality and morbidity from major trauma. ◆
THE FOUNDATION YEARS 3:1
© 2006 Elsevier Ltd. All rights reserved.
Assessment of acute trauma patient
intracranial pressure may follow spine stabilization using head blocks and tape. Breathing with ventilation Assessment of breathing must exclude simple or tension pneumothorax, flail chest, pulmonary contusion and haemothorax. Needle decompression is a temporary measure for tension pneumothorax; tube thoracocentesis is the definitive therapy. Inadequate ventilation should be assisted.
Richard Thomas Charles D Deakin
Circulation with haemorrhage control The degree of hypovolaemia should be assessed using capillary refill, peripheral temperature, blood pressure and the conscious level. Blood pressure cannot be predicted accurately merely by the presence or absence of particular peripheral pulses. The most common aetiology of shock in trauma is haemor rhagic hypovolaemia. External haemorrhage should be managed by direct manual pressure and elevation of the affected part. If peripheral intravenous access is impossible, femoral vein cannulation or surgical cut-down can be life saving. Limited evidence suggests that crystalloid solutions may be better than colloids; whichever are chosen, they are best administered warm. O negative blood should be available immediately to maintain the haemoglobin level above 8.0 g/dl, but full crossmatching should also be undertaken. Non-haemorrhagic causes for shock should be identified and treated. For instance, cardiac tamponade requires pericardiocentesis or pericardiotomy. Specific manoeuvres may be required for pregnant trauma patients. For instance, the gravid uterus should be displaced laterally, using a wedge or blankets under the left hip, to avoid hypotension associated with aorto-caval compression. If the patient requires immobilization on a spinal board, the wedge should be placed underneath the board. Occasionally the patient has to undergo salvage surgery (i.e. laparotomy for exsanguinating abdominal haemorrhage) as part of the primary survey.
Since the introduction of the Advanced Trauma Life Support (ATLS) programme in the UK in 1988, there have been major improvements in educating healthcare professionals in the principles of assessment and management of the traumatized patient. In-hospital preparation: each hospital should ensure that an adequately equipped area is available to receive the patient. A ‘trauma team’, including members of the accident and emergency, anaesthetic/ICU, orthopaedic and surgical departments, should attend all major trauma cases and team members should be aware of their roles. When arriving at the accident and emergency department with the patient, paramedics should give a detailed handover to hospital staff. This should include the mechanism of injury, because this is important in anticipating likely injuries.
Primary survey: assessment and resuscitation Life-threatening injuries must be identified and treated simultaneously in order of clinical priority using the ABCDE sequence. Airway maintenance with cervical spine control Recognizing the high risk of cervical spine injury associated with multisystem trauma (especially in patients with blunt trauma or altered consciousness), airway patency should be confirmed while the cervical spine is immobilized manually or using a correctly sized hard collar, lateral supports and fixation (see page 282). Interventions such as removing foreign bodies, chin lift or jaw thrust or the institution of a definitive airway (tracheal intubation or surgical airway) may be required. High concentration oxygen should be administered to all traumatized patients. Loosening the cervical collar to avoid rises in
Disability A rapid assessment of neurological status, using the AVPU (see Anaesthesia and Intensive Care Medicine 3:7: 235) or Glasgow Coma Score (GCS; see Anaesthesia and Intensive Care Medicine 3:4: 132) systems, capillary size and reaction should be performed as part of the primary survey. An altered conscious level may indicate hypoxaemia or shock. Therefore, the ‘ABCs’ should be re-evaluated before ascribing the neurological state to CNS trauma. Regular re-evaluation of disability is essential to monitor trends. A comatose patient (GCS < 8) requires intubation. Secondary brain injury is minimized by ensuring adequate oxygenation (patent airway), adequate ventilation (to prevent cerebral vasodilation caused by hypercapnia) and normotension to ensure adequate cerebral perfusion. Timely consultation with a neurosurgeon is recommended, particularly in patients who have clinical or radiographic evidence of expanding space-occupying lesions.
Richard Thomas is Specialist Registrar in Anaesthesia. He graduated from St Mary’s Hospital, Paddington, London, and is now training with the Wessex School of Anaesthesia. He has a clinical interest in trauma and is an ATLS instructor. Charles D Deakin BChir FRCA is Eponymous Professor at the Royal College of Anaesthetists. He qualified from Cambridge University and King’s College Hospital, London, and trained in London and Southampton. His interests include cardiac anaesthesia, pre-hospital care and resuscitation.
THE FOUNDATION YEARS 3:1
Exposure and environment control The patient’s clothing should be removed to allow a complete examination. Log roll the patient and examine the back.
© 2006 Elsevier Ltd. All rights reserved.
History taking and examination
ypothermia is common and can be minimized by warming H the room, warming inspired gases and intravenous fluids, using blankets and warmed-air devices (e.g. BairHugger®).
injury. Immobilization should continue until the spine has been cleared of bony, ligamentous and neurological injury. Patients who have suspected trauma to neck vasculature may require angiographic examination. Thoracic and lumbar spine – examine for deformity, tenderness and neurological signs. The mechanisms of injury are important clues. Chest – repeated evaluation is required to ensure a patent airway and adequate ventilation. Any deterioration of the patient should trigger a repeat of the primary survey. Positive-pressure ventilation may rapidly convert a small simple pneumothorax into a life-threatening tension pneumothorax. Plain chest radio graphy does not always detect rib fractures. An apparently widened mediastinum is common in portable, supine chest radiographs, but should trigger suspicion of an aortic injury; contrast aortography is required to exclude the diagnosis. Abdomen – early surgical assessment is vital to identify and manage covert intra-abdominal injury. Bleeding from the liver and spleen can be predicted from the mechanism of injury and bruising patterns, but remains under-recognized, especially in unconscious patients who are unable to complain of pain. Diagnostic peritoneal lavage and ultrasonography can be performed at the bedside; more complex radiological evaluation (e.g. angio graphy) should be reserved for stable patients. Exploratory laparotomy may be required as a diagnostic procedure in some patients. Perineum (including rectal and vaginal examination) – rectal examination is required before urethral catheterization and may provide information about pelvic fractures, integrity of the rectal wall and anal tone (spinal injury). A pregnancy test should be undertaken in women of childbearing age. Musculoskeletal – a ‘look, feel, move’ approach is required for every bone and joint. Neurovascular assessment of extremities should be performed and repeated after any manipulation. Pelvic mobility should be assessed once only. Injuries to the extremities are often overlooked, but remain a major source of litigation; the secondary survey is the time to discover them. Neurological – early consultation with a neurosurgeon is required in all patients with neurological injury. The most important measures to minimize secondary brain injury are the maintenance of adequate oxygenation, ventilation and cerebral perfusion. The management of acutely raised intracranial pressure and convulsions is best discussed locally, because neuro surgical preferences differ.
Adjuncts to the primary survey • All trauma patients should be monitored using ECG, blood pressure, pulse oximetry, temperature and capnography. • A gastric tube should be placed in all patients with life- threatening injuries, but the nasal route is contraindicated in those with basal skull fracture (risks of intracerebral migration via fractured cribriform plate). • Urinary catheters permit accurate measurement of urine output, but urethral injury should be excluded before catheterization (suspected by blood at penile meatus, perineal bruising, scrotal haematoma or a high-riding prostate on rectal examination). • Plain anteroposterior radiographs of chest, pelvis and lateral cervical spine should be taken in the resuscitation area. They may provide information to guide resuscitative efforts (e.g. pelvic fracture can explain hypotension resistant to fluid infusion). • Diagnostic peritoneal lavage and abdominal ultrasonography may reveal occult abdominal haemorrhage. Transfer: depending on the patient’s injuries and the local f acilities, intra- or inter-hospital transfer may be required. This can be facilitated by administrative staff, but the patient should be stable before being moved. Occasionally, transfer of a patient to salvage surgery (i.e. laparotomy for exsanguinating abdominal haemorrhage) may form part of the primary survey.
Secondary survey The secondary survey, a meticulous head-to-toe evaluation (including log-roll), should not commence until the primary survey is complete. It is also a useful time to re-evaluate injuries identified in the primary survey and to arrange targeted radiological and laboratory tests. History: the important aspects of patient history are covered by the mnemonic AMPLE (Allergies, Medications, Past illness/ pregnancy, Last meal and Events/environment related to injury). Physical examination: clinical examination should be systematic. All injuries should be documented for clinical and medicolegal reasons. Head and skull – the entire head and scalp should be examined for lacerations, contusions and fractures. Eyes should be examined early, in case eyelid oedema precludes subsequent examination. Auditory canals should be examined for CSF leak, tympanic membrane integrity and haemotympanum. Maxillofacial – facial burns and trauma can lead to airway obstruction or major blood loss. Patients with mid-face fractures should be assessed for nasal CSF leak and ocular mobility (entrapment of extraocular muscles may occur with orbital fractures). Cervical spine and neck – patients with injuries above the clavicles should be assumed to have an unstable cervical spine
THE FOUNDATION YEARS 3:1
Adjuncts to the secondary survey The specialized diagnostic tests indicated by the findings of the secondary survey (e.g. CT, angiography, bronchoscopy) involve transfer of the patient away from the resuscitation area. As a general rule, the patient should be stable and should be accompanied by a team and equipment that permits continuing resuscitation. Post-resuscitation monitoring and re-evaluation The successful management of trauma depends on frequent re-evaluation. Invasive blood pressure monitoring may be a useful adjunct to the monitoring previously described.
© 2006 Elsevier Ltd. All rights reserved.
History taking and examination
Intravenous opiates (e.g. morphine, 2 mg increments) should be titrated to effect. An anti-emetic should also be administered.
Further reading American College of Surgeons. Advanced Trauma Life Support Course Manual, 6th ed, 1997. Mattox KL, Feliciano DV, Moore EE, eds. Trauma. McGraw-Hill, 1999. Driscoll P, Skinner D, Earlam R. ABC of Major Trauma, 3rd ed. London: BMJ Books, 2000.
Definitive care Definitive care usually involves early surgery or admission to ICU. Control of haemorrhage and optimization of oxygen delivery to all organs is vital in minimizing mortality and morbidity from major trauma. ◆
THE FOUNDATION YEARS 3:1
© 2006 Elsevier Ltd. All rights reserved.