INITIAL ASSESSMENT Jeffry L. Kashuk, MD, FACS
CHAPTER 15
II. TRAUMA
1. What is the ‘‘golden hour’’? This first hour of injury provides a unique opportunity to initiate life-saving interventions. More than half of trauma deaths occur during this time period as a result of brain injury or exsanguinating hemorrhage, therefore, rapid transport, appropriate triage, and organized systems of assessment (advanced trauma life support [ATLS]) are important standardized procedures that can save lives. 2. Name the major components of the initial assessment of the trauma patient. Primary survey, resuscitation, secondary survey, reevaluation, and definitive care. 3. What is the purpose of the primary survey? To identify life threatening injuries via a reproducible prioritized system and time frame. 4. Define the ABCDE mnemonic of the primary survey that reinforces the fact that life-threatening injuries kill in a predicable order. Airway control with cervical spine protection Breathing with oxygenation and ventilation Circulation with hemorrhage control Disability or neurologic status Exposure of patient with temperature control 5. What are the adjuncts to the primary survey? All trauma patients should initially receive high-flow supplemental oxygen by nasal cannula or face mask. Continuous monitoring should include pulse oximetry, cardiac electrocardiogram (ECG) monitor, and a cycled blood pressure (BP) cuff. Two large-bore intravenous (IV) lines are placed as blood is drawn for screening tests, including blood type and cross-match. Nasogastric (NG) or orogastric tubes are placed for gastric decompression and to prevent aspiration. A Foley catheter is inserted to assess urine flow and character of urine. Radiographs should include the ‘‘big three’’ for major trauma ‘‘mechanism’’: cervical spine, chest x-ray, and pelvic x-ray. Cervical spine x-ray may be deferred if the patient is going to computed tomography (CT) scan. 6. Identify the one concept that can prevent unexpected acute deterioration of the trauma patient during initial assessment. Reevaluation: If deterioration occurs, proceed back to the ABCs in sequential order. 7. Name the two major causes of death during the first 24 hours after injury. Exsanguination secondary to bleeding from traumatic wounds, and central nervous system (CNS) injury.
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92 CHAPTER 15 INITIAL ASSESSMENT 8. How is the airway assessed? Ask the patient a question. A response in a normal voice suggests that the airway is not in immediate danger. A horse, weak, or stridorous response may imply airway compromise. An agitated or combative response indicates hypoxia, until proven otherwise. No response indicates the need for a ‘‘definitive airway’’ (ideally, a cuffed tube in the trachea). 9. What are the causes of upper airway obstruction in the trauma patient? The tongue, followed by blood, loose teeth or dentures, vomit, and soft tissue edema. 10. What are the initial maneuvers used to restore an open airway? The chin lift and jaw thrust physically displace the mandible and the tongue anteriorly to open the airway, which will facilitate manual clearance of debris and suctioning of the oropharynx to optimize patency. Oropharyngeal and nasopharyngeal airways (trumpets) are useful adjuncts in maintaining an open airway in an obtunded patient. One should always assume the presence of a cervical spine injury until proven otherwise, performing in-line stabilization while evaluating the airway. 11. What are the indications for a definitive airway? Apnea, inability to maintain or protect the airway (compromised consciousness), inability to maintain oxygenation, hemodynamic instability, need for muscle relaxation or sedation, and need for hyperventilation. 12. List the types of definitive airway that are available in their order of priority. & Orotracheal intubation. & Nasotracheal intubation. & Surgical airway (cricothyroidotomy or tracheostomy). 13. What are the indications for a surgical airway? Extensive maxillofacial and trauma, high-risk anterior neck trauma, or any situation in which airway intubation cannot be accomplished safely. Contraindications include: direct laryngeal trauma, suspected tracheal disruption, and children, who have a greatly increased risk of stenosis in this region after the procedure. Preferred options in this group are tracheostomy and transtracheal ventilation. 14. How does one ‘‘clear the C-spine’’? Injury must be excluded before moving the head or neck of a trauma patient. Alert patients without other significant ‘‘distracting injuries’’ may be cleared if they are asymptomatic and have no tenderness on exam by direct palpation. Other patients require radiologic evaluation. Most bony injuries may be found with definitive CT scan of the neck, reserving magnetic resonance imaging (MRI) evaluation for suspected soft tissue ligamentous injury that can cause instability. In the absence of CT scan capability, a three-view cervical spine series (anteroposterior [AP], lateral, and odontoid) are required, with visualization to the level of C7-T1. This level is frequently difficult to view, requiring a ‘‘swimmers view’’ to accentuate the visualization of this anatomic region. 15. What are the five non-airway conditions that pose an immediate threat to breathing in the trauma patient? Tension pneumothorax: air in the pleural space under pressure that obstructs the venous outflow by kinking the vena cava, treated with urgent decompression with needle or tube thoracostomy. Open pneumothorax: an open wound of the chest wall casing free communication of the pleural space with the air interfering with the thoracic bellows mechanism treated with tube thoracostomy.
CHAPTER 15 INITIAL ASSESSMENT 93 Flail chest: multiple rib fractures with a free-floating segment and potential underlying pulmonary contusion, treated with tube thoracostomy and frequently endotracheal intubation. Massive hemothorax: a large collection of blood in the pleural space that limits lung ventilation and oxygenation treated with tube thoracostomy and possible thoracotomy. Pericardial tamponade: inhibition of diastolic filling and associated cardiac output (CO)—the major cause of cardiogenic shock in trauma—requires evacuation of the tamponade initially by aspiration if possible, and subsequent emergency thoracotomy with correction of the underlying injury. 16. What are the preferred sites of emergent intravenous access? Peripheral venous access in the upper extremities with large bore (14- to 16-gauge) catheter. Other options include ankle or groin saphenous vein. Central venous access (subclavian or jugular routes) is indicated for measurement of central venous pressure (CVP) after the initial fluid boluses to assess hemodynamic instability. In children <6 years, the interosseous route at the distal femur or proximal tibia is an effective alternative. 17. What are common, simple measures of assessing hemodynamic stability in a trauma patient? Mental status (alert, verbal, pain, or unresponsive). Skin perfusion (pink/warm versus pale/cool). Hemodynamic parameters (BP, heart rate [HR], and respiratory rate [RR]). Gross estimates of systolic blood pressures: radial pulse: >80 mm Hg; femoral: >70 mm Hg; carotid: >60 mm Hg. Urine flow of >½ milliliters per kilogram per hour suggests good end organ perfusion. 18. What is the Glasgow Coma Scale and what does it measure? The Glasgow Coma Scale (GCS) is an assessment of mental status, papillary status, and best motor activity. Best eye-opening response, scored 1 to 4 Best verbal response, scored 1 to 5 Best motor response, scored 1 to 6 Points are added up. An overall score of 13 to 15 indicates a mild head injury, 9 to 12 indicates moderate injury, and <8 indicates a severe injury and mandates endotracheal intubation. 19. What fluids should be used for initial resuscitation? Lactated Ringer’s or normal saline are the mainstay of fluid resuscitation via rapid infusion. Early blood and plasma should be administered to optimize oxygen carrying capacity and prevent progressive coagulopathy in patients who present with signs of acidosis (pH <7.25), hypothermia (temperature <34 C), coagulopathy (international normalized ratio [INR] >1.5) in the face of severe shock (systolic BP <70 mm Hg). Colloid infusions are more expensive and have no proven advantage in the trauma setting. 20. What does FAST mean, and how does it help in trauma evaluation? FAST stands for focused abdominal sonography in trauma. The four areas examined by ultrasound include the pericardial area, right upper quadrant, left upper quadrant, and the pelvis. The test is reported as positive (blood) or negative. 21. What is DPL, and does it have a role in trauma evaluation? DPL stands for diagnostic peritoneal lavage, in which a small catheter is inserted into the patient to assess for intraperitoneal bleeding. Its chief usefulness in the era of FAST and CT scan is in the hemodynamically unstable patient whose initial FAST is negative to better rule out the abdomen as a source of hemorrhage.
94 CHAPTER 15 INITIAL ASSESSMENT 22. How can I learn proficiency at initial assessment? Take the ATLS course of the American College of Surgeons, which emphasizes the skills necessary to initially treat the trauma patient.
KEY POINTS OF INITIAL ASSESSMENT 1. Follow the ABCDEs of the ATLS system when evaluating a trauma patient, and return to the same sequential order when reevaluating the patient. 2. Assume every trauma patient has a cervical spine injury until proven otherwise, and carefully assess methods to evaluate or clear the cervical spine. 3. Establish a secure airway based on the injury pattern present, or the neurological status of the patient (GCS). 4. Evaluate for presence of shock and initiate fluid, blood, or plasma resuscitation based on the level of shock and associated signs of coagulopathy, hypothermia, and acidosis via largebore peripheral IV infusions. 5. Establish central venous catheterization to help assess homodynamic stability. 6. Use FAST, DPL, and CT scan to evaluate the extent of injuries and triage the patient appropriately.
BIBLIOGRAPHY 1. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support Course 7th ed., Chicago, 2004, American College of Surgeons. 2. Cha J, Kashuk JL, Moore EE: Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma, in press. 3. Cothren CC, Moore EE: Emergency department thoracotomy In: Trauma, 6th ed., New York, 2008, McGraw Hill. 4. Fisher A, Young WF: Is the lateral cervical spine x-ray obsolete during the initial evaluation of patients with acute trauma? Surg Neurol 70(1):25-28, 2008. 5. Kashuk JL, Moore EE, Johnson JL et al.: Post-surgery life threatening coagulopathy: is 1:1 FFP: RBC the answer? J Trauma 66:xx, 2008. 6. Kaufmann CR: Initial assessment and management. In Trauma, 6th ed., New York, 2008, McGraw-Hill. 7. Rabb CH, Johnson JL, VanSickle D et al.: Are upright lateral cervical radiographs in the obtunded trauma patient useful? A retrospective study, World J Emerg Surg 2:4, 2007. 8. Sanchez B, Waxman K, Jones T et al.: Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol. J Trauma 59:179, 2005.