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Trauma in Adults Peter A. Cameron Barry J. Knapp William Teeter INTRODUCTION AND EPIDEMIOLOGY Traumatic injury accounts for more than 40 million ED visits in the United States each year,1 and worldwide, about 6 million people die each year as a result of injuries. By 2030, road traffic crashes are predicted to become the fifth leading cause of death worldwide. 2 In the United States, firearm, suffocation, and drowning/submersion have the highest case fatality rates. 2 Trauma remains the leading cause of death among chil dren and adults under the age of 46 years, accounting for nearly half of all deaths in these age groups. 3 In all countries, the incidence of death from injury increases more than threefold with increasing poverty. For the 90% of patients who survive the initial trauma, the burden of ongo ing morbidity from traumatic brain injury, loss of limb function, and ongoing pain is even more significant. The major causes of death following trauma are head injury, chest injury, and major vascular injury. Trauma care should be organized according to the concepts of rapid assessment, triage, resuscitation, diagnosis, and therapeutic intervention. 4 Worldwide, there are few countries or regions that have comprehensive systems of trauma care, from roadside to rehabilitation, and that incorporate effective injury prevention strategies. TRAUMA SYSTEMS AND TIMELY TRIAGE A systematic approach is required to reduce the morbidity and mortality that occur after traumatic injury (Figure 254-1). Recognizing the need to establish a system to triage injured patients rapidly to the most appropriate setting and to promote collaboration among emergency medicine, trauma surgery, and trauma care subspe cialists, the U.S. Congress passed the Trauma Care Systems Planning and Development Act of 1990. 5 This act provided for the development of a model trauma care system plan to serve as a reference document for each state in creating its own system. Each state must determine the appropriate facility for treatment of various types of injuries. Trauma centers are certified based on the institution’s commitment of personnel and resources to maintain a condition of readiness for the treatment of critically injured patients. Some states rely on a verification process offered by the American College of Surgeons for the designation of certain hospitals as trauma centers. 4 In a well-run trauma center, the critically injured patient undergoes a multidis ciplinary evaluation, and diagnostic and therapeutic interventions are performed with smooth transitions between the ED, diagnostic radiology suite, operating room, and postoperative intensive care set ting. Table 254-1 details the requirements for designation as a Level 1 trauma center. A well-functioning trauma system defines trauma centers with spe cific triage criteria, so that patients can be initially transported by EMS to these centers or transferred to trauma centers from other hospitals after stabilization (Table 254-2). In accordance with the principles of advanced trauma life support, injured patients are assessed and treated based on three concepts: 1. Treat the greatest threat to life first. 2. The lack of definitive diagnosis should never impede the application of an indicated treatment. 3. A detailed history is not essential to begin the evaluation of a patient with acute injuries.
life support, injured patients are assessed and treated based on three concepts: 1. Treat the greatest threat to life first. 2. The lack of definitive diagnosis should never impede the application of an indicated treatment. 3. A detailed history is not essential to begin the evaluation of a patient with acute injuries. PRIMARY SURVEY Prior to the patient’s arrival at the hospital, EMS providers should inform the receiving ED about the mechanism of trauma, suspected injuries, vital signs, clinical symptoms, examination findings, and treatments provided. In preparation for the patient’s arrival, ED staff should assign tasks to team members, prepare resuscitation and procedural equipment, and ensure the presence of surgical consultants and other care team members. For patients transported to EDs that are not trauma centers, consider immediately whether transfer to a trauma center is appropriate and what resuscitation or stabilization can or should be performed prior to transfer. A focused history obtained from the patient, family members, wit nesses, or prehospital providers may provide important information regarding circumstances of the injury (e.g., single-vehicle crash, fall from height, environmental exposure, smoke inhalation), ingestion of intoxicants, preexisting medical conditions (e.g., diabetes, depres sion, cardiac disease, pregnancy), and medication use (e.g., steroids, β-blockers, anticoagulants) that may suggest certain patterns of injury or the physiologic response to injury. ED care of the trauma patient begins with an initial assessment for potentially serious injuries. A primary survey is undertaken quickly to identify and treat immediately life-threatening conditions, with simultaneous resuscitation and treatment. Specific injuries that should be immediately identified and addressed during the primary survey include airway obstruction, tension pneumothorax, massive internal or external hemorrhage, open pneumothorax, flail chest, and cardiac tamponade. After assessing the patient’s airway, breathing, and circulation, perform a more thorough head-to-toe examination (the secondary survey) (Table 254-3). Follow the secondary survey with appropriate diagnostic testing, further therapeutic interventions, and disposition. When derangements are identified in any of the systems assessed in the primary survey, undertake treatment immediately. AIRWAY MANAGEMENT WITH CERVICAL SPINE CONTROL Determine airway patency by inspecting for foreign bodies or maxil lofacial fractures that may result in airway obstruction. Perform a jaw thrust maneuver (simultaneously with in-line stabilization of the head and neck) and insert an oral or nasal airway as part of the first response to a patient with inadequate respiratory effort. Insertion of an oral airway may be difficult in patients with an active gag reflex. Avoid nasal airway insertion in patients with suspected basilar skull fractures. Whenever possible, use a two-person spinal stabilization technique in which one provider devotes undivided attention to maintaining in-line immobilization and preventing excessive movement of the cervical spine while the other manages the airway. If the patient vomits, logroll the patient and provide pharyngeal suction to prevent aspiration. Perform endotracheal intubation in comatose patients (Glasgow Coma Scale score between 3 and 8) to protect the airway and to prevent Trauma SECTION CHAPTER Tintinalli_Sec21_p1669-1766.indd 1669 8/1/19 12:20 PM
s the airway. If the patient vomits, logroll the patient and provide pharyngeal suction to prevent aspiration. Perform endotracheal intubation in comatose patients (Glasgow Coma Scale score between 3 and 8) to protect the airway and to prevent Trauma SECTION CHAPTER Tintinalli_Sec21_p1669-1766.indd 1669 8/1/19 12:20 PM 1670 SECTION 21: Trauma secondary brain injury from hypoxemia. Agitated trauma patients with head injury, hypoxia, or drug- or alcohol-induced delirium may be at risk for self-injury. Trauma patients are frequently difficult to intubate due to the need for neck immobilization, the presence of blood or vomitus, or upper airway injury. Video laryngoscopy devices are beneficial because they aid in vocal cord visualization while minimizing cervical spine manipulation. Use a rapid-sequence intubation technique for intubation (see Chapter 29A, “Tracheal Intubation” and Chapter 29B, “Mechanical Ventilation”). If anatomy or severe maxillofacial injury precludes endotracheal intubation, cricothyroidotomy may be needed. Clearance of the cervical spine from serious injury involves careful clinical assessment, with or without radiologic imaging. Not all patients require cervical spine radiographs. The National Emergency X-Radiography Utilization Study (NEXUS) criteria ( Table 254-4) 7 and the Canadian Cervical Spine Rule ( Table 254-5)8 are useful only in awake and alert patients and are not a substitute for good clinical judgment. Patients meeting NEXUS or Canadian criteria for low risk of cervical spine injury should undergo full examination of the cervical spine, including active range-of-motion testing in all directions along with a thorough neurologic examination. If the patient is obtunded, assume a cervical spine injury until proven otherwise. Even when plain radiographs or CT images show normal findings, it is possible for a patient to have unstable ligamentous injuries. TABLE 254-1 Essential Characteristics of Level 1 Trauma Centers • Meet the admission volume requirements (at least 1200 trauma patients yearly or have 240 admissions with an Injury Severity Score of >15) • Maintain a surgically directed critical care service • Participate in the training of residents and be a leader in education and outreach activities • Conduct trauma research TABLE 254-2 Triage and Trauma System Entry Criteria Physiologic abnormalities • Systolic blood pressure <90 mm Hg • Glasgow Coma Scale score <14 • Inadequate airway or need for immediate intubation Injury pattern • Penetrating wound to head, neck, or torso • Gunshot wound to extremities proximal to elbow or knee • Extremity with neurovascular compromise • Amputation proximal to wrist or ankle • CNS injury or paralysis • Flail chest • Suspected pelvic fracture Mechanism of injury • MVC with intrusion into passenger compartment >12 in • MVC with major vehicular deformity >20 in • Ejection from vehicle • MVC with entrapment or prolonged extrication of >20 min • Fall of >20 feet • MVC with fatality in same passenger compartment • Auto–pedestrian or auto–bicycle collision at >5 mph • Motorcycle crash >20 mph Abbreviation: MVC = motor vehicle crash. FIGURE 254-1. Phases of a preplanned trauma care continuum. ICU = intensive care unit. [Reproduced from U.S. Department of Health and Human Services, Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: U.S. Department of Health and Human Services; 2006. Available at: https://www.facs.org/quality-programs/ trauma/vrc/resources. Accessed February 12, 2018.] Therefore, maintain spinal immobilization during the resuscitation. Imaging of the spine should not delay urgent operative procedures because imaging results will not change the immediate management.
Services; 2006. Available at: https://www.facs.org/quality-programs/ trauma/vrc/resources. Accessed February 12, 2018.] Therefore, maintain spinal immobilization during the resuscitation. Imaging of the spine should not delay urgent operative procedures because imaging results will not change the immediate management. CT of the cervical spine is the preferred initial imaging modality. For full Tintinalli_Sec21_p1669-1766.indd 1670 8/1/19 12:20 PM
Services; 2006. Available at: https://www.facs.org/quality-programs/ trauma/vrc/resources. Accessed February 12, 2018.] Therefore, maintain spinal immobilization during the resuscitation. Imaging of the spine should not delay urgent operative procedures because imaging results will not change the immediate management. CT of the cervical spine is the preferred initial imaging modality. For full Tintinalli_Sec21_p1669-1766.indd 1670 8/1/19 12:20 PM CHAPTER 254: Trauma in Adults 1671 TABLE 254-3 Primary and Secondary Survey in Trauma Resuscitation PRIMARY SURVEY (RAPID IDENTIFICATION AND MANAGEMENT OF IMMEDIATELY LIFE-THREATENING INJURIES) A. Airway and cervical spine • Assess, clear, and protect airway: jaw thrust/chin lift, suctioning. • Perform endotracheal intubation with in-line stabilization for patient with depressed level of consciousness or inability to protect airway. • Create surgical airway if there is significant bleeding or obstruction or laryngoscopy cannot be performed. B. Breathing • Ventilate with 100% oxygen; monitor oxygen saturation. • Auscultate for breath sounds. • Inspect thorax and neck for deviated trachea, open chest wounds, abnormal chest wall motion, and crepitus at neck or chest. • Consider immediate needle thoracostomy for suspected tension pneumothorax. • Consider tube thoracostomy for suspected hemopneumothorax. C. Circulation • Assess for blood volume status: skin color, capillary refill, radial/femoral/carotid pulse, and blood pressure. • Place two large-bore peripheral IV catheters. • Begin rapid infusion of warm crystalloid solution, if indicated. • Apply direct pressure to sites of brisk external bleeding. • Consider central venous or interosseous access if peripheral sites are unavailable. • Consider pericardiocentesis for suspected pericardial tamponade. • Consider left lateral decubitus position in late-trimester pregnancy. D. Disability • Perform screening neurologic and mental status examination, assessing: • Pupil size and reactivity • Limb strength and movement, grip strength • Orientation, Glasgow Coma Scale score • Consider measurement of capillary blood glucose level in patients with altered mental status. E. Exposure • Completely disrobe the patient, and inspect for burns and toxic exposures. • Logroll patient, maintaining neutral position and in-line neck stabilization, to inspect and palpate thoracic spine, flank, back, and buttocks. SECONDARY SURVEY (HEAD-TO-TOE EXAMINATION FOR RAPID IDENTIFICATION AND CONTROL OF INJURIES OR POTENTIAL INSTABILITY) • Identify and control scalp wound bleeding with direct pressure, sutures, or surgical clips. • Identify facial instability and potential for airway instability. • Identify hemotympanum. • Identify epistaxis or septal hematoma; consider tamponade or airway control if bleeding is profuse. • Identify avulsed teeth or jaw instability. • Evaluate for abdominal distention and tenderness. • Identify penetrating chest, back, flank, or abdominal injuries. • Assess for pelvic stability; consider pelvic wrap or sling. • Inspect perineum for laceration or hematoma. • Inspect urethral meatus for blood. • Consider rectal examination for sphincter tone and gross blood. • Assess peripheral pulses for vascular compromise. • Identify extremity deformities, and immobilize open and closed fractures and dislocations. TABLE 254-4 NEXUS (National Emergency X-Radiography Utilization Study) Criteria for Omitting Cervical Spinal Imaging* • No posterior midline cervical spine tenderness • No evidence of intoxication • Alert mental status • No focal neurologic deficits • No painful distracting injuries *Failure to meet any one criterion indicates need for cervical spine imaging. TABLE 254-5 Canadian Cervical Spine Rule Any high-risk factor that mandates radiography?
ne cervical spine tenderness • No evidence of intoxication • Alert mental status • No focal neurologic deficits • No painful distracting injuries *Failure to meet any one criterion indicates need for cervical spine imaging. TABLE 254-5 Canadian Cervical Spine Rule Any high-risk factor that mandates radiography? (Age >64 y or dangerous mechanism or paresthesias in extremities) If Yes, radiography indicated Any low-risk factor that allows safe assessment of range of motion? (Simple rear-end collision or sitting position in the ED or ambulatory at any time or delayed onset of neck pain or absence of midline cervical spine tenderness) Yes If No, radiography indicated Able to rotate neck actively? (45 degrees left and right) Yes If No, radiography indicated No radiography indicated if all criteria are met discussion of cervical spine imaging and management in trauma, see Chapter 258, “Spine Trauma. ” BREATHING Once the airway is controlled, inspect, auscultate, and palpate the thorax and neck to detect abnormalities such as a deviated trachea (tension pneumothorax); crepitus (pneumothorax); paradoxical movement of a chest wall segment (flail chest); sucking chest wound; fractured sternum; and absence of breath sounds on either side of the chest (simple or ten sion pneumothorax, massive hemothorax, or right mainstem intubation). Any of these findings warrants immediate intervention, including needle thoracostomy for tension pneumothorax (see the section “Needle Decompression” in Chapter 68, “Pneumothorax”); insertion of large-bore chest tubes (36F) to relieve hemopneumothorax (see Chapter 261, “Pulmonary Trauma”); and application of an occlusive dressing to a sucking chest wound. For asymmetric or absent breath sounds in the intubated patient, partially withdraw the endotracheal tube from the right mainstem bronchus or reintubate. If no breath sounds are heard, and if massive hemothorax or vascular injury is suspected (initial chest tube output of >1500 mL, or >200 mL/h), a thoracotomy or video-assisted thoracic surgery is indicated to identify and control the source of bleeding. CIRCULATION AND HEMORRHAGE CONTROL Assessment of the patient’s overall hemodynamic status is critical. This assessment includes evaluation of level of consciousness, skin color, and presence and magnitude of peripheral pulses. Note the heart rate and pulse pressure (systolic minus diastolic blood pressure), particularly in young, previously healthy trauma patients, as these may be early clues to impending hemodynamic compromise. As part of the primary survey in the prehospital and hospital settings, identify and control external hemorrhage. Apply direct pressure, a compression bandage, or a hemostatic dressing to control active external bleeding. QuikClot Combat Gauze is a kaolin-impregnated rayon and polyester hemostatic dressing that is safe and effective for arterial or venous bleeding.4,9 For exsanguinating extremity injury, apply a tourniquet ( Fig. 254-2). Prehospital and battlefield use of tourniquets is common. With aggres sive tourniquet use, death rates from isolated limb exsanguination in Iraq decreased to 2% compared to 9% in the Vietnam War. 10 In civilian trauma, the need for tourniquet application is less common but lifesaving in some cases. CIRCULATION Any hypotensive trauma patient is at risk for development of hemor rhagic shock, a common cause of postinjury death. One system is com monly used for classifying the degree of hemorrhage ( Table 254-6), Tintinalli_Sec21_p1669-1766.indd 1671 8/1/19 12:20 PM
tion is less common but lifesaving in some cases. CIRCULATION Any hypotensive trauma patient is at risk for development of hemor rhagic shock, a common cause of postinjury death. One system is com monly used for classifying the degree of hemorrhage ( Table 254-6), Tintinalli_Sec21_p1669-1766.indd 1671 8/1/19 12:20 PM 1672 SECTION 21: Trauma REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta BACKGROUND Exsanguinating hemorrhage is a leading cause of prev entable death follo wing trauma. The U.S. military has impro ved surviv al from ex sanguinating ex trem ity injuries by means of field tourniquet applica tion, but noncompr essible torso hemorrhage remains a difficult problem. Historic ally, definitive con trol of noncom pressible torso hemorrhage has been att empted through the field applica tion of specially designed tourniquets , as well as emergen t thorac otomy. Thor acotomy and laparotomy for definitive hemorrhage con trol requir e rapid transpor t to surgi cal care. One tool for alterna tive hemorrhage con trol is resuscita tive endov ascu lar balloon occlusion of the aorta (REBOA ), which was originally described during the Korean War and has been re -popularized during the rec ent wars in Iraq and Afghanistan. REBOA inv olves insertion and inflation of an endov ascular balloon int o the proximal aorta via the common femor al art ery. Balloon inflation is a temporiz ing maneuver until definitive hemostasis by vasc ular int erventional proc edures or open surgical control. INDICATIONS REBOA is primarily used in the United Sta tes for trauma or intr aoperative ex sanguination. It has been used int ernationally for a wider range of indica tions and for many years . Other indications reported in the liter ature include massive ex sanguination from postpartum hemorrhage, upper GI bleeding, pelvic surger y, and ruptur ed aortic aneurysm. Although many protocols exist, exper ts generally agree that ex sanguinating hemorrhage originating from a source below the diaphragm, which is unresponsiv e or transien tly responsiv e to resuscitation, could benefit from REBOA.1 In addition, REBOA can be consider ed for acut e trauma tic cardiac arrest due to presumed life -threatening hemorrhage below the diaphragm. The balloon catheter can be inflat ed int o one of tw o general “z ones” of the descending aorta. Inflation of the balloon at zone 1 is for control of hemorrhage originating from below the diaphragm to abov e the renal art eries (Figure 1). If the source of hemorrhage is below the level of the renal art eries, including sever e pelvic, groin, or pro ximal low er ex tremity hemorrhage, the balloon may be inflat ed within zone 3. Zone 2 extends from the diaphragm to the lowest renal artery and is generally avoided due to the presence of the visceral arteries. FIGURE 1. Anatomic zones for REBOA placement. Avoid inflation in Zone 2. Zone 1 Zone 3 Zone 2 FIGURE 2. Suggested REBOA algorithm. Yes Pelvic x-ray fracture? FAST positive? CXR possible aortic injury? Hypotensive (SBP <90) partial or non-responder Access common femoral artery for a line or REBOA Yes Yes No REBOA Position REBOA in ZONE 1, inflate and proceed to Emergent Laparotomy Position REBOA in ZONE I and inflate Position REBOA in ZONE III and inflate Tintinalli_Sec21_p1669-1766.indd 1672 8/1/19 12:20 PM
injury? Hypotensive (SBP <90) partial or non-responder Access common femoral artery for a line or REBOA Yes Yes No REBOA Position REBOA in ZONE 1, inflate and proceed to Emergent Laparotomy Position REBOA in ZONE I and inflate Position REBOA in ZONE III and inflate Tintinalli_Sec21_p1669-1766.indd 1672 8/1/19 12:20 PM CHAPTER 254: Trauma in Adults 1673 REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta (Cont.) TABLE 254-6 Classification of Hemorrhage Based on Estimated Blood Loss at Initial Presentation Class I Class II Class III Class IV Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000 Blood loss (% blood volume) Up to 15 15–30 30–40 40 Pulse rate (beats/min) <100 100–120 120–140 >140 Blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or increased Decreased Decreased Decreased *Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L. PROCEDURE (S ee Video: REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta ) A general description of the proc edure was originally described by Stannar d and colleagues2 as a five-step procedure including art erial acc ess, balloon selection and positioning, balloon inflation, balloon deflation, and sheath remo val. With the developmen t of purposedesigned REBOA ca theters through smaller intr oducer sheaths , the proc edure requir es few er steps with more rapid insertion and inflation compar ed to previous technology adapted from vascular surgery. Training typically consists of a course discussing the risks, benefits, and applica tion of the technique, coupled with simulation, animal model, or cadaver model training.3,4 Procedural steps include obtaining vasc ular acc ess in the common femor al art ery 1 cm below the inguinal ligament by either US- guided perc utaneous or open exposur e acc ess. Many experts recommend open access in cardiac arrest. Insert the catheter sheath using the Seldinger technique. Measure the balloon for insertion length, which can be obtained by using either external landmarks, using the xiphoid for zone 1 and umbilicus for zone 3, or standardized length measuremen ts, which place the balloon corr ectly for a large portion of the population. Then insert the balloon to the measured length and inflat e with sterile fluid with or without radiopaque con trast. Imaging may be obtained aft er ca theter insertion and balloon inflation to confirm placemen t within the aorta, but some exper ts feel this is not necessary. After inflation, assess patien t response and send the patien t for definitive hemorrhage control as soon as possible. The prime consideration for the emergenc y pro vider is the most rapid disposition of the patient possible from the ED to definitive hemorrhage con trol in the opera ting room or by interventional radiology .3 Field application is possible in the military or in systems with robust prehospital resour ces as long as there is ver y rapid transpor t for definitive hemorrhage control. The effec ts of prolonged aortic occlusion with REBOA, including partial or intermittent REBOA for mitigation of distal ischemia, are poorly studied. William Teeter, MD, MS REFERENCES 1. http://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/ REBOA_for_Hemorrhagic_Shock_06_Jul_2017_ID38.pdf (Join t Tr auma Syst em Cl inical Practice Guideline: Resuscitativ e Endo vascular Balloon Oc clusion of the Aor ta.) Ac cessed May 28, 2019. 2. Stannard A, Eliason JL, Rasmussen TE: Resuscitativ e endov ascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Tr auma 71: 1869, 2011. [PMID: 22182896] 3. Napolitano LM: Resuscitativ e endov ascular balloon occlusion of the aorta: indica tions, outcomes, and training . Crit Care Clin 33: 55, 2017.
JL, Rasmussen TE: Resuscitativ e endov ascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Tr auma 71: 1869, 2011. [PMID: 22182896] 3. Napolitano LM: Resuscitativ e endov ascular balloon occlusion of the aorta: indica tions, outcomes, and training . Crit Care Clin 33: 55, 2017. [PMID: 27894499] 4. Brenner M, Bulger EM, Perina DG, et al: Joint stat ement from the Americ an College of Sur geons Committee on Trauma (A CS CO T) and the Americ an College of Emer gency Physicians (A CEP) regarding the clinical use of Resuscitativ e Endo vascular Balloon Oc clusion of the Aor ta (REBOA). Trauma Surg Acute Care Open 3: e000154, 2018. [PMID: 29766135] although it has not been validated and there is wide variability in indi vidual patient response to hypovolemia. Hemorrhage and shock are on a continuum, and some patients can compensate for significant blood loss better than others. Hemorrhage of up to 30% of total blood volume may be associated with only mild tachycardia and a decrease in pulse pressure, but may quickly progress to profound hypoperfusion and decompensated shock if not recognized early. Be aware that medica tions, such as β-blockers, can mask early hemodynamic indicators of shock. Establish two large-bore IV lines (18 gauge or larger), infuse lactated Ringer’s, and obtain blood samples or specimens for laboratory stud ies, particularly blood type and screen. In patients who are unstable or in whom upper extremity peripheral veins are not easily cannulated, establish central venous access via the subclavian, internal jugular, or femoral vein. Avoid placement of a central venous line distal to a potential venous injury. Placement of an IO catheter is a second-line option (after peripheral IV attempt) because it is quick and easy and can accommodate infusion of large volumes. Most medications including blood products can be administered IO. Use a pressure bag to maximize flow rates. A balanced crystalloid, such as lactated Ringer’s, is the fluid of choice for initial resuscitation. There is some advantage of lactated Ringer’s over normal saline when large volumes are given in order to avoid hyperchloremic acidosis, although this is unlikely to be significant for most patients during initial resuscitation. Reassess hypotensive patients without an obvious indication for surgery after rapid infusion of 2 L of crystalloid solution. If there is no marked improvement, then transfuse type O blood (O-negative for females of childbearing age). Aggressive volume resuscitation is not a substitute for definitive hemorrhage control. Patients requiring massive transfusions generally require urgent surgical intervention to control hemorrhage. A well-defined source of bleeding may be evident on external examination, assessment of chest tube output, extended FAST examination (Figure 254-3), or conventional or CT imaging of the chest or abdomen. There may also be con siderable blood loss from blunt trauma to the pelvis and limbs without a discrete source. Immobilize open pelvic fractures in a pelvic wrap or sling and reduce and immobilize limb fractures to tamponade bleeding from fractured bone ends. Major trauma patients may develop a bleeding diathesis almost from the time of injury, which results in defective clotting and platelet function. Data from both military and civilian experience reveal that patients receiving >10 units of packed red blood cells showed decreased mortality when they simultaneously receive fresh frozen plasma in a ratio of packed red blood cells to fresh frozen plasma of 1:1 rather than 1:4 (26% vs. 87.5% mortality, respectively).
. Data from both military and civilian experience reveal that patients receiving >10 units of packed red blood cells showed decreased mortality when they simultaneously receive fresh frozen plasma in a ratio of packed red blood cells to fresh frozen plasma of 1:1 rather than 1:4 (26% vs. 87.5% mortality, respectively). 13 There is general consensus that there should be a higher ratio of fresh frozen plasma and platelets to packed red cells up to 1:1:1 ratio in massive transfusion protocols. FIGURE 254-2. C.A.T.® tourniquet. [Source: J.E. Tintinalli, J.S. Stapczynski, O.J. Maa, D.M. Yealy, G.D. Meckler, D.M. Cline: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th ed. www.accessmedicine.com. (Copyright © McGraw-Hill Education. All rights reserved.)] Tintinalli_Sec21_p1669-1766.indd 1673 8/1/19 12:20 PM
tourniquet. [Source: J.E. Tintinalli, J.S. Stapczynski, O.J. Maa, D.M. Yealy, G.D. Meckler, D.M. Cline: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th ed. www.accessmedicine.com. (Copyright © McGraw-Hill Education. All rights reserved.)] Tintinalli_Sec21_p1669-1766.indd 1673 8/1/19 12:20 PM 1674 SECTION 21: Trauma TABLE 254-7 Glasgow Coma Scale (GCS) with Motor Glasgow Coma Scale GCS Score 6 5 4 3 2 1 Best motor response Obey command Localize the pain Withdrawal to pain Flexion to pain Extension to pain None Verbal response Oriented Confused Inappropriate word Incomprehensible sound None Eye opening Spontaneous To verbal To pain None FIGURE 254-3. Positive extended FAST exam with blood identified in Morison’s pouch. [Photo contributed by Barry Knapp, MD.] Both acidosis and hypothermia contribute to the coagulopathy and should be corrected as quickly as possible. An emerging tool in the management of noncompressible torso hemorrhage is resuscitative endovascular balloon occlusion of the aorta (REBOA). REBOA is potentially indicated for traumatic life-threatening hemorrhage below the diaphragm in patients in hemorrhagic shock who are unresponsive to resuscitation. Depending on the location of hemorrhage, an inflatable balloon catheter is inserted in the femoral artery and advanced to the distal thoracic aorta or distal abdominal aorta. REBOA should be considered as a bridging therapy to definitive surgery. The technique should not delay definitive surgery and is suitable for only a limited number of patients. It is important to note that no current, high-grade evidence clearly demonstrates REBOA improves outcomes or survival compared to standard treatment of severe hemorrhage. 11,12 Complications of REBOA include arterial disruption, hematoma, thromboemboli, dissection, and extremity ischemia. TRANEXAMIC ACID (TXA) Tranexamic acid is an antifibrinolytic agent that reduces blood loss after surgery and may reduce blood loss after traumatic injury. It prevents cleavage of plasmin and degradation of fibrin. It is on the World Health Organization list of essential medications affecting coagulation. 15 Studies involving >20,000 patients reported a risk reduction of death from bleeding of 10% to 15%. There was no reported difference in risk of death from myocardial infarction, vascular occlusion, stroke, pulmonary embolism, mutiorgan failure, or head injury. 16 Criticism of the Clini cal Randomization of an Antifibrinolytic in Significant Hemorrhage 2 (CRASH-2) study was that the patient populations studied were heterogeneous in terms of injury and were in low- to middle-income countries with basic and very limited resources for major trauma management. 17,18 Nevertheless, the evidence to date indicates that tranexamic acid may reduce mortality without significant adverse side effects when given as early as possible after injury, with administration within 1 hour of injury reported to decrease the relative risk of death from bleeding by 32% and within 1 to 3 hours by 21%. 19 Administration of tranexamic acid more than 3 hours after injury is less effective and potentially harmful.16 Tranexamic acid must be given before transfer/arrival to a trauma center in order to meet the time requirement of early administration. 17 The dose is 1 gram of tranexamic acid IV bolus over 10 minutes, followed by 1 gram IV over 8 hours. DISABILITY Once airway, breathing, and circulation have been addressed and stabilized, perform a focused neurologic evaluation to assess level of consciousness, pupillary size and reactivity, and motor function. Con sider alternative causes of altered sensorium, including measurement of capillary blood glucose level and intoxicants.
e airway, breathing, and circulation have been addressed and stabilized, perform a focused neurologic evaluation to assess level of consciousness, pupillary size and reactivity, and motor function. Con sider alternative causes of altered sensorium, including measurement of capillary blood glucose level and intoxicants. Despite the concomitant use of drugs and alcohol in many trauma patients, do not simply attri bute altered mental status to intoxication. Assess the Glasgow Coma Scale (GCS) (Table 254-7). The GCS is an instrument widely used for assessment of consciousness at the site of injury, in EDs, and in hospitals, and it helps monitor progress or deterioration during treatment. The GCS consists of the following three components: eye (scored 1 to 4), verbal (scored 1 to 5), and motor (scored 1 to 6). Scores on each of these components are added to obtain the total Glasgow Coma Scale (tGCS) score. 20 Assume that a patient with a history of head trauma associated with altered mental status (tGCS <15) has a significant intracranial injury until proven otherwise. Because a persistent tGCS score of ≤8 generally suggests a poorer prognosis than scores >8, secure a definitive airway to protect against aspiration or asphyxia. The tGCS scale assessment can be insensitive in patients with normal or near-normal tGCS score, and a score of 15 does not exclude the presence of trau matic brain injury. Because the tGCS is often difficult to record for trauma patients, some systems have begun using only the motor component of the GCS (mGCS) to triage patients. An mGCS score <6, “patient does not follow commands, ” is almost as accurate as the tGCS in predicting traumatic injury outcome. 21,22 Sensitivity, specificity, and accuracy of GCS score ≤13 versus mGCS score <6 are very similar (69.8% vs. 67.3% for sensitivity; 88.1% vs. 90.1% for specificity; and 87.1% vs. 88.8% for accuracy, respectively). 21,22 Direct efforts toward resuscitating brain-injured patients in order to maintain normal cerebral perfusion. Monitor serum glucose levels and maintain euglycemia. Mild hyperventilation may reduce intracra nial pressure, although at the expense of cerebral vasoconstriction and hypoperfusion. Avoid hyperventilation during the first 24 hours after injury when cerebral blood flow is often critically reduced. Prophylactic hyperventilation (partial pressure of arterial carbon dioxide of 25 mm Hg or less) is not recommended. EXPOSURE No primary survey is complete without completely disrobing the patient and examining carefully for occult bruising, lacerations, impaled for eign bodies, and open fractures. After completing the primary survey, logroll the patient, with one team member assigned to maintain in-line cervical stabilization. Palpate the spinous processes of the thoracic and lumbar spine for tenderness or deformity, and then carefully logroll the patient back to a neutral position. Routine rectal examination is not performed, but it is useful in pelvic injury to identify gross rectal bleeding or loss of rectal tone in patients with suspected spinal injury. Examine the perineum for bruising, laceration, or bleeding. Cover the patient with warm blankets to prevent heat loss. Some have advocated the use of hypothermia in cases of severe brain injury. However, as of this writing, there is no conclusive evidence in favor of this therapy. Potential therapeutic benefits must be weighed against the coagulopathy, increased bleeding, and reduced myocardial function that hypothermia can cause. Tintinalli_Sec21_p1669-1766.indd 1674 8/1/19 12:20 PM
es of severe brain injury. However, as of this writing, there is no conclusive evidence in favor of this therapy. Potential therapeutic benefits must be weighed against the coagulopathy, increased bleeding, and reduced myocardial function that hypothermia can cause. Tintinalli_Sec21_p1669-1766.indd 1674 8/1/19 12:20 PM CHAPTER 254: Trauma in Adults 1675 SPECIFIC INJURIES OF IMPORTANCE Place special emphasis on identifying the injuries described in the fol lowing sections during the primary survey, because they can be rapidly fatal if not recognized and treated. SEVERE HEAD AND SPINAL TRAUMA Rapidly assess neurologic status in patients with suspected traumatic brain injury. To quickly identify patients with intracranial injuries who may benefit from operative treatment, defer any procedures that do not correct a specific problem discovered during the primary survey until after the head CT is performed. In patients requiring intubation, provide in-line immobilization when the cervical collar is removed during intubation, and then reapply after intubation. Obtain a chest radiograph or US to assess endotracheal tube placement and exclude pneumothorax. TENSION PNEUMOTHORAX, OPEN PNEUMOTHORAX, AND MASSIVE HEMOTHORAX Tension pneumothorax, open pneumothorax, and massive hemothorax all should be readily apparent during the primary survey. If tension pneumothorax is clinically suspected, immediately perform tube thoracostomy. If equipment is not immediately available, needle thoracostomy can be a temporizing measure. Delays in diagnosis and treatment (including awaiting confirmatory chest radiograph) can result in complete hemodynamic collapse. In equivocal cases, US can confirm the presence of pneumothorax and prompt emergent intervention. Perform tube thoracostomy in a timely manner in patients with a significant pneumo- or hemothorax, as determined by US, chest radiograph, or CT (see Chapter 261). PENETRATING ABDOMINAL TRAUMA Abdominal tenderness or distention on palpation, coupled with hypotension, indicates the emergent need for exploratory laparotomy in a patient who has sustained a penetrating abdominal injury; this should prompt immediate transport to the operating room if unstable. Early operative intervention in patients experiencing penetrating trauma who are in shock results in better outcomes. Placement of nasogastric, urinary, and IV catheters may proceed in the ED only if they do not delay definitive operative intervention. Otherwise, these procedures should take place in the operating room as the patient is being prepared for general anesthesia. In the setting of a penetrating gunshot wound to the abdomen, CT is not indicated if the patient requires emergent exploratory laparotomy. IMPALED OBJECTS Objects deeply impaled in the chest and abdomen should be left in place and the patient emergently transported to the operating room for surgical removal under direct visualization to ensure vascular control and hemostasis. The impaled object may be cut or shortened outside the skin to facilitate transport. TRAUMATIC CARDIAC ARREST Unless obvious signs of death are present in the field, providers in most emergency medical systems continue to transport patients without pulse or respiration to a hospital once cardiopulmonary resuscitation has been initiated. For patients in traumatic arrest upon arrival to the ED, a critical decision must be made regarding the appropriate level of intervention and, specifically, the use of emergent thoracotomy. One study analyzing 862 patients undergoing ED thoracotomy at a regional trauma center showed that the proportion of neurologically intact survivors was 3.9%. The best outcomes were in patients with stab wounds to the chest.
rding the appropriate level of intervention and, specifically, the use of emergent thoracotomy. One study analyzing 862 patients undergoing ED thoracotomy at a regional trauma center showed that the proportion of neurologically intact survivors was 3.9%. The best outcomes were in patients with stab wounds to the chest. Further analysis revealed that the survival rate was 23% among thoracic stab wound victims who showed breathing or pulse in the field and 38% among those who were moribund, but had some indication of respiration or pulse on arrival to the ED. Therefore, the strongest recommendation for performing ED thoracotomy can be made for patients with penetrating chest trauma with witnessed signs of life during transport to or in the ED and at least cardiac electrical activity upon arrival. 25-27 There were no survivors among patients with blunt trauma and no respiration or pulse in the field. ED thoracotomy for this group is not indicated (including in the presence of myocardial electrical activity). Any recommendation for the termination or escalation of resuscita tive efforts (penetrating or blunt) should be based on an immediate search for readily reversible causes. US can identify some of these causes including cardiac tamponade, pneumothorax, massive hemoperito neum, and the presence or absence of ongoing cardiac activity. One suggested algorithm for this decision making is outlined in Figure 254-4. SECONDARY SURVEY The secondary survey is a rapid but thorough head-to-toe examination for injuries (Table 254-3). Do not start the secondary survey until basic functions have been corrected in conjunction with the primary survey (airway, breathing, circulation, disability, exposure) and resuscitation has been initiated. The secondary survey can help set priorities for ongoing evaluation and management. Frequent reassessment of the patient’s blood pressure, pulse rate, and response to interventions should continue during this period. Scalp lacerations can bleed profusely. Bleeding can be controlled with plastic Raney clips (see Chapter 42, “Face and Scalp Lacerations”) or staples that grasp the full thickness of the scalp. Inspect the tympanic membranes for hemotympanum and repeat the pupil examination. Repeat the examination of the neck and thorax for any changes. When there is facial trauma or evidence of basilar skull fracture, insert the gastric tube through the mouth rather than the nose. Inspect the urinary meatus, scrotum, and perineum for the presence of blood, hematoma, or laceration. Perform a rectal examination, noting sphincter tone, gross blood, and prostatic bogginess or displacement. The rectal examination is no longer routinely performed in alert patients without evidence of pelvic or spinal injury. If the prostate is normal and there is no blood at the urethral meatus, a urinary catheter can be placed in the bladder. If meatal blood is present or the prostate is displaced, which suggests a urethral injury, perform retrograde urethrography before inserting a Foley catheter. If there is vaginal bleeding, perform a manual and speculum examination to identify a possible vaginal laceration in the presence of a pelvic fracture. Evaluate the extremities for fracture and soft tissue injury, with attention to peripheral pulses. Perform a more thorough neurologic examination, carefully checking motor and sensory function. Certain conditions are typically not evident during the secondary survey unless specifically sought. Injuries to the esophagus, diaphragm, and small bowel often remain undiagnosed, even with diligent examination, and further imaging and hospital observation for delayed presentation may be required. The most frequently missed conditions are orthopedic.
not evident during the secondary survey unless specifically sought. Injuries to the esophagus, diaphragm, and small bowel often remain undiagnosed, even with diligent examination, and further imaging and hospital observation for delayed presentation may be required. The most frequently missed conditions are orthopedic. Careful consideration of orthopedic extremity injuries is essential in patients with multisystem trauma. A tertiary survey has been recommended in patients with multisystem trauma within the first 24 hours to lessen the risk of missed injury. IMAGING AND LABORATORY TESTING For patients who are not rapidly transported to the operating room or CT suite after the initial assessment, standard radiographic imaging may include cervical spine, chest, and pelvic radiographs. The chest and pelvic radiographs image regions outside the peritoneal cavity that can accommodate volumes of blood sufficient to produce hypotension and shock. In patients with gunshot wounds to the torso, a chest radiograph is required, with or without abdominal films, depending on the site of injury. The extended FAST examination is a rapid and effective screening tool for the identification of major intraperitoneal bleeding, pericardial tamponade, pneumothorax, and hemothorax as the source of hypo tension or shock. 30 It should be performed to identify causes of shock immediately after the primary survey. Perform a CT scan with IV Tintinalli_Sec21_p1669-1766.indd 1675 8/1/19 12:20 PM 1676 SECTION 21: Trauma Cardiac arrest/ Periarrest situation? Return of spontaneous circulation? Consider termination of CPR Universal ALS algorithm Hypoxia Tension pneumothorax Tamponade Hypovolaemia Likely Unlikely Consider non-traumatic cause Simultaneously address reversible causes 1. C ontrol external catastrophic haemorrhage 2. Control airway and maximise oxygenation 3. Bilateral chest decompression 4. Relieve cardiac tamponade 5. Surgery for haemorrhage control or proximal aortic compression 6. Massive transfusion protocol and fluids Consider immediate resuscitative thoracotomy Elapsed time < 10 min since arrest? Expertise? Equipment? Environment? Trauma patient Start/ Continue ALS
. Bilateral chest decompression 4. Relieve cardiac tamponade 5. Surgery for haemorrhage control or proximal aortic compression 6. Massive transfusion protocol and fluids Consider immediate resuscitative thoracotomy Elapsed time < 10 min since arrest? Expertise? Equipment? Environment? Trauma patient Start/ Continue ALS FIGURE 254-4. Decision-making algorithm. ALS = advanced life support. [Reproduced with permission from Truhlar AJ, Deakin, CD, Soae J, et al: European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances. Resuscitation 95: 148-201, 2015. Copyright Elsevier.] contrast for definitive imaging of the chest and abdomen-pelvis. Obtain appropriate extremity radiographs to exclude fractures as directed by the physical examination findings. In obtunded patients or those with multisystem trauma, consider imaging of the entire spine if the mechanism of injury warrants it. Contrast imaging of the vertebral and carotid arteries can identify blunt carotid and vertebral artery injury, especially in patients with head, cervical spine, and chest injuries. 31 See Table 260-7 for risk factors. In patients undergoing head CT, most EDs perform cervical spine CT at the same time. If chest and abdominal CTs are performed, CT images of the thoracic and lumbar spines can be reconstructed. In the setting of significant trauma, a liberal approach to the use of CT scanning has been recommended by some, as it can be done quickly and has the potential to detect injuries not clinically apparent. 32 The benefits of this “pan scan” approach need to be balanced by the unde sirable consequences of increased ionizing radiation exposure. Studies have questioned this “pan scan” approach. The REACT-2 (Randomized Study of Early Assessment by CT 2) trial found no significant difference in in-hospital mortality in patients with severe trauma who underwent immediate total-body CT scanning compared with the standard workup with conventional imaging and selective CT scanning. Routine laboratory studies often include blood type and screen, hemoglobin level, urine dipstick testing for blood, and ethanol level. In women of childbearing age, always perform a pregnancy test. The use of bedside viscoelastic hemostatic tests such as rotational thromboelas tometry and thromboelastogram are not routine but show promising results in some centers in directing massive transfusion protocols. Check capillary blood glucose level in patients with altered mental status or a history of diabetes mellitus. In patients older than 55 years, consider obtaining an ECG and measuring levels of markers for cardiac ischemia, such as troponin I. DISPOSITION AND FOLLOW-UP Expeditiously transport patients with hemodynamic instability and ongoing bleeding to the operating room or transfer the patient to another facility with appropriate surgical or critical care resources. Complete a rapid but thorough primary and secondary survey prior to transfer. In most urban Level 1 trauma centers, the trauma surgeon will have been present for the primary and secondary surveys. In rural hospitals that transfer the most severely injured trauma patients, the resuscitating physician should relate all the physical findings discovered during the primary and secondary surveys to the physician receiving the patient. Laboratory results, imaging studies, and the chronologic record of the patient’s blood pressure, pulse, fluids infused, urine output, gastric output, and neurologic findings should accompany the patient. Personnel capable of performing ongoing resuscitation of the patient should accompany a patient transported to another facility. Serial examinations are essential for patients without clear indications for surgery identified on initial assessment.
t, gastric output, and neurologic findings should accompany the patient. Personnel capable of performing ongoing resuscitation of the patient should accompany a patient transported to another facility. Serial examinations are essential for patients without clear indications for surgery identified on initial assessment. Patients may be admitted to the hospital or an ED observation unit. Blunt abdominal injuries such as those involving the pancreas and bowel may not be readily appar ent on initial CT. These injuries may become clinically apparent upon serial examinations. In addition, consider admission or observation for patients with closed head trauma who have normal levels of conscious ness and require repeat neurologic examinations as well as patients at risk for delayed pneumothorax or pulmonary contusion that require repeat chest radiography. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec21_p1669-1766.indd 1676 8/1/19 12:20 PM