I

HAPTEB C

Initial Assesrnent and ent Mana

I OBJECTIVES:
Upon completion of this topic, the student will be able to demonstrate the ability to apply the principles of emergency medical care to the multiply injured patient. Specifically, the doctor will be able to: A. Identify the correct sequenceof priorities in assessingthe multiply injured patient. B. Apply the principles outlined in the primary and secondary evaluation surveys to the assessmentof the multiply injured patient. C. Apply guidelines and techniques in the initial resuscitative and definitive-care phases of treatment of the multiply injured patient. D. Identify how the patient's medical history and the mechanism of injury contribute to the identification of injuries. E. Anticipate the pitfatls associated with the initial assessment and management of the injured patient and apply steps to minimize their impact. F. Conduct an initial assessment survey on a simulated multiplv injured patient, using the correct sequence of priorities and explaining management techniques for primary treatment and stabilization.

Life Support idilautced Traunm

t1

CHAPTEB NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

I. INTRODUCTION
'fhe treartmentof the serioush' injurecl patient requires rtrpicl assesslllentof the' injuries and institutio. of iiie-preser'ing therapr'. Becausetime is of that celube earsilt' ap1-rroach a Systemartic the essencc, aurclpracticecl is desirable. This process is revic-l,t,ed altd inclucles: termerl "itritial clSSSSll1nt" 1. Preparartictn 2. Triage 3. prinary surye\, (ABCDEs) l. R e s u s c i t.tti o tr 5. Adjuncts to primarv survev antl resuscitation ancl 6. Seconclarvsurvel' (heacl-to-toeer';rluatic-ru historv) 7. Acljuncts to the secondarv survev B. Continuecl postresuscitation monitoring ancl reevaluation 9. Definitive care The primary and secondary surveys should be repeated frequently to ascertain any deterioration in the patient's status and any necessary treatment to be instituted at the time an adverse change is identified. This sequenceis presented in this chapter as a longitudinal progression of errents.In the actual clinical situation, many of these activities occur in parallel or simultaneously. The linear or longitudinal progression allorvs tl-re doctor an opportunitt' to ^"r-rtoliv re\riert, the progress of an actual trauma resuscitation. ATLSo' is intended to guide the assessment and resuscitation of injured patients' judgment is required to determine what procedures are neces,uiy, because not all patients require all of these procedures.

P l hase A. Prehospita
coclrclination r.r,ith the prc-hospital agellcv atrcl personnel can greatlt' expe-clitethe treaturent itr ihe fielcl' The prehospitarlS)'stetlrshoulcl be set up such tirat tl-rerece'iving hospital is notiiiecl before the prehosprital personnel trausl'rort the patient irom the scene. This allort's mobilization of the that all necessc'r hospital's trauma team nte.t'nbers soatl personnel and resources c-lrc Presc'lrtiri the. errrerge.llcydr'partrne'nt at the- tiure tlf the patietrt's in the prehospital phase shoultl be arrivil. En-rphasis placed trr',oirovov tlaintellance, coutrol of external Lleecling anrl shock, irnmolrilization of the peltierlt, ancl immecliate trarnsportto the closest appropriate facility, preie-rablva Verified traurnarcenter' Everv effort -shoulclbe macle to rninimize scene time. (See The National Schr.me.) Florvchart 1, Triage De.cisiorr Techuicians' Association of Emergencr. IVIec-lical Prehospital Traurna Life Support Committee', in .nop"tition rvith the Committee on Traruma (COT) of tire AtnericarnCollege of Surgeons (ACS), has tleVeloped a coLlrseu'ith a format sirnilar to the ATLS issuesfor the prehospit.ll carer Couise that adclresses the injured patient. Emphasis also should be place-cl orr obtaining ancl reporting information needeclfor triargeat the hospital, eg, time of iniurr', e'\'ents related to the injurv, and patient historr'. The mechanistns of injun' malr suggest the tlegree of injurv as rvell as specific injuries for r.t'hich the patietrt must be evaluatecl.

Plh a s e B. Inhospita
Aclvancecl planning for the trauma patient's arrival is essential.Ideallv, a resuscitation area shouid be avai l abl efor traunra pati ents.P rope r air wav equiptube's)shouIcl be grgauizecl, ment (eg,Iarr.'ngoscopes, it is ip-rnediately acceswhere testecl, ancl placed crvstalloid solutions (eg, intravenous sible. Warmed inand reat11'to available be should Ringer's lactate) monitorAppropriate arrives. fuse n,hen the patient ing capabilities should be immediately ar''ailable'A methoc-lto summon extra medical assistanceshoulcl be in place. A means to assure prompt responsebv laboratorv and radiologv persollnel is necessarY. Transfer agreements rvith a verified trautna center shoulcl be established and operatiolal. (Reference: fttr Optinml ACS Committee on Trauma, Resottrc?s of patient revielv Perioclic Careo.ffhe Iniured PLtiutt.) is process improvement care through the qualitr,' trauma hospital's the of an essential component proEirarll. Collegt'of Surgeorrc Arnericntt

II. PREPARATION
Preparation for the trauma patient occurs in 2 different clinical settings. First, during the prehospital phase, all events must be coordinated n'ith the doctors at the receiving hospital. second, during the hospital phase, preparations must be made to rapiclh,, facilitate tl're resuscitatior-rpf the trauma patient.

12

1I CHAPTER NN TDM A N A G E M E N T I N I T I AA T S S E S S M EA

All personnel who have contact with the patient must be protected from communicable diseases. Most prominent among these diseases are hepatitis and the acquired immune deficiency syndrome (AIDS). The Centers for Disease Control and Prevention (CDC) and other health agencies strongly recommend the use of standard precautions (eg, facemask, eye protection, water-impervious apron, leggings, and gloves) when coming in contact with body fluids. The ACS COT considers these to be minimum precautions and protection for all health care providers. This also is an Occupational Safety and Health Administration (OSHA) requirement in the United States.

of the care provided through quality assurance/ improvement activities is essential.

B . M a s sC a s u a l t i e s
The number of patients and the severity of their injuries exceed the capability of the facility and staff. In this situation, those patients with the greatest chance of survival and with the least expenditure of time, equipment, supplies, and personnel, are managed first.

I V . P R I M A RS YU R V E Y
Patients are assessedand their treatment priorities established based on their injuries, their vital signs, and the injury mechanism. In the severely injured patient, logical sequential treatment priorities must be established based on overall patient assessment. quickThe patient's vital functions must be assessed ly and efficiently. Patient management must consist of a rapid primary evaluation, resuscitation of vital functions, a more detailed secondary assessment, and, finally, the initiation of definitive care. This process constitutes the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence: A Airway maintenance with cervical spine protection B Breathing and ventilation C Circulation with hemorrhage control D Disability: Neurologic status E Exposure/Environmental control: Completely undress the patient, but prevent hypothermia During the primary survey, life-threatening conditions are identified and management is instituted simultaneously. The prioritized assessment and management procedures reviewed in this chapter are identified as sequential steps in order of importance and for the purpose of clarity. However, these steps are frequently accomplished simultaneously. Priorities for the care of the pediatric patient are the same as those for adults. Although the quantities of blood, fluids, and medications, the size of the child, degree and rapidity of heat loss, and injury patterns may differ, assessment and management priorities are identical. Specific problems of the pediatric trau-

III. TRIAGE
Triage is the sorting of patients based on the need for treatment and the available resources to provide that treatment. Treatment is rendered based on the ABC priorities (Airway with cervical spine protection, Breathing, and Circulation with hemorrhage control) as outlined later in this chapter. Triage also pertains to the sorting of patients in the field and the medical facility to which they are to be transported. It is the responsibility of the prehospital personnel and their medical director to see that the appropriate patients arrive at the appropriate hospital. It is inappropriate for prehospital personnel to deliver a severely traumatized patient to a nontrauma center hospital if a trauma center is available. (SeeFlowchart 7, Tfiage Decision Scheme, adapted with permission from ACS Committee on I'rauma, Resources for Optimal Care of the Injured Patirltt.) Prehospital trauma scoring is helpful in identifying those severely injured patients who should lrc transported to a trauma center. (SeeAppendix 1, 'l'riage Scenarios and Appendix 5, Trauma Scores: l{evised and Pediatric.) Two types of triage situations usually exist:

Casualties l. Multiple
number of patients and the severity of their in,irt.:l"hc Jurit's do not exceed the ability of the facility to ren*r care. In this situation, patients with life-threatenproblems and those sustaining multiple-system urics are treated first. use of prehospital care protocols and online ieal direction can facilitate and improve care iniin the field. Periodic multidisciplinary review

t't'il'f rauma Ltfe Support

1E B T CHAPT NN TDM A N A G E M E N T I N I T I AA T S S E S S M EA

Measure Vital Signs and Level of Consciousness

STEP1

. C C S < 1 - 1o r . R I { < 1 0 o r ) ? c )o r

'Sl'stolic BP <c)(J or 'RTS <11 or

'PTS <9

YES, Takt- to trauma cetlter, ;rlt-rt tr.tu trta te.t l-l-t

N O , A - : t ' : 5 . l l l , l t t ) l l l vo i i r r i u r r '

STEP2

. . . .

Fliril chest Tlvo L)rl-rloreprroxiurallong-bonc'fr;lctttres to lvrist/.rnkIe Amputation prroritn.rI tr.lunta to head, treck,ttlrstt, All petretr;'rting to elbon' .rtrd kuee and extrettritiesprr-rxinral . Open antl depressecl sktrll frarcture

. . . '

pdralr.sis L.irn[r Pclvic iractures tratttn.rrvith burns Cc-rmbitr.rtiotr b u r n s \lajor

YES, Take to traunl.t cetttt'r; alt'rt trauma te'am

NO, Eva h.r.rtt'ftlr ttlechalristr-t o f i r r j t r t ' t . t t i t - lc r i t l t ' t r t ' t ' o l ' high-energv inrp.1q1

STEP3

' Eiection from autt-r . Death in same passenger ctlmpartnlent . Pec-lestrianthron'n or rlltl over ' High-speecl auto crash* 'lnitial speecl >.10 n'rph (6-l kplt) 'N'lajor auto defonnitr' >20 itrches (50 cm) . lutrusion into passenger compartment >-l2 inches (30 cm)

. . . .

title >?0 minutes Extricatiotr >20 (6 rn) it Fiills Rollover* Auto-petlestriauinjtrrl'n'ith >5 mph (.skplt) impact . Nkrtoro'clecrash >21) mph (32 kph) or u'ith seParationof ricler atrclbike'
*Unrestraiued P.1sst'nger

YES, Contact meclicalcorrtrol; consider transPort to trauma .llert teatrt rr a t t t t t a c e r r t e rc ; o n s i r { et

STEP4

. Age <5 or >55 \'etars . Pregnancy . Immunosuppressed p.rtietrts

. Cardiac disease; respiraton' disease . Insulin-dep't1t-lent tliabetes;cirrhosis; coagulopathl' rnorbid obesitr.';

YES, Contaci meclicalcontrol; consider tratlsport to trauma center; considt'rtr.lunt.l teanralert

NO, Reevaluate n'ith medical contrc)l

When in Doubt, Take to a Trauma Center!

14

o.fSurseolls AnrcricanCollt'ge

1T CHAPTFR NN T DM A N A G E M E N T I N I T I AA L S S E S S M EA

ma patient are addressed in Chapter 10, Extremes of Age: A. Pediatric Trauma. Priorities for the care of the pregnant woman are similar to the nonpregnant patient, but the anatomic and physiologic changes of pregnancy may modify the patient's response to injury. Early recognition of pregnancy by palpation of the abdomen for a gravid uterus and laboratory testing (HCG), and early fetal assessmentare important for maternal and fetal survival. Specific problems of the pregnant patient are addressed in Chaptet 17, Trauma in Women. Trauma is a common cause of death in the elderly. With increasing dge, cardiovascular disease and cancer overtake the incidence of injury as the leading causes of death. Interestingly, the risk of death for any given injury at the lower and moderate Injurv Severity Score (ISS) levels is greater for the elderly man than for the elderly woman. Resuscitation of the elderly patient necessitates special attention. The aging process diminishes the physiologic reserve of the elderly trauma patient. Chronic cardiac, respiratory, and metabolic diseases may reduce the ability of the patient to respond to injury in the same manner that younger patients are able to compensate for the physiologic stressimposed bv injury. Comorbidities such as diabetes, congestive l-reartfailure, coronary artery disease, restrictive and obstructive pulmonary disease, coagulopathy, liver rlisease, and peripheral vascular disease are more (-ommon in and adversely affect outcome following irrjury to the older patient. The chronic use of medieations may alter the usual physiologic response to injury. The narrow therapeutic window frequently It'rrclsto over- or underresuscitation in this patient Pol'rulation, and early invasive monitoring is fretprently a valuable adjunct to management. Despite lhcsc facts, most elderly trauma patients recover ;rrrtl return to their preinjury level of independent , *ti:tivity if appropriately managed. Prompt aggres:,,givcrcsuscitation and the early recognition of pre;.sxisting medical conditions and medication use can pr()ve the survival of this group. (SeeChapter L0, trt:rnesof Age: B. Trauma in the Elderly.)

facial, mandibular, or tracheal/laryngeal fractures that may result in airway obstruction. Measures to establish a patent airway should be instituted while protecting the cervical spine. Initially, the chin lift or jaw thrust maneuvers are recommended to achieve this task. If the patient is able to communicate verbally, the airway is not likely to be in immediate jeopardy; however, repeated assessmentof airway patency is prudent. Additionally, severe head-injury patients with an altered level of consciousnessor a Glasgow Coma Scale (GCS) Score of B or less usually require the placement of a definitive airway. The finding of nonpurposeful motor responses strongly suggests the need for definitive airway management. Management of the pediatric airway requires knowledge of the unique anatomic features of the position and size of the larvnx in children, as well as special equipment. (See Chapter 10, Extremes of Age: A. Pediatric Trauma.) While assessing and managing the patient's airway, great care should be taken to prevent excessive movement of the cervical spine. The patient's head and neck should not be hyperextended, hyperflexed, or rotated to establish and maintain the airway. Based on the history of the trauma incident, the loss of stability of the cervical spine should be suspected. Neurologic examination alone does not exclude a cervical spine injury. Protection of the patient's spinal cord with appropriate immobilization devices should be accomplished and maintained. If immobilizing devices must be removed temporarlly, 7 member of the trauma team should manually stabilize the patient's head and neck using inline immobili zation techniques. Stabilization equipment used to protect the patient's spinal cord should be left in place until cervical spine injury is excluded. Protection of the spine and spinal cord is the important management principle. Cervical spine xrays may be obtained to confirm or exclude injury once immediate or potentially life-threatening conditions have been addressed. Remember: Assume a cervical spine injury in any patient with multisystem trauma, especially with an altered level of consciousness or a blunt iniury above the clavicle. (SeeChapter 7, Spine and Spinal Cord Trauma.) Every effort should be made to promptly identify airway compromise and secure a definitive airway. Equally important is the necessity to recognize the potential for progressive airway loss. Frequent re-

Spine with Cervical AirwayMaintenance oction

iuitial evaluation of the trauma patient, the first to ascertain patency. :tay should be assessed

for signs of airway obstrucrnpid assessment

*lroukl include inspection for foreign bodies and

' l' rntrnrn Life Support

1E B CHAPT NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

o i a i rl v a v s e c u ri tv i s e s senti alto i cl enti fv ev at lu a ti o n the atrilitt' to maint.ritr at-t the p;rtient rvlro is losir-rg tt.ttt' .ti rtt'a\'. ad t'r1 P i t fa l l s : .1. Dc,spilethe eiforts Of er,en the rtrostprurlent arrd atteltiye clt-lctor,there are circut'ustauceslt'here clifpr{lves to bt exceptit'ltrallf' manageme-nt .linr-a-ry to .lchieve.Ecluip-'impr-rssible iicult utrcltlcce'rsiopaIII' the light e-g, be .rrrticipated, ment failure ttftetrcatrnclt orr the lctrvltgoscopeLrurns out or the cuff otr the' placed n'ith erceptitlnal tube that n't-rs errclotr.tche;rl leaks becauseit rvas torlt or1the p.rtietlt's c-liificultV teeth rlurilrg the intubation struggle. 2. Another tragic pitfall is the patient u'ho catruot after paralvsis or the patierrt itr r'r'hcltn be intuba-rtec1 cannot be performecl expetliently airr,var. arsurgical obesitt'p31ig1rt's clue to the 3. Enclotracheal intuLratiolr of a patient rt'ith an unknorvn larvngeal fracture or incomplete upper airlvav transection lllav precipitate total airrvat' trausectiou.Tl-riscan occlusion ttr ccttnpleteainr,'a1' of clinical finclings suggesting occur irr the absencer the potenti;rl for att air\l'av problern or rt'hcn the the immecliatetreecl situ;rtion clictertes urgencv oi tl-re aitlt';lY tlr veutilatitln. for a sL-cure These pitfalls catruot ;lltvtl\'s be prevented. Hon'e\rer, ther. shoulcl be anticipated ancl preparations sliould be macle to nliuiurize their impact.

contusion, trtassi'u'ehetlclthor;rx, ertrtl opetl pn'urnothorax. These ir-rjuries shor-rkl bt- iclentifietl in the primarrl' surve\'. Simple pneulllo- or hc'tnc-lthorax, fracturecl ribs, a1d pulur6ln.lry ctltrtusiptt ttray conlprotnise ventilatiotr to a lesst'r tlegrt'e' ;rtrd erre usu.rllt. identifiecl in the seconclart' sllrve\'. Pitfa||s: Differentiatittn oi vetrtilartion problt't-tts frour ainvat' contlrronrise mav be-clifficuIt. 1. A [-,e proftlu trcllt' c1t'splreic atlc] giving the impressiou that tht' primar\' 1,,,6111:pneic, prrll-rlet'nmay be relarteclto atr itr.rdequi-ttt'airrt'ar'' If the ve-ntilaltiotr prottleni is protluce.cl br- a Lrlleunlothorax or te'nsion pneultrothorax, intub.ttic-rn n.ith patient lrla\' visorous bag-valvc. r.entilatior-r coulcl ler,rdto further cleterioration of the patient. 2. When intutratictn and verrtiltrtioll llre necessar\/ in the unccrttscious patie'nt, the prrtlcedure itself a1p11E'sllclthorax' and the nlav ulllnask or c1$$rc1\'c1tc patient's chest tnust be ret't'aluatetl. Chest x-rcl\'s shoulcl be obtainecl as soon aiter itrtubatiou.rtrd itritiation of 'u,eutil.rtionas is practical.

eontrol n i t h H e m o r r h a gC C . C i r c u l a t i 0w c utPut a n dc a r d i a o volume l. Blood

oi preHemorrharge is the P1t'c{ominatrt Cc-lttS follorvyentable postipjurl, cleaths.Ht,p-roteusion hvpovcllernic be tt-r be consiclerecl injun'must ing in origin until proved othern'ise. Rapiclatttl acCuof the injured patieut's he-tnod1''rate assessmeut The elements e-Sselttial. is tl-rereforr' status narnic infttrimport;rnt that Yield of clinical observatiorr consciousness, of lt-r'el are secoucls mation r,vithin skin color, ancl pulse-. a . L e v e lo f c o n s c i o u s n e s s When circulating bloclcl t'olutlle is retluced, cerebral perfusiorl lttav be criticallv impaired, resulting in altered levels of cousciousness. patient arlsotnal' hat'e However, a cLlt-tscitlus lost a significant amount oi bloocl. b . S k i nc o l o r Skin color can be he-lpful iu evaluating the injured patient r.t'hois hvpovolemic. A patient with pink skin, especiallv in the face ancl extremities, is rareh' t-riticallv hr,'povolemicafter

gn dV e n t i l a t i o n B . B r e a t h i na
Airu,av pateuctr aloue does not assure adequate veutilation. Adequate gas exchange is requirc'cl to diclxide eliminar1laximize.ctxvgenationand Cartrott function of the aclequate requires tion. \/entilation compouelrt Each tliaphragn. antl r,r'all, lungs, chest rapidlt'' evaluatec-l atrcl must be examinecl The.patient's chest should be exposeclto adecluatel'r' excursion. Auscultation shoulcl be chest r,r,all assess performecl to assure gas flor,r' in the lungs. Percusof air or blood in iior-r*ov clemonstratethe Frresence pralpationmav dethe chest. Visual inspectiotr anc-l compromise tect injuries ttt the chest n'all th.rt n-lal\r ventilation. Injuries that lna\r acutelv impair ventilation are tension pueutnothorax, fl;ril chest n'ith pulmonarv

16

tts CJf..q. o.iStu' gert A, nl iir,r,,,,

i I CHAPTER NN T DM A N A G E M E N T I N I T I AA T SSESSMEA

injury. Conversely, the ashen, gtay skin of the face and the white skin of the exsanguinate extremities are ominous signs of hypovolemia. c. Pulse Pulses, usually an easily accessible central pulse (femoral or carotid artery), should be assessedbilaterally for quality, rate, and regularity. Full, slow, and regular peripheral pulses are usually signs of relative normovolemia in a patient who has not been taking beta-adrenergic-blocking medications. A rapid, thready pulse is usually a sign of hypovolemia, but may have other causesas well. A normal pulse rate does not ensure that the patient is normovolemic. An irregular pulse usually is a warning of potential cardiac dysfunction. Absent central pulses, not attributable to local factors, signify the need for immediate resuscitative action to restore depleted blood volume and effective cardiac output if death is to be avoided. 2. Bleeding External hemorrhage is identified trolled in the primary survey. and con-

tion, tachycardia. Blood pressure has little correlation with cardiac output in the older patient group. 2. Children, at the other extreme, usually have abundant physiologic reserve and often demonstrate few signs of hypovolemia even after severe volume depletion. When deterioration does occur, it is precipitous and catastrophic. 3. The well-trained athlete has similar compensatory mechanisms, is normally relatively bradycardic, and does not demonstrate the usual level of tachycardia with blood loss. 4. It also is common that the "AMPLE" history, described subsequently in this chapter, is not available, and the health care team is not aware of the patient's use of medications for chronic conditions. Anticipation and an attitude of skepticism regarding the patient's "normal" hemodynamic status are appropriate.

N e u r o l o gE ic D . D i s a b i l i t(y valuation)
A rapid neurologic evaluation is performed at the end of the primary survey. This neurologic evaluation establishes the patient's level of consciousness, pupillary size and reaction, lateralizing signs, and spinal cord injury level. The GCS is a quick, simple method for determining the level of consciousness,and is predictive of patient outcome (particularly the best motor response). If not done in the primary survey, the GCS should be performed as part of the more detailed, quantitative neurologic examination in the secondary survey. (SeeChapter 6, Head Trauma and Appendix 5, Trauma Scores:Revised and Pediatric.) A decreasein the level of consciousnessmay indicate decreasedcerebral oxygenation and/or perfusion or may be due to direct cerebral injury. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status. Hypoglycemia, alcohol, narcotics, andf or other drugs also may alter the patient's level of consciousness.However, if these are excluded, changes in the level of consciousness should be considered to be of traumatic central nervous system origin until proven otherwise. Pitfalls: Despite proper attention to all aspects of managing the patient with a closed head injury,

Rapid, external blood loss is managed by direct manual pressure on the wound. Pneumatic splinting devices also may help control hemorrhage. These devices should be transparent to allow monitoring of underlying bleeding. Tour- niquets should not be used (except in unusual circumstances such as a traumatic amputation of an extremity) because they crush tissues and cause distal ischemia. The use of hemostats is time consuming, and surrounding structures, such as nerves and veins, can be injured. Hemorrhage into the thoracic or abdominal cavities, into soft tissue surrounding a major long-bone fracture, into the retroperitoneal space from a pelvic fracture, or as a result of a penetrating torso injury are the major sources of occult blood loss. Pitfalls: Trauma respects no patient population barrier. The elderly, children, athletes, and others with chronic medical conditions do not respond to volume loss in a similar or even in a "normal" manner. 1. Healthy elderly patients have a limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of volume deple-

LifeSupport Adaanced Trauma

17

1 CHAPTER NN TDM A N A G E M E N T I N I T I AA T S S E S S M EA

neurologic cleterioration can occur, oftetr rapliclh'. n'ith acute The lucid iutervarlclassicallv associatecl e.pidural hematotla is an example of a situation Ivhere the patient n,ill "talk and die." (SeeChapter 6, Head Trauma.) Frequent neurologic reevaluation can minimize this problem bv allor,vingearlv cletection of changes.It mav be necessarvto return to the prirnarv sllrvev and tcl confirm that the patient has a secure airwa\', aclequate ventilation antl oxvijel-lartion,ancl adequate cerebral perfusion. Earlt' consultation r.t'ith the neurosurgeol-talso is necessarvtcr guide rrdditional managetnentefforts.

in the conscious lish ancl maintain rtirtt'Av p-ratencv patient. lf the patient is uuconsciousauci has llo gag tnal' be helpful reflex, au oropharvngeal air\,\'a1\' temporarilr'. However, a definitive airway should be established if there is any doubt about the patient's ability to maintain airway integrity.

B. Breathing/Ventilation,/0xygenati0n
Definitive cotrtrol of the ainvav iu patients l'l'ltc-r have cornpromiseclainvavs clue to mechanical facproblems, or are ttncouscic'rus tors, have 'n,entilatort' is achievecl bv endotracheal intubation, either shoulcl be accomnasallv or orallv. This procec-lure plished r,r'ithcontinuous protection of the cervical spine. A surgical airwav should tre perforrneclif oral or cantrot be or nasal intubation is contrainclicatecl accomplished.(SeeCl-rapter), Airrt'av ancl Ventilatorv Managetnent.) A tension plleumothorax comventilation ernd circulation dratnaticallv prc-rmises and acutelv, ancl,if suspected,chest decompressiotr imrnecliatelv-Even' injurecl should be accomplishec-l patient shoulcl rr'ceive supplemental oxvgen. If not intubatecl,the patient should have oxvgen cleliverecl ox\'bv a mask/reserr.'oirdevice to achieve clptin-ral genation. The use of the pulse oximeter is valuable in ensuring adequate hemoglobin saturation. (See Chapter 2, Airr,r'av trnclVentilatorl' Manageme-nt.)

Cn otn atl r o l E. Exposure/Environme

The patient should be completelv utldressed,usually b)'cutting off the garments to facilitate thorough examination and assessment. After the p-ratient's clothing is removed and assessmentis completed, it is imperative to cover the p.rtient with l\/arm blankets or an external r.l'arming device to pre'"'ent hvpothermia in the emergenc\rdepartment. Intravenous fluids shoulci be lvarmed before infusion, ancl a \,varm environment (room temperature) shoulc-l be maintainecl. It is the patient's body temperature that is most important, not the comfort of the health care providers. Pitfalls: Injured patients mal' arrive in the emergenc\r department hvpothermic, and some of those who require massive transfusions ancl crvstalloicl resuscitation become hvpothermic despite aggressive efforts to maintain bodv heat. The problem is best minirnizecl bv earlv control of hemorrhage. This may require operative intenrention or the application of an external device to reduce the peivic 'u'olume for certain tvpes of pelvic fractures. Efforts to relt'arm the patient and to prevent hypothermia should be considered as important as any other component of the primary survev or resuscitation phase.

C. Circulation
Control bleeding by direct pressure or operative intervention.
of 2large-caliber intravenous (IV) cath'fhe maximum rate of eters should be establishecl. is determined bv the internal fluid administration diameter of the catheter ancl inversely by its length, not bv the size of the veitr in which the catheter is placed. Establishtrrertt of u pprcr extremitl' preripheral IV access is prcfcrrctl. ()ther peripheral lines, cutA minimum downs, and cctrtt'itl t'cttoLts lintts should be utilizecl \ /ith thc skill level of the as necessarv itr .tt't'ttl'rlalt(r(' d o c t o r c a t r i r r gl ' o r t l t t ' P i r t i t ' r r t . ( S t ' t ' S k i l l s S t a t i o n I V , and Skills StaShock Assr'csnr('nt .ttttI N'l.ttt.'tgt'tl'tt'ltt, tion V, Vt'notts ('ttttlorvtt, irr ('ltirpltlr 3, Shock.) A t t l r t ' t i n t t ' o l l V i t t " . ' r t i o t t ,t l t ' i t t t ' l r l o o c lf o r t y p e a n d c r o s s t t r . r t ltt , r t t , l l o l ' l r , t ' i t ' l i l t t ' h t ' r n a t o l o g i c s t u d i e s , \ tt'rt lol' .lll fernalesof childi t t c l t r t l i l t r '. ,r l r t ( ' i i l t . t l l ( bcrtt'in1. l r1',(' Aggrt'ssivt' .uttl r'otttirrttctl volume resuscitation is rrol a srrlrrtilrrtt' l'rtt ttl.ltltral or operative control

V. RESUSCITATION
Aggressive resuscitation and the management of life-threatening injuries, as they are identified, are essential to maximize patient survival.

A. Airway
The ainvay should be protected in all patients and secured when the potential for airway compromise exists. The jaw thrust or chin lift maneuver mav suffice. A nasopharl'ngeal airwav may initiallv estab-

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CHAPTER 1I I N I T I AA T S S E S S M EA NN T DM A N A G E M E N T

of hemorrhage. Intravenous fluid therapy with a balanced salt solution should be initiated. Ringer's lactate solution is preferred as the initial crystalloid solution and should be administered rapidly. Such bolus IV therapy rrray require the administration of 2-3 liters of solution to achieve an appropriate patient response in the adult patient. All IV solutions should be warmed either by storage in a warm environment (37'C to 40oC or 9B.6oF to 104"F) or by fluid-warming devices. Shock associated with injury is most often hypovolemic in origin. If the patient remains unresponsive to bolus IV therapy, type-specific blood may be administered as necessarv.If type-specific blood is not available, O-negative blood is considered as a substitute. For life-threatening blood loss, the use of unmatched, type-specific blood is preferred over type O blood unless multiple, unidentified casualties are being treated simultaneously. Hypovolemic shock should not be treated by vasopressors, steroids, sodium bicarbonate, or by continued crystalloid/ blood infusion. If blood loss continues, it should be controlled by operative intervention. The process of operative resuscitation provides the surgeon the opportunity to stop the bleeding in addition to the maintenance and restoration of intravascular volume. Hypothermia may be present when the patient arrives, or it may develop quickly in the emergency department in the uncovered patient and by rapid administration of room-temperature fluids or refrigerated blood. Hypothermia is a potentially lethal complication in the injured patient, and aggressive measures should be taken to prevent the loss of body heat and to restore body temperature to normal. The temperature of the resuscitation area should be increased to minimize the loss of body heat. The use of a high-flow fluid warmer or microwave oven to heat crystalloid fluids to 39'C (102.2F) is recommended. Blood products should not be warmed in a microwave oven. (SeeChapter 3, Shock.)

ment changes, may indicate blunt cardiac injury. Pulseless electrical activity (PEA, formerly termed electromechanical dissociation) may indicate cardiac tamponade, tension pneumothorax, and/ or profound hypovolemia. When bradycardia, aberrant conduction, and premature beats are present, hypoxia and hypoperfusion should be suspected immediately. Extreme hypothermia also produces these dysrhythmias. (SeeChapter 3, Shock.)

B. Urinary andGastric Catheters

The placement of urinary and gastric catheters should be considered as part of the resuscitation phase. A urine specimen should be submitted for routine laboratory analysis. 1 . U r i n a r yc a t h e t e r s Urinary output is a sensitive indicator of the volume status of the patient and reflects renal perfusion. Monitoring of urinary output is best accomplished by the insertion of an indwelling bladder catheter. Transurethral bladder catheterization is contraindicated in patients in whom urethral transection is suspected. Urethral injury should be suspected if there is (1) blood at the penile meatus, (2) perineal ecchymosis, (3) blood in the scrotum, (a) a high-riding or nonpalpable prostate, or (5) a pelvic fracture. Accordingly, the urinary catheter should not be inserted before an examination of the rectum and genitalia. If urethral injury is suspected,urethral integrity should be confirmed by a retrograde urethrogram before the catheter is inserted. Pitfalls: The doctor may encounter situations in which anatomic abnormalities (eg, urethral stricture or prostatic hypertrophy) preclude placement of an indwelling bladder catheter despite meticulous technique. Excessivemanipulation of the urethra or the use of specialized instrumentation by the nonspecialist must be avoided. Consult a urologist early. 2. Gastri ccatheters A gastric tube is indicated to reduce stomach distention and decrease the risk of aspiration. Decompression of the stomach reduces the risk of aspiration, but does not prevent it entirely. Thick or semisolid gastric contents will not return through the tube, and actual passage of the tube may induce vomiting. For the tube to be effective,

VI. ADJUNCT TS OP R I M A RS YU R V E Y A N DR E S U S C I T A T I O N
A . E l e c t r o c a r d i o g r aM ph ci t o r i n g oin
Electrocardiographic (ECG) monitoring of all trauma patients is important. Dysrhythmias, including unexplained tachycardia, atrial fibrillation, premature ventricular contractions, and ST sesAduanced Trauma Life Support

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1F R CHAPT NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA
clioxitle, rVhich reflccts the aclt'cluacY oi Vcntiltrtion. A small sellsor is plact-d tlu the iitrger, toe, earlol-re, or solllL. other cotrVettient pl'rce' N'lost rle.r,icesc'liSplal' pulse r.ttr' attd o\\'gt'll S.ltur.ttit-rn continuousll'. Pitfalls: The pulse oximeter serrsorshoultl uot bc. platceclclistal to thc bkrocl Pressure cuif. I\'lisle.rtlrrl a tiotr re'qard i n g hetn tl gl tl Lritr s.rt u-ratiotr in g in f c) rvhen thr- cuff is inand pulse callt be gc.neratec-l fl.rtr.d and occlucles Lrlooti ilorr'. tiolt fro tI the' p tr Ise oxi t-uetcr Her-nctglctbin s.rt r-rr.t should be conrl-,aretl lYith the Valtte clbtaitretl from the arterial bktorl gils clllillVsis. ltrcousistetrcv indicates thart .rt le;tst I of the 2 tlett'rtnitr.rtitlus is in errclr. 3. The bloclc-lpressuft) shoulrl bt'nttAsurcrl, reali z i n g t l - r a ti t n r a l ' b c - a l r o o r n l e ; ] s u r e t l i ; r c t u a l t i s sne perfusiou. P i t f a l l s : N o n n a l i z e r t i O r - ro f h c m o r l ) , t r a t n i c s i n i n jurecl partients rerluires ntore than simplv treing s.-rtisiied n'ith a trtlrtui.rl trlootl L)rcssure' A returu to normtrl pc-riphe'rt-rlpcrfusiotr tlttst be establishecl. This mar, be prolrler]latic in the-elclerlv, trs ir-rclicatetl pre'r'iousl\,, and ctlnSielt.raticln shtluld of cart-li.-tc be giVen tO earll' inVasir,e mc'rt-titclritrg t h e s e i n function Praticnts.

it must Lrc positiorred prtlperlt', arttachecl to ;-rpLre functiorritrg. Bloclcl in suctiOn, arrrc-l pr-op-rri.rte ihe. gastric .-rspiraten1a' represeut .r'pha^,trge;rl or alctu il I (s*,il lr.',r'c'tl ) bl.otl, trilu m a tic in serticln, iniun, to the Lrpper disestive tract. Ii the crilrriis fr.icturerl ttr .t fr.lcturt. iS Suspecteci, iornr'pla-rtcthe gastric tube should be insertetl or'rllV to preVent intr.rcranial passilge. In this sitttatiou' atrl' n.rsophart,ngeal instrttmetrt.rtiotr is potenti.rllt' c-larrgt'rtlus. Placernr.nt t-rf it gastric cathett'r lllc-l\r or gagging atltl proclttce the vomitius itrcluce its placemer]t is intetrtlt'tl th;rt specific problem Futrcticlnal sttctiol't equipaspiration. to prt'r'ent: Pitfalls: mcut should tre immet1iatelr' ;-r't'ailable'

C. Monitoring
bl, iulproveresuscitationis best assessecl Aclecluate blootl pulst'rate, in phf,siologic paranleters,ie, ,-,.,.-r-rt t'rrterial rate, pressure, pulse pr"rr.,t", r'entilertorv i.,looclgas alalVsis, bod'n'te'rpterature,attcl uritrarl' clottc. output, rather than the qualit.ttive asslsslllent pathese for in the priuratrt' surve\r. Actual values practical as rameters should be obtained as soon after completing the primary survey' Periodic reevaluation is prudent. l. Ventilatory rate and arterial blood gases shoulrl be used to monitor the .rrleqttacvt'rf resbe clislotlgec-l ;rir.itions. Enclotrachealtubes can whenever the patient is moved. A colorimetric carbon clioxicle cletector is a device captrble tri cletectingcarbon dioxicle in exhaled gas' lt is useful in coirfirming that the endotrachealtube is loin the ainr,av of the Ventiiateci cated somer,vhere the esophagus.It cloesnot conin not ancl patient firm proper placernentof the tube in the ;-lirn'll\'. ior are artailatrleA vaiietv of quantitative clevices ?, VentilrrAinval'attt1 Chaprtt'r (See this purpose. torl' Ivl;lragement.) patients occasiotralh' Pitfalls: Cor-nbativetrrrurnal the'ir t11.1\'occluc1e .1lso Thel' extubate themselves. it. biting b}' cuff the tutre or cleilate enclotrarcheal uecessar\'. is ainvaV the Frecluentreevaluation of 2. Pulse oximetry is a valuable adjunct ft)r n-ronitoringoxYgenation in iniured patients' l'he pulse. oximeter measures the oxr.geu saturatit-rt] of hemoglobin coloritnetricallr', but cloes not measure the partial pressure of oxvgen' It also cloesnot measur:ethe partiarlPressureof carbon

i ct u d i e s a n dD i a g n o s t S D. X-rays
X-rays shoulcl be used jutliciousll' .rnr-lshould not clelai, patie'nt resuscitation. The. antt'roposteri.r (AP) chest film ancl an AP pelvis rnav provide ineiforts of the formation that c.rn guirlc resttscitatior-r mat' clete'ct patient r,r'ithblunt traum;r. Chr'st X-fclVS retltrire that potentiallY life-threatenitrs iniuries treatnrent, ancl prelvic films mat' tiemotrstrate fractures of the pelvis that inclicrrtethe neetl for earlv bloocl trarrrsiusion.A laterarl cervical spine X-ra1r an iniun' is .tn imptlrtant fintling, thartclemonstrartes iilm does not exa negative ctr in.rc-lecluate r,r,hereas fihns catr Lretaken clude cervicaf spine itrjurr'. Tl-rese in the resuscitationArea, usualh' r.vith a portatrle xra1. unit, but should not interrupt the resuscitation pr ocess. Thev mav be clt-ferrecl to the secondarY sur\re\/rvhen appropriate. During the secouclarysllrve\', complete cervic'll atlcl fihns mart' be obt;rinetl w'ith a thoracolumbar s1-rine if the patient's care.is uot co111unit x-rav lrortable prornised and if the rnechauism of injurv suggests

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CHAPTER 1I I N I T I AA T S S E S S M EA NN T DM A N A G E M E N T

the possibility of spinal injury. Spinal cord protection should have been performed in the primary survey and maintained. An AP chest film and films pertinent to the site(s) of suspected injury should be obtained. Essential diagnostic x-rays should not be avoided in the pregnant patient. Diagnostic peritoneal lavage (DPL) and abdominal ultrasonography are useful tools for the quick detection of occult intraabdominal bleeding. Their use depends on the skill and experience level of the doctor. Early identification of the source of occult intraabdominal blood loss may indicate the need for operative control of hemorrhage. Pitfalls: Technical problems can be encountered when performing any diagnostic procedure, including those necessary to identify intraabdominal hemorrhage. Obesity and intraluminal bowel gas may compromise the images obtained by abdominal ultrasonography. Obesity also can make DPL difficult. Even in the hands of an experienced surgeon, the effluent volume from the lavage may be minimal or zero.In these circumstances, an alternative diagnostic tool should be chosen. The surgeon should be involved in the evaluation process and guide further diagnostic or therapeutic procedures.

physical examination, including a reassessment of all vital signs. Each region of the body is completely examined. The potential for missing an injury or failure to appreciate the significance of an injury is great, especially in the unresponsive or unstable patient. (SeeTable 2, Secondary Survey, in Skills Station I, Initial Assessment and Management.) In this survey a complete neurologic examination is performed, including a GCS Score determination, if not done during the primary survey. During this evaluation, examination-indicated x-rays are obtained. Such examinations can be interspersed into the secondary survey at appropriate times. Special procedures, eg, specific radiographic evaluations and laboratory studies, also are obtained at this time. Complete evaluation of the patient requires repeated physical examinations.

A. History
Every complete medical assessmentshould include a history of the mechanism of injury. Many times such a history cannot be obtained from the patient. Prehospital personnel and family must be consulted to obtain information that may enhance an understanding of the patient's physiologic state. The AMPLE history is a useful mnemonic for this purpose. A Allergies M Medications currently used P Past illnesses/Pregnancy L Last meal E Events/Environment related to the injury

VII. CONSIDE NR EED FOR PATIENT TRANSFER

During the primary survey and resuscitation phase, the evaluating doctor frequently has enough information to indicate the need for transfer of the patient to another facility. This transfer process may be initiated immediately by administrative personnel at the direction of the examining doctor while additional evaluation and resuscitative measures are being performed. Once the decision to transfer the patient has been made, referring doctor-to-receiving-doctor communication is essential. Remember, lifesaving measures are initiated when the problem is identified, rather than after the primary survey.

V I I I . S E C O N D AS RU YR V E V
The secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are well established, and the patient is demonstrating normalization of vital functions. The secondary survey is a head-to-toe evaluation of the trauma patient, ie, a complete history and

The patient's condition is greatly influenced by the mechanism of injury. Prehospital personnel can provide valuable information on such mechanisms and should report pertinent data to the examining doctor. Some injuries can be predicted based on the direction and amount of energy force. Injury usually is classified into 2 broad categories, blunt and penetrating. (SeeAppendix 3, Biomechanics of Injury.) 1 . B l u n tt r a u m a Blunt trauma results from automobile collisions, falls, and other transportation-, recreation-, and occupation-related injuries. Important information to obtain about automobile collisions includes seat belt usage, steering

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n i u r yP a t t e r n s S u s p e c t eId sf I n j u r ya n d R e l a t e d T a b l e1 - M e c h a n i s mo
ME C H AN ISM O F I N JU R Y Frontal In'rpact . Bent steering r'r'heeti . Kpt-e irtrpript, dashlroartl . Bltll's-et'e' iractttre, lvinc-iscreet-t . . . . . . . . . . . . ' .

INIURY PATTERNS SUSPECTED

Cen'ic.tl spine fratctttrt' Anterior flail chest cotrtusit,rt't i\'1r'oc.trdial P ri eurnrrtl ror.tr Tr.rurrati caorti c di srupti on or liver Fracturetl sprle'elr of hip, (11e.1 Posterior iractut'e'/clislt-rc.rtion

Si de Intpact, a u tttt'not'rile

trecksprai n C ontral ater.rl L' r' ryi calspi rrel ' r.rcture Later.rl il;ril chest Prreuntothcllitx Traunratic aortic disn-rption rttprfllrs Diapl-rrctgmatic tleprg11ii11t liver, kic-lnev Fractured splsq.11/ on si de of i mpact . Fr.tcturedpel vi s ctracet.rbul um . C en' i c.rlspi ne i nj urr' . S oft-ti ssr:e i ni urv to treck ' Ejection frot-uthe vehiclt'pre.clttdes prediction of iniurr,'Pdtterus, meaningfr-rl pratient.ttgretrterrisk from but plarces r.irtuallv all injurl' ttrech.rttisurs . . . . He;rcliniuly Traumatic .lortic clisrup'riion A bdomi nal vi scerali nj uri es l ou' er ertremi ti t.s/pc-l vi s Fracturecl

Rear Impact, autotnobile collision Ejection, r'ehicle

Motor Vehicle In'rpactwith Pedestrian

r,t,heelrleiort-natiotr,clirection of inrpact, claurage to the automolrile in tertus of majtlr clefortnation atld or intrusion into the passengerConlpclrtlTlent, of the passeltgt'rircttn the' r'ehicle. Ejecejectior-r gre'.rtlviucreasesthc'chance ticln from the 'u'ehicle of major injurr'. Injury. patterus mav oiterr be 1-rretlictedbv tl-re mechanisrn of injun'. Such injr-rrv patterns also are iniluetrceclb1' age srouPs ancl ;rctivities.(See of Injurv and Related SusTable 1, lv{ech.rnisms Patterns.) Injurt' pectecl rauma 2 . P e n e t r a t i ntg The inciclence of penetr.rtiue tralttttt.t (injuries frorn fireartns,stabbings,ancl impalirre objects)is increasing rapidlr'. Factors dc-tertniningthe type ancl extetrtof injurv anclsubsequentmanagetnetrt include the region of the botlr' injured, the organs

in the prorimitv to the p.rth of the frenetratingobiect,;rnclthe'r'elocitvof the nrissile.Therefore,the velocitv, caliber,LrresumedP.lth oi the bullet, ancl ttlav frotn the rt'e.rpott tcl the rl'c-rutrtl the distar-rce injun'. of the t'xtettt to provide itnportattrtclues (See Appendix 3, Biornechanics oi Injurv, clrd 1, N l i ssi l eK i neti c E ner gr - . ) rel atecl ' fabl e d u e t o b u r n sa n d c o l d 3. Injuries Burns arreanother sienificant tvpe tti tr.luma that n'ith blunt mav occur alone or ltla\/ be cor-rple't1 zrrrclpenetrating trauma resulting frour .r burtti.g arutomobile, explosion, falling de'trris, the' patient's attempt to escape a fire, or all assault lt ith a firearur or knife. Irrhalatitrn injurv antl carlron monoxicle poisoning often complicate buru injurv' Tht'refore, it is itnPollsnt to ktrort' the circumstances of the burn iniurl'. Spet-ificallt', knonrleclge oi the envirottltrent in n'hich At rrcri cmr Co//rrrrco.fSt rrsc()rl-s

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CHAPTEB 1I I N I T I AA L S S E S S M EA NN T DM A N A G E M E N T

the burn injury occurred (open or closed space), as well as of substancesconsumed by the flames (eg, plastics, chemicals) and possible associated injuries sustained, is critical in the treatment of the patient. Acute or chronic hypothermia without adequate protection against heat loss produces either local or generalized cold injuries. Significant heat loss may occur at moderate temperatures (15'C to 20'C or 59oF to 68"F) if wet clothes, decreased activity, andf or vasodilatation caused by alcohol or drugs compromise the patient's ability to conserve heat. Such historical information can be obtained from prehospital personnel. 4. Hazardoue s nvironment Histories of exposure to chemicals, toxins, and radiation are important to obtain for 2 reasons. First, these agents can produce a variety of pulmonary, cardiac, or internal organ dysfunction in the injured patient. Secondly, these same agents also present a hazard to health care providers. Frequently, the doctor's only means of preparation is to understand the general principles of management of such conditions and establish immediate contact with the Regional Poison Control Center.

printed material, eg, a hand-held Snelling Chart, words on an IV container, or a 4 x 4 dressing package. Ocular mobility should be evaluated to exclude entrapment of extraocular muscles due to orbital fractures. These procedures frequently identify optic injuries not otherwise apparent. (SeeAppendix 7, OcuIar Trauma.) Pitfalls: Facial edema in patients with massive facial injury or patients in coma can preclude a complete eye examination. Such difficulties should not deter the doctor from performing those components of the ocular examination that are possible. (SeeAppendixT, Ocular Trauma.) 2. Maxillofacial (SeeChapter 6, Head Trauma, and Skills Station IX, Head and Neck Trauma Assessment and Management) Maxillofacial trauma, not associatedwith airway obstruction or major bleeding, should be treatei only after the patient is stabilized completely and life-threatening injuries have been managed. At the discretion of appropriate specialists, definitive management may be safely delayed without compromising care. Patients with fractures of the midface may have a fracture of the cribriform plate. For these patients, gastric intubation should be performed via the oral route. Pitfalls: Some maxillofacial fractures, eg, nasal fracture, nondisplaced zygomatic fractures, and orbital rim fractures, may be difficult to identify early in the evaluatio., pro."rs. Theref or", fr"quent reassessmentis crucial. 3. C ervi calspi ne and neck (S eeC hapter T, Spine and Spinal Cord Trauma) Patients with maxillofacial or head trauma should be presumed to have an unstable cervical spine iniury (fracture and/or ligamentous injury), and the neck should be immobilized until all aspects of the cervical spine have been adequately studied and an iniury has been excluded. The absence of neurologic deficit does not exclude iniury to the cervical spine, and such injury should be presumed until a complete cervical spine radiographic series is reviewed by ^ doctor experienced in detecting cervical spine fractures radiographically.

B. Physica l xamination E
l. Head (SeeChapter 6, Head Trauma)

The secondary survey begins with evaluating the head and identifying all related neurologic and significant injuries. The entire scalp and head should be examined for lacerations, contusions, and evidence of fractures. Becauseedema around the eyes may later preclude an in-depth examination, the eyes should be reevaluated for a. Visual acuity b. Pupillarv size c. Hemorrhages of the conjunctiva and fundi d. Penetrating injury e. Contact lenses (remove before edema occurs) f. Dislocation of the lens g. Ocular entrapment A quick visual acuity examination of both eyes can be performed by having the patient read

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IEB CHAPT NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

-l'ire iclentificilticllrtli ct'rt'ical ner\/e' roctt or 2. plexus injurv tttav not lre possible in tht. br.rchiatl conratoselpatit-nt. Considc-ration tli the t'uecha'ism oi i^furt, '1tr' trr. the onlt' clue avail.trle to the cloctor. m av c1t 'r 'elu lce. r 3. In sonrepati ents,a tl ectrbi ttrs orc'lS frotl-I Other or sacn:m op quicklY ove'r the fronr the or Lroarrl spine ligicl ar immobilization On th e'possibilit i'1- li excl utl e to cervi calcol l ar.E fforts as st ) oll .ls i ni ti ateti [rt' PI 'act ii nj urr shoul rl spi rr.rl HOWever, reSUSrett-tt)t,etl. cleviCeS cal riltcl theSe. citation .rnclefforts to ic{entifr'life-threatenitrsor injtrries should rrot be life'-threartenitrg protr.nti.rllV comprotui sed. -1, ThoracicTr 'r unr 'r ) 4. C hest (S ee' C h.rpter both anterior ancl Visual erraluatiorrof the che.st, as opell pneucorrditiorls identifiessuch poste'rior, A corlplete: segmetrts. rlrtthorax and large flail of palpaltitln retluires evaluatic-nof the chest r,r'irll ribs' clavicle, the cage, irrcludins chc-st the er-rtire ancl sternunt. sternal pressure mav tre pariniul if the sternum is fractured clr costochondral Sepclhematomas oi the r.rtions exist. Contusiolts cil1cl chest rvall sl-rouldalert thc doctor to the prossibili tv of occul t i uj urr' . significant chest injun' nla\' [-remanifestt'd bt' E'aluation includes puit-t,d'spue.a, or ht'pc-rxial. auscult,rtionoi the chest atrd a chest x-ra\'. Brc-ath are auscultatedhigh on the anterior chest sourrcls w,all for pneur-lpthorax and ;rt the posterior trases for hemothorax. Auscultaton' findiugs mal' be difiicult to eYaluate in il noisv environment, but mat, be extremeh' helpful. Distant heart sounds ur..i ,-torro*' pulse pressure maf i'tlicate cardiac pneuot tensit'rt1 Carclirrctatnponac1e tarnpclnacle. of presence the b1' suggestecl be urav motirorax hypoassociatecl although Veills, treck clistendeci r.olenriamarvminimize this fincling or eliminate it breath souncls,hVperresoaltogether. Decreasecl shock mal' be the o1l1' .rnd to prercttssiott, rlance teusiotr of intlications Lrlleulnothorax atrci the need for itnmediate chest decompression' The chest x-rav confirurs the presence of a hemothorax or simple pneulllothorax. Rib fractures mav be present, but thel' ma1' not be visible on the x-rav. A rt'idenecl mediastinum or other radiographic signs mav suggest an aortic rttpture'

E r a m i n a ti o n o f th e n e c k i n c lucl es i trspecti otr, Cervi61l 5prinetetrattcl uuscuItatiot-r. p.rlpr.'ttiotr, tr;lcheal em1-tht'setua' .1"at-,"ra, subcutalret)us bt- clis111a\r fracture ltrn'nge'al tier,'ii-ttiou,antl caroticl The exatnitrirtiorr. rletailec-l a on coVe.rec-l ior irr:scultateci ancl palpatecl Lre iirteries shoulcl ( )\' el ' V C S S T' l s tl resc i rri u rr' t' tl u rrt o f [ r r rri ts EV . i t.l e rrc c a aroLlse sfiould if prt.seltt, atrrl, sh6r,rltlLren()terc-l i ni un' . .rrtert' c a r oti d fo r s u s p i c i o n hig l r i n c l e r o [ nr.t' arrtert' carcttid thr. oi Otlclusi.n or c'lisset-tit-rn process rt'ithottt ttntecedlate ir-rthe injr-rrY oCCLrr e-ntsigus ttr st'mptoll1s.Angiogl-arphl'or duplex tlle mav be recluire.tlto erclr-rclE' ultr..s,-,n.-rgraphl' rvhen ilriurv r,ascul.tr cervicerl possibilitr:t-,fmajor of iniurr. suggests this possibilihe ,neclia-rnism itr'. lv{ost r-najorcen'ical vascttlar injuries are the r.lsult of per-retr.ti.g i'jurr'. Ho*'e'et", blunt i.rce to the ,-l".k or artraction injun'frclm a shoulcle'rresult in intinral clisruption, harnessrr.straintcerrr rombosis. ttttclth clisst:ctiott, cervical spilrc urrstalrle Protection of a protentiallV \\rearingtrnl' tvpe for patier-rts irrjurv is iurpe'rative of protectire helrnet. Ertreme care nrust tre t.rketr rvlretr ret-uoviu5;the helmet. (See Ch'rpter 2' Atrvav ;rnd Veutil.ltorr' lvlantrgenrcrrt') Perretratinginiuries to the neck have the potential oi injtuing sel'eral orgaln st'stems' Wourrds that extend through the plat'sma sh.uld u.t beexplored manuallt' or probecl r,r,ithinstrunlents in the eltlergencv department, or bV inclivicluals in the eurergencv clepartment rvho are uot trained to deal rvith sucir injuries. The emergenc\: clepartrnentusuallv is not equipped to clealr'r'ith th.rt mav be encountereciunexpectedlt'' prol-,1".r-r, require evaluation b1' a surgeoll injuries These or r,r.ithspecializeclcliagnostic either operattivelr,' direct superu'isionb1' the suruncler proce-dures of active arterial bleeding' arn finding The g",-tt-t. arterial bruit, or airwav hematoma, exp.-rncling surgical operative requires usuallv .o*p.on'rise parail'sis of isolated or Unexplainecl evalttatic-rn. suspicion the raise' should an uPper extremitY be accuand injurv root nen'e signs of ,r cervicai rateh' documented. P i t fa l l s : Blur-rtinjury to the neck mav procluce injuries ir-rr,t'hich clinical signs and svmptoms clevelop present during the initial late and may not L-re the intima of the carotid to examinartion.Injurv a rte ri e si s a n e x .rm p l s ' '1.

?ii

o.fSurgeotn Arnericnr Co/ltr,qc

CHAPTER 1I I N I T I AA L S S E S S M EA NN TDM A N A G E M E N T

P i t fa l l s : 1. Elderly patients may not tolerate even relatively minor chest injuries. Progression to acute respiratory insufficiency must be anticipated and support instituted before collapse occurs. 2. Children often sustain significant injury to the intrathoracic structures without evidence of thoracic skeletal trauma. A high index of suspicion is essential. 5. Abdomen (SeeChapter 5, Abdominal Trauma) Abdominal injuries must be identified and treated aggressively. The specific diagnosis is not as important as recognizing that an injury exists and surgical intervention may be necessary. A normal initial examination of the abdomen does not exclude a significant intraabdominal injury. Close observation and frequent reevaluation of the abdomen, preferably by the same observer, is important in managing blunt abdominal trauma. Over time, the patient's abdominal findings may change. Early involvement by a surgeon is essential. Patients with unexplained hypotension, neurologic injury, impaired sensorium secondary to alcohol and/or other drugs, and equivocal abdominal findings should be considered as candidates for peritoneal lavage, abdominal ultrasonography, or, if hemodynamically normal, computed tomography (CT) of the abdomen with IV and intragastric contrast. Fractures of the pelvis or the lower rib cage also may hinder accurate diagnostic examination of the abdomen, because pain from these areas may be elicited when palpating the abdomen. P i t fa l l s : 1. Excessive manipulation of the pelvis should be avoided. The AP pelvic x-ray, performed as an adjunct to the primary survey and resuscitation, may provide valuable information as to the presence or absence of pelvic fractures, which have the potential of being associated with significant blood loss. 2. Injury to the retroperitoneal organs may be difficult to identify, even with the use of CT. Classic examples include hollow viscus and pancreatic injuries.

Knowledge of injury mechanism, associated injuries that can be identified, and a high index of suspicion are required. Despite the doctor's appropriate diligence, some of these injuries are not diagnosed initially. 6. Perineum /rcctum/vagina (SeeChapter 5, Abdominal Trauma) The perineum should be examined for contusions hematomas, lacerations, and urethral bleeding. A rectal examination should be performed before placing a urinary catheter. Specifically, the doctor for the presenceof blood within the should assess bowel lumen, a high-riding prostate, the presence of pelvic fractures, the integrity of the rectal wall, and the quality of the sphincter tone. For the female patient, a vaginal examination also is an essential part of the secondary survey. The doctor should assessfor the presence of blood in the vaginal vault and vaginal lacerations. Additionally, pregnancy tests should be performed on all females of childbearing age. Pitfall: Female urethral injury, while uncommon, does occur in association with pelvic fractures and straddle injuries. When present, such injuries are difficult to detect. 7. Musculoskeletal(SeeChapter 7, Spine and Spinal Cord Trauma, and Chapter B, Musculoskeletal Trauma) The extremities should be inspected for contusion or deformity. Palpation of the bones and examining for tenderness or abnormal movement aids in the identification of occult fractures. Pelvic fractures can be suspected by the identification of ecchymosis over the iliac wings, pubis, labia, or scrotum. Pain on palpation of the pelvic ring is an important finding in the alert patient. Mobility of the pelvis in response to gentle anterior-to-posterior pressure with the heels of the hands on both anterior iliac spines and the symphysis pubis can suggest pelvic ring disruption in the unconscious patient. Since such manipulation can initiate unwanted bleeding, it should be done (if at all) only once/ preferably by the orthopaedic surgeon responsible for the patient's care. Additionally, assessment of peripheral pulses can identify vascular injuries.

*
tl

dr

&

Aduanced Trauma Life Support

25

1E B CHAPT NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

S i g n i f i c a n t e x t r e t n i t v i n i u r i e s l l 1 i ' l ve x i s t w i t h o u t fractures being evident on examitratiotr or xra\'-s. L.igametrt ruptures proc-luce joint 1t-t51.1Lrilit]'. Muscle-tentlott unit injuries intt'rfere w'ith active rlotion of the .rfiecte'clstructures. hlrpairecl sensaticrn arnrl/or loss ctf r.'oluntilrv I1-lusclecoutraction strength metv be cltte to ner\/e injurY or to ischemia, including that due to compartrnent sVndrclnte-. l'horat-ic anrl lutnbatr spinal fri'rctttres anc-l/or neurologic irtjuries urust Lrecousiclereci btlsetl ou p'rhvsicalfindings ancl nrechanism of injurr'. Otl-rer injuries mav mask the phvsica'rlfindings of sprinal injuries, r.trhich mav Eo Lrllsuspectecl utrless the doctor obtains the appropriate X-rcl\'S. The' rloctor must retttet-ttber that the muscttloskeletal examiuation is not complete n'ithout an examinatiou of the p.rtietrt's back. Unless the patient's back is exaurinecl, sigr-rificaurtirrjuries mat,be missed.

E;rrlv t-onsultatiotr u'ith a lteurosurgL'oll is requirecl for p;11ie'ntsr.r'ith treurologic ilrjurr'. The fratie.trtshoulcl t.'e fretlueutlv nronitorecl for cleterioration in the level of corrsciollsness ttr chauges in the' nenrologic examinatiott, as the'sefindings nrav re'flect proeressiotr of the- itrtracratrii'rl iniurl'. Ii .'rp.rtierrt r,r'ith rr head iniurv deterior.rtes ueurtllogicirllt', oxl'gen;rtictn aud prerfusion oi the bra-rin vf v e t r t i l ; t t i o n ( A B C D E s ) m u s t a n d t h c ' a c - l e r l t t a r co ltttracranit'rl strrgical inten'elrtion bt' reassc'SSerl. mav bc' necessitrv or nleasurt's institutt'cl to reduce intracratri.rl pressLlre. Thc. ltellrosur5leoll m u s t n t a k e t h e r l e c i s i c l ni v h e t h e r s u c h c o n c i i t i o t r s i'ls epridural .urrl subrlural ht-ltttttotlt.ts recluirc skull fr.lctttres need evacuation, or r-lt'Prg.551-cl operati ve i trtc'rvetrtictn. Pitf alls: Anv itrcrease irr itrtracr.rtrial pressure ( fC P ) C c . m r e d u c e c c r e b r a l p e r f u s i o l l p r e s s u r e .rnc1leacl to se'cotrclarv br.titt itrjurr'. lvlost oi the tiiagnostic arnd therapetutic tl;rnetl\rers nL'cessar\' of the brain-injuretl for the evalu.rtic'ril clrtrl Cc-IrL' patie'nt increase ICP. Tracheal intubaticln is c-I cl.rssic exatnplt., anc-l iu the p.rtietrt u'ith bririn injun', it should be perforure.cl expeditiouslv ar-rt1 as sntoothlv as possible. Itapid trt'ttrologic cleterioration of tl-reLrrain-iniured patient catr occur c-lespilgthe applir-.ttiott ttf .rll tllt'asures to t-otrtrtll intracranial pressure ;rnrl nrainttlitr .rppropriate of the ceutr.tl ltervous sYsteur. su1-r1-rort Anv evidetrce of loss of sens;rtit-rn,palr;rlt'sis, or rveakness sugge'sts urajor iniun' tcl the spinarl colLrnln or prglipher;tl ltc'r\''L)us st'stem. Neurologic deficits should be documented when iclentified, even n'hen trarusfer to another facilitv or doctor [ t l r s 1 ' r r ' 6 i . r l t tc ' .tre is ttecess.tr\'. lnrnrotrilization of the entire patient, using a long s1-rineboarcl, ar semirisid cen'ical collar, arrtl/or othc-r cen'ical itnmobilizaition clet,ices, tnust be maintained until sl-ritralinjurv carn be excluclecl. The conlmon nristake of immobilizing the head ancl freeing the torso arllor'r's the cen'ical spine to flex rt'ith the bodv as a fulcrum. Protection of the spinal cord is required at all times until a spine iniury is excluded. Early consultation with a neurosurgeon or orthopaedic surgeon is necessary.

P i t fa l l s : 1. Blood loss fronr peh'ic fractures that iucrease pelvic volurue can be c-lifficultto control and faof urgenct' tal hemorrhage mav result. A settsL' shoulcl clccompitnv the managemetrt of these' inj u ri e s . 2. Fractures involrring the bones of the h.1ndS, lvrists, arrd fe'et are ofte'n not diargnosedin the seconclarv survev perfonnecl in the emergellcv department. It mav be onh' after the patierrt has regained consciousnessor other major injuries are resolveclthat the-p.rtieut indicates pain irr the area of au occult injurr'. 3. Injuries to the soft tissues arouncl joints are' frequentlv diagnosed after the patient begins tcr recover. Therefore, freclueut reerraluatiou is essential. ancl 8. N e u ro l o g i c(Se eC h a p te r 6 , Head Traut' na, Spinal Corcl Traurna) Chapter 7, Spine anr-l A comprehensir.e neurologic examination includes not oulv motor ancl sensorv evaluation of the extremities, but also reevaluation of the and pupillary size patient's level of consciousness The GCS Score facilitates detection and resl-ronse. of earlv cl'ranges and trencls in the neurologic status. (SeeAppendix 5, Trauma Scores:Revisecl and Pecliatric.)

TS OT H E SECONDARY IX. ADJUNCT SURVEY

diagnostic tests mav be prglf6lmed durSpecializecl ing the secondarvsurvev to identify specificirriuries. o.fSurgaons Collcgc Antt:ricnrt

26

CHAPTER 1I I N I T I AA T S S E S S M EA NN T DM A N A G E M E N T

These include additional x-rays of the spine and extremities; CT scansof the head, chest, abdomen, and spine; contrast urography and angiography; transesophageal ultrasound; bronchoscopy; esophagoscopy; and other diagnostic procedures. Often these procedures require transportation of the patient to other areas of the hospital where equipment and personnel to manage life-threatening contingencies are not immediately available. Therefore, these specialized tests should not be performed until the patient's hemodynamic status has been normalized and the patient has been carefully examined.

X. REEVALUATION
The trauma patient must be reevaluated constantly to assure that new findings are not overlooked, and to discover deterioration in previously noted findings. As initial life-threatening injuries are managed, other equally life-threatening problems and less severe injuries may become apparent. Underlying medical problems that may severely affect the ultimate prognosis of the patient may become evident. A high index of suspicion facilitates early diagnosis and management. Continuous monitoring of vital signs and urinary output is essential. For the adult patient, maintenance of urinary output of 0.5 mL/kg/hour is desirable. In the pediatric patient more than 1 year old, an output of 1 mL/kg/hour should be adequate. Arterial blood gas analyses and cardiac monitoring devices should be used. Pulse oximetry on critically injured patients and end-tidal carbon dioxide monitoring on intubated patients should be considered. The relief of severe pain is an important part of the management of the trauma patient. Many injuries, especially musculoskeletal injuries, produce pain and anxiety in the conscious patient. Effective analgesia usually requires the use of IV opiates or anxiolytics. Intramuscular injections should be avoided. These agents should be administered judiciously and in small doses to achieve the desired level of patient comfort and relief of anxiety while avoiding respiratory depression, the masking of subtle injuries, or changes in the patient's status.

the multiple-injured patient. (Reference, American College of Surgeons Committee on Trauma, Resources for Optimnl Care of the Injured Patient.) These criteria take into account the patient's physiologic status, obvious and anatomic iniury, mechanisms of injury, concurrent cliseases, and factors that may alter the patient's prognosis. Emergency department and surgical personnel should use these criteria to determine if the patient requires transfer to a trauma center or closestappropriate hospital capable of providing more specialized care. The closest appropriate local facility should be chosen based on its overall capabilities to care for the injured patient. (See Chapter 72, Transfer to Definitive Care and Flowchart 1, Triage Decision Scheme,in this chapter.)

XII. DISASTER
Disasters frequently overwhelm local and regional resources.Plans for management of such conditions must be developed, reevaluated, and rehearsed frequently to enhance the possibility of salvage of the maximum number of injured patients.

X I I I .R E C O RA DN SD tEGAt CONS DIE R AO TN I S

A. Records
Meticulous record keeping with time documented for all events is very important. Often more than 1 doctor cares for the patient. Precise records are essential to evaluate the patient's needs and clinical status. Accurate records during the resuscitation can be facilitated by a member of the nursing staff whose sole job is to record and collate all patient care information. Medicolegal problems arise frequentl/, and precise records are helpful for all concerned. Chronologic reporting with flowsheets helps both the attending doctor and consulting doctor to quickly assess changes in the patient's condition. (SeeAppendix 6, Sample Trauma Flowsheet, and Chapter 12, Transfer to Definitive Care, Table 2, Sample Transfer Form.)

B. Gonsent for Treatment

Consent is sought before treatment, if possible. In life-threatening emergencies it is often not possible to obtain such prospective consent. In such cases treatment should be given first and formal consent obtained later.

XI. DEFINITIV CE ARE

The interhospital triage criteria help determine the level, pace, and intensity of initial management of

Adaanced Trauma Life Support

27

CHAPTER NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

C , F o r e n s i cE v i d e n c e lf ir-rjurr.clue to crirlinal activitt' is suspectecl,the pc'rsonrlelcaring for the patient must presr-rrtethe All items, such rrs clothins ancl Lrullets, evic-lc.nce. Labopersc-rnncl. rnust be s.rvedfor larv enforceruetrt r;rtorv t'letermirrationsof blooci .rlcohol cottcetrtrartions ancl other clrugs may be pitrticularrlt'pertiuelrt (Se'e Appenlegal irnplicertions. arncl h;rvesutrstarrtial of lniurt'.) dix 3, Biomecharnics

b. Errcl-ticlal carbon clioxicle rcliograrpl'r c. Electrocrr d. P ul seoxi nretrr' e. BlclotiL)resslrre 2. Urinary a n d g a s t r i cc a t h e t e r s a n dd i a g n o s t i c studies 3. X-rays a. C hest h. P e' l vi s c. C -spi ne d. DPL or FAST

X I V .S U M M A R Y
The irrjurecl patient must be evaluatecl rapriclh'arncl thoroughlv. The cloctor must develop-rtreattnent priorities for the overall marlagernentof the patient scl that rro steps in the process are omittertl. An ac-lequatc.patient histort' antl accounting of the inciare important in evaluating anr'lman.rging the cle.nt ir-rtcr trauma patient. Evaluatit-ruancl care are clir.iclecl of rliscussiou phases for the purposes the follor,r,ing anrl to provide claritr'. lrr actual situations, assessancl lrer-lt, resuscitation or treatment, reer,'alu;rtion, rnaY occur sirnultatleoush',but priorities cliargnosis s hou l d n o t c h a n g e .

D . S e c o n d aS urvey T , o t a lP a t i e nE t valuation: ry Physica E lxaminatio an dH i s t o r y

l . H ead arrci skul l 2. N { ari l l ofaci al ancl i ntraor.rl 3. Neck 4. C hest 5. A bdomen (i ncl ucl i ngback) 6. Perirreum/ rectum/ r'agina 7. Musculoskeletal 8. Neurologic exarninartion

y u r v eA nf tABCDEs A . P r i m a rS y s s e s s m eo
1. Airlva)' arndcervical spine protection 2. Breathing 3. Circulation ivith control of external hernorrhage 4. Disabilitt': Brief neurolop;icevaluation 5. Exposure/Enr,'ironment:Completely undress the patient, but prevent hvpothennia.

o t h eS e c o n d a r S yu r v e y E . A d j u n c tts
Specializecldiagnostic procecluresthat are utilizecl to confirm susprectedir-rjur1'should onlt' be performecl after the patient's life-threatening injuries have been identifieclancl managed, ancl the patient's hemocl\,namic ancl r'er-rtilation sttrtus returtrerl to normal . 1. Computecl tomographv 2. Contrast x-ra\r stuclies 3. Extremitr. x-ravs 4. Encloscop), and ultrasolography

B. Resuscitation
1. Oxvgenation ancl ventilation 2. Shock management, IV lines, r,rrarmedRinger's lactatesolution 3. Ivlanagementof life-threatening problems iclentifiecl in the primarv sur\re\ris continued.

andHesuscitation Survey to Primary C. Adjuncts 1. Monitoring

a. Arterial blood gas analvsis ancl ventilatory rate

F . D e f i n i t i vC ea r e
After identifving the patient's injuries, rnana*ing life-threatening problems, and obtaining special studies, definitive care begins. Definitive care, as-

28

1I CHAPTER NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

sociated with the major trauma entities, is described in later chapters.

7. Ivatwy RR, Cayten CG (eds): Textbook of Penetrating Trauma. Baltimore, Williams and Wilkins, 1996. 8. Lucas CE, Ledgerwood AM: Initial evaluation and management of severely injured patients. In: Wilson RF, Walt A] (eds): Management of Trauma: Pitfalls and Practice,2nd Edition. Baltimore, Williams & Wilkins,7996. 9. Mattox KL, Feliciano DV, Moore EE (eds): Trauma, 4th Edition. New York, McGraw-Hill, 2000.

G. Transfer
If the patient's injuries exceed the institution's immediate treatment capabilities, the Processof transferring the patient is initiated as soon as the need is identified. Delay in transferring the patient to a facility with a higher level of care may significantly increase the patient's risk of mortality. (SeeChapter 12,Transfer to Definitive Care.)

10. McSwain NE Jr, Frame S, Salomone J, et al (eds):

Prehospital Trauma Life Supporfi Basic and Advanced,4th Edition. St. Louis, Mosby, 2003.

BIBLIOGRAPHY
1 . American College of Surgeons Committee on Trauma: Resources for Optimal Care of the Injured Patient. Chicago, 1999 and In publication.

77. Morris JA, MacKinzie EJ, Daminso AM, et

al: Mortality in trauma patients: Interaction between host factors and severity. |ournal of 6-1'482. Trauma 1990; 30:1,47

2. Battistella FD: Emergency department evaluation of the patient with multiple injuries. In: Wilmore DW, Cheung LY, Harken AH et al (eds): Scientific American Surgery. New York, Scientific American, 1988-2000.

12. Nahum AM, Melvin J (eds): The Biomechanics

of Trauma. Norwalk, Crofts, 1985. CT, Appleton-Century-

3 . Bell RM, Krantz BE: Initial assessment.In: Mattox KL, Feliciano DV, Moore EE (eds): Trauma, 4th Edition. New York, McGraw-Hill, 2000.

13. Pepe PE: Prehospital management of trauma. In: Schwartz GR, et al (eds):Principles and Practice of Emergency Medicine, 4th Edition. Baltimore/ Williams & Wilkins,7999, pp 217-222. L4. Rhodes M, Brader A, Lucke J, et al: Direct transport to the operating room for resuscitation of trauma patients. |ournal of Trauma 1989; 29: 907-915. 15. Wilson RF, Walt AJ (eds): Management of Trauma. Pitfalls and Practice,2nd Edition. Baltimore, Williams & Wilkins,1996.

4. Blaisdell FW, Trunkey DD (eds): Cervicothoracic Trauma, 2nd Edition. New York, Thieme Medical Publisher s, 1994.

5. Enderson BL, Reath DB, Meadors J, et al: The

tertiary trauma survey: a prospective study of missed injury. |ournal of Trauma 1990; 30: 666-670. 6. Esposito TJ, Kuby A, Unfred C, et al: General surgeons and the Advanced Trauma Life SUP port course: Is it time to refocus? journal of Trauma 1995; 39:929-934.

LifeSupport Trauma Adaanced

29

t ffiffiffiffi STATISru $E{!*"1$

N STATIt] I(ILLS S

InitialAsse mentand Mana ment

I OBJECTIVES:
performance at this station will allow the participant to practice and demonstrate the following activities in a simulated clinical situation: l. Communicate and demonstrate to the instructor the systematic initial assessmentand management of each patient. 2. Using the primary survey assessmenttechniques, determine and demonstrate: a. Airway patency and cervical spine control b. Breathing efficacY c. Circulatory status with hemorrhage control d. Disability: Neurologic status e. Exposure/Environment: Undress the patient, but prevent hypothermia. 3. Establish resuscitation (management) priorities in the multiply injured patient based on findings from the primary survey. 4. Integrate appropriate history taking as an invaluable aid in the assessmentof the patient situation. b. Identify the injury-producing mechanism and discuss the injuries that may exist and/or may be anticipated as a result of the mechanism of injury. 6. Using secondary survev techniques, assessthe patient from head to toe. 7. Using the primary and secondary suruey techniques, reevaluate the patient's status and response to therapv instituted. 8. Given a series of x-raYs: a. Diagnose fractures. b. Differentiate associatedinjuries. g. Outline the definitive care necessaryto stabilize each patient in preparation for possible transport to a trauma center or closest appropriate facility. 10. As referring doctor, communicate with the receiving doctor (instructor) in a logical, sequential manner:

4 1

AdanncedTraumn Life SuPPort

J I

of i ni urv a . Pa ti e n t' sh i s to rv , i trc l u d i rrstnechart-ri sm fi n c l i n g s b . Ph r,s i c .rl c. lv{an.-r genlent instittrtetl re s p o u s eto th e rap' r' d . P a ti e rrt' s e. Di.rgnostictestsperfornteclanri results f. Neecl for tr;rtrsport g. Nlethoc-l of transportatiotr h. Anticipirtt'r1tinre of arrival

o_f Surgr'otls Anu'ricnt Co//cgc

I T CHAPTER 1_SKILLS STATION

lnitial Assessment and Management

NN T DM A N A G E M E N T I N I T I AA T S S E S S M EA

SKILTSPROCEDURES INTERACTIVE

andManagement Initial Assessment

I . P R I M A RS YU R V EA YN DR E S U S C I T A T I O N
The student should: (1) outline preparations that must be made to facilitate the rapid progression of assessing and resuscitating the patient; (2) indicate the need to wear appropriate clothing for self- and patient protection from communicable diseases;and (3) indicate that the patient is to be completely undressed, but that hypothermia should be prevented. Note: Standard precautions are required whenever caring for the trauma patient.

Protection Spine A. Airwaywith Cervical 1. Assessment

a. Ascertain patency. b. Rapidly assessfor airway obstruction. ahp a t e n ta i r w a y 2. Management-Establis a. Perform a chin lift or jaw thrust maneuver. b. Clear the airway of foreign bodies. c. Insert an oropharyngeal or nasopharyngeal airway. d. Establish a definitive airway. 1) Orotracheal or nasotracheal intubation 2) Surgical cricothyroidotomy e. Describe jet insufflation of the airway, noting that it is only a temporary procedure. 3. Maintain the cervical spine in a neutral position with manual immobilization as necessary when establishing an airway. 4. Reinstate immobilization of the c-spine with appropriate devices after establishing an airway.

B. Breathing: Ventilation and0xygenation l. Assessment

a. Expose the neck and chest: Assure immobilization of the head and neck. b. Determine the rate and depth of respirations. c. Inspect and palpate the neck and chest for tracheal deviation, unilateral and bilateral chest movement, use of accessory muscles, and any signs of injury. d. Percuss the chest for presenceof dullness or hyperresonance. e. Auscultate the chest bilaterally.

Trauma Life Support Aduanced

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I STATION 1-SKILLS CHAPTER NN T DM A N A G E M E N T INITIAA L S S E S S M EA

2. Management of ox1'getr' a. Aclnrilristt.r high cot'tcctrtratitltrs clevice' b. Ventilate r'r'ith a btrg-r'alve-nriSk c. AlIe'u'iilte tensitltl pllelllllt)tltt-rr'rr' d. St.al opell Lrlleumothoralr' e'Att.rclraL-o.nrtltritoringtle-r'icettltlrt.etrdotr.rchealtuLle. oxitneter' f . A t t a c h t h e p r a t i e n tt o a p u l s e

Control n ith Hemorrhage c . C i r c u l a t i ow L Assessment

gui natrn g hetlorrlra ge' al' ersartr a. I clentiiv so Llrce tli eltt'rtr b.Iclerrtift,p-ltlterrtialsource(s)ofitrte'rtrallretnorrlrage. antl pr'rrador c. Pulse: Quarlitt', r'1te' regularitl" d. Skin color e. Blootl prLlssure, tinre pertlitting

2. Management

t0 t'xterll.ll bleecline a . Ap p l v c l i re c tPre s s u rt' and tlbtain neetl for operative itrtervetrtiott' o f intcrual henrorrhage atrd potential b . C ,rn s i tl c rP re s e n c e

site'

s u rg i c a lc o trs u l t' c. Itrsert 2 ltrrge-caliberlV catheters' test' tl'preatrd crossan'-rlvses' PregllallL-\' for hematologic anclchemical blooc{ obtain d. simultaneoush, match, and arterial bloocl gases' blootl replacemetrt' ar-rd itl-rl'.artned Ritrger'sltrctatesolution e. I.iti;rte t\/ fluicl t6erapy f to control hemorrhage' inclicatecl spli.ts ars gar'rent .'r,p,-r"ur-,..rtic .rntishock p^eumatic the f . Appll, g. Prer:entht'Pothertnia'

i cx a m i n a t i o n B:r i e fN e u r o l o g E D. Disability
l.Determinetheler,elofconsciousllessusirrgtlreGCSScore. and reaction' 2. Assessthe pupils for size' equalitr" c o mpl c-ter' E. Ex p o s u re /E n v i ro n m e n t: h1' pothertni ' t' undress trreparti e.t,but pre' ent

a n dR e s u s c i t a t i o n y urvey o PrimarS F . A d i u n c tts

l.obtarirrarrterialblooc]gasanall,sisandr'entil.rttlr\'rate' device' CO, r,r,ithan apPropriate rnonitorins Z. lvlor.ritorthe patient,s exhaled monitor. 3. Attach the Patient to an ECG the patierrt's hourrl' uri.ar' unress contrai'clicated a.rl mo.itor catheters gastricand 4. lnsert urinarv otttpt-tt. cross(2) an AP prelvisx-ra\" ancl (3) a lateral' obtain (1) an AP chest x-rav, 5. Consider the need for and x-ra\'' cervical sPinctarble ultras..ographr" for a'd perform DPL or abclorni.'rl 6. Consider the nee-d
,\r t tt r ictrrt Co//cgc trf S ttrtcorls

34

I K STATION 1_SKILLS CHAPTER NN T DM A N A G E M E N T T S S E S S M EA lnitial lssess ment and Management I N I T I AA

t ransfer f o r P a t i e nT N re e d sn dC o n s i d e s B C O Ea th s e P a t i e n t 'A G. Reasses stain thisskills Survey, 2,Secondary Table SURVEYAND MANAGEMENT (See ll. SECQNDARY
tion)

mf l n i u r y a n dM e c h a n i s o History A. AMPLE
1. Obtain AMPLE history from patient, family, or prehospital personnel. 2. Obtain history of injury-producing event and identify injury mechanisms.

a n dM a x i l l o f a c i a l B. Head 1. Assessment
a. Inspect and palpate entire head and face for lacerations, contusions, fractures, and thermal injury' b. Reevaluatepupils. c. Reevaluate level of consciousnessand GCS Scored. Assesseyes for hemorrhage, penetrating injury, visual acuity, dislocation of the lens, and presence of contact lenses. e. Evaluate cranial nerve function. f. Inspect ears and nose for cerebrospinal fluid leakage. g. Inspect mouth for evidence of bleeding and cerebrospinal fluid, soft-tissue lacerations, and loose teeth. 2. Management a. Maintain airway; continue ventilation and oxygenation as indicated. b. Control hemorrhage. c. Prevent secondary brain injurv. d. Remove contact lenses.

a n dN e c k Sl p i n e C. Gervica 1. Assessment
a. Inspect for signs of blunt and penetrating injury, tracheal deviation, and use of accessoryrespiratory muscles. b. palpate for tenderness,deformity, swelling, subcutaneous emphysema, tracheal deviation, and symmetry of pulses. c. Auscultate the carotid arteries for bruits. d. Obtain a lateral, crosstablecervical spine x-ray. Z. Management:Maintain adequate in-line immobilization and protection of the cervical spine.

D. Chest t. Assessment
a. Inspect the anterior, lateral, and posterior chest wall for signs of blunt and penetrating injury, use of accessorybreathing muscles, and bilateral respiratory excursions. b. Auscultate the anterior chest wall and posterior basesfor bilateral breath sounds and heart sounds. c. palpate the entire chest wall for evidence of blunt and penetrating injury, subcutaneous emphysema,

LifeSupport Trauma Adaanced

35

I STATION 1-SI(ILLS CHAPTER NN T DM A N A G E M E N T I N I T I AA L S S E S S M EA

tendertress, ilt1tl crepitatiou' or dulltress' d. Percuss ior cvitlLtnce of h'n'pt'rres()llclnce

2. Management
a. perio'r tube thOr.rctlstolll\', ds inclic'rtec-l' sp-r.rs1'or r-rt-ttlledecompression oi Lrlq'u1.11 deVict.' b. Attac6 tfie cl-rcstttrbe tr-r..llrullrlertt'ater seal tlraintrge c. Correctlv drt-ss al1 ofrell chest u'ouud' d. I)t'ricat'tlioct'utt:sis, .'tsirrdicated' ii indic']te'cl' e. Perform tr;trrsfer the paltient to the operatilrg roolll,

E. Abdomen l. Assessment itrtertral irrjurYatrc'l of Lrluntatrclpc'tretr.ltiug iclr sigr-rs abcfur-rrc-n the.'rteri.r arrrlpostr'rior a. lrrspect bleetlirrg.
b. Auscultate for presetrce-/absence 9f bor'r'el stluutls' c'Percussthetrlldtlnrentoelicitsubtlerebtlulrdtettt.lernt.ss' nruscle guarrclitlg, ullecluivoctrl reboutrd tetrclerd. palpate the atrdor'en for tenclemess, involuntarv lleSS,or a gr(-l\rid uterus' x-ra\'. e. Otrt;rin a 1-reh''ic f. Perform DPL/abdol-uit'tal ultrasound, if rt'arratrtecl' trornrtrl. g. Obtain CT of the.rbdome'n ii the patient is hernoclt'tramicarlh'

2. Management if inclicated. the operatine roL)111, a. Transier the patient tc'r arsheet ;rroutrcltl'repeli'is b. Apph, the pneurnatic .rntishock garnretrt or \\'rc'Lp antl control hc'tnorrhagefrtlur .'rpelVic iracture'' pel.,ic^r'olume
indic.rterl to retlttcc

F. Perineum/Rectum/Vagina l sessment 1 . P e r i n ea s
and he'tlatomas a. Cor-rtusions b. Lacerations c. Urethral bleecling 2 . R e c t a la s s e s s m e n t a. Rectal blood b. Anal sPhincter tolre c, Bo'rvellvall integritr' d . Bo n t' fra g m e rrts e. ProstatePosition l ssessment 3 . V a g i n aa a. Presenceof bloocl in the \/aginal vault h. Vaginal lacerations

36

C,'il.g. of Strrgeons Arrrc:ricntt

I-SKILLS STATION CHAPTER ANDMANAGEMENT lnitial,4ssessment andManagement INlTlAt ASSESSMENT

G. Musculoskeletal 1. Assessment
a. Inspect the upper and lower extremities for evidence of blunt and penetrating injury, including contusions, lacerations, and deformity. b. Palpate the upper and lower extremities for tenderness,crepitation, abnormal movement, and sensation. c. Palpate all peripheral pulses for presence,absence,and equality. d. Assessthe pelvis for evidence of fracture and associatedhemorrhage. e. Inspect and palpate the thoracic and lumbar spine for evidence of blunt and penetrating injury, including contusions, lacerations, tenderness,deformit/, and sensation. f. Evaluate the pelvic x-ray for evidence of a fracture. g. Obtain x-rays of suspected fracture sites as indicated. 2. Management a. Apply andf or readjust appropriate splinting devices for extremity fractures as indicated. b. Maintain immobilization of the patient's thoracic and lumbar spine. c. Apply the pneumatic antishock garment or wrap a sheet around the pelvis as indicated to reduce pelvic volume and control hemorrhage associatedwith a pelvic fracture. d. Apply a splint to immobilize an extremity injury. e. Administer tetanus immunization. f. Administer medications as indicated or as directed by specialist. g. Consider the possibility of compartment syndrome. h. Perform a complete neurovascular examination of the extremities.

H. Neurologic 1. Assessment
a. Reevaluate the pupils and level of consciousness. b. Determine the GCS Score. c. Evaluate the upper and lower extremities for motor and sensory functions. d. Observe for lateralizing signs. 2. Management a. Continue ventilation and oxygenation. b. Maintain adequate immobilization of the entire patient.

L Adjuncts to the Secondary Survey

testsas the patient'sconditionpermits and warrants: Considerthe needfor and obtain thesediagnostic 1. Additional spinal x-rays 2. CT of the head,chest,abdomen,andf or spine 3. Contrasturography 4. Angiography 5. Extremityx-rays 6. Transesophageal ultrasound
Adaanced Trauma Life Support

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S 1E -S LT SA T IIO N CHAPT RK I L NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

7. 8.

Bronchttscofrv Esoph.rgt)scop\'

TE E V A L U A T I O N I I I . P A T I E NR
'ttltl rgt r l ' c h a t r g c s i n t h e f r . l t i e n t ' s t : t l t r c l i t i O r t I 1 e e v . t l ' a t e ,t 6 t p . r t i e p t , p c t t i p g , r e . p t t r t i n u , . l l l r l r l o c r r r - t ' r e t t t i t ra SPollSt'Stclresttscitatir't'efitlrts.Jrrciicit-,trsuSe'clfarr.rlgcsicSll1a\.'beerrlpllor.ec].C'cltrtitrutlustrltltrittlrit is t.ssctrtia|. ttl tre.ltt.tretlt , i * , - . , . ,t t r i t r a r l ' c r u t p L l f , . l t r d t h t ' p a t i e t r t , s r e s L r ( ) n S c

ARE VE TR OD E F I N I T I C IV.TRANSFE
Otrtiirrer.ttitlnaleiclrp;ltierrttra'rtrsfer,tt.at'isitlIPrt)C]tlLtrt'S,p;1[ignt,Stteet1stlurir"rgtratlsfet., f or cli rt'ct rl octclr-ttl-tltlc tor collllll Lll1icatitln.

3B

o_iSrtt'.qcor/s t Co/iergc A t t rcri c ttr

1_SKILLS CHAPTER STATION I ffi ANDMANAGEMENT andManasement lNlTlAt ASSESSMENT lnitial,Assessment

Tahle 2-Secondary Survey

ESTABLISHES/ ITEM TO ASSESS IDENTIFIES
Level of Consciousness . Severity of head injury ASSESS . CCS Score FINDING . (8, Severe head injury . 9-L2,Moderate head injury . 73-75, Minor head injury . Mass effect . Diffuse brain injury . Ophthalmic injury
a a

CONFIRM BY
a a

CT scan Repeat without paralyzing agents

Pupils

. Typ" of head injury . Presenceof eye injury

a a

a a a

Size Shape Reactivity

. CT scan

Head

Scalpinjury Skull injury

Inspectfor lacerations and skull fractures Palpable defects

Visual deformity Malocclusion Palpation for crepitus Visual inspection Palpation Auscultation

Scalp laceration Depressed skull fracture Basilar skull fracture Facial fracture Soft-tissue injury

. CT scan

Maxillofacial
a a a

Soft-tissue injury Bone injury Nerve injury Teeth/mouth injury

a a

a a

a a

Facial-bonex-rav CT scan of faciai bones

Neck

Laryngeal injury C-spineinjury Vascularinjury Esophageal injury Neurologic deficit

Thorax

. Thoracic wall injury . Subcutaneous emphysema . Pneumo/ hemothorax . Bronchial injury . Pulmonary contusion . Thoracic aortic disruption

Visual inspection Palpation Auscultation

. Laryngeal deformity . Subcutaneous emphysema . Hematoma . Bruit . Platysmal penetration . Pain, tenderness of c-spine . Bruising, deformity, or paradoxical motion . Chest-wall tenderness, crepitus . Diminished breath sounds . Muffled heart tones . Mediastinal crepitus . Severe back pain

C-spine x-ray Angiography / duplex exam Esophagoscopy Laryngoscopy

. . . . .

Chestx-rav CT scan Angiography Bronchioscopy Tube thoracostomy . Pericardiocentesis . TE ultrasound

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S 1E -S LT SA T IIO N CHAPT BK I L NN TDM A N A G E M E N T I N I T I AA L S S E S S M EA

T a b l e 2 - S e c 0 n d a r y S u r v e y( c o r r r r n u e r j )
ESTABLISHES/ I T E M T O A SS ES S I D E N T I F I E S . At-'c1or-t-rinal lvall Abdomeny' injun' Flank . In tr.rp e ri toneal i rrj urv . Iletropt'ritouetrl injurv

Pelvis

C ONFI RM BY FINDING . A[-rdornir-rerl rt'all ' D PL/ ult r asouncl p.rin/ tenc-lenress . CT scarr . P eri tone.rl i rri ta- . Celiotourl' . C ont r astCl xti on . \/isceral injr-rrv rav st uc- lics . Angir-rgrap-rhr, . l {etropcri to11gal org.in i nj trn' . Pelvic X-rc-r\1 CU tract injurv G U tra c t i nj uri t-s ' P al patesyl n. C I U cont r ait for ( h e n r ; r t u r i a ) prhvsis;rubis P e l ri c f r a c t u r e ( s ) sttrd ics Pelvic fr.rctttre n.idcnitrg . Urethrot]rc-lnr . Palp;rtebont' Ilectal, \'.teitt.tl, . Cvst ogr anr ainrl/or perine'trl prelvisior te'rtdt'r. I\tP i n j u n ' IlL-SS . C-ontrast-en. Dt'tt'rntirrr p' e l v i t ' l-rancecl CT orrl r staLri l i tv ASSESS . V i sual i nspecti on ' Palpation . A uscul tati orr . D ctcrrl i ne path of penctrati on
' oIlCe' Ittsprl'q1 l'rt't'itreunl . Rc'ctal/r'agitral L.XAn]

Spinal Cord

a a

C r;rn i a li nj un' Corcl injuri' Pc'ripher.rl injurv nen,e'(s)

lv{otor response Itaitr resp-rortst-

a a a

cr.rUnilarter:al ni al mass ei i ect Quadriplegia Paraplegia Nenre root i nj urv

P l . r inspir r exrit VS

NlRI

V er te b ra l C o l u mn

. Column injurv . Vertebrarl irrstatri l i tv

. 1\ervL- llllurY

Extremities

. Soft-tissueirrjury . Bonv deforrnities . Joini erbnormaliti e s . Neurovarscular defects

Verlral resfrorlse . F r a c t t r r e v s rlislocattion to pai n, l ateral i zi rrg si gns Palpate for tenderness Deformitv V i sual i nsl rt' cti otr . Sn'elling, bruisP al pati orr irrg, pallor . Iv{alarlignrttent . Pain, tenclerness, crepi tus . Absent/ di mi ni shed pulses . Tense rnuscttiar com[)artl nel l ts . Neurologic deficits

. P l air rx- r avs . CT sc;rtr

. Specific x-ra1vS. ' Dttppler exall-llna t ion ' C-ompartt'uent Pressures . Angiographv

t l -t ltu

rgeons Sr"t A ntttr i cnrr Cttll ege o_f