CHAPTER

35
Assessment and Stabilization of
the Trauma Patient
Jeff Solheim

N H at
hour after injury (thesis
T
rauma has far-reaching effects on society. Uninten-
tional injury ranks as the fifth leading cause of death in
the United States, claiming 41 of every 100,000 people.1 try
p
to trauma patient survival.
The best
• your third morbidity peak
so-called “golden hour”) is crucial

date netitits
When intentional injuries such as assaults and suicide
l occurs days to weeks follow-
ing trauma. Death during this period results from

100,000 people.2 Yet death rates account for only a small complications. I
attempts are added, the rate increases to 60.5 deaths perinfectionsepsis, multiorgan failure, or respiratory or other

portion of the effects of trauma. In 2004, 1.9 million hos- To maximize patient care, trauma systems have been
pitalizations were trauma related and trauma accounted for developed to minimize the impact that this trimodal distri-
6% of all hospital discharges.3 Trauma also directly affects bution of death has on traumatically injured patients. A
the health care system. For example, 42.2 million people trauma system is “an organized, to coordinated e effort in a
m e
visit emergency departments every year for treatment of
2 it
defined geographic area that delivers
we Mo g
the full range of care

unintentional injuries. Annually, $33.7 billion is spent on
inpatient trauma care, $31.8 billion dollars is spent on
emergency department costs, and another $13.6 billion is
spent on outpatient visits.3
Stabilization of the trauma patient is best implemented
with a standardized approach that ideally involves a team of
uniquely trained individuals. Emergency department staff
need to be prepared to care for patients who are traumati-
cally injured.
Egg
to all injured patients and is integrated with the local public
health system.”4 Trauma systems begin with inclusive 9-1-1
paramedics
sik
emergency systems that activate trained prehospital provid-
ers. If patients are to survive the first morbidity peak, help
must arrive in a timely fashion.
Minimizing death in the second trimodal peak requires to
a responsive prehospital system that can transport patients
rapidly, providing stabilizing care in transit and delivering
patients to the most art.si se of
appropriate facility that is capable

et
providing the needed care, preferably within that “golden
hour.” The American College of Surgeons as well as many
THE TRAUMA SYSTEM state trauma systems have developed is a trauma designation
Death from trauma has a trimodal I patternI of distribution. classification that assists prehospital personnel in determin-
• The first morbidity peak occurs within seconds or ing which facility would be most prepared to receive a
minutes of injury. These deaths result from lacerations traumatically injured patient. Table 35-1 gives an overview

tearof
i
wall
of the heart, large vessels, brain, or spinal cord. Because
of the severity of such injuries, few patients are
of what resources
designation it isg exist at a facility based on the trauma
given.
heart salvageable. Regardless of the type of emergency department to
my • The second morbidity peak takes place minutes or hours
after the traumatic event. Deaths in this period generally
which a trauma patient is taken, initial assessment and care
of the trauma patient should be delivered in a standardized
result from intracranial hematomas or uncontrolled
T
fashion by a coordinated team of health care providers

Tung s i
hemorrhage from pelvic fractures, solid organ lacera- trained in the delivery of trauma care. The team leader (or

d
Is
tions, or multiple wounds. Care received during the first captain) oversees the course of patient resuscitation. Team
M p a C wow
369
 370 UNIT 4 Trauma

TABLE 35-1 TRAUMA VERIFICATION LEVELS

LEVEL CRITERIA

says 4T •
Level I trauma center • Highest level of care available in the trauma system
emergencydoctors surgeons
staff and equipment available 24 hours per day
Has a full range of specialists
• Admits at least 1200 trauma patients yearly with 240 of those admissions having an injury severity

III
score exceeding 15 severinjurysever's
• Maintains an education, prevention, and outreach program is organization
• Is actively involved in trauma research
locatigedgraphic
1
• Acts as a referral source for communities in0nearby regions 4a Geographia
Level II trauma center • Works in collaboration with Level I trauma centers t
Fir • Provides comprehensive traumaso

Level III trauma center
l i
care supplementing the clinical expertise of the Level I institutions
• 24-hour availability of all essential specialties, personnel, and equipmentb
l i m
qq.jo
• Lacks 24-hour availability of specialists but maintains resources for emergency resuscitation,

EEi F surgery, and intensive care of most trauma patients

i
Y
a with Level I or II trauma centers to transfer patients that exceed its
in
• Maintains transfer agreements
capabilitiesc
Level IV trauma center to but is not verified by the American College of Surgeons
• This level is recognized by some states
• Provides initial evaluation, stabilization, and diagnostic capabilities until transfer to a higher level of
care can be facilitated
a services CJasics
• Surgery and critical
k
may be used, but most patients are transferred to a facility with a
higher trauma designation
Pediatric trauma center The American College of Surgeons designates pediatric facilities as Level I and Level II pediatric trauma
centers using similar criteria with an emphasis on being able to provide trauma care to pediatric
patientsd,e
a
American College of Surgeons. (2010, April 22). Level I requirements by chapter. Retrieved from http://www.facs.org/trauma/vrc1.pdf
b
American College of Surgeons. (2010, April 22). Level II requirements by chapter. Retrieved from http://www.facs.org/trauma/vrc2.pdf
c
American College of Surgeons. (2010, April 22). Level III requirements by chapter. Retrieved from http://www.facs.org/trauma/vrc3.pdf
d
American College of Surgeons. (2010, April 22). Level I pediatric requirements by chapter. Retrieved from http://www.facs.org/trauma/vrcped1.pdf
e
American College of Surgeons. (2010, April 22). Level II pediatric requirements by chapter. Retrieved from http://www.facs.org/trauma/vrcped2.pdf

a'on
composition varies from facility to facility but usually con-
sists of at least one physician, one nurse, and ancillary care
•
• I
H—History and head-to-toe assessment
I—Inspect the posterior surface cry survey
stabilizehead Extremities
Person 24
personnel.
u g g
THE PRIMARY ASSESSMENT
APPROACH TO CARE OF F
The first five letters in the mnemonic (A-B-C-D-E) repre-
THE TRAUMA PATIENT sent the first part of trauma resuscitation: airway, breathing,
An easy way to remember the steps in assessing and caring circulation, disability, and exposure and environmental
for a trauma patient is to recall the first nine letters of the
É
control. These first five steps include assessment of poten-
win

is
w
th
alphabet: A-B-C-D-E-F-G-H-I. These letters can serve as a
reminder of the steps in early resuscitation of the traumati-
tially life-threatening injuries and appropriate interven-
tions. Potentially lethal conditions such as pneumothorax,
É
cally injured patient. hemothorax, pericardial tamponade, flail chest, and hemor-
• A—Airway (with consideration given to cervical spine rhage can be detected during the primary no assessment. As
injuries) stabilization immobility each major problem is identified, appropriate interventions
• B—Breathing are initiated. a
• C—Circulation
I
coat beats Airway
• D—Disability
negro brain
guys • E—Exposure of the patient and environmental control An adequate airway is required for breathing and circula-

wtf
• F—Full set of vital signs, focused adjuncts, and family
presence
tion; therefore assessment and protection of the airway is
always paramount in care of the trauma patient. Patients at

sit • G—Give comfort measures particular risk of a compromised airway are those with

stabilized case
Secondary survey
 CHAPTER 35 Assessment and Stabilization of the Trauma Patient 371

TABLE 35-2 AIRWAY AND CERVICAL SPINE ASSESSMENT AND INTERVENTIONS

COMPONENT OF
ASSESSMENT FINDINGS OF CONCERN POTENTIAL INTERVENTIONS
Airway •
•
Absence of breathing
Trauma to the face, mouth, pharynx, neck, or chest
•
• C
Allow position that maximizes airway
Perform jaw thrust or chin lift F
•
•
I
Inability to speak (age appropriate)
Substernal or intercostal retractions
oust •
•
Remove or suction out loose objects
Insert a nasopharyngeal or oropharyngeal
• Depressed level of consciousness
hand t
airway (Never insert a nasopharyngeal airway
• Inspiratory or expiratory stridor
I
into patients with facial trauma. Consider the
nasopharyngeal airway for g
•
I
Pale, cyanotic, or dusky-gray skin color or ruddy or
bright purple coloring
conscious patients
who require assistance to maintain their
goa airway.) it
• Anticipate intubation or advanced airway
techniques
a• Initiate cervical spinal immobilization
Cervical spine
L • Mechanism of injury consistent with possible
cervical spinal injury
• Inability to move or feel extremities
• Pain on movement or palpation of the neck

got
• Abdominal breathing (possible paralysis of the
breathing muscles)
• Bowel or bladder incontinence or retention
• Signs of neurogenic shock
• Priapism
prolonged erection
altered levels of consciousness (Glasgow Coma Scale score
of 8 or less) and those with maxillofacial and neck injuries.
See Chapter 8, Airway Management, for further discussion
of airway management techniques.
Most traumatic incidents place a patient at risk for spinal
cord injury. In fact, it is estimated that there are 12,000 new
cases of spinal cord injury every year associated with
trauma.5 It is also estimated that as many as 25% of spinal
I
cord injuries occur after the initial insult as part of patient
transport and initial management.6 Therefore assessment
and protection of the spinal cord should begin with the
zD
initial stages of trauma assessment and care, that is, with
airway management. See Chapter 37, Spinal Cord and Neck
Trauma, for further discussion of spinal cord injuries.
Table 35-2 summarizes assessment findings of concern
and potential interventions associated with the airway and
cervical spine.
Breathing
Even with an open airway, a patient must be able to exchange
gases through the airway for effective breathing. Therefore
assessment and interventions for breathing should always
follow those for the airway. See Chapter 18, Respiratory
Emergencies, for further discussion of respiratory assess-
at assessment findings of
ments. Table 35-3 summarizes
concern and potential interventions associated with
breathing. y As part of this process, the trauma team should carefully
Iii
b
Circulation hearts
E
go
The exchange of gases associated with breathing is useful
C
only if the circulatory system can circulate those gases.
Circulatory deficits in trauma are frequently related to the É
presence of shock, especially hypovolemic or obstructive
shock. Chapter 20, Shock, reviews the assessment and treat-
ment of shock. Table 35-4 summarizes assessment findings
of concern and potential interventions associated with
circulation.
Disability
The “D” in primary assessment is meant to remind caregiv-
ers to assess neurologic status. Profound alterations in
neurologic function may indicate significant neurologic
trauma. The negativesame long-term effects of neurologic
É
trauma can sometimes be minimized with prompt inter-
ventions; therefore assess neurologic status early so that
appropriate interventions can be initiated promptly. See
Chapter 36, Head Trauma, for further information regard-
ing head trauma and neurologic assessments. Table 35-5
summarizes assessment findings of concern and potential
interventions associated with disability.
Exposure and Environmental Control snake scorpio
Clothing can obscure son injuries; therefore remove all bite
me obvious
clothing from the patient as part of the primary assessment.
chemical
 372 UNIT 4 Trauma

TABLE 35-3 BREATHING TABLE 35-4 CIRCULATORY

ASSESSMENT AND ASSESSMENT AND
INTERVENTIONS INTERVENTIONS

DWI
FINDINGS OF CONCERN
POTENTIAL
INTERVENTIONS
FINDINGS OF
CONCERN
POTENTIAL
INTERVENTIONS

É • Blunt or penetrating trauma

to the neck, chest, back, or
abdomen
• History of breathing
diseases such as asthma or
emphysema
• Administer
supplemental oxygen
• Heart rate <60 beats per
• Assist with
ventilations using
saybag-mask device
• Perform needle
minute or >100 beats per
• Begin chest
compressions for
minute in adults absence of pulse (or
accompanied by inadequate perfusion in
indications of circulatory pediatric patients who
compromise may still have a pulse)

apnea I I
• Dyspnea, tachypnea, or decompression or
chest tube insertion as
• Heart rate >100 beats per
minute or <80 beats per
• Control external
bleeding through direct

g
• Agonal breathing indicated minute in small children pressure, pressure
• Shallow respirations emchest
• Cover any open accompanied by dressings, and
• Weak or gasping wounds with a indications of circulatory application of a
respirations za nonocclusive dressing I compromise tourniquet higher than
is
E
• Cyanosis, diaphoresis • Pulse with abnormal systolic blood pressure
• Respiratory distress strength or quality (weak if other measures fail
• Decreased or absent breath and thready, full and • Begin fluid resuscitation
sounds bounding)
• Severe retractions • Uncontrolled external bleed
• Open or sucking chest bleeding any
teeY
ad ggi
wounds • Pallor or cool, diaphoretic
• Paradoxical chest wall
movement
t skin
• Systolic blood pressure tram Direct
• Inability to converse in innate below normal for age a pressure
phrases or complete (<90 mm Hg in adults)
sentences • Verbalization of sense of
• Pulse oximetry readings p impending doom
less than 95% (or below • Restlessness or anxiety
patient’s baseline) • Capillary refill >2 seconds
• Abnormal arterial blood gas
results
TABLE 35-5 NEUROLOGIC
ASSESSMENT AND
INTERVENTIONS
53 FINDINGS OF POTENTIAL
assess the exposed body for abnormalities that may require
immediate intervention, such as opena wounds
ex or fractures, CONCERN INTERVENTIONS I
uncontrolled bleeding, or eviscerations. soon • Unequal pupils or pupils • Maintain head midline
Environmental control is meant to remind the trauma that are sluggish to react with the head or the bed

0
team of the importance of keeping a patient warm. Numer-
ous factors increase the risk of a patient becoming hypo-
or fail to react
• Decreased Glasgow to degrees E J
flat or elevated 30 to 45

thermic during trauma resuscitation, including: reasons Coma Scale scores, • Consider mannitol
altered level of (Osmitrol) for changes in

Ibb
a
• Ambient temperature of the resuscitation room (which
my is lower than body temperature) t consciousness level of consciousness
• Infusion of large amounts of fluids or bloodm products t • Weakness on one side or associated with
that are below body temperature
• Elevated blood alcohol levelsin IUDs
(resulting in vasodilation)
I
in one extremity or loss
of function of one side or
increased intracranial
pressure Jake
I 3 C
• Impaired thermogenesis secondary to shock and brain
one extremity
• Abnormal posturing c
• Decrease external stimuli
l
injuries

Year
 CHAPTER 35 Assessment and Stabilization of the Trauma Patient 373
• bAge (pediatric
a and older patients b
d have decreased abilities • Continuous cardiac and oxygen saturation monitoring
to regulate body temperature) • Placement of a gastric tube
a conditions dis
y's
• Moisture on the body from environmental • Insertion of an indwelling urinary catheter (unless there
and bleeding is evidence of lower genitourinary trauma)a
T
f
• Use of anesthetics and paralytics for intubation (which • Collection of appropriate laboratory studies
en mi
decreases internal heat production) • Focused assessment with sonography for trauma (FAST)
a and large
• Injuries to the pelvis, extremities, abdomen,
blood vessels (which carry a greater risk of heat loss)7
If the core body temperature of a trauma patient drops Common Laboratory Tests Used During
below 95°F (35°C) during resuscitation, the patient has an Assessment
increased risk of the following:
• Developing acidosis a
2results 1
• Type and crossmatch or type and screen
• Complete blood count
emerging
• Tissue and cerebral hypoxia • Basic chemistry panel (electrolytes, glucose, and renal
• Increased diuresis with exacerbation of hypovolemia function tests)
• Infection due to suppression of the immune system K • Urinalysis
I
• Coagulopathies, including disseminated intravascular • Pregnancy test
t • Ethanol level
coagulation8
TY DID • Toxicology screen
• Clotting studies
THE SECONDARY ASSESSMENT • Serum lactate and base deficit

SEAL t
Once the primary assessment is complete and issues involv-
ing the patient’s airway, breathing, circulation, disability
status, and exposure and environmental control have been Family Presence
addressed, proceed to the secondary assessment. This is not The presence of the family during the resuscitation of

peg I g
a final examination; it is a rapid, thorough inspection of the trauma patients has been shown to improve family members’
patient’s entire body from head to toe. Unlike the primary
assessment,saissues noted onT
j
secondary assessment are not 4
ability to cope with the situation. There is strong evidence
l
that it may also assist the patient who is aware of their pres-
M
treated immediately.
a
They are noted and then prioritized
a If the patient develops an airway,
for later intervention. stole ence during this stressful time. Based on this evidence, the
Emergency Nurses Association has adopted a formal posi-
breathing, or circulatory problem at any time, return at
I
once to the primary assessment and intervene as indicated.
tion statement encouraging family presence at the bedside
of critically ill or injured patients.9
a Ed
The last four letters of the mnemonic (F-G-H-I) make up
the secondary assessment. Give Comfort Measures K
The trauma victim is often in physical and psychological
Full Set of Vital Signs O
distress. Pharmacologic e
and nonpharmacologic methods

IIfis aappropriate
complete set of vital signs has not yet been obtained, it of reducing pain and anxiety are available for this popu-
lation. The trauma team is obliged to recognize pain d
to do so at this point. These vital signs will
t
C
serve as a baseline for continued reassessment. Patients with and intervene as necessary. See Chapter 11, Care of the

e g
suspected chest trauma should have apical and radial pulse
rates documented and blood pressure assessed in both r arms.
Patient with Pain, for further information on pain
management.

fit History
g Patients with chest trauma who are at risk for aortic trauma should
have blood pressure and pulse measured in both arms and one leg.
t
If the patient is awake, alert, and cooperative, try to elicit

IT
A difference of 10 mm Hg or more in blood pressure or a difference
in pulse quality between sites should raise the index of suspicion
l T
pertinent medication, allergy, and medical history infor-
mation. Family members are also a resource for these data. d

t
for aortic trauma.
I u L
If a patient is transported via prehospital personnel, they
will also serve as an excellent resource, providing informa-
I
tion regarding the mechanism of injury, injuries suspected,
Focused Adjuncts finding in try or any and treatment prior to arrival, including vital signs in
A Interventions that should be considered at this point depend the field.
on the findings of the primary and secondary assessments
f
Although each traumatic situation is unique, the trauma

2
and may include the following: team may anticipate many injuries based on the mechanism

experience
 374 UNIT 4 Trauma
of injury that is described by the patient, bystanders, or • Ed
Penetrating trauma may appear less serious than it is,
prehospital personnel. Injuries can be blunt, where the with minimal surface trauma but significant underlying

T
injuring force does not penetrate the skin, or penetrating,
where an object penetrates the skin. Table 35-6 summarizes
some injuries that can be anticipated based on common
mechanisms of blunt trauma.
a •1
Obtaining any available details regarding the mecha-
nism of a penetrating injury can be helpful in determining
35 I
the extent of traumatic injury. Numerous considerations
should also be taken into account when caring for patients
a consider the following facts:
with penetrating trauma:
trauma. A knife, for example, may create a very small
wound on the skin surface, but if the assailant moved the
knife up and down while it was in the body or if the victim
moved while the knife was in the body, the underlying
g yo
1
damage may be much greater than the surface trauma.
When dealing with injuries as a result of firearms,
a
a
is
• Hollow point projectiles cause more extensive
damage than solid projectiles.

TABLE 35-6 ANTICIPATED INJURIES ASSOCIATED WITH BLUNT TRAUMA

MECHANISM OF TRAUMA
Front impact motor vehicle crash
Side impact motor vehicle crash
I
Rear-end impact motor vehicle crash
119T
Rollover motor vehicle crash
i as extremities protrude out of broken windows. Nearly any injury is possible with this type
ASSOCIATED INJURIES
• The body tends to be thrown forward in the car, causing it to strike surfaces in front of it
and leading to traumatic brain injury, facial trauma, spinal trauma, sternal injuries,
pulmonary and cardiac injuries, hip and femur fractures, and ankle fractures.a
s
• The frame of the car collapses in on the side of the patient and the patient is thrown
broken ribs
toward the impact, resulting in rotational cervical spinal injuries, flail chest segments,
pulmonary injuries, abdominal injuries (the spleen is affected morec often in the driver andyd
the liver is affected in the passenger secondary to the position of these organs against
A
side of impact), and pelvic injuries.a
city
• The patient is often forced toward the top of the car and the seat reclines slightly and
then springs forward, thrusting the patient to the front of the vehicle. This can cause
intracranial injury (from the head being driven into the ceiling on initial impact) and flexion-
extension injuries of the cervical spine.
1 I
• Other patterns of injury are similar to those with front impact crash because the patient is
thrown to the front of the vehicle.a
• Axial loading with burst fractures of the spine or Jefferson fractures, and extremity trauma

Motorbike crash
t É
a E
of crash because of the multiple and varied points of impact.a a
• Head injuries, especially when the rider is not wearing a helmet or the helmet is damaged.
• Separation of the rider from the bike increases the risk of injury.
a
se
• Riders who are crushed between their bike and another vehicle or other object can have
significant trauma to the extremities. I
C
• Riders who are dragged or slide across surfaces sustain severe integumentary trauma.
Bicycle (nonmotorized) crash
ta • Injury considerations for bicycles are similar to those for motorbikes.

y
• Heavier road bikes tend to propel the patient into the handlebars, increasing the risk of

pm t
pancreatic, liver, splenic, and diaphragmatic injury. a
• Patients are more likely to be propelled over the handlebars with lighter speed bikes,
sustaining head, face, shoulder, and upper arm trauma.

O Fall
at p
• A fall from three times a victim’s height or greater should raise the concern for significant
injury.

I
• Patients who land on their feet tend to get calcaneus, lumbar spine, and wrist trauma as
energy goes from the feet up the back and they fall forward on outstretched hands.
• Patients who land on their sides usually put their hands out to protect themselves,
resulting in arm trauma. As the arm buckles into the body, rib fractures, pulmonary trauma,
and spleen or liver trauma can result.
• The energy from landing on the buttocks results in energy being transmitted to the pelvis,
abdominal organs, and chest organs with severe life-threatening injuries.

M s
h
a
Hazarika, S., Willcox, N., & Porter, K. (2007). Patterns of injury sustained by car occupants with relation to the direction of impact with motor vehicle
trauma—evidence based review. Trauma, 9 (3), 145–150.

I x
 CHAPTER 35 Assessment and Stabilization of the Trauma Patient 375

I
•
I t
Firearms with longer barrels fire projectiles at greater
speeds than firearms with shorter barrels and tend to
• Reassess the pupils for symmetry, light response, and
accommodation. r u
produce more tissue damage. • Check gross visual acuity. a
• The closer the trauma patient was to the firearm, the • Ask the patient to open and close the mouth to check
i N more significant the trauma tends to be. e for malocclusion, lacerations, loose or missing teeth, and
y Patients involved in explosions can have a variety of dif- foreign bodies. L
ferent injuries: vape
• Primary injuries: When a solid or liquid changes to a gas,
Diagnostic Procedures
• Noncontrast computed tomography (CT) scans
as happens in an explosion, it expands. The expansion • Panoramic radiographic views of the jaw
causes a displacement of air that travels away from the
blast site. When the blast of air strikes the body it can Neck

ng i C
compress gas-filled organs, leading to injuries such as • While another team member provides cervical spine

J
ruptured tympanic membranes, pneumothoraces, air immobilization, partially remove the rigid cervical collar
i
p emboli, and gastric or intestinal ruptures.
I
• Secondary injuries: As displaced air travels from the
see y
blast site, it carries small pieces of debris for long dis-
•
Y
to assess the patient’s neck.
y
Palpate and inspect for obvious wounds, ecchymosis,

tances that can strike and imbed in bodies that may be
a significant distance from the blast site. The resulting
d lacerations and impaled objects are referred to as sec-
ondary injuries.
• Tertiary injuries: Displaced air can hurl bodies
a away from the blast site and throw them into other
l
objects, resulting in a variety of blunt traumatic
injuries. y of alcohol or drug intoxication or major distracting injuries. Con-
Head-to-Toe Examination d
Items to be considered during a head-to-toe examination
I
neck vein distention, subcutaneous air, or endotracheal
a
deviation. u u ji
• Auscultate the carotid arteries for bruits.
N
• Palpate for deformities, defects, or cervical vertebral ten-
derness before reapplying the collar.
y
The cervical spine cannot be cleared adequately in the presence
r
versely, the cervical spine of a low-risk, alert, oriented, nonintoxi-
I
cated patient can be cleared based on clinical examination alone
in the absence of pain, tenderness, or neurologic findings.10

are addressed only briefly in this section. Refer to Chapters

36 through 41 for specific trauma information. Diagnostic Procedures. Four radiographic views are y
needed to visualize the cervical spine fully:
Head
• The head is inspected systematically and assessed for any
obvious wounds, deformities, or asymmetry. ja
• Anterior-posterior
• Lateral r
f
• Cross-table lateral (must visualize C1 to T1)
c
• Palpate the skull for depressed bony fragments, hemato- • Open-mouth odontoid t d d
y g z
mas, lacerations, or tenderness. Obtain CT studies if plain radiographs are incon-
• Note any areas of ecchymosis or discoloration. Ecchy-
l
clusive. Flexion-extension views are used to check for soft

IT
mosis behind the ears, over the mastoid process (Battle
sign), or in the periorbital region (raccoon eyes)
tissue damage and are performed much less frequently.

Chest
a
q
increases the suspicion for a basilar skull fracture.
Therapeutic Interventions • ECthe
Visually inspect
d for asymmetry, deformity,
G chest
• Do not allow the patient to become b
hypotensive or penetrating trauma, and other wounds.
Auscultate the heart and lungs. g
•
hypoxic.
Lbo er to decrease
Mannitol may be administered intravenously
•
• Palpate the chest wall for deformities, subcutaneous air,

•
I intracranial pressure.
i
Facilitate surgical intervention or intracranial pressure
and areas of tenderness.
Diagnostic Procedures
a
monitoring. • Obtain a portable chest radiograph if the patient cannot
sit upright for anterior-posterior and lateral views.
Face
•
Uh
Inspect the face for wounds and asymmetry.
• Obtain a 12-lead electrocardiogram in patients with
suspected or actual blunt chest trauma.
• Note any drainage from the ears, nose, eyes, or mouth. • Consider drawing arterial blood gases if the patient has

I T g
Clear drainage from the nose or ears is assumed to be
cerebrospinal fluid until proven otherwise.
any symptoms of airway obstruction or respiratory dis-
tress or has been placed on a mechanical ventilator.

b u d
376 UNIT 4 Trauma
missed. Cervical spinal alignment must be maintained by
Abdomen
YA
using approved logrolling techniques.
• Inspect the abdomen for bruising, masses, pulsations, • With the back exposed, look for bruising, discoloration,
and penetrating objects. and any open wounds.
•
contents. IE
Observe for distension or evisceration of bowel

t it
• Palpate the vertebral bony prominences for deformity,
movement, and pain.
s
• Auscultate for bowel sounds in all four quadrants. • Remove any clothing or wet items left under the patient.
• Gently palpate the abdomen checking for rigidity and • If the spine is cleared or the patient can lie still, remove

I
areas of tenderness, rebound pain, or guarding. the backboard (according to institutional protocol).
Diagnostic Procedures Spox
Therapeutic Interventions
• FAST
•
a
Diagnostic peritoneal lavage (used infrequently) • Consider padding or removing the backboard. d
• CT scan of the abdomen (usually performed with a • Assess for signs of skin breakdown.
contrast medium) u
• Abdominal or kidneys-ureter-bladder (KUB) radio-
r REEVALUATION AND ASSESSMENT 2
graphic series
a

Pelvis
• Visually inspect the pelvis for bleeding, bruising, defor-
mity, and penetrating trauma. y
• Inspect the perineum for blood, feces, and any obvious
hey
As long as the trauma patient is in the emergency depart-
i
ment, assessment is never complete. Re-evaluate patients
regularly to identify deterioration and injuries that were
overlooked. Additionally, trauma patients may have under-
lying medical conditions that were not addressed during

•
injury.

I l
A rectal examination is performed to assess sphincter I
the initial resuscitation. Consider the following:
l
• Reassess pain and provide additional pain medication 353
tone, identify blood, and check the position of the pros-
tate. A high-riding prostate, blood at the urinary meatus,
(as indicated) but watch for respiratory depression.
Narcotic analgesics also may mask subtle signs of neu-
a
or the presence of a scrotal hematoma are contraindica-
tions to bladder catheterization until a retrograde ure-
rologic deterioration.
IM
• Monitor urinary output and intervene as necessary.
throgram can be performed. • As in all aspects of health care, thorough documentation
•
I
Gently press inward (toward the midline) on the iliac
crests to assess pelvic stability. Also palpate over the
is essential. Because of the multiple assessments, inter-
ventions, and reassessments, recording trauma patient

I
symphysis pubis. Stop if pain or motion are elicited and
obtain radiographic studies.
care in a timely fashion is crucial.
no
• The patient who has sustained a trauma requires con- a
Y
sistent and uniform care from all members of the team.
Extremities d
• t
Inspect all four limbs for deformity, dislocation, ecchy- l
If life-threatening injuries are found, the team needs
to intervene and correct them. Care of the trauma a
mosis, swelling, and other wounds. patient is enhanced by the use of a team approach and
• Check the sensory, motor, and neurovascular status of a consistent assessment technique such asn the A-I

•
each extremity.
Palpate for areas of tenderness, crepitus, and tempera-
mnemonic.
n i
ture abnormalities.
•
3
If injuries are present, reassess distal neurovascular
status regularly.
a
REFERENCES
Diagnostic Procedures 1. Centers for Disease Control and Prevention. (2010, October 5).
• Radiographs of the affected extremities Accidents or unintentional injuries. Retrieved from http://
Therapeutic Interventions www.cdc.gov/nchs/fastats/acc-inj.htm
2. Centers for Disease Control and Prevention. (2010, October
• Splinting
27). All injuries. Retrieved from http://www.cdc.gov/nchs/
• Wound care i fastats/injury.htm
Inspect the Posterior Surface 15 3. Bergen, G., Chen, L. H., & Fingerhut, L. A. (2008). Injury in the
United States: 2007 chartbook. Hyattsville, MD: National Center

o
It is essential to remember that 50% of the body’s surface
lies against the stretcher. Failing to roll the patient and
for Health Statistics.
4. National Highway Transportation Safety Administration.
inspect the back can result in numerous injuries being (n.d.). Trauma system: Agenda for the future. Retrieved from
 CHAPTER 35 Assessment and Stabilization of the Trauma Patient
http://www.nhtsa.gov/People/injury/ems/emstraumasystem03/
index.htm
5. The National Spinal Cord Injury Statistical Center. (2009,
June). Spinal cord injury statistics. Retrieved from http://
www.fscip.org/facts.htm
6. Consortium for Spinal Cord Medicine. (2008). Early acute
management in adults with spinal cord injury: A clinical prac-
tice guideline for health-care professionals. Journal of Spinal
Cord Medicine, 31(4), 403–479.
7. Hildebrand, F., Giannoudis, P. V., van Griensven, M., Chawda,
M., & Pape, H. C. (2004). Pathophysiologic changes and effects
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8. Solheim, J. (n.d.). Cold comfort: Treating hypothermia in
the trauma patient. Retrieved from http://ce.nurse.com/
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presence during invasive procedures and cardiopulmonary resu-
scitation (position statement). Retrieved from http://www.
ena.org/SiteCollectionDocuments/Position%20Statements/
FamilyPresence.pdf
10. Stanford University School of Medicine. (n.d.). C-Spine
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edu/2007-2008/c-%20Spine%Protocol%20-%20McCall%20v2.
pdf