Trauma ABCs

Primary Survey (ABCDE)

1. Airway with Cervical Spine Protection (A)
• inadequate delivery of oxygenated blood to the brain and other vital structures is the quickest killer of the injured patient
• prevention of hypoxia requires a protected, unobstructed airway and adequate ventilation
• airway and ventilation take priority over all other conditions


1. Clinical Assessment
• if the patient is able to communicate verbally, the airway is not likely to be in immediate jeopardy
• frequent reassessment of airway patency and adequacy of ventilation are critical
• rapid assessment of airway obstruction should include inspection for foreign bodies (teeth and blood) and facial, mandibular, and laryngeal fractures
• tachypnea may be an early sign of airway obstruction
• patients who refuse to lie down may be having difficulty maintaining their airway
• look to see if the patient is agitated or obtunded:
• agitation suggests hypoxia
• obtundation suggests hypercarbia
• cyanosis of the nail beds or circumoral skin implies hypoxemia
• retractions and the use of accessory muscles suggests airway compromise
• listen for abnormal sounds:
• noisy breathing is obstructed breathing
• snoring, gurgling, and stridor may be associated with partial occlusion of the larynx
• hoarseness implies obstruction of the larynx
• an abusive or belligerent patient may be hypoxic
• feel for the location of the trachea and determine if it is midline
• chin lift or jaw thrust are the initial maneuvers to establish a patent airway
• C-spine must be protected while assessing and managing the airway – manually stabilize the patient’s head and neck using inline mobilization techniques


2. C-Spine Protection
• spinal cord must be protected until spinal injury has been ruled out by clinical assessment and/or imaging
• removal of helmets and collars is a two-person job (one person provides manual in-line immobilization while the other removes the helmet or collar)
• in-line immobilization is mandatory during all procedures to maintain or obtain an airway


3. Supplemental Oxygen
• should be administered immediately to all trauma patients


4. Airway Maintenance Techniques
• tongue may fall backwards and obstruct the hypopharynx if the patient has a decreased level of consciousness
• this form of obstruction can be corrected by the chin lift or jaw thrust maneuvers and maintained with an oropharyngeal or nasopharyngeal airway


1. Oropharyngeal Airway
• cannot be used in a conscious patient because it will induce gagging, vomiting, and aspiration
• when inserting, must be careful not to push the tongue backward and block the airway


2. Nasopharyngeal Airway
• better tolerated in a responsive patient


3. Laryngeal Mask Airway (LMA)
• not a definitive airway
• useful if intubation has failed, or is unlikely to succeed
• requires appropriate training
• if an LMA is in place, must make plans for a definitive airway
• intubating LMA (ILMA) is a device that allows for intubation through the LMA


4. Additional Airway devices
• laryngeal tube airway
• multilumen esophageal airway


5. Definitive Airway
1. Definition
• requires a tube present in the trachea with the cuff inflated, the tube connected to some form of oxygen-enriched assisted ventilation, and the airway secured in place with tape
• 3 varieties: orotracheal tube, nasotracheal tube, cricothyroidotomy


2. Indications
• apnea
• inability to maintain a patent airway by other means
• airway protection from blood and vomitus
• impending airway compromise:
• large or expanding neck hematoma
• laryngeal/tracheal injury
• maxillofacial trauma (especially bilateral mandible fractures)
• facial burns
• inhalation injury
• closed head injury with GCS < 8
• inadequate oxygenation
• inadequate ventilation


3. LEMON Airway Assessment
• used to predict the difficulty of intubation



4. Techniques
1. Orotracheal Intubation
• most commonly chosen technique
• can be performed rapidly under direct vision
• suitable in both awake and apneic patients
• 2-person technique with in-line cervical spine immobilization should be used
• drug-assisted technique may be used in responsive patients (succinylcholine/Etomidate), cricoid pressure
• if the cords can’t be visualized on laryngoscopy, a gum elastic bougie often facilitates a successful intubation
• after intubation the chest and abdomen should be auscultated for equal bilateral breath sounds
• CO₂ monitor confirms proper intubation of the airway
• CXR is necessary to confirm proper positioning of the tube in the airway


2. Nasotracheal Intubation
• blind technique requiring a spontaneously breathing patient
• contraindicated in apneic patients and patients with severe maxillofacial trauma and basilar skull fractures
• most appropriate in hemodynamically stable patients with C-spine injuries since less neck manipulation is required


3. Cricothyroidotomy
• indicated when orotracheal and nasotracheal intubation is unsuccessful or contraindicated
• must be performed with the neck in the neutral position
• easier, quicker, and associated with less bleeding than emergency tracheostomy
• percutaneous tracheostomy should not be done because the patient’s neck must be hyperextended
• should be converted to a formal tracheostomy as soon as the patient is stable
• not recommended for children < 12 years’ old


4. Jet Insufflation (Needle Cricothyroidotomy)
• provides oxygen on a short-term basis until a definitive airway can be placed
• 12- or 14-guage IV catheter is placed through the cricothyroid membrane into the trachea
• catheter is then connected to high-flow (15 L/min) wall oxygen
• to provide ventilation, a hole is cut in the oxygen tubing and the hole is covered for 1 second and uncovered for 4 seconds
• some exhalation occurs in the 4 seconds that oxygen isn’t flowing
• adequate oxygenation can only be maintained for 30 to 45 minutes
• CO₂ slowly accumulates, further limiting the usefulness of this method


2. Breathing and Ventilation (B)
1. Clinical Assessment
• airway patency does not assure adequate ventilation
• ventilation requires adequate functioning of the CNS, lungs, chest wall, and diaphragm, as well as a patent airway
• look for symmetric and adequate chest wall excursion
• asymmetry suggests splinting or a flail chest
• labored breathing implies an imminent threat to the patient’s oxygenation
• listen for movement of air on both sides of the chest
• decreased or absent breath sounds over one or both hemithoraces indicates a thoracic injury
• patients should be monitored with a pulse oximeter (monitors oxygenation, not ventilation)
• life-threatening thoracic injuries such as tension pneumothorax, open pneumothorax, and massive hemothorax should be treated immediately


2. Life Threating Emergencies
1. Tension Pneumothorax
1. Pathophysiology
• ‘one-way valve’ air leak occurs either from the lung or through the chest wall
• air is forced into the thoracic cavity without any means of escape
• ipsilateral lung collapses and as the thoracic pressure increases, the mediastinum is shifted to the opposite side, decreasing venous return


2. Diagnosis
• clinical diagnosis: hypotension, respiratory distress, tracheal deviation, neck vein distention, unilateral absence of breath sounds
• may be difficult to distinguish from cardiac tamponade


3. Management
• immediate decompression with a large-bore needle into the 5th intercostal space just anterior to the midaxillary line or finger thoracostomy
• converts the injury into a simple pneumothorax
• definitive treatment requires insertion of a chest tube


2. Open Pneumothorax (‘Sucking Chest Wound’)
1. Pathophysiology
• if a defect in the chest wall is greater than 2/3 the diameter of the trachea, then air will follow the path of least resistance and pass preferentially through the chest defect, rather than the mouth, with each respiration
• result is impaired ventilation, leading to hypoxia and hypercarbia


2. Management
• wound is covered with a sterile occlusive dressing and taped securely on three sides
• goal is to create a flutter-type valve: as the patient breathes in, the dressing is sucked over the wound, preventing air from escaping
• when the patient breathes out, the open end of the dressing allows air to escape
• if the dressing is taped on all 4 sides, air can accumulate in the thoracic cavity, resulting in a tension pneumothorax
• a chest tube should be placed remote from the wound as soon as possible
• definitive surgical closure of the defect is often required


3. Flail Chest
1. Pathophysiology
• segment of the chest wall does not have bony continuity with the rest of the thoracic cage
• results when 2 or more ribs are fractured in 2 or more places
• the unstable segment moves paradoxically during respiration
• major insult in flail chest results from the underlying pulmonary contusion, not the chest wall instability
• associated pain with restricted chest wall motion also contributes to hypoxia


2. Diagnosis
• physical exam will show paradoxical chest wall movement
• chest x-ray will show multiple rib fractures


3. Management
• goal is to treat and/or prevent hypoxia
• many patients will require intubation and mechanical ventilation to maintain an acceptable PO₂
• aggressive pulmonary toilet and pain management (consider epidural catheter or intercostal rib blocks) are the other cornerstones of management
• open reduction/internal fixation of the flail segment is rarely warranted


4. Massive Hemothorax
1. Mechanism of Injury
• results from the rapid accumulation of 1000 - 1500 cc of blood in the chest cavity
• may result from blunt or penetrating trauma
• usually results from a systemic arterial (intercostal, internal mammary) or pulmonary hilar injury
• since the lung is a low-pressure system, bleeding from the lung parenchyma does not cause massive hemothorax


2. Diagnosis
• hypovolemic shock associated with absence of breath sounds and/or dullness to percussion on one side of the chest
• chest x-ray shows a large fluid collection


3. Management
• insertion of a chest tube (28 – 32 F) that is connected to an autotransfusion device
• restoration of blood volume with crystalloid and blood
• most patients with initial blood loss >1500 cc will require thoracotomy
• patients with ongoing blood loss of 250 cc/hr for 3 hours are also likely to need thoracotomy
• patient’s physiologic status is the best guide for the need for surgery


5. Cardiac Tamponade
1. Pathophysiology
• most commonly results from penetrating injuries
• pericardial sac is a fixed fibrous structure that does not distend and as little as 150 cc of blood may impair diastolic filling


2. Diagnosis
• can be difficult in the trauma setting
• Beck’s triad (present in 1/3 of cases): 1) distended neck veins, 2) muffled heart sounds, 3) hypotension
• Kussmaul’s sign: rise in venous pressure with inspiration when breathing spontaneously
• tension pneumothorax can mimic tamponade
• pulseless electrical activity (PEA) in the absence of hypovolemia and tension pneumothorax suggests cardiac tamponade
• FAST is a valuable non-invasive tool for showing fluid in the pericardial sac (false-negative rate = 5%)


3. Management
• volume resuscitation will transiently improve cardiac output
• subxiphoid pericardiocentesis is both diagnostic and therapeutic
• patients with a positive pericardiocentesis or FAST exam will require thoracotomy or sternotomy for definitive repair of the heart


6. Role of ER Thoracotomy
• patients with penetrating chest injuries who arrive pulseless, but with myocardial electrical activity, may be candidates for immediate resuscitative thoracotomy
• patients sustaining blunt injuries who arrive pulseless are not candidates for ER thoracotomy
• therapeutic maneuvers that can be accomplished with ER thoracotomy include:
• release of pericardial tamponade
• direct control of exsanguinating hemorrhage
• open cardiac massage
• cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart


3. Circulation with Hemorrhage Control (C)
• hemorrhage is the main cause of early death following injury
• hypotension following injury is hypovolemic in origin until proven otherwise
• bleeding will be from one or more of 5 locations: chest, abdomen, retroperitoneum (often pelvic fractures), long bones, and external sites


1. Clinical Assessment
• tachycardia is the earliest physiologic response to blood loss
• cutaneous vasoconstriction is another early sign of blood loss
• systolic blood pressure may not fall until 30% of the blood volume has been lost
• altered level of consciousness as a result of decreased cerebral perfusion accompanies profound blood loss
• acute blood loss cannot reliably be estimated using the hemoglobin or hematocrit concentration
• CXR to evaluate for thoracic bleeding
• pelvic x-ray to identify pelvic fractures
• FAST, DPL to evaluate for intra-abdominal bleeding


2. ATLS Classification of Hemorrhagic Shock



• athletes (conditioning), elderly patients (medications), and pregnant patients (hypervolemia) may deviate from this classification


3. Control of Blood Loss
• external blood loss is managed by direct manual pressure on the wound
• pelvic binder or pneumatic antishock garment may be used to control bleeding from pelvic fractures
• long bone fractures should be splinted
• chest tube for intrathoracic bleeding


4. Resuscitation
1. Vascular Access
• 2 large-bore peripheral IVs should be started immediately
• if peripheral access cannot be obtained, central lines, cutdowns, or intraosseous infusion can be used


2. Initial Resuscitation
• blood should be sent immediately for type and crossmatch
• adults should receive an initial fluid bolus of one liter
• if the patient remains hypotensive, O-negative, type-specific, or type and crossmatched blood should be given, depending upon their availability
• consider autotransfusion in any patient with a major hemothorax
• all IV fluids and blood products should be warmed to prevent hypothermia


3. Massive Transfusion
• a small subset of patients will require massive transfusion (> 10 units PRBCs in 24 hours)
• goal is to minimize excessive crystalloid infusion
• PRBCs, FFP, and platelets are given in a balanced ratio (often 1:1:1)
• simultaneously, the source of bleeding must be controlled as fast as possible


4. Coagulopathy
• consumption of coagulation factors, dilution, hypothermia, and acidosis all contribute to coagulopathy
• many patients are also taking antiplatelet or anticoagulation drugs
• baseline PT, PTT, and platelet count should be obtained early
• prothrombin complex concentrate can be used to reverse Coumadin
• tranexamic acid – an antifibrinolytic agent – administered within 3 hours of injury improves survival


4. Disability (D)
• the goal of management is to maintain cerebral perfusion and oxygenation, thereby preventing secondary brain injury
• a rapid neurological exam is performed at the end of the primary survey
• patient’s level of consciousness as well as pupil size and reactivity should also be assessed
• Glasgow Coma Scale (GCS) is a quick neurological evaluation that is predictive of patient outcome (motor response)



5. Exposure and Environmental Control (E)
• patient must be completely exposed to facilitate a thorough examination
• after the patient has been assessed, then he must be covered with warm blankets or an external warming device to prevent hypothermia
• the trauma room should be warm
• all IV fluids and blood products should be warmed before infusion


6. Adjuncts to the Primary Survey
1. EKG Monitoring
• required of all trauma patients to detect dysrhythmias


2. Pulse Oximeter
• measures the oxygen saturation and heart rate


3. Blood Pressure Monitor
• automated device is used and frequently cycled


4. Urinary Catheter
• urinary output is a sensitive indicator of volume status and reflects renal perfusion
• transurethral catheter placement is contraindicated if urethral transection is suspected:
• blood at the penile meatus
• perineal ecchymosis
• blood in the scrotum
• pelvic fracture
• if urethral injury is suspected, then a retrograde urethrogram must be performed before the catheter is inserted


5. Nasogastric Tube
• purpose is to decrease gastric distention and reduce the risk of aspiration
• if a fracture of the cribriform plate is suspected, then the tube should be inserted orally to prevent intracranial passage
• insertion of the gastric catheter may induce gagging and vomiting and cause the specific problem it was intended to prevent: aspiration


7. X-rays and Diagnostic Studies
1. X-rays
1. Chest X-ray
• should be obtained in all patients with blunt or penetrating torso trauma or who are in respiratory distress
• additional indications include any unconscious patient or any patient going to the operating room


2. Pelvic X-ray
• should be obtained in any patient sustaining blunt trauma to the torso
• additional indications include gross hematuria, gross blood on rectal or vaginal examination, and unexplained hypotension


2. Diagnostic Studies
1. Diagnostic Peritoneal Lavage (DPL)
• 98% sensitive for intraperitoneal bleeding
• used in hemodynamically unstable blunt trauma patients if FAST is not available
• only absolute contraindication is an existing indication for laparotomy
• relative contraindications include previous abdominal surgery, morbid obesity, and coagulopathy


2. Diagnostic Ultrasound (FAST)
• as accurate as DPL for detecting hemoperitoneum, and has largely replaced DPL in most trauma centers
• requires special training
• may be repeated at intervals to detect progressive hemoperitoneum