Trauma scenarios

• Clinicians assess injuries and start therapy when treating injured patients.
• A systematic approach to the initial assessment ensures speed and accuracy in life-preserving therapy.
• Initial assessment includes preparation, triage, primary survey (ABCDEs), adjuncts, transfer consideration, secondary survey, monitoring/reevaluation, and definitive care.
• The primary and secondary surveys are repeated to identify changes in patient status and need for intervention.
• The assessment sequence is generally linear but can occur simultaneously.
• ATLS principles guide assessment and resuscitation but procedures are determined by the individual patient's needs.

Preparation

• Preparation for trauma patients occurs in the field and hospital.
• Coordination with prehospital agencies expedites treatment in the field.
• The prehospital system notifies the receiving hospital for trauma team mobilization and resource availability.
• Prehospital providers focus on airway maintenance, bleeding/shock control, immobilization, and transport to the closest appropriate facility, preferably a verified trauma center.
• Prehospital providers minimize scene time, as emphasized by the Field Triage Decision Scheme with MyATLS mobile app.
• The information needed for triage includes time/events of injury, and patient history.
• Injury mechanisms can suggest injury degree and specific injuries for evaluation and treatment.
• The National Association of Emergency Medical Technicians' Prehospital Trauma Life Support (PHTLS) is similar to ATLS, but addresses prehospital care of injured patients.
• Prehospital care protocols and online medical direction can improve field care.
• Regular multidisciplinary review of patient care is essential to a hospital's trauma program.
• Advance planning for trauma patient arrival is essential (see Pre-alert checklist on the MyATLS mobile app.)
• The hand-over between prehospital providers and the receiving hospital should be smooth.
• Critical aspects of hospital preparation include an available resuscitation area, accessible airway equipment, intravenous crystalloid solutions, protocols to summon assistance, and operational transfer agreements with the verified trauma center.
• Standard precautions (e.g., face mask, eye protection, water-impervious gown, and gloves) are recommended by the CDC and OSHA the ACS COT considers these to be minimum precautions and protection for all healthcare providers.

Triage

• Involves sorting patients based on treatment and available resources.
• Treatment order is based on ABC priorities (airway, breathing, circulation with hemorrhage control).
• Triage includes sorting for appropriate receiving medical facility and trauma team activation for severely injured patients.
• Trauma scores are often helpful in identifying severely injured patients who warrant transport to a trauma center.
• Triage situations are categorized as multiple casualties or mass casualties.
• Multiple-casualty incidents are those in which the number of patients and the severity of their injuries do not exceed the capability of the facility to render care.
• In such situations, patients with life-threatening problems and multiple-system injuries are treated first.
• In mass-casualty events, the number of patients and the severity of their injuries exceeds facility capability.
• Staff will need to prioritize those that have the greatest chance of survival and who need the least things to survive, the least time, equipment, supplies, and personnel are treated first

Primary Survey with Simultaneous Resuscitation

• Patients are assessed, and their treatment priorities are established, based on their injuries, vital signs, and the injury mechanisms.
• Logical and sequential treatment priorities are established based on the overall assessment of the patient.
• The patient's vital functions must be assessed quickly and efficiently.
• Management consists of a rapid primary survey with simultaneous resuscitation of vital functions, a more detailed secondary survey, and the initiation of definitive care (see Initial Assessment video on MyATLS mobile app).
• The primary survey encompasses the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence:
  • Airway maintenance with restriction of cervical spine motion
  • Breathing and ventilation
  • Circulation with hemorrhage control
  • Disability(assessment of neurologic status)
  • Exposure/Environmental control
• Clinicians can quickly assess A, B, C, and D in a trauma patient (10-second assessment) by identifying themselves, asking the patient for his or her last name, and asking what happened.
• Appropriate patient response to communication during the 10 second assessment suggests there is no major airway compromise, breathing is not severely compromised and the level of consciousness is alert enough to describe what happened.
• Failure to respond to these questions suggests abnormalities in A, B, C, or D that warrant urgent assessment and management.
• During the primary survey, life-threatening conditions are identified and treated in a prioritized sequence based on the effects of injuries on the patient's physiology, because at first it may not be possible to identify specific anatomic injuries.
• Regardless of the injury causing airway compromise, the first priority is airway management: clearing the airway, suctioning, administering oxygen, and opening and securing the airway.
• Treat the abnormality posing the greatest threat to life first.
• The prioritized assessment are presented as sequential steps in order of importance and to ensure clarity; in practice, these steps are frequently accomplished simultaneously by a team of healthcare professionals (see Teamwork, on page 19 and Appendix E).

Airway Maintenance with Restriction of Cervical Spine Motion

• First assess the airway to ascertain patency.
• Inspect airway for obstruction, and facial, mandibular, and/or laryngeal fractures.
• Clear accumulated blood with suctioning.
• Establish a patent airway while restricting cervical spine motion.
• A patient’s ability to communicate verbally suggests the airway is not in immediate jeopardy but airway patency needs assessment.
• Patients with severe head injuries who have an altered level of consciousness or a Glasgow Coma Scale (GCS) score requires definitive airway
• Jaw-thrust or chin-lift maneuvers often suffice as an initial intervention and if the the patient is unconscious and has no gag reflex then the the placement of an oropharyngeal airway may temporarily help.
• Establish definitive airway if there is any doubt about the patient's ability to maintain airway integrity.
• The finding of nonpurposeful motor responses strongly suggests the need for definitive airway management.
• Management of the airway in pediatric patients requires knowledge of the unique anatomic features of the position and size of the larynx in children, as well as special equipment (see Chapter 10: Pediatric Trauma).
• Take great care to prevent excessive movement of the cervical spine when assessing the airway to prevent neurologic deficits.
• Based on the mechanism of trauma, assume that a spinal injury exists.
• The cervical spine is protected with a cervical collar.
• When airway management is necessary, the cervical collar is opened, and a team member manually restricts motion of the cervical spine.
• It is important to recognize every effort should be made to recognize airway compromise promptly and secure a definitive airway as well as the potential for progressive airway loss.
• Frequent reevaluation of airway patency is essential to identify and treat patients who are losing the ability to maintain an adequate airway.
• Establish an airway surgically if intubation is contraindicated or cannot be accomplished.

Breathing and Ventilation

• Airway patency alone does not ensure adequate ventilation.
• Adequate gas exchange is required to maximize oxygenation and carbon dioxide elimination by adequate function of the lungs, chest wall, and diaphragm.
• Clinicians assess position of the trachea, and chest wall excursion, expose the patient's neck and chest.
• Auscultate to ensure gas flow in the lungs.
• Visually inspect the chest for abnormalities by palpation and percussion.
• Airway injuries that significantly impair ventilation include tension pneumothorax, massive hemothorax, open pneumothorax, and tracheal or bronchial injuries.
• Tension pneumothorax compromises ventilation and circulation so chest decompression follows immediately when suspected
• Every injured patient should receive supplemental oxygen, and monitor hemoglobin oxygen saturation by using a pulse oximeter
• Simple pneumothorax can be converted to a tension pneumothorax when a patient is intubated and positive pressure ventilation is provided before decompressing the pneumothorax with a chest tube.

Circulation with Hemorrhage Control

• Compromise in trauma patients can result from a variety of injuries.
• Volume, cardiac output, and bleeding are major circulatory issues to consider.
• Hemorrhage is the predominant cause of preventable deaths after injury and its identification and rapid control is essential.
• If tension pneumothorax has been excluded, assume hypotension following injury is due to blood loss until proven otherwise.
• Rapid and accurate assessment of an injured patient's hemodynamic status is essential.
• Elements of observation that yield information within seconds are level of consciousness, skin perfusion, and pulse
• When circulating blood volume is reduced, cerebral perfusion may be critically impaired, resulting in an altered level of consciousness.
• A patient with pink skin, especially in the face and extremities, rarely has critical hypovolemia after injury.
• Conversely, a patient with hypovolemia may have ashen, gray facial skin and pale extremities.
• A rapid, thready pulse is typically a sign of hypovolemia in contrast to Assess using a central pulse (e.g., femoral or carotid artery) bilaterally for quality, rate, and regularity.
• Absent central pulses that cannot be attributed to local factors signify the need for immediate resuscitative action.
• Direct manual pressure on the wound manages rapid external blood loss via tourniquets in massive exanguination of an extremity.
• A tourniquet carries a risk of ischemic injury to that extremity and should be used when only when direct pressure is not effective and the patient's life is threatened.
• Blind clamping damage nerves and veins.
• Major internal hemorrhage areas include chest, the abdomen, retroperitoneum, pelvis so diagnosis via examination and imagine is key.
• Immediate management may includes chest decompression, and application of pelvic stabilizing device and/ or extremity splints. Definitive management may require surgical or interventional radiologic treatment and pelvic and long-bone stabilization. Initiate surgical consultation or transfer procedures early in these patients.
• Along with controlling bleeding, appropriate replacement of intravascular volume is key by placing two large-bore peripheral venous catheters to administer fluid, blood, and plasma.
• Blood samples for baseline hematologic studies and assessment of shock with blood gases and/or lactate level are obtained.
• When peripheral sites cannot be accessed, intraosseous infusion, central venous access, or venous cutdown depending on the patient's injuries and the clinician's skill level. Aggressive and continued volume resuscitation is not a substitute for definitive control of hemorrhage. Shock associated with injury is most often hypovolemic in origin so initiate IV fluid therapy with all solutions warmed either by storage in a warm environment (i.e., 37°C to 40°C, or 98.6°F to 104°F) or administered through fluid-warming devices.
• If a patient is unresponsive to initial crystalloid therapy, they should receive a blood transfusion after an an isotonic solution administered to achieve a response.
• Severely injured trauma patients are at risk for coagulopathy, which can be further fueled by resuscitative measures by use of massive transfusion protocols with blood components administered at predefined low ratios.
• Some severely injured patients arrive with coagulopathy already established by administering tranexamic acid preemptively in severely injured patients bolused in the field and a subsequent infusion over 8 hours in the hospital.

Disability (Neurologic Evaluation)

• A rapid neurologic evaluation establishes the patient's level of consciousness and pupillary size and reaction; identifies the presence of lateralizing signs; and determines spinal cord injury level, if present.
• The GCS is a quick, simple, and objective method of determining the level of consciousness.
• The motor score of the GCS correlates with outcome.
• A decrease in a patient's level of consciousness may indicate decreased cerebral oxygenation and/or perfusion, or direct cerebral injury requiring immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status.
• Hypoglycemia, alcohol, narcotics, and other drugs can also alter a patient's level of consciousness requiring presumption that changes in a change in the levels is a result of CNS injury.
• Primary brain injury results from the structural effect of the injury to the brain.
• Prevention of secondary brain injury by maintaining adequate oxygenation and perfusion are the main goals of initial manage- ment and because evidence of brain injury isn’t always apparent repeated examination is key.

Exposure and Environmental Control

• During the primary survey, completely undress the patient by cutting off his or her garments to facilitate a thorough examination and assessment.
• After completing the assessment, cover the patient with warm blankets or an external warming device to prevent him or her from developing hypothermia by using a fluid warmer to heat crystalloid fluids to 39°C (102.2°F) if they are not available then warm the crystalloid fluids in a microwave instead of blood.

Adjuncts to the Primary Survey with Resuscitation

• Adjuncts used include ECG monitoring, pulse oximetry, carbon dioxide (CO₂) and rate ventilation, and arterial blood gas (ABG) measurement and other helpful tests include blood lactate, x-ray examinations (e.g., chest and pelvis), FAST, extended focused assessment with sonography for trauma (eFAST), and DPL along with monitoring of physiologic parameters.

Electrocardiographic Monitoring

• Dysrhythmias like unexplained tachycardia, arterial fibrillation and changes can indicate blunt cardiac injury and PEA indicates cardiac tamponade or hypovolemia.

Pulse Oximetry

• A valuable adjunct for monitoring oxygenation in injured patients to display rate and saturation continuously or determine absorption and hemoglobin levels.
• In addition, hemoglobin saturation from the pulse oximeter should be compared with the value obtained from the ABG analysis to provide accurate data on oxygen levels and ventilation

Urinary and Gastric Catheters

• This should occur following airway survey and is helpful for monitoring fluid resuscitation. Transurethral bladder catheterization is contraindicated (perineal ecchymosis) and an examination of the perineum/genetalia must occur prior to insertion .
• At times anatomic abnormalities (e.g., urethral stricture or prostatic hypertrophy) preclude placement of indwelling bladder catheters, despite appropriate manipulation
• A gastric tube is used to compress distention and decompress the risk of aspiration while blood indicates oropharyngeal (swallowed) blood, traumatic insertion, or actual upper digestive injury

X-Ray Examinations and Diagnostic Studies

• These are used to guide assessment of trauma patients.
• Anteroposterior (AP) chest and AP pelvic films often provide information and essential diagnostic x-rays must be obtained even in pregnant patients.
• FAST, eFAST, and DPL is based on clinician's skill and their use requires surgical consultion.

Consider the Need for Patient Transfer

• During the primary survey with resuscitation, the evaluating doctor frequently obtains sufficient information to determine the need to transfer the patient to another facility for definitive care by avoiding testings that delay transfer.
• Once the decision to transfer a patient has been made, communication between the referring and receiving doctors is essential

Special Populations

• Patient populations that warrant special consideration during initial assessment are children, pregnant women, older adults, obese patients, and athletes who may have anatomic differences or physiological responses that may require special tools for trauma care

Secondary Survey

• The secondary survey does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are under way, and improvement of the patient's vital functions has been demonstrated.
• The secondary survey including complete history and exam should happen simultaneously.
• Every complete medical assessment includes a history of the mechanism of injury by AMPLE history and understanding the mechanism is key to provide clues to the injuries

Physical Exam

• During the secondary survey, physical examination follows the sequence of head, maxillofacial structures, cervical spine and neck, chest, abdomen and pelvis, neuralogical etc.
• Injuries are divided into two broad categories: blunt and penetrating trauma (see Biomechanics of Injury).
• The secondary survey begins with evaluating the head to identify all related neurologic injuries and any other significant injuries

Cervical spine and Neck

• Patients and with maxillofacial or head trauma should be presumed to have a cervical spine injury (e.g., fracture and/or ligament injury), and cervical spine motion must be restricted

Chest

• Visual, palpation percussion, distan sounds and evaluation of the chest, both anterior and posterior can help identify thoracic components such as open pneumothorax and large flail segments

Abdomen and Pelvis

• An intra-abdominal injury doesn't require knowing if someone needs operative intervention but rather abdominal reevaluation is necessary.

Perineum, Rectum, and Vagina

• The perineum should be examined, while vaginal and reical examinations can assess for any interior issues during the patient's truama.

Musculoskeletal System

The extremities should be inspected for contusions and deformities (including bone for patapation and injuries) if the patient sustained any issues.

Reevaluation

• Trauma patients must be reevaluated constantly to ensure that new findings are not overlooked and to discover any deterioration in previously noted findings.
• Continuous monitoring of vital signs, oxygen saturation, and periodic tidal carbon dioxide are useful.

records

• Meticulous record keeping is crucial during patient by signing a member of the trauma team the primary responsibility to accurately record and collate all patient care information.
• If a need occurs the patient's treatment needs exceed the capability of the receiving institution, transfer is consi-dered.
• These guidelines take into account the patient's physiologic status, obvious anatomic injury, mechanisms of injury, concurrent diseases and other factors that can alter the patient's prognosis and decisions are made by ED personnel rather than transfer.

Teamwork

• To perform effectively, each trauma team should have a team leader who can effectively implement the medical plan to aid trauma.
• The ABC assessment requires individual assessment during each member of the trauma team.

These questions cover the diagnosis, and management of vascular, blunt force, and penetrating traumas to the head and neck. It emphasizes the importance of airway management, diagnostic imaging, and cautious handling in trauma care.