Good morning everyone, today we are going to do Grand Rounds on the Trauma Unit. Trauma may be located in the Emergency Department but it is a far different animal all together. In order for the staff to determine where the patient belongs, they must complete triage with an initial assessment. The initial assessment is detailed below and will end part 1 of this multi-part series about the Trauma Unit.
From my Medscape account:
Trauma has been dubbed the forgotten epidemic and the neglected disease of modern society. Trauma annually impacts hundreds of thousands of individuals and costs billions of dollars in direct expenditures and indirect losses. Trauma care has improved over the past 20 years, largely from improvements in trauma systems, assessment, triage, resuscitation, and emergency care.
However, an Institute of Medicine report identified a US crisis in access and distribution to emergency care that may impact trauma system efficiency and effectiveness. Similarly, a predicted deficit in critical care practitioners may similarly degrade the post-emergency department care of the critically injured patient. The American College of Surgeons Committee on Trauma (ACS-COT) and the American Association for the Surgery of Trauma (AAST) acute care surgery initiative is designed to integrate trauma, emergency general surgery, and surgical critical care and to bolster new trainee interest in this field. Its sensitivity for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
Work must still be done to continuously improve trauma care nationally, regionally, and institutionally, and the ACS-COT applies rigorous standards to performance improvement prior to verifying US trauma centers. For this improvement to occur, the ongoing application of the unique principles and practice of intensive care medicine is necessary.
Patient outcomes after major trauma have improved in regions where comprehensive trauma systems have evolved. Crucial components of such a system should include a coordinated approach to both prehospital care and hospital care and to training providers in both areas. Paramedics and medical staff should be provided with a clear and objective framework for assessing patients, establishing and engaging treatment protocols, following triage guidelines, engaging in transportation and communication protocols, and implementing ongoing performance improvement programs. It is essential to recognize that care of the significantly injured patient is critical care in that critical care is a concept, not a location.
The most seriously injured patients must be identified in the field and safely transported to a designated trauma center where appropriate care is immediately available. This is the principle of triage and is subject to both under-triage and over-triage. Clearly, from a patient-centered view, over-triage is preferable, but, from a system perspective, over-triage may be problematic in an overcrowded and oversubscribed emergency department.
Trauma scoring systems describe injury severity and correlate with survival probability. Various systems facilitate the prediction of patient outcomes and the evaluation of aspects of care. The scoring systems vary widely, with some relying on physiologic scores (eg, Glasgow Coma Scale [GCS] score, Revised Trauma Score), and others relying on descriptors of anatomic injury (eg, Abbreviated Injury Score, Injury Severity Score). No universally accepted scoring system has been developed, and each system contains unique limitations. This limitation has resulted in the use of a number of such systems in different centers around the world.
Principles involved in the initial assessment of a patient with major trauma are those outlined by the American College of Surgeons (ACS) in their Advanced Trauma Life Support (ATLS) guidelines or those of the Australasian College of Surgeons in the Early Management of Severe Trauma guidelines. The principles involved consist of (1) preparation and transport; (2) primary survey and resuscitation, including monitoring, urinary and nasogastric tube insertion, and radiography; (3) secondary survey, including special investigations, such as CT scanning or angiography; (4) ongoing reevaluation; and (5) definitive care.
Preparation and Communication
Trauma-receiving hospitals should receive advance communication from emergency medical services care providers about the impending arrival of seriously injured patients. The patient’s mechanism of injury, vital signs, field interventions, and overall status should be communicated. This allows for the in-house trauma team to be called and for the emergency department staff to make appropriate preparations.
The trauma team members vary based on world geography but incorporate many similar elements, including representation from emergency medicine, trauma, critical care, with or without anesthesia, nursing, respiratory therapy, blood bank, radiology, social services, and registration. A team leader is identified, and it is the team leader’s responsibility to ensure that the resuscitation proceeds in an organized and efficient manner through the diagnostic and therapeutic protocols. Additional consultants may be engaged in response to specific injuries. In addition to this team, many trauma centers also have a trauma care coordinator (usually a nurse), who follows the patient through his or her hospital course.
On the patient’s arrival, a concise transfer of the patient from the paramedics should occur. One person should be talking, while everyone else is listening; this is crucial information for the whole team. In many trauma centers, the team leader is a senior or chief resident in surgery or emergency medicine, with close supervision from appropriate attending staff. Increasingly, mid-level practitioners (eg, physician associates, nurse practitioners) may serve in this role as well.
Most trauma centers use a system of prehospital triage that characterizes patients into those with physiologic derangements and those who have a suggestive mechanism of injury. Those patients with obvious derangements should prompt a full team response, while patients with less injury may be cared for by a modified team complement.
The primary survey aims to identify and treat immediately life-threatening injuries relying on the ABCDE system. This system comprises airway control with stabilization of the cervical spine, breathing (work and efficacy), circulation including the control of external hemorrhage, disability or neurologic status, and exposure or undressing of the patient while also protecting the patient from hypothermia. These elements are explored below.
Airway with control of the cervical spine
Airway assessment should proceed while maintaining the cervical spine in a neutral position. The latter is achieved by using a rigid cervical immobilization collar. Airway clearance maneuvers are extensively described elsewhere and are not reviewed in this article.
When the airway is in jeopardy, or when the GCS score is less than 8, an artificial airway is essential. Airway control is commonly achieved by means of rapid-sequence orotracheal intubation (OETT) performed with in-line stabilization of the cervical spine. Correct placement of the endotracheal tube is confirmed (1) by the aid of an end-tidal carbon dioxide monitoring device, (2) by observation of the tube passing through the vocal cords, and (3) by auscultation of the chest.
Several well-defined options for achieving airway control must be established in the event that OETT placement is not able to be achieved. These options include laryngeal mask airway (LMA), intubating LMA, fiberoptic intubation, percutaneous cricothyroidotomy, and surgical cricothyroidotomy (tracheostomy in children). Tracheal inspection is essential to determine if there is peritracheal crepitus or deviation from the midline indicating potential direct airway injury or intrathoracic pulmonary or major vascular injury.
One must next assess the adequacy of gas exchange. This is most readily accomplished by visual inspection of thoracic cage movement, palpation of the thoracic cage movement, and auscultation of gas entry. One is assessing for inequalities from one side to the other, crepitus, and local movement asymmetry as in paradoxic thoracic cage movement in flail chest. One is also evaluating for signs of impending respiratory failure, such as uncoordinated thoracic cage and abdominal wall movement, accessory muscle use, and stridor.
Inadequate ventilation may result in hypoxemia, hypercarbia, cyanosis, depressed level of consciousness, bradycardia, tachycardia, hypertension, or hypotension. As a general rule, until stability has been assured, administer high-flow oxygen by mask to all patients to abrogate the potential for hypoxemia.
Classic signs of a tension pneumothorax, hemothorax, or combined hemopneumothorax include tracheal deviation, jugular vein distension, hypoxia, tachycardia, and hypotension. Intrathoracic tension physiology is a clinical diagnosis and requires immediate decompression. This is initially commonly accomplished with a 14-gauge catheter-over-needle assembly placed in the second intercostal space (ICS) midclavicular line (MCL). Patients treated in this way should have a tube thoracostomy placed to manage simple pneumothorax and to evacuate thoracic cavity blood when present. Life-threatening hemorrhage identified when placing a tube thoracostomy may be managed with a resuscitative thoracostomy.
Circulation and hemorrhage control
Emergent treatment of patients with exsanguinating hemorrhage or shock can be life-saving. This assessment includes identifying and managing rapid external hemorrhage. This can often be achieved with a simple pressure dressing, but surgical intervention may be required. As more experience is gained with procoagulant dressings (used principally by the military), external hemorrhage control may gain pharmacologic support embedded in dressings.
Shock in trauma patients, defined as inadequate organ perfusion and tissue oxygenation, is most commonly caused by hemorrhage leading to hypovolemia, but many other causes are readily identified, including cardiac tamponade, tension pneumothorax or hemothorax, and spinal cord injury. Signs of shock include tachypnea, tachycardia, decreased pulse pressure, hypotension, pallor, delayed capillary refill, oliguria, and a depressed level of consciousness. In patients with hypovolemia, the neck veins may be flat. A normal mental status generally implies an adequate cerebral perfusion pressure, while diminished mentation may be associated with shock with or without intracranial trauma.
ATLS readily identifies 4 different classes of shock. Class I and II shock generally does not need red cell mass restoration and is well managed with asanguineous fluids for plasma volume expansion. Hypotension and disordered mentation generally indicate at least class III shock and should prompt plasma volume expansion and red cell mass repletion if the hypotension fails to resolve after an initial 2000-cc crystalloid bolus, according to ATLS.
A systematic approach for detecting the source of hypovolemic shock should consider 5 sources of ongoing hemorrhage, as follows: (1) external (eg, from the scalp, skin, or nose), (2) pleural cavities, (3) peritoneal cavity, (4) pelvis/retroperitoneum, and (5) long-bone fracture. Fracture alignment and stabilization is essential in limiting blood loss. Pelvic fractures may be initially stabilized with a pelvic binder or a wrapped sheet secured with a towel clip as a means of reducing pelvic volume to limit hemorrhage.
During the acute resuscitation period, a brief assessment of neurologic status should be performed. This assessment should include the patient’s posture (ie, any asymmetry, decerebrate or decorticate posturing), pupil asymmetry, pupillary response to light, and a global assessment of patient responsiveness.
A recommended system is the AVPU method, as follows: A = Patient is awake, alert, and appropriate; V = Patient responds to voice; P = Patient responds to pain; U = Patient is unresponsive.
A complementary assessment using the GCS should be made at this time, during the secondary survey, and at any time that the patient’s mental status appears to change. A more detailed assessment of the patient’s neurologic status is to be made during the secondary survey.
Patients should be completely disrobed during the initial assessment and the subsequent secondary survey. This helps ensure that significant injuries are not missed. At the same time, efforts to prevent significant hypothermia, using a warm ambient room (28-30°C), overhead heating, and warmed IV fluids, should be instituted. The patient’s temperature should be measured on arrival at the emergency department, and strenuous efforts should be made to avoid significant hypothermia during resuscitation and therapeutic intervention.
Urinary drainage catheters are commonly placed to assess for genitourinary system hemorrhage and to monitor urine flow. Precautions to avoid urethral injury should be taken for patients with pelvic trauma and for those who have blood at the urethral meatus. Digital rectal examination to identify a high-riding prostate should precede catheter insertion. Abnormal findings from the rectal examination or concern as to the continuity of the urethra should prompt a retrograde urethrocystogram to identify a urethral injury. If identified, a suprapubic catheter should be inserted, and a urologist should be consulted.
Gastric drainage tubes should be orally inserted into all major trauma patients requiring endotracheal intubation. Even in the absence of brain injury, oral gastric tube insertion is preferred to decrease the likelihood of sinusitis from drainage pathway obstruction. Children, in particular, are prone to gastric dilatation, which can significantly impair their respiration and lead to hemodynamic compromise. Immediate decompression may be life-saving. Ongoing monitoring of pulse rate, blood pressure, respiratory rate, oxygen saturation, and temperature is a standard of care in the US.
Initial imaging in the resuscitation room should be limited to a portable anteroposterior (AP) chest radiograph plus an AP pelvic image if the patient was involved in a high-speed motor vehicle collision or a fall from a height. Prior recommendations for lateral cervical radiography have been supplanted by routine pan-cervical imaging with image reformation using CT scanning, especially if the patient will undergo a brain CT scan.
Definitive clearing of the neck is managed in different ways in different institutions, but certain common features are identified. Patients with a clear sensorium and no distracting injuries may be clinically cleared if there is no neck pain on palpation and active flexion/extension/rotation. Patients with a normal CT scan but an abnormal mental status should remain in a rigid cervical immobilization device until they may participate in a physical examination or they undergo early (< 72 h postinjury) MRI to detect the presence of ligamentous injury.
Chest radiographs should be assessed for the position of tubes and lines, the presence of treatable life-threatening conditions, including space-occupying lesions, mediastinal widening, lung parenchymal injuries, and injuries to the thoracic cage or vertebral column.
A high-energy pelvic fracture identified on physical examination or pelvis film may substantially contribute to shock. Persistent hypotension suggests the need for early operative external stabilization, operative extraperitoneal pelvic packing, or angioembolization. Technique selection depends on the facility’s resources and practitioner skill set.
The secondary survey follows in the wake of correction of immediately life-threatening injury and completion of the primary survey. Thus, the secondary survey may not occur until after an emergency operation has been completed. The secondary survey includes a detailed history, complete physical examination, additional radiologic examinations, and special diagnostic studies. Many institutions include the focused assessment with sonography in trauma (FAST) examination as part of the primary survey rather than part of the secondary survey.
The history should include an assessment of the following items, which can be remembered by using the AMPLE acronym: A = Allergies; M = Medications; P = Past medical, surgical, and social history; L = Last meal; and E = Events leading to injury, scene findings, notable interventions, and recordings en route to the hospital.
Head and face and neurology
Palpate the entire cranium and face evaluating for injury and instability. Sutures, staples, or Rainey clips may be helpful in controlling bleeding from large scalp flaps. Palpate for facial crepitus and a mobile middle third of the face as a clue to potential difficulty in airway control. Hemotympanum and the presence of bruising around the eyes (ie, raccoon eyes) and mastoid process (ie, Battle sign) suggest basal skull fracture.
Recheck the pupils, and repeat GCS scoring. Evaluate the cranial nerves, peripheral motor and sensory function, coordination, and reflexes. Identify any neurologic asymmetry. Patients with lateralizing signs and those with an altered level of consciousness (GCS score of < 14) should undergo cranial CT scanning. Patients with traumatic brain injury (TBI) are particularly susceptible to secondary brain injury, in particular from hypoperfusion, hypoxia, hypercarbia, hyperglycemia, hyperthermia, and seizure activity. While primary brain injury and primary brain damage (induced apoptosis after primary brain injury) are beyond the clinician’s control, secondary injury is a preventable complication with careful attention to detail.
Maintaining cervical spine stabilization when removing a rigid cervical immobilization device is imperative. Penetrating injuries of the neck may require angiographic, bronchoscopic, or radiologic examination depending on the level of injury (ie, zone I, II, or III). In particular, zone II injuries that violate the platysma may be readily explored, while those injuries in zone I or III benefit from additional investigation because of the difficulty in identifying and controlling injuries in those zones.
Reexamine the chest. Initiate further investigations as indicated by physical examination findings or radiography results. While aortography was previously identified as the criterion standard investigation to identify aortic transaction, CT angiography has essentially replaced intra-arterial contrast injection. Transesophageal echocardiography using an omniplane probe may be safely used as well but suffers from difficulty with technology access after hours, dependence on user skill set, problematic probe insertion in patients requiring cervical immobilization, and blind spots at the aortic arch.
Inspect, percuss, palpate, and auscultate the abdomen, noting tenderness and examining for fullness, rigidity, guarding, or an obvious bruit (rare). Remember that blood is not always a peritoneal irritant, and hemoperitoneum may occur without obvious external signs.
Inspection of the abdomen may be confounded by distracting injuries and impaired consciousness from TBI, intoxicants, or prescription medications. FAST scans are routine in most emergency departments and serve to establish the presence or absence of fluid in 4 distinct domains: pericardium, right upper quadrant, left upper quadrant, and pelvis. Diagnostic peritoneal lavage is now rarely used. Extended FAST scanning may also interrogate the thoracic cavity for evidence of pneumothorax. The practitioner should be aware that FAST scanning is not organ-based imaging, and FAST scanning should not be used to establish the presence or absence of solid organ injury. Hemodynamically acceptable patients with a positive FAST scan generally undergo CT scanning to establish the source of presumed hemorrhage. Patients with a positive FAST scan who are unstable generally proceed to operative intervention in the emergency department (cardiac tamponade) or the operating room (intraperitoneal hemorrhage).
FAST scanning does not evaluate the retroperitoneum, and a normal FAST scan may coexist with substantial retroperitoneal hemorrhage. Also, a positive FAST scan may indicate ascites instead of blood, especially in those with renal or hepatic impairment.
Inspect, palpate, and move the limbs to determine their anatomic and functional integrity. Pay attention to the adequacy of the peripheral circulation and integrity of the nerve supply. Arterial insufficiency in patients with a displaced fracture or dislocation requires immediate treatment, generally fracture reduction and/or joint relocation. Pulse inequality should be assessed by means of an ankle-brachial index with diagnostic intervention reserved for those with an absolute ABI difference of 0.2 or greater from one side to the other. Liberal use of diagnostic plain radiography is essential in excluding extremity fracture in patients with mixed mechanisms of injury and in those who cannot participate in an examination because of significant TBI, intoxicants, or other causes.
The log roll refers to the slow controlled turning of the patient to each side to assess the dependent part of the supine trauma patient. Care must be taken to avoid secondary injury from an as-yet undiagnosed unstable fracture. This examination concentrates on the back of the head, neck, back, and buttocks, and it includes a rectal examination. The log roll also provides a convenient time to remove the long immobilization board. The board has not been shown to prevent injury in the presence of an unstable vertebral fracture, but it is highly correlated with pressure ulceration in patients who remain on the board for prolonged periods of time (ie, until diagnostic intervention is complete).
This procedure should be carried out by at least 4 people. The first person stabilizes the head and neck, the second and third persons turn the patient, and the fourth person examines the patient’s dorsum and performs the digital rectal examination. At the completion of the examination, and if the patient is not on an x-ray film bearing stretcher, the chest x-ray plate is readily positioned behind the patient. Spine imaging most commonly proceeds as part of the CT scan using reformatted images. This technique has been demonstrated to have equal, and in some studies superior, efficacy to AP and lateral thoraco-lumber spine imaging for fracture identification.
During the secondary survey, the ABCDE system should be used to constantly reevaluate the patient, and an ongoing diagnostic and therapeutic plan should be revised, as indicated, by the patient’s response to intervention and diagnostic test results.