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TheApproachtoTrauma
WRITTENBY:NICHOLASE.KMAN,MD
THEOHIOSTATEUNIVERSITY

EDITEDBY:DAVIDM ANTHEY,MD
WAKEF ORESTM EDICALSCHOOL

"Wehaveamotorvehicleaccident5minutesoutperEMSreport."
47yearoldmaleunrestraineddriver,ejected15ftfromcararrivesviaEMS.VitalSigns:BP:
100/40,RR:28,HR:110.Hewasinitiallycombativeatthescene,butnowdifficulttoarouse.
Hedoesnotopenhiseyes,withdrawalsonlytopain,andmakesgurglingsounds.EMSplaced
aCcollarandBackboard,butcouldnotstartanIV.
Whatdoyoudo?

Traumaistheleadingcauseofdeathinthefirstfourdecadesoflifeinmostdevelopedcountries.To
thisend,therearemorethan5milliontraumarelateddeathseachyearworldwide.Motorvehicle
crashescauseover1milliondeathsperyear.Injuryaccountsfor12%oftheworld'sburdenofdisease.

Objectives
Uponcompletionofthisselfstudymodule,youshouldbeableto:
PerformanaccuraterapidassessmentwithfocusonABCDE's
Resuscitateandstabilizebypriority
Discusssecondarysurvey
Head/CNSTrauma
CervicalSpine
Chest
Abdomen
Musculoskeletal
Discussappropriatelabsandancillarystudiestothetraumainjuredpatient
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Learndisposition

InitialActions
Whatinitialactionsshouldyoutaketocareforthetraumapatient?
Assesstheprimarysurvey,withfocusonABCDE's
Addressproblemswithanyportionofthesurveybeforemovingon
Logrollthepatient
XrayandFASTExam
SecondarySurvey
Resuscitationandstabilization
PrimarySurvey
Aswithallofyourpatients,yourassessmentshouldalwaysbeginwithaddressingairway,breathingand
circulation.Eachproblemisaddressedpriortomovingtothenextpriority(ie,manageairwaypriorto
treatinghemorrhage).
A:AirwayMaintenancewithCERVICALSPINEprotection
B:BreathingandVentilation
C:Circulationwithhemorrhagecontrol/shockassessment
D:Disability:Neurologicalstatus
E:Exposure/Environmentalcontrol
Airway
Firstyou'llneedtojudgeiftheairwaypatent?
Havethepatientspeaktoyoutoestablishpatencyandtoevaluateforvoicechangeandstridor
Isthereevidenceofpoolingsecretionsorcyanosis?
Whileyoumayhaveanintactairwaynow,lookforproblemswhichmaycausethepatienttolosethat
airwayinthenearfuture.Itisusuallyeasiertoactnowbeforetheairwayisgone,thentodealwitha
patientwhoprogressedtoaninabilitytoventilateoroxygenate.
facialinjurycausingobstructionorbleeding
laryngealfractures
expandinghematomas
GCSof9orlessrequiresintubation
Ifyoufeelthepatient'sairwayisn'tintact,you'llneedtoact!
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ALWAYSMAINTAINCSPINEIMMOBILIZATION
Considerperformingjawthrusttoestablishpatencyoftheairway.
Consideruseofanasoororopharyngealairwayduringbagvalvemaskventilations(BVM)
RapidSequenceintubationifneededforairwaystabilizationorprotection(e.g.forGCSof9orless)
Evaluateneckforlandmarksassociatedwithcricothyroidotomyandtoassessthepatientfor
subcutaneousemphysemaortrachealdeviation.
Breathing
ApatentairwayDOESNOTmeanadequateventilation!Ventilationrequiresadequatelyfunctioninglungs,
chestwall,anddiaphragmtoproducethedepthandrateofrespirationaswellastheappropriategas
exchange.
Inordertoassessforadequatebreathing,you'llneedtolook,listenandfeelthechest.
Inspect:lookforcyanosis,JVD(tensionpneumothoraxorcardiactamponade),asymmetric
movementofthechest(flailchest),accessorymuscleuse(tensionpneumothorax)oropenchest
wounds(openpneumothroax).
Ausculate:listenforstridor(upperairwayinjury),lungbreathsounds(pneumoorhemothorax)
Percuss:feelforhyperresonance(pneumothorax)ordullness(hemothorax),subcutaneous
emphysema(airwayinjury),paradoxicalmovements(flailchest)crepitence&pointtendnerness(rib
fractures)orbruising(pulmonarycontusion).
TensionPneumothorax
TensionPneumothoraxpresentsasprogressivedeteriorationand
worseningofasimplepneumothorax,associatedwiththeformationofa
onewayvalveatthepointofaruptureinthelung.
Airbecomestrappedinthepleuralcavitybetweenthechestwalland
thelung,andbuildsup,puttingpressureonthelungandkeepingitfrom
inflatingfully.Hypotensiondueto:
Increasedintrathoracicpressuredecreasingpreload
Lossofleftheartbloodflowduetolossofpulmonaryvasculatureto
affectedlung
Compressionofmediastinum
TensionpneumothoraxisaCLINICALdiagnosisandXraysarenotappropriateinthissetting.If
tensionpneumothoraxissuspected,immediateneedledecompressionisundertaken
Thetreatmentisaneedledecompressionusing1416gaugelongangiocathinsertedatmidclavicular
lineinthesecondintercostalspace,overtheribtoavoidtheneurovascularbundle(showninpicture
below).
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MassiveHemothorax
Thisisanotheremergencywhichmayrequireurgentinterventionduringtheprimarysurvey.Asystemic
orpulmonaryvesseldisruptionleadsto:
>1500mLbloodlossinitially
>400ccperhourfor2hours
Neckveinsareexpectedtobeflatbutmaybefullduetosupinepositionorassociatedtension
pneumothoraxortamponade.Consideramassivehemothoraxinpatientsinshockwithnobreath
soundsand/orpercussiondullness.
Thetreatmentconsistsofplacingalarge(36f)chesttubeandpossiblyatriptotheoperatingroom
(OR)forhemorrhagecontrol.
Circulation
Thegoalhereistoestablishthatthepatientisgettingadequatetissueperfusionandoxygenation.Any
activehemorrhageshouldbecontrolledwithdirectpressure.
Firstfeelforpulses.Ifaradialpulseispalpable,itsuggestsasystolicbloodpressureofatleast80
mmHg.Ifthefemoralorcarotidarepalpable,thesesuggestasystolicbloodpressureofatleast60
mmHg.Noteiftheyarethreadyversusbounding.
Manypatientsmaynotmountatachycardicresponse.
Neurogenicshocktosympatheticcorddisruption
Betablockade,Calciumchannelblockade
Elderly
Childrenandyoungadults
Conditionedathletesstartwithalowerbasallevel.Doublingtheirrestingheartrateof4550shows
afalselyreassuringheartrateof90100.
ATLSClassificationsofhemorrhagicshock

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Disability
The"D"fordisabilityrepresentsaquickchecktoassessneurologicstatus.Youcanquicklyassess
mentalstatusviatheAVPUscale:
Alertafullyawakepatient.
Voicethepatientrespondswhenverballyaddressed.Responsetovoicecanbeverbal,motor,or
witheyes.
Painthepatientmakesaresponseonanyofthethreecomponentmeasuresonlywhenpain
stimulusisdelivered.
UnresponsiveIfthepatientdoesnotgiveanyEye,VoiceorMotorresponsetovoiceorpainful
stimuli.
Performagrossmotor/sensoryexaminationtodetermineifCNSisintact.Thisisnotafullneurologic
examination.Forexample,traumateamleaderwillaskthepatienttowiggletheirtoestoassessmotor
responsetoaverbalcommand.Afullneurologicexamisdonelaterinthesecondarysurvey.
Assesspupilsforsize,symmetryandreactivity.Uncalherniationwillpresent
asa"blownpupil."Thisresultsfromtheparalysisofparasympatheticfibers
ofpupillaryconstrictorsofCNIII.Youwillseeadilatedpupildueto
unopposedsympatheticactivity.Thepictureshowsadilatedpupilinahead
injuredpatient.
TheGlascowComaScore(GCS)evaluatesmentalstatusviaassessment
ofeyeopening,motorresponse,verbalresponse.Eachareisgivenascore
from1to34or5.Thebestpossiblescore15,worstscore3.Youcannot
haveascoreofzero.
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GCSValue

Finally,logrollthepatientusingspinalimmobilizationtopalpatethespineforstepoffsorpain.
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Exposure/Environment
Completelydisrobepatienttoassessforanyhiddeninjury.Keeppatientwarmtopreventcoagulopathy.
AdjunctstothePrimarySurvey
Thesearetestswhichcanbedoneduringthe
primarysurvey:
StandardTraumaXrays:suchasanAPchest,
APpelvis
FASTExam(FocusedAssessmentSonography
inTrauma)israpidnoninvasive,inexpensiveand
8697%accurate(operatordependent).Thereare
fourviewstakenthesubxiphoidcardiacview,
splenorenal,hepatorenal,andbladderviews.Any
blooddetectedduringtheFASTexammay
representperitonealpenetration.Ifthepatientis
unstable,theyshouldgotoORandNOTtoCT
scanner.Conversely,anegativeFASTdoesnot
excludeinjury.

SecondarySurvey
TheSecondarySurveyisnotstarteduntilallaspectsoftheprimarysurveyhavebeenaddressedand
vitalsignshavebeenaddressed.
History:
StartwiththeAMPLEhistory:
Allergies
Medications
Pastillnesses
Lastmeal
Events/Environment/Mechanismofinjury
Physical
Next,initiateaheadtotoedirectedassessmentfocusingon:
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SecondarySurveyInTrauma

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0:Totalparalysis
1:Palpable/visiblecontraction
2:FROMw/gravityeliminated
3:FROMagainstgravity
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5:Normalstrength
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BluntTraumamayresultincrushedlarynx,trachealdisruption,expanding
hematoma,esophagealleak.
Penetratingtraumamayresultininjurytomajorvascularstructures,pharynx,
larynx,trachea,esophagus

Obstructionsecondarytotraumamaybeduetodirecttraumatolarynxorneck.
Thepresentationmaybeofinspiratorystridor(supraglottic)orexpiratorystridor
(subglottic),muffledvoice,difficultyhandlingsecretions.Exammaybemisleadingas
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necktraumamayshowsubtlesymptomsandsignspriortoobstruction.
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Inordertoclearthecervicalspineandremovethepatient'scollar,theymusthave
thefollowingfindings:
Alert,notintoxicated
Absenceofneckpain
Absenceofmidlinenecktenderness
Absenceofdistractinginjury
Absenceofsensoryormotorcomplaint

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Inspectforobviousinjurieswithconsiderationformechanism.
Palpateforsubcutaneousemphysema,chestwallstability.
Percussfordullnessorhyperressonance.
Auscultatefordiminishedbreathsounds(pneumoorhemothorax)
Somelifethreateningconditions:

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Atracheobronchialtreedisruptionwillpresentonphysicalassubcutaneous
emphysema.Youmaynoticethatafterplacingachesttube,thelungrefusesto
inflate.Theremaybeapersistentairleak.Youmayneedtoplaceasecondchest
tube,andifthisfails,thepatientneedstogototheOR.
Apulmonarycontusionmayinitiallypresentasmildhypoxiabutafterfluid
resuscitation,thecorrespondingpulmonaryedemaworsensandsodoesthe
hypoxia.Thiscanbediagnosedonchestxray(orCT)andistreatedbyproper
oxygenationandventilation(oftenwithintubation),andmaintaining
normovolemia.
Abluntcardiacinjuryisdifficulttodiagnosis.Oftentheonlysignmaybean
abnormalECGortracingonthecardiacwaveform.Echocardiographymayshowa
hypokineticheart.Treatmentconsistsofmedicatingdysrhythmiasthateffect
hemodynamics.
Atraumaticaorticdisruptioniscausedbyarapidacceleration(or
deceleration)causingatearintheaorta.Normallythisisimmediatelyfatal,but
thosewhosurvivemayshowawidenedmediastinumonCXR.Thiscanbe
confirmedwithCTscanorangiographyoftheaortaandrequirespromptsurgical
correction.
Aflailchestiscausedbytwoormorefracturesin2+contiguousribscreatinga
freefloatingsegmentofchestwall.Thissegmentwillmoveintheopposite
directionoftherestofthechestwallduringinspirationandexpirationanddisrupts
thenormalnegativepressureventilatorymechanics.

Inspectforbruisingpatterns(Cullen'ssignofperiumbilicalbruisingorGreyTurner's
signofflankbruising,bothassociatedwithretroperitonealhemorrhage)oraseatbelt
sign.
Auscultateforabsentortympanicbowelsounds.
Palpateandpercussforreboundtenderness,guardingordiffusedullness(peritoneal
signs).
Frequentreevaluationsareimportantsincetheprocessmayprogress.

Presentswithpain/instabilityonpalpationorunequalleglengths.Ifthepelvicringis
disrupted,itmayshearbloodvesselssuchasthepelvicvenousplexusorinternaliliac

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disrupted,itmayshearbloodvesselssuchasthepelvicvenousplexusorinternaliliac
arterialsystem.Thiscanleadtosevere
hemorrhage,andthepelviscanhidea
lotofblood(5L).
Treatmentinvolvesstabilizingthepelvis
bywrappingasheetaroundit(to
compress),longitudinaltraction,pelvic
binders,MASTtrousers(fallingoutof
favor).

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Examineperineumforcontusions,scrotalhematomas,lacerations,orbloodatthe
urethralmeatuswhichcanbesignofurethraldisruption.Ontherectalexam,lookfor
diminishedsphinctertonewhichcanbeasignofaspinalcordinjury.Examprostateto
checkpositionasahighridingprostatecanbesignofapelvicfractureorurethral
injury.Finally,assessforrectalwallintegrityandgrossblood.

Alwayscheckfordistalperfusionandneurovascularstatus.Besuretodocumentthat
eachextremityis"neurvascularlyintact."Theworrisomediagnosisoftheextremityis
acompartmentsyndrome(anincreasedpressureisaclosedfascialspace).This
presentseventuallywiththefiveP's(Pallor,Pain,Paresthesia,Poikilothermic,
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Pulseless(latefinding)).Injuriespronetodevelopingcompartmentsyndromeinclude
forearmandtibialinjuries,tightdressingswithunderlyingincreasingswelling,
prolongedexternalpressureorecrushinjuries,orcircumferentialburns.The
treatmentisaafasciotomy.

DifferentialDiagnosis
Atthispointyoushouldalreadyhaveyourdifferentialdiagnosisestablishedasthiswillguideyour
furthermanagement.Itshouldincludeallthelifethreateningcriticaldiagnoses:

TraumaCriticalDiagnoses
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Thediagnosesyoumustconsiderinpatientswithtraumaaremany.Discussionofeachof
thesewillbepresentedinfurtherdetailsinotherchapters.Someinclude:
Airwayobstruction/insufficiency
Tensionpneumothorax
Openpneumothorax
Flailchest
Cardiactamponade
Massivehemothorax
TraumaticAorticDisruption

TraumaDiagnosticStudies
TypeandCross
ATypeandCrossmatchismostimportantlabintraumapatient,asitprocuresbloodforpotential
transfusion.Thisdoestaketimetoperform,though.
Fullycrossmatchedblood:1hourprocessingtime
Typespecificblood:ABOandRhonlytested,10minuteprocessingtime.
TypeONegative(malesmayreceiveOPositiveblood):isimmediatelyavailable
Otherlabs
Otherlabstudiestoconsiderinmosttraumapatientsbasedoninjuriessuspected:
CBCtocheckhemoglobin,hematocritandplatelets
ABGandLactatetoscreenforshock
Chemistrypanel
Urinalysis
EtOH
EKGifindicated.
StandardTraumaXrays
APchestandAPpelvisxraysaredoneasadjunctstotheprimarysurvey.
CervicalSpineXrays:lateralview(detects80%fractures),AP,openmouth"Odontoid"view,and
obliques
Otherimaging&Testing
CTscan(maybeperformedofhead,face,Cspine,chest,abdomenandpelvis)
FAST(seededicatedsectioninprimarysurvey)
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Xrays(seededicatedsectioninprimarysurvey)plusother
EKG(especiallyforfall,drowning,syncopeorsinglecarMVA)
Retrogradeurethrogramifconcernforurethralinjury.
DiagnositicPeritonealLavage
ThisinvasivetesthasmostlyreplacedbyUltrasound(rarelyperformedtoday)butmaybeusedfora
hypotensive,unstablepatient.Itis98%sensitiveforbleedingandisusedtodetectbowelinjury(often
missedonCT).
Atestisconsideredpositiveifitreturns
Grossblood(10ml)
100,000RBCs/mm3
Morethan500WBCs/mm3
PositiveGramstain
Foodfibers
Bacteria,bile,feces
Itisinvasiveanddoesmissretroperitonealinjuries.
TraumaDisposition
Significanttraumashouldbecaredforatalevelonetraumacenter
Processfortransferstartedassoonasneedfortransferisidentified.
Lifethreateninginjuriesshouldbeevaluated&addressedpriortotransfer.
Considersecuringairwayandtreatingborderlineinjuriesfortransfer.

"Wehaveamotorvehicleaccident5minutesoutperEMSreport."
47yearoldmaleunrestraineddriver,ejected15ftfromcarthenarrivesviaEMS,Vital
Signs:100/40,RR28,HR110.Initiallycombativeatthescene,butnowdifficulttoarouse.He
doesnotopenhiseyes,withdrawalsonlytopain,andmakesgurglingsounds.EMSplaceda
CcollarandBackboard,butcouldnotstartanIV.
Asyoumovethepatientovertothegurney,younoticetrachealdeviation,paradoxicalchest
movement,andalargeboggyrightparietalscalphematoma.Yourealizeyouhavetomove
quicklyusingwhatyou'velearned!
Whatdoyoudofirst?
Youscreamout"ABC's,IV,O2,Monitor!"asyoutendtothepatient'sprimarysurvey.
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A:IsAirwayintact?No,patientneedstobeintubatedwithinlinestabilizationasheis
alteredandcombative
B:IsBreathingintact?No,gurglingbreathsoundswithincreasedrespiratoryrateand
trachealdeviation.Thispatientneedsaneedledecompressionfollowedbyachesttube.
C:Aretheresignsofshock?Yes,tachycardiaandhypotensionwithalteredmentalstatus.
Theseresolvedwhenyouplacedthechesttube.
D:WhatistheGCS?Eyesclosed(1),withdrawsonlytopain(4),makesincomprehensible
sounds(2)=totalof7.Lessthan8,intubate!
E:Uponexposureyouseeacold,bluerightfoot.Youreducethefoottoregainpulses.
NextyouperformaSecondarySurvey
HEENT:largeboggyrightparietalscalp,
thepupilsaresluggishandthere's
hemotympanumontherightside.Younote
nofacialtrauma.Thetracheaisalso
deviatedtotheleft.
Chest:absentbreathsoundsonright
Heart:tachy
Abdomen:soft,noguardingorobvious
tenderness
Extremities:Leftankleopen,dislocatedcold,nopulse
Neck/Back:normal
Youbegintoresuscitatewith2litersIVNormalSaline,order
Typeandcross,cbc,chem7,u/a,andcoags.Notingthe
trachealdeviationtotheleftanddecreasedbreathsoundsontheright,youquicklyperforma
needledecompressionandplaceachesttube.Theycometoshootyourchestxrayandyou
nownotearesolvingRsidedsimplePTX.Pelvisxrayisnegative.FASTisnegative.
YouorderAntibiotics,tetanusboosterandcallortho.Whenthepatient
isstablizedyoumovetoCTscanwherethefollowingscansare
obtained:CToftheHead,Cspine,Chest,AbdomenandPelvis.
Therestofhisscansrevealtheresolvedpneumothoraxandchesttube
youplaced,severalbrokenribsontheright,novisceralinjuriesandno
pelvictrauma.HeistakenemergentlytotheORfortreatmentofhis
epiduralhematomaaswellaswashoutofhisopenankle
fracture/dislocation.
HespendsseveraldaysintheSICUwithanexcellenthospitalcourse,
isextubated,andhasnormalneurologicalfunction.Hischesttubeispulledandheis
dischargedhomeinexcellentcondition.
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