The initial management of the severely injured patient requires
the surgeon to make rapid choices between various diagnostic and therapeutic
interventions. In patients with a single severe injury there is a single set of
priorities. In sharp contrast, a patient with critical injuries to several
different organ systems often presents conflicting priorities in management.
The thoughtful and accurate ordering of diagnostic and therapeutic
interventions is critical to provide the optimal outcome and is perhaps the
most important task of the trauma surgeon.[13]
It is essential to begin with the assumption that the
physiologic state of the patient is likely to deteriorate, perhaps abruptly,
and that there is more than one serious injury present. It is also essential to
realize that the most obvious or most dramatic injury may not be the most
critical one. The trauma surgeon must adopt a very focused approach in which
problems are addressed in strict order of their threat to life and function.
Even a small delay for the treatment of a more minor injury cannot be
tolerated. Within this focused approach, the surgeon must be constantly
reassessing the situation as new data are obtained and be able to instantly
change the focus and the order of priorities as new injuries or new findings are
brought to light. The necessity to balance various conflicting priorities and
accurately direct the initial diagnosis and treatment requires an approach to
the patient as a whole, not as isolated organ systems. The overall management
of the patient is best directed by one person who has the experience and
authority to make difficult immediate decisions under stressful circumstances.
The correct prioritization of diagnostic and therapeutic
interventions requires an assessment of the criticality of the intervention,
the time frame in which action must be taken, and the cost of delay imposed on
other injured systems. In general, establishing a patent airway with adequate
oxygenation and ventilation are the primary concerns during resuscitation. Next
the physiologic stabilization of the patient and control of significant
hemorrhage must be addressed. Under these circumstances, optimal resuscitation
of the patient is the best resuscitation for any specific organ system. Once
immediately life-threatening problems have been controlled, management of
possible brain injury is the next priority. Patients with a high likelihood of
intracranial mass lesion requiring surgical intervention should undergo
computed tomography (CT) of the head as soon as practicable. This group would
include patients with Glasgow Coma Scale (GCS) score less than 8, especially in
the presence of lateralizing signs. After management of brain injury has been
undertaken, injuries causing less immediate threat to life and function should
be addressed. Damage-control laparotomy for control of visceral injury,
angiography for control of pelvic bleeding or to assess potential aortic
injury, revascularization of an ischemic extremity, or management of a
contaminated open fracture are examples of this type of problem. Treatment of
injuries that present no immediate threat to life or function
should be deferred until all other more critical issues have been resolved.
This group of injuries is often orthopedic and includes closed-extremity
fractures, spine fractures without neurologic compromise, facial fractures, and
most soft tissue injuries.
The initial evaluation of the trauma patient consists of a
rapid primary survey, aimed at identifying and treating immediately
life-threatening problems. The primary survey should be completed in no more
than 5 to 10 minutes. After all critical issues in the primary survey have been
addressed, a full head-to-toe secondary survey is undertaken, with the goal of
carefully examining the entire patient and identifying all injuries. The
primary survey is conducted according to the mnemonic ABCDE: Airway, Breathing,
Circulation, Disability, Exposure.
The crucial first step in managing an injured patient is
securing an adequate airway. The mechanical removal of debris and the chin lift
or jaw thrust maneuver, both of which pull the tongue and oral musculature
forward from the pharynx, are often useful in clearing the airway of less
severely injured patients. However, if there is any question about the adequacy
of the airway, if there is evidence of severe head injury, or if the patient is
in profound shock, more definitive airway control is necessary and appropriate.
In the majority of patients this is accomplished by endotracheal intubation.
Endotracheal intubation must be done rapidly, under the assumption of cervical
spine instability, and in a fashion that does not induce increased intracranial
pressure (ICP) in patients with head injury. This is best accomplished through
a technique borrowed from surgical anesthesia known as rapid-sequence
induction. In rapid-sequence induction, the patient is given a fast-acting
anesthetic agent followed by a neuromuscular blocking agent. This combination
of deep sedation and muscular relaxation allows careful intubation without
cervical hyperextension and with minimal physiologic impact. The technique can
be used with a number of different pharmacologic agents, depending on the
knowledge and preferences of the individual practitioner. It is incumbent on
the individual responsible for the procedure to be fully aware of the dosage,
risks, and indications associated with the agents chosen. Excessive ventilation
must be avoided after intubation, particularly in the hypovolemic patient,
because it will increase mean intrathoracic pressures and compromise cardiac
filling.
Although nasotracheal intubation has been widely suggested
as a central modality, if not the primary modality, for emergency airway
control in the past, we believe that nasotracheal intubation now should be used
only rarely in the initial management of the injured patient. Nasotracheal
intubation has a number of drawbacks, and the goal of safe endotracheal
intubation with cervical spine precautions can be better accomplished using
orotracheal intubation after rapid-sequence induction.
In a few patients, endotracheal intubation is either
impractical or impossible and a surgical airway is required. Indications for a
surgical airway include massive maxillofacial trauma, anatomic distortion due
to neck injury, and inability to visualize the vocal cords because of the
presence of blood, secretions, or airway edema. Cricothyroidotomy is the
preferred emergency procedure in the majority of circumstances. Actual
tracheotomy may be indicated in select patients, such as those with laryngeal
injuries. Either surgical procedure may be preceded by needle cricothyroidotomy
with jet insufflation to improve oxygenation and allow the surgical procedure
to be performed in a more orderly fashion. Emergency airway procedures are one
of the few immediately lifesaving interventions that a surgeon is
likely to be called on to perform. By their nature, such procedures are always
done under suboptimal conditions and under high stress. It is important for the
trauma surgeon to have fully planned the approach to secure a surgical airway
before being called on to actually perform the procedure.
After a secure airway has been established, the nature and
adequacy of tidal ventilation is assessed. Inspection, palpation, and
auscultation of the chest will demonstrate the presence of normal, symmetrical
ventilatory effort and adequate bilateral tidal exchange. A supine
anteroposterior chest radiograph is the primary diagnostic adjunct,
demonstrating chest wall, pulmonary parenchymal, and pleural abnormalities. If
there is decreased respiratory drive or severe chest wall injury, assisted
ventilation is usually necessary. In addition to these mechanical factors,
pulmonary parenchymal injury may lead to poor gas exchange and inadequate
oxygenation, which necessitates mechanical ventilation. In either circumstance,
the decision to provide assisted ventilation should be made early, as soon as
it appears likely that the patient will not be able to sustain adequate
oxygenation and ventilation, rather than at the point of overt ventilatory
failure. Serial measurement of arterial blood gases should be used to monitor
patients who are at risk and to assist in appropriate adjustment of the
ventilator. It is especially important to prevent episodes of hypoxemia and
hypoventilation in patients with associated head injury. There is also a body
of evidence that suggests that hyperventilation may be detrimental to cerebral
perfusion, accentuating the need for accuracy in ventilator management and
vigilance in monitoring pH and Paco2.
Once the airway is secured, and adequate breathing has been
established, the focus shifts to the circulatory system. The primary goal is
the identification and control of the hemorrhage. External hemorrhage is
controlled by direct pressure on the wound, while the possibility of hemorrhage
into the chest, abdomen, or pelvis is rapidly assessed. In patients with known
pelvic fracture, a pneumatic antishock garment may be applied or
circumferential compression can be accomplished with a bed sheet wrapped around
the pelvis. While steps are being taken to control hemorrhage, at least two
large-bore intravenous lines should be placed to allow fluid resuscitation.
These lines are usually placed percutaneously in the vessels of the arm. If
peripheral upper extremity access is inadequate, alternative routes include the
placement of a large-bore venous line in the femoral vein at the groin or
cutdown on the greater saphenous vein at the ankle. The subclavian vein is a
poor site for emergency access in the hypovolemic patient and should be used
only when other sites are not available. In small children, intraosseous
infusion is the preferred alternative route if peripheral access cannot be
established. Fluid resuscitation begins with a 1000-mL bolus of lactated
Ringer’s solution for an adult or 20 mL/kg for a child. Response to therapy is
monitored by clinical indicators, including blood pressure, skin perfusion,
urinary output, and mental status. If there is no response or only transient
response to the initial bolus, a second bolus should be given. If ongoing
resuscitation is required after two boluses, it is likely that transfusion will
be required, and blood should be administered early. The primary goal is the
control of hemorrhage, and fluid resuscitation is of value only if active
measures to control hemorrhage are in progress.
The clinician must be vigilant for possible causes of hypotension
that require immediate intervention during the primary survey, such as
pericardial tamponade or tension pneumothorax. If the pattern of injury and
clinical presentation raise suspicion of such injuries, immediate steps must be
taken, often before the chest radiograph is available. For example, if a
patient presents with profound hemodynamic instability and there is a high
suspicion of tension pneumothorax, a needle catheter decompression of the
affected hemithorax should be performed immediately, without radiologic
confirmation. Needle catheter decompression can be done with relative impunity,
even bilaterally, in patients who are intubated and on positive-pressure
ventilation. Much greater care must be taken in patients who are breathing
spontaneously, because the process of needle catheter decompression can induce
pneumothorax and worsen ventilatory dysfunction, especially if done on both
sides of the chest.
The next step is a rapid examination to determine the
presence and severity of neurologic injury. Level of consciousness measured by
the Glasgow Coma Scale (GCS) score ( Table 20–2 ), pupillary response, and
movement of extremities are evaluated and recorded. The assessment of neurologic function can be
complicated by endotracheal intubation and administration of neuromuscular
blocking agents. Pupillary response still can be assessed in the paralyzed
patient, but the GCS measured under these circumstances is of no value.
Intubation interferes with the assessment of the verbal component of the GCS,
and there is no standard method for interpretation. If the GCS is used in
intubated and paralyzed patients, notation should be made about the
circumstances of the assessment to signify that the score may be inaccurate.
Eye Opening
|
|
No response
|
1
|
To painful stimulus
|
2
|
To verbal stimulus
|
3
|
Spontaneous
|
4
|
Best Verbal Response
|
|
No response
|
1
|
Incomprehensible sounds
|
2
|
Inappropriate words
|
3
|
Disoriented, inappropriate content
|
4
|
Oriented and appropriate
|
5
|
Best Motor Response
|
|
No response
|
1
|
Abnormal extension (decerebrate
posturing)
|
2
|
Abnormal flexion (decorticate
posturing)
|
3
|
Withdrawal
|
4
|
Purposeful movement
|
5
|
Obeys commands
|
6
|
Total
|
3–15
|
The final step in the primary survey is to completely
undress the patient and do a rapid head-to-toe examination to identify any
injuries to the back, perineum, or other areas that are not easily seen in the supine,
clothed position. Evidence of blunt trauma, fracture, and unexpected
penetrating injuries is likely to be discovered.
After completion of the primary survey and after all
immediately life-threatening injuries have been addressed, a complete physical
examination is performed. This secondary survey is often done in a head-to-toe
manner and includes ordering and collecting data from appropriate laboratory
and radiologic tests. This time period also allows for the placement of
additional lines, catheters (e.g., nasogastric tube or Foley), and monitoring
devices. Data accumulated then can be used to reset priorities and plan
definitive management of all injuries.
A number of minor injuries may not become apparent until the
patient has been under medical care for 12 to 24 hours. By this time, competing
pain from other major injuries has often subsided, and the patient has had an
opportunity to take inventory of all bodily complaints. It is very important
for the physician to return and perform a tertiary survey, which is another
complete head-to-toe physical examination aimed at identifying injuries that
may have escaped notice in the first several hours.
