Trauma Evaluation

Aka: Trauma Evaluation, Trauma Exam, Primary Trauma Evaluation, Primary Trauma Survey, Trauma Primary Survey, Primary Survey, ATLS, Traumatic Injury, Trauma, Advanced Trauma Life Support

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II. Epidemiology

  1. Trauma is the leading cause of death under age 40 years (fifth leading cause of death overall)
  2. Worldwide Trauma deaths: 5 Million per year
  3. Trimodal distribution of Trauma deaths
    1. First Minutes
      1. Catastrophic injury (Aortic Rupture, high cervical cord injury)
    2. First Hours ("Golden Hour")
      1. Intracranial injury (e.g. Epidural Hematoma, acute Subdural Hematoma)
      2. Pneumothorax
      3. Hemorrhagic Shock
    3. Days to Weeks
      1. Secondary Trauma complications (e.g. infection)

III. Precautions

  1. See Emergency Decision Cycle (OODA Loop, AAADA Model)
  2. Overhead Page all full Trauma Team Activations
  3. Maintain careful, time-stamped records of evaluation and management of the Trauma patient
  4. Deliver medications intravenously (instead of IM, SQ) due to erratic or delayed medication absorption in Trauma
  5. Ensure smooth hand-offs from EMS
    1. Consider en-route triaging to the most appropriate facility
      1. See Trauma Triage in the Field
    2. Hand-off in the emergency department (MIST mnemonic)
      1. Mechanism and time of injury
      2. Injuries identified (or suspected)
      3. Symptoms and signs
      4. Treatment initiated (by EMS or outside facility)
  6. Team Leads (assign roles before EMS arrival in "zero point survey")
    1. Team leader (medical provider)
      1. Maintains calm environment
      2. Directs task/procedure assignments (and performs procedures when team needs help)
      3. Communicates with Podium Nurse in closed-loop communication
    2. Podium Nurse
      1. Records Resuscitation and calls out times
      2. Medications and equipment direction flow through podium nurse to staff performing activities

IV. Pitfalls: Common

  1. Inadequate airway maintenance
    1. Delayed definitive airway (e.g. Endotracheal Intubation)
    2. Inadequate protection of Cervical Spine
    3. Airway obstruction by foreign matter (e.g. blood)
    4. Airway obstruction by Tongue or epiglottis
  2. Inadequate fluid Resuscitation in head injured child
  3. Failure to recognize and treat internal Hemorrhage
  4. Inadequate exposure (missed sites of injury)

V. Background: Protocol Changes

  1. "Fingers and Tubes in every orifice" mantra has caveats in 2014 ATLS
    1. Urinary Catheterization and Gastric Catheterization have specific indications in 2014
    2. Rectal Exam in the Trauma Secondary Survey has specific indications

VI. Protocol: Primary Survey (Mnemonic: ABCDEFG)

  1. See ABC Management
  2. See Rapid ABC Assessment
  3. Airway maintenance with C-Spine Control
    1. See Primary Survey Airway Evaluation
    2. See Advanced Airway for intubation indications
    3. Maintain spine stabilization and use Jaw Thrust maneuver
    4. Establish a definitive airway if any concern that patient cannot maintain their own airway
      1. However, hypoperfusion at time of intubation risks hemodynamic collapse and peri-intubation arrest
      2. May temporize with Nasal Trumpet (or if comatose, an Oral Airway or LMA) until fluid resuscitated
  4. Breathing and Ventilation
    1. See Primary Survey Breathing Evaluation
    2. Apply Supplemental Oxygen
    3. Positive Pressure Ventilation as needed
    4. Monitor Pulse Oximetry
    5. Identify Tension Pneumothorax and decompress immediately (needle or Finger Thoracostomy)
    6. Use lung protective Ventilator settings if intubated (Tidal Volume 5-7 ml/kg, low PEEP, increased rate)
  5. Circulation with Hemorrhage Control
    1. See Primary Survey Circulation Evaluation
    2. See Emergent Reversal of Anticoagulation
    3. See Hemorrhage Management
  6. Disability: Neurologic Status
    1. See Primary Survey Disability Evaluation
    2. Glasgow Coma Scale, Pupil Reaction, and movement of all extremities (prior to RSI)
  7. Exposure and Environmental Control
    1. See Primary Survey Exposure Evaluation
    2. Assess for easily missed sites of injury
      1. Mnemonic: Armpits, Breasts and Back, Butt cheeks and Sac
      2. Log Roll the patient (and remove the Backboard)
    3. All clothing should be removed to completely assess for injuries
      1. Expose Penetrating Trauma first
    4. Prevent Hypothermia (and treat if present)
      1. Apply warm blankets
      2. Warm Intravenous Fluids
  8. FAST Exam (trauma Ultrasound survey)
    1. Evaluate for Pneumothorax and Hemothorax
    2. Evaluate for Pericardial Effusion
    3. Evaluate for intra-abdominal Hemorrhage
  9. Glucose/Girl
    1. Check Serum Glucose
    2. Check serum or Urine Pregnancy Test

VII. Protocol: Secondary Survey

  1. See Trauma Secondary Survey
  2. Backboard may be discontinued when Secondary Survey log-roll is performed (if no contraindication)
    1. See Backboard Clearance
    2. Backboards do not typically have a role in the hospital (outside the pre-hospital and transfer setting)
  3. Obtain Trauma History
  4. Other initial measures
    1. Urinary Catheterization
      1. See Urinary Catheterization for contraindications (e.g. Urethral meatus blood, perineal/scrotal Hematoma)
      2. Indicated for monitoring of fluid Resuscitation (and adequacy of hydration)
      3. Normal Urine Output is >0.5 ml/kg/h in adults (>1 ml/kg/h in children, >2 ml/kg/h in infants)
    2. Gastric Catheterization (e.g. Nasogastric Tube or Orogastric Tube)
      1. Indicated for aspiration risk
      2. No longer automatically recommended for all Trauma patients (as of 2014 ATLS)
      3. Placement may also induce Vomiting
  5. Consider mechanisms of injury
    1. See Trauma Mechanism

VIII. Diagnostics

  1. See Trauma Diagnostic Testing

IX. Imaging

  1. Precautions
    1. Radiology
      1. Imaging should be in the emergency department Trauma bay until stabilized
      2. Radiology department imaging is reasonable in stabilized Trauma patients
        1. However, patients should be accompanied by appropriate staff in case of acute decompensation
    2. Transfer
      1. Avoid pan-scan (head to Pelvis CT) if Transferring a patient to a Trauma Center
      2. Make electronic copies (e.g. CD) of all imaging to send with patient
      3. Avoid imaging that will not acted upon at your sending facility (unless no delay)
  2. CT Head
    1. Indicated for signs of Head Injury including Altered Level of Consciousness (especially if anticoagulated, Intoxication)
    2. See Head Injury CT Indications in Adults
    3. See Head Injury CT Indications in Children (PECARN)
  3. CT C-Spine
    1. Indicated for any ill patient who needs Cervical Spine imaging (replaces Cross Table lateral XRay)
    2. See Cervical Spine Imaging in Acute Traumatic Injury (e.g. NEXUS Criteria)
  4. Chest XRay
    1. Indicated in nearly all Trauma patients (especially for confirmation of ET placement prior to transport)
    2. Consider placing xray cassette during Log Roll
    3. However, Chest XRay misses major injuries in significant Chest Trauma or mechanism
      1. FAST Scan followed by Chest CT is preferred in these cases
      2. Langdorf (2015) Ann Emerg Med 66(6): 589-600 +PMID:26169926 [PubMed]
    4. However Chest XRay is often sufficient
      1. CT Chest often identifies more injuries than Chest XRay, but that do not require additional interventions
      2. Rodriguez (2019) Ann Emerg Med 73(1): 58-65 +PMID: 30287121 [PubMed]
  5. Pelvis XRay
    1. Indicated for suspected Pelvic Fracture (optional if CT Abdomen and Pelvis are performed immediately)
    2. Consider placing xray cassette during Log Roll and performing at same time as Chest XRay
  6. FAST Exam (trauma Ultrasound survey)
    1. Performed as part of the initial Primary Survey (see above)
  7. Chest CT
    1. See Nexus Chest CT Decision Rule in Blunt Trauma for indications
  8. CT Abdomen and Pelvis
    1. Not needed if benign Abdomen and Pelvis without pain, tenderness and if vitals signs stable, normal FAST Exam

X. Management: Fluid Resuscitation and Hemorrhage Management

  1. See Hemorrhagic Shock
  2. See Fluid Resuscitation in Trauma
  3. See Emergent Reversal of Anticoagulation
  4. Control Hemorrhage (local pressure, Tournique, Topical Hemostatic Agent)
    1. Assume Hemorrhage as cause of shock (but consider other shock causes)
    2. Administer Tranexamic Acid (TXA) within 3 hours of injury for active bleeding
    3. Consider blood loss sites (thorax, Abdomen/Pelvis, Retroperitoneum, long bone Fractures)
  5. Initial fluids - Replace up to the first liter with crystalloid (until Blood Products available)
    1. Precaution
      1. Trauma patients do not bleed saline
      2. Blood loss replacement should be with blood as soon as available (see below)
    2. Start with Isotonic crystalloid (Normal Saline or Lactated Ringers)
      1. Use minimal crystalloid if no signs of blood loss and hemodynamically stable
      2. Expect mild Sinus Tachycardia from pain and stress of emergency evaluation
      3. Excessive crystalloid dilutes blood, Hemoglobin And Coagulation Factors
    3. Use warmed crystalloid
      1. Trauma patients are typically hypothermic (and secondarily coagulopathic)
    4. Hypertonic Saline may be used instead (?antiinflammatory) but studies do not support benefit
      1. Bulger (2011) Ann Surg 253(3): 431-41 [PubMed]
  6. Subsequent fluids (after first 500 to 1000 ml of crystalloid)
    1. Replace blood loss with Packed Red Blood Cells
      1. Early initiation of Packed Red Blood Cells within the first hour improves survival
      2. Every 10 minute delay of Blood Transfusion decreases survival
      3. Powell (2016) J Trauma Acute Care Surg 81(3):458-62 +PMID:27050884 [PubMed]
    2. Massive Blood Transfusion is typically accompanied by Platelet Transfusion and Plasma Transfusion
      1. Initiate if 4 units pRBC required within the first hour, or 10 units anticipated in first 24 hours
      2. Replace 1 unit of plasma for every 1-2 units of Packed Red Blood Cells
      3. Replace 1 unit of apheresis Platelets for every 8 units of Packed Red Blood Cells
      4. Holcomb (2012) Arch Surg 15:1-10 [PubMed]
  7. References
    1. Inaba and Herbert in Majoewsky (2013) EM:Rap 13(7): 4

XI. Management: Disposition of Seriously Injured Patient

  1. See Trauma Transfer
  2. See Trauma Team Activation (TTA)
  3. Goal: Disposition multisystem Trauma within 30 minutes
    1. Level 1 Trauma Center
    2. Operating Room
    3. Intervention Radiology

XII. Management: Disposition of patients with Trauma and reassuring clinical findings

  1. Neuroimaging negative in Mild Head Injury
    1. See Management of Mild Head Injury for discharge criteria
  2. Abdominal imaging negative in stable Blunt Abdominal Trauma
    1. Adults: Abdominal imaging may miss a serious adult injury in 0.5% of cases
      1. Overall safe to disharge if exam, imaging are reassuring and reliable follow-up in place
    2. Children: Abdominal imaging may miss a serious pediatric injury in 1 per 2600 cases
      1. Overall safe to discharge if exam, imaging are reassuring and reliable follow-up in place
      2. (2010) Acad Emerg Med 17(5): 469-75 [PubMed]

XIII. Resources

  1. Trauma Team Activation Video (Regions Trauma)
    1. http://www.youtube.com/watch?v=J8estsbxEWI

XIV. Reference

  1. Swadron, Inaba and Mallon in Herbert (2019) EM:Rap 19(9): 4-5
  2. Herbert and Inaba in Herbert (2014) EM:Rap 14(3): 5-6
  3. Mell in Herbert (2015) EM:Rap 15(2): 1-2
  4. Weingart and Swaminathan in Herbert (2021) EM:Rap 21(3): 5-8
  5. (2008) ATLS Manual, American College of Surgeons
  6. (2012) ATLS Manual, 9th ed, American College of Surgeons

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