Trauma care begins before the patient arrives at the hospital. Typically, rescue personnel respond to a call and provide pre-hospital care. In general, pre-hospital care is grounded in basic life support (BLS), advanced cardiac life support (ACLS), and pediatrics advanced life support (PALS). Similarly, basic principles of trauma care are applied in the field under the auspices of pre-hospital trauma life support (PHTLS). The hospital team needs to understand the capabilities and limitations of their local rescue teams to predict better what will present on arrival.
As a call comes in from the field, the hospital team should begin to triage the patient based on their age, mechanism of injury, coagulation status, and other factors that can impact the management of the case. The team should also prepare all the necessary equipment and don personal protective equipment (PPE) such as gowns, masks, gloves, and X-ray lead vests, if available. The team leader should carry out prompt coordination, and all appropriate services (e.g., blood bank, lab, X-ray, respiratory therapy) should receive a notification. Finally, all care team members should be assigned specific roles before the patient arrives; this allows the team to intervene immediately in parallel and avoid confusion once the patient enters the trauma bay. This approach also gives everyone a general place to situate themselves and their equipment. There are common areas that members of an interprofessional team can assume during the care of the trauma patient. While every hospital operates differently, the map provided is a general guide for trauma team members to follow.
The Primary Survey
When a trauma patient presents to the emergency department, an immediate assessment must take place to determine their status. In conjunction with obtaining the history of events provided by the rescue team and/or witnesses, most patients are promptly placed on a cardiac monitor, pulse oximeter, and blood pressure monitor while a complete set of vital signs are collected. This initial history and the baseline vital signs dictate the preliminary management of the patient.
Once this has occurred, the primary survey can begin in a sequential set of steps, A.B.C.D.E., with the most vital areas taking precedence:
- Exposure/Environmental Control
An important thing to remember is that these steps can and should be repeated throughout the course of the patient’s care. For example, if the provider completed the airway and breathing portion of the exam, but the circulation portion required an intervention, restarting the primary survey from the beginning (e.g., at airway) is recommended. First, the provider’s intervention may take time to accomplish, allowing enough time to pass for the patient’s airway and breathing status to deteriorate. Second, any intervention has the potential to compromise any aspect of the primary survey. For example, if a provider determines that a central venous catheter, placed in the patient’s jugular vein, is required, they must confirm that the pleural space, vascular wall, or cardiac tissue were not violated. This could result in a tension pneumothorax, hemorrhaging, or inadequate cardiac output and deteriorate the patient’s breathing and circulatory status. Thus, the reassessment of these critical areas in sequential order is necessary. Any deterioration in the patient's clinical status mandates a repeat primary survey, including a reassessment of previous interventions to ensure they remain effective.
The first and most important portion of the primary survey is the patient’s airway. Typically, one provider stands at the head of the bed and is responsible for assessing the patency of the patient’s airway. This includes checking for any foreign bodies, tongue swelling, blood, vomitus, or saliva occluding the oropharyngeal space. However, a classic way to rapidly assess for patency is by asking the patient their name; any weakness, hoarseness, gurgling, or stridor may indicate significant airway damage. The provider also should assess for any injuries or deformities of the neck that can occlude the airway, such as an expanding hematoma, foreign bodies embedded in the soft tissue, perioral and perinasal burns or soot, or any other pathology that has the potential to imminently occlude the trachea. One must also assess the patient’s face for any gross abnormalities such as maxillofacial fractures, creating airway difficulties throughout the treatment course.
In addition to airway patency, the provider at the head of the bed is responsible for assessing and maintaining midline cervical-spine alignment. If necessary, a cervical collar can be placed to reduce the risk of any vertebral instability damaging the spinal cord. Throughout the treatment course, this provider should maintain cervical stabilization during stretcher-to-bed transfers, logrolls, and any other maneuver that may cause vertebral motion.
If the provider determines that a patient’s airway is compromised, immediate intervention is indicated. The provider can use a simple chin-lift or jaw thrust maneuver to re-align the airway. They can also insert an artificial airway that is appropriate for the patient’s situation. This includes, but is not limited to, oropharyngeal airways (OPA), nasopharyngeal airways (NPA), supraglottic airways such as a laryngeal mask airway (LMA), definitive airways such as intubation with an endotracheal tube (ETT), or a surgical airway such as a needle cricothyroidotomy or a surgical cricothyroidotomy.
Arguably the most preferred airway technique is endotracheal intubation. It is a non-surgical, definitive airway that can be placed for long-term use and is easily removable in most cases. When attempting to intubate a patient, a provider can approximately predict the difficulty of the intubation for each patient. This is done to predict how long a patient may be unoxygenated or if other equipment or specialists should be readily available before an attempt should occur. One method used to predict airway difficulty is the L.E.M.O.N. criteria:
- Look: at the patient’s face for micrognathia, maxillofacial trauma, a small oral opening, or any apparent external signs that may make intubating difficult.
- Evaluate 3-3-2: First, while approximating the patient’s finger width, they should be able to accommodate three fingers stacked vertically between the midline of their front teeth with their mouth fully opened. Second, they should be able to stack three fingers horizontally between their chin and their hyoid bone. Finally, they should be able to stack two fingers between the thyroid cartilage and the floor of their mouth. If all three criteria are met, the provider can anticipate that the patient's anatomy will allow for easier intubation.
- Mallampati: while asking the patient to open their mouth and stick their tongue out externally, the provider should inspect the oropharyngeal space and attempt to visualize the uvula. A score of 1 to 4 is given depending on uvular visualization. A score of 1 is easier to intubate than a score of 4:
- Class 1- full uvular visualization
- Class 2- the tongue occludes the distal portion of the uvula
- Class 3- the entire uvula is occluded except for the base or proximal portion
- Class 4- the uvula is unable to be visualized
- Obstruction: foreign bodies or fluids.
- Neck: patients with short necks, those that have a cervical collar placed, or patients that have limited movement of the cervical spine, such as those with cervical osteoarthritis or fused cervical vertebrae, can impair the provider’s ability to manipulate the airway for endotracheal tube placement.
If attempting endotracheal intubation, the provider should prepare all necessary equipment and ensure airway adjuncts are readily available before beginning the procedure. It is essential to follow a particular order during the procedure to reduce the risk of complications occurring:
- Prepare the oxygen supply with a nasal cannula, face mask, bag-valve mask, and suction equipment, and adjust the bed height to a comfortable level.
- Suction the oropharynx, as needed
- Provide a sedative
- Provide a paralytic
- Place the tube
- Immediately check for proper placement via capnography, 3-point auscultation, and chest X-ray.
- Provide ventilation settings: tidal volume, respiratory rate, PEEP, and FiO2
Once the airway is managed, the provider can move on to the next part of the primary survey (A.B.C.D.E.); breathing. Airway deals with maintaining an avenue for oxygen to enter and carbon dioxide to leave the lungs. Breathing, on the other hand, deals with the mechanics of ventilation. Although it may be obvious that this involves assessing and treating injuries to the lungs, a provider must also assess the patient’s diaphragm and chest wall, including the ribs, intercostal muscles, and intercostal neuro-vasculature. Mechanically, these components create the proper pressures needed to move air. Thus damage to any one of these can interfere with a patient’s ability to ventilate. Although supplemental oxygen should be delivered to every patient with breathing difficulty, the provider must also treat the underlying issue causing their ventilatory compromise. Trauma can lead to rib fractures and flail chest, tension pneumothorax, diaphragmatic rupture, bronchial rupture, and damaged lung parenchyma that can lead to a pulmonary contusion or a hemothorax. Although the pathology listed above can cause mechanical and physiological impediments to oxygenation, the pain that patients experience can also inhibit them from taking full breaths. The pain can be so severe that atelectasis may occur simply from a lack of proper breathing.
Assessing ventilatory issues involves placing the patient on a pulse oximeter, counting their respiratory rate, and inspecting the chest for obvious deformities, bruising, open wounds, increased work of breathing, or abnormal breathing patterns. The provider should next auscultate both sides of the chest for the presence and symmetry of breath sounds. The provider should then palpate the chest wall for tenderness, crepitus, and deformities not noticed on inspection. Finally, although challenging to execute in a noisy trauma bay, percussing bilaterally for hyper-resonance or dullness can provide evidence for internal injuries such as pneumothorax or hemothorax. Once the physical exam is complete, imaging to evaluate for fractures, diaphragmatic injury, pleural effusion, pneumothorax, parenchymal injury, foreign bodies, etc., can be performed to confirm the clinician’s exam.
Treatments vary depending on the injury. Some patients may only require pain control for chest wall injuries, while others may need supplemental oxygen via a nasal cannula or non-rebreather face mask. Other patients may require positive airway pressure support such as BiPAP or assisted ventilation after intubation, particularly if a flail chest segment is present. Needle decompression or chest tube placement to re-inflate the lungs and/or drain fluid from the thoracic cavity may be required. Unfortunately, others may require emergent operative management. It is the role of the team leader always to try to predict what a patient may need, as early as possible, to expedite the patient’s path to definitive care.
After addressing the patient’s airway and breathing, the patient’s cardiovascular status should be the provider’s next priority. The essential components of the circulatory system are the heart, the vasculature, and the blood. Areas of concern that merit consideration during traumas include mechanical, electrical, and pressure-related injuries.
Anything that decreases blood flow can be detrimental to all organ systems. After noting the vital signs, to evaluate circulation, the provider should assess the presence and strength of central vs. peripheral pulses and how they compare bilaterally. Next, they should inspect the patient’s skin for color, warmth, and any obvious deformities that can compromise the blood flow. Imaging modalities commonly used during trauma cases include ultrasound for the FAST exam protocol and X-ray or CT examination. The provider should also utilize serial vital sign readings to determine the patient’s circulatory trajectory throughout the course of treatment.
In trauma patients, common injuries to consider are vessel disruptions that create hemorrhage, myocardial contusions that can lead to poor contractility and output, and pressure-like injuries such as cardiac tamponade, compartment syndrome, and tension pneumothorax which decrease venous return to the heart and thereby also diminish cardiac output. Treatment of these conditions includes addressing the underlying issue; patients may require advanced cardiac life support (ACLS) for arrhythmias caused by cardiac contusions or electrical shock, while others may need needle decompression or pericardiocentesis to allow the heart to fill and contract appropriately. The most common concern during trauma cases, however, is hemorrhage.
Treatment of hemorrhage depends on the source and severity of the bleed. For example, a superficial bleed may only require gauze while others may need prolonged direct pressure; a compound fracture of the femur with vascular disruption may require a tourniquet and immediate surgical intervention. Patients might also need external compression devices, such as a pelvic binder, to tamponade internal bleeds. Often, patients require fluid replacement to maintain appropriate perfusion pressures. The amount of blood loss determines the level of fluid resuscitation and the use of blood products (red blood cells, platelets, and fresh frozen plasma). According to ATLS, hemorrhage gets grouped into Classes I to IV, with Class IV being the most severe and require the most aggressive treatment; this may include vasopressors and massive transfusion protocols depending on the facility’s policy. Factors that define the patient's class status include changes in heart rate, blood pressure, urine output, and GCS, among others. In conjunction with the treatment modalities mentioned before, it is important to know a patient’s hemoglobin, hematocrit, and INR/PTT levels, along with their anticoagulation status, blood type, and Rh factor status. The ATLS hemorrhagic shock classes are described below:
- Class I: less than 15% blood loss with normal vital signs, urine output, and Glasgow Coma Scale (GCS) score
- Class II: 15 to 30% blood loss with tachycardia and hypotension
- Class III: 31 to 40% blood loss with tachypnea, decreased urine output, and decreased mentation
- Class IV: over 41% blood loss with severely worsening vital signs and negligible urine output
This portion of the primary survey is related to the neurological status of a trauma patient. The neurological exam can be done using the Glasgow Coma Scale (GCS), assessing pupillary size and response, screening for blood glucose levels, and checking drug and alcohol levels. A patient with altered mentation and/or neurological deficits will require a CT examination of the brain as well as a CT of the cervical spine to evaluate for a neck injury. However, imaging can only occur if the patient is stable enough to tolerate the length of the study without any intervention. If trauma to the brain or spine is suspected, the provider should have a low threshold to consult neurosurgery, depending on their facility’s capabilities, or initiate a transfer to a higher-level trauma center if required.
Although neurological injuries are commonly associated with motor deficits, poor sensation, loss of consciousness, aphasia, agnosia, or simply dizziness and a headache, they can also affect vital signs. An example of the relationship between neurological injury and a patient’s hemodynamic status occurs when a patient presents with hypotension and concern for spinal cord injury. Providers may anchor themselves to the diagnosis of hemorrhagic shock during traumas simply due to the prevalence of bleeding that occurs during these cases. However, if a patient’s hypotension is refractory to fluid resuscitation and bradycardia is observed, the patient may be suffering from neurogenic shock. This condition occurs with an insult near the upper-thoracic and cervical regions of the spinal cord, which disrupts the sympathetic fibers responsible for cardiovascular regulation—the effect results in hypotension and bradycardia that can be refractory to fluids. Treatment typically requires vasopressors to compensate for the loss of sympathetic tone and vasodilation that occurs.
The previous four sections of the primary survey relate to the patient’s airway, respiratory, cardiovascular, and neurological systems. Exposure refers to the removal of all articles of clothing from the patient. This is required because the provider must inspect for any deformities, lacerations, abrasions, bruising, or foreign objects that may have been hidden by the patient’s clothing or blankets given by rescue. Another important step is to log-roll the patient to inspect posteriorly. Occult injuries are commonly found once the patient is properly exposed. However, one consideration to address while exposing the patient is to maintain their core body temperature; many trauma patients tend to lose body heat quickly. For this reason, trauma bays are at a higher temperature than the rest of the emergency department. It is important to cover the patient quickly upon completion of the examination. If possible, warm fluids and blankets can mitigate temperature loss. Hypothermia is known to exacerbate a patient’s hypocoagulative state, contribute to any preexisting acidosis, and increase mortality.
The Secondary Survey
Once the primary survey is complete, the provider must gather more details about the events that led to the patient’s injuries and learn about their medical history to tailor the treatment plan. In a team environment, one member can complete the primary survey while another completes the secondary survey in parallel. Essentially, it is an expedited history and physical to make sure that nothing has been overlooked. This may be challenging in an unresponsive or altered patient. It is important to assess every organ system comprehensively. Again, providers can utilize any adjunct laboratory testing and imaging throughout the secondary survey. The elements to cover can be remembered using S.A.M.P.L.E.:
- Signs and Symptoms: these items pertain to any new developments that have occurred post-trauma. It is important to gather key elements of the patient's pain or discomfort, including but not limited to the following: characterization, whether it is constant or intermittent, radiation, severity, progression, and any alleviating or precipitating factors.
- Allergies: specifically to medications
- Medication List: careful attention should focus on anticoagulation and platelet inhibitor status
- Past Medical History: including previous surgeries
- Last Meal (time)
- Events: this history should be limited to the events that lead up to the injury and any ancillary information that can help the providers understand how severe the trauma was
In traumas, the mechanism of injury can provide enough information for the provider to begin an effective treatment plan. Traumas can broadly categorize as a penetrating, blunt, decelerating, or thermal injury. Penetrating injuries include stabbings, gunshots, and general foreign body wounds. Blunt and deceleration injuries include falls, motor vehicle collisions (MVC), and general impacts from projectiles. Finally, thermal injuries include fire burns and/or inhalations, chemical burns, cold injuries, and electrical burns.
Blunt injuries cause shear forces at weak points attached to fixed structures. Damage to the bone and soft tissue can occur singularly or simultaneously. The provider must keep the directionality of the impact in mind. Axial forces to the vertebrae cause different injuries than perpendicular forces, and the impact from a patient landing on their feet can have bony repercussions in the pelvis and spine. In MVCs, frontal collisions can cause unique injuries to the pelvis versus lateral collisions. Depending on the mechanism, there are unique ancillary questions of the history that a provider should ascertain. For example, things to consider in MVC cases include whether the airbags deployed, whether the patient was restrained or ejected from the vehicle, the status of the other passengers involved with the collision (e.g., death in the same vehicle compartment), how fast the vehicle(s) were moving at the time of the incident and was there an underlying medical incident that caused the patient to lose control of the vehicle? Regardless of the mechanism, this line of thinking will allow the provider to understand how much damage may have been inflicted during the incident, if there are other medical considerations to keep in mind, or if law enforcement should be involved.
Penetrating injuries can be devastating, depending on the depth and tissue invaded. However, some argue that such injuries are diagnostically easier to assess because the location of the injury may be more obvious. Despite the point of entry, the angle of penetration and the object's position within the patient’s body can pose different consequences. The path of a projectile, such as a bullet, may not be a simple straight line. Often, the path can be random due to a bony ricochet or flight movement changes due to different media through which the projectile passes. Some bullets are designed to deform and fragment on impact, which makes their trajectories through the body more unpredictable.
Thermal injuries, depending on the site and total body surface area (TBSA) affected, can cause severe and life-altering injuries, if not death. There are many complications that the provider should address. Fire and hot-gas inhalation burns can deteriorate the skin and mucosa. If the burns are severe enough, hypothermia, infection, and reduced mobility can ensue via contracture burn scars. Also, depending on the proximity of the burn to the peri-oral and peri-nasal region, the patient’s airway can suffer. Cold burns can cause ischemia and progress to gangrene or limb amputation. Electrical burns can cause arrhythmias, rhabdomyolysis, and even compartment syndrome.
Once a patient has been evaluated and adequately resuscitated, the team leader can begin to develop a plan regarding the patient’s future care. This involves appropriate consultation and determining the patient's disposition. The interprofessional team often decides the patient's ultimate disposition. Depending on the capabilities of the provider's facility, the patient may need a transfer for definitive care.