Immediate Assessment and Management
Immediate Assessment and Management
The patient suffering from multiple traumas must be thoroughly assessed on admission so that life threatening injuries can be corrected. The condition of the patient must be stabilized and plans made for further treatment of their injuries. All trauma cases should receive initial assessment.The initial assessment of the trauma patient can be divided into primary, secondary, and tertiary surveys. The primary survey should take 2 - 5 min and consists of the ABCDE sequence of trauma: Airway, Breathing, Circulation, Disability, and Exposure.
If the function of any of the first three systems is impaired, resuscitation must be initiated immediately. In critically ill patients, resuscitation and assessment proceed simultaneously by a team of trauma practitioners. Basic monitoring including the electrocardiogram (ECG), noninvasive blood pressure, and pulse oximetry can often be initiated in the field and is continued during treatment.
Trauma resuscitation includes two additional phases: control of hemorrhage and definitive repair of the injury. More comprehensive secondary and tertiary surveys of the patient follow the primary survey.
Primary Survey and Resuscitation
The purpose of the primary survey is to diagnose immediate life threatening conditions. These should be treated as soon as they are discovered before continuing the survey.Airway
Establishing and maintaining an airway is always the first priority. If a patient can talk the airway is usually clear, but if unconscious the patient will likely require airway and ventilatory assistance. Important signs of obstruction include snoring or gurgling, stridor, and paradoxical chest movements, a condition affecting someone with broken ribs, where the chest appears to move in when he or she breathes in, and appears to move out when he or she breathes out. The presence of a foreign body should be considered in unconscious patients. Advanced airway management (such as endotracheal intubation, cricothyrotomy, or tracheostomy) is indicated (Table 4:1) if there is apnea, persistent obstruction, severe head injury, maxillofacial trauma, a penetrating neck injury with an expanding hematoma, or major chest injuries.
N.B. Make sure you put the patient on 100% oxygen before proceeding to the next step (B)
Cervical spine injury is unlikely in alert patients without neck pain or tenderness. Five criteria increase the risk for potential instability of the cervical spine: (1) neck pain, (2) severe distracting pain, (3) any neurological signs or symptoms (numbness, loss of sensation), (4) intoxication, and (5) loss of consciousness at the scene. A cervical spine fracture must be assumed if any one of these criteria is present, even if there is no known injury above the level of the clavicle (Figure 4.1).
Table 4.1 Indication for Endotracheal Intubation in Trauma
- Inadequate airway protection
- Loss of consciousness
- High spinal cord injury
- Impending loss of airway
- Severe maxillofacial fractures
- Neck hematoma
- Inhalational (burn) injury
- Laryngeal or tracheal injury
- Inadequate ventilation
- Severe closed head injury (GCS score _8 or<)
- Poor respiratory efforts
- Inadequate oxygenation
To avoid neck hyperextension, the jaw-thrust maneuver is the preferred means of establishing an airway. Oral and nasal airways may help maintain airway patency. Unconscious patients with major trauma are always considered to be at increased risk for aspiration, and the airway must be secured as soon as possible with an endotracheal tube or tracheostomy. Neck hyperextension must be avoided and manual immobilization (manual in-line stabilization or MILS) of the head and neck by an assistant should be used to stabilize the cervical spine during laryngoscopy. The assistant places his or her hands on either side of the head, holding down the occiput and preventing any head rotation. MILS may be most effective than other techniques like axial traction, sandbags, forehead tape, soft collar and hard collar but it makes direct laryngoscopy more difficult.
Laryngeal trauma makes a complicated situation worse. Open injuries may be associated with bleeding from major neck vessels, obstruction from hematoma or edema, subcutaneous emphysema, and cervical spine injuries. Closed laryngeal trauma is less obvious but can present as neck hematoma, dysphagia, hemoptysis, or poor phonation. An awake intubation with a small endotracheal tube (6.0 in adults) is indicated. A rapid sequence induction should be considered since all patients should be treated as though they have a full stomach. If facial or neck injuries and obstruction from upper airway trauma preclude endotracheal intubation, cricothyrotomy or tracheostomy under local anesthesia should be considered.
Do not put nasal airways, nasotracheal tubes, or stomach tubes in the nose of patients with facial fractures. These tubes can end up inside the cranial cavity and/or cause meningitis.
Assessment of ventilation is best accomplished by the look, listen, and feel approach.
- Look for cyanosis, use of accessory muscles, flail chest, and penetrating or sucking chest injuries.
- Listen for the presence, absence, or diminution of breath sounds.
- Feel for subcutaneous emphysema, tracheal shift, and broken ribs.
In patients with respiratory distress tension pneumothorax and hemothorax should be suspected therefore, pleural drainage may be necessary before anesthesia. When the trauma patient arrives at the hospital he/she should be given oxygen by mask.Circulation
Adequacy of circulation is based on pulse rate, pulse fullness, blood pressure, and signs of peripheral perfusion. Signs of inadequate circulation include tachycardia, weak or unpalpable peripheral pulses, hypotension, and pale, cool, or cyanotic extremities.Hemorrhage
Loss of blood results in hemorrhagic shock. The term shock denotes circulatory failure leading to inadequate vital organ perfusion and oxygen delivery. There are many causes of shock such as pericardial tamponade, tension pneumothorax, and myocardial contusion considered as cardiogenic shock particularly in patients with chest injuries. In trauma patient shock is usually due to hypovolemia.
Protective mechanisms of the body compensate for the loss of blood by increasing sympathetic nervous system output. Heart rate is increased, blood vessels to less-vital organs constrict, and blood is shunted to the heart, brain, kidneys, and liver. A price is paid for shunting blood. Hypoxic changes in poorly perfused tissues cause acidosis and can have a negative affect during resuscitation when acidotic fluid re-enters the circulation. Because of the constriction of blood vessels and conservation of fluid, urine output decreases, a sign the patient is hypovolemic (urine output less than 0.5 ml/kg/hr).
Serum hematocrit and hemoglobin concentrations are often not accurate indicators of acute blood loss. Estimating blood loss in the trauma patient is a guess. Management is explained in session management of circulatory shock and anesthetic consideration.
Two priorities of circulation to be considered in the trauma patient are to stop the bleeding and replace the lost blood.
Stop the Bleeding
- Apply pressure to the sites of obvious hemorrhage.
- Bleeding of the extremities should be treated with direct pressure, pressure dressings, and packing the wound. Tourniquets may be used but must be applied carefully and for short periods of time to avoid injuring the tissue distal to and under the tourniquet.
- Penetrating objects should be left in place. The surgeon should remove the object in the operating room when appropriate.
- Chest trauma bleeding is often from intercostal arteries. Re-expansion of the lung can often reduce or even stop this bleeding.
- Bleeding from abdominal trauma may be decreased or stopped by the accumulation of the blood within the closed space of the abdomen. Do not be deceived. Bleeding will start immediately when the surgeon removes the accumulated blood. Prior to surgical intervention the anesthesia provider should ensure that a minimum of two large bore IVs are in place.
The central nervous system should be quickly assessed by ascertaining the level of consciousness, spinal cord function and pupillary response to light. Conscious level is assessed by recording patient eye opening and motor response to various stimuli. These are graded as spontaneous, in response to direct questioning, uncomfortable stimuli or none at all. All four limbs should be tested for response to assess spinal cord function. In addition to checking the level of consciousness, checks blood glucose level and pupillary light reflex.Exposure
The patient should be undressed to allow examination for injuries. In-line immobilization should be used if a neck or spinal cord injury is suspected.
The secondary survey begins only when the ABCs are stabilized.
Following the initial survey and resuscitation, the patient should undergo a thorough secondary survey with the aim of documenting any other injuries. During this survey, however, the basics of the primary survey (airway, breathing and circulation) should be regularly reassessed to detect any unexpected deterioration. In the secondary survey, the patient is evaluated from head to toe and the indicated studies (eg, radiographs, laboratory tests, invasive diagnostic procedures) are obtained. Tetanus immunization and prophylactic antibiotics can be administered if necessary. A history should be obtained and include the following information:
- Medications and tetanus immunity
- Previous medical history
- Last meal
- Events leading to the injury
The temperature of the patient should be recorded. Remember to keep the patient covered unless an examination or procedure is being carried out.
A tertiary survey is defined as a patient evaluation that identifies and catalogues all injuries after initial resuscitation and operative interventions. It typically occurs within 24 h of injuries.
Many trauma centers also advocate a tertiary trauma survey to avoid missed injuries. Between 2% and 50% of traumatic injuries may be missed by primary and secondary surveys, particularly following blunt multiple trauma (eg, car accident). This delayed evaluation normally results in a more awake patient who is able to fully communicate all complaints, more detailed information on the mechanism of injury, and a detailed examination of the medical record to determine preexisting disease.