Chapter 10

Time is of the essence in caring for patients with multiple injuries. To emphasize the time-sensitive nature of this care, the critical period immediately following injury was historically termed the “golden hour.”1 Mortality from trauma during this crucial time was estimated to be approximately 60%. This high mortality rate has been attributed in part to inadequate assessment and resuscitation. In order to minimize morbidity and mortality for these patients, appropriate and aggressive initial care must be delivered. The “golden hour” is no longer sacred, as we know that patient outcome is directly related to the time from injury to definitive care. Rapid assessment of injuries and institution of life-preserving measures have helped to reduce the preventable death rate of 35% to <10%.24

In order to save time, the initial assessment and management should follow a systematic approach that can be easily learned and practiced. This approach is the foundation for the Advanced Trauma Life Support (ATLS) course.5 Lack of a systematic approach to the initial assessment can result in errors from which the resuscitation team, and ultimately the patient, do not recover.6 Initial assessment and management includes the following:

• Preparation
• Triage
• Primary survey (ABCDEs)
• Resuscitation
• Adjuncts to the primary survey and resuscitation
• Consideration of need for transfer
• Secondary survey (more detailed evaluation, diagnosis, and treatment)
• Adjuncts to the secondary survey
• Continued postresuscitation monitoring and reevaluation
• Definitive care

Initial assessment and management is a linear progression of steps that includes both the primary and secondary surveys. The name of this phase—initial assessment and management—highlights the need for evaluation and simultaneous intervention for life-threatening injury when identified. During the primary survey, remembered by the mnemonic ABCDE (airway, breathing, circulation, disability, exposure/environment), the patient is rapidly assessed for life-threatening injury. It is not always possible to dissociate diagnostic procedures from simultaneous resuscitation and treatment measures during this phase, and the treatment of life-threatening injury should not be delayed for definitive evaluation. Following the primary survey and its adjuncts, the secondary survey is performed. During the secondary survey, the patient is evaluated for potentially life-threatening and/or occult injuries. It is important to emphasize that both the primary and secondary surveys may be repeated as often as necessary. Once adjuncts to the secondary survey are completed, definitive care requirements such as type of facility and location are considered while postresuscitation monitoring is continued.

The preparatory phase is an integral component of trauma care and occurs in two different clinical settings: the prehospital and hospital settings.

### Prehospital Phase

The first aspect of the prehospital phase occurs before patient involvement and concerns the establishment of protocols aimed at directing the safe transport of the right patient to the appropriate trauma center at the earliest possible time using the ideal transport method. Physicians involved in trauma care should be familiar with these protocols, and should optimally be involved in their establishment, review, ...

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