The primary survey is a sequence of steps to identify immediately life-threatening but treatable injuries. Assessment and management proceed simultaneously, and life-threatening situations are managed as they are encountered during the course of resuscitation. This is made possible through close coordination of the trauma team, with each team member performing his or her designated role under the direction of the captain. The primary survey involves airway maintenance with cervical spine protection, breathing and ventilation, circulation with hemorrhage control, disability with respect to neurologic status, and exposure/environmental control, where the patient is completely undressed but kept warm to prevent hypothermia.
The priorities of the primary survey can be applied to all patients with certain caveats that do not alter the underlying alphabet or priorities, including pediatric patients, the elderly, pregnant women, and obese patients.
Pediatric patients: When caring for the pediatric patient, the size of the child and specific injury patterns must be kept in mind. Serious pediatric trauma is usually blunt trauma, often involving the brain. Brain injuries can lead to apnea, hypoventilation, and hypoxia, and protocols for pediatric trauma patients stress aggressive management of the airway and breathing to prevent these consequences. These physiologic derangements occur more often than hypovolemia with hypotension in seriously injured children.
Geriatric patients: The geriatric patient has overall less physiologic reserve to withstand injury. Their response may also be altered or blunted by comorbidities and chronic medication use. Resuscitation of these patients must take into account possible preexisting cardiac, pulmonary, and metabolic diseases.11 For example, minor injuries can cause serious complications due to multiple medications, especially anticoagulant use.
Pregnant women: The anatomic and physiologic changes of pregnancy can be a challenge, and the response of the pregnant patient may be modified.12 Knowledge of pregnancy and early monitoring of the fetus are important in maternal and fetal survival. Unnecessary x-ray exposure should be avoided, but treatment of the mother takes precedence.
Obese patients: The problem of obesity is on the rise.13 These patients pose a particular challenge in the trauma setting, as their anatomy can make procedures such as intubation difficult and hazardous.14 In addition, obese patients typically have cardiopulmonary disease limiting their ability to compensate for injury and stress. Treatment of these patients may exacerbate their underlying comorbidities.
Although these special populations each have their unique characteristics, the assessment and management priorities are the same. Treatment of these patients is elaborated elsewhere in this text.
Airway Maintenance with Cervical Spine Protection
Maintenance of the airway is the most important priority in caring for the trauma patient. Inadequate ventilation leads to hypoxia and inadequate oxygen delivery to tissues. Although important in all patients, this is particularly important in patients with head injury, as hypoxia contributes to secondary brain injury and hypoventilation may increase intracerebral pressure.15 Application of a pulse oximeter as an early adjunct to the primary survey in all patients helps in recognition and monitoring of hypoxemia.
In acute trauma, upper airway obstruction is the most common cause of inadequate ventilation. Structures of the upper airway such as the tongue, edematous soft tissues, blood, foreign bodies, teeth, and vomitus are common causes of obstruction. Quick assessment of the airway begins by asking the patient his or her name. A normal response implies the airway is not in immediate jeopardy, but frequent reassessment is required. Breathlessness, weak or absent voice, or hoarseness suggests airway compromise. Objective signs of potential airway problems include noisy breathing, cyanosis, and the use of accessory muscles. Unconscious and obtunded patients with a Glasgow Coma Score (GCS) of less than 8 should have their airway protected with an endotracheal tube to provide oxygenation and ventilation, and reduce the chance of aspiration. Indications for a definitive airway are listed in Table 10-1.
Table 10-1 Indications for Definitive Airway |Favorite Table|Download (.pdf)
Table 10-1 Indications for Definitive Airway
|Need for Airway Protection||Need for Ventilation or Oxygenation|
- Neuromuscular paralysis
|Severe maxillofacial fractures||Inadequate respiratory efforts |
|Risk for aspiration ||Severe closed head injury with need for brief hyperventilation if acute neurologic deterioration occurs|
|Risk for obstruction |
- Neck hematoma
- Laryngeal or tracheal injury
|Massive blood loss and need for volume resuscitation|
|Adapted with permission from American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. 8th ed. Chicago, IL: American College of Surgeons Committee; 2008: p. 33.|
A definitive airway is defined as a cuffed endotracheal tube in the trachea.5 In children under 9 years of age, an uncuffed tube should be used to prevent tracheal injury from the cuff. The most important aspect of securing the airway involves preparation. A skilled physician must be present with the necessary medication and equipment close at hand for intubation.16
When airway compromise occurs, initial maneuvers to maintain the airway are performed. The first involves opening the mouth and inspecting for foreign bodies or other obstructive causes. Either a chin lift or jaw thrust in conjunction with an oral or nasal airway can relieve obstruction caused by the tongue (Fig. 10-1). Care must be taken to protect the cervical spine during these maneuvers. The chin lift or jaw thrust can temporarily maintain oxygenation in preparation for a definitive airway. Rapid sequence intubation is employed for obtaining the definitive airway in the potentially combative trauma patient.17 An induction agent (often etomidate) is used in combination with a short-acting depolarizing agent such as succinylcholine to minimize duration of paralysis. In case of failed orotracheal intubation, the team should be ready to perform a surgical airway. Confirmation of tube placement occurs by auscultation over the epigastrium and the bilateral chest wall. There should be no breath sounds over the epigastrium and equal breath sounds heard over the chest. A CO2 monitor is attached to the endotracheal tube and confirms the presence of CO2 by color change.18 A chest x-ray is also obtained to confirm position. Once a definitive airway is established, securing by means of tape or a commercial device is imperative. In addition, frequent evaluation of tube position should be performed to prevent dislodgement of the tube and subsequent airway loss.
Chin lift and jaw thrust maneuvers to establish an airway. (Reproduced with permission from American College of Surgeons Committee on Trauma. Advanced Trauma Life Support For Doctors. 8th ed. Chicago, IL: American College of Surgeons Committee; 2008: p. 30.)
Breathing and Ventilation
After securing the airway, attention may be turned to breathing and ventilation. This includes both oxygenation and adequate exchange of carbon dioxide. Pulse oximetry is an effective noninvasive means of measuring arterial blood saturation by colorimetric measurement.19 Pulse oximetry may be inaccurate in the presence of peripheral vasoconstriction, carbon monoxide poisoning, or jaundice. Pulse oximetry may also be unreliable in hypothermic or severely anemic patients.20 Depending on the patient’s partial pressure of oxygen and its location on the oxyhemoglobin dissociation curve, oxygen levels may change more quickly than indicated by the pulse oximeter measurement due to limitations in instrument response time. In these situations, the partial pressure of oxygen is more accurately determined using an arterial blood gas measurement.
A patent airway does not ensure adequate ventilation.5 Evaluation of breathing begins by looking at, listening to, and feeling the chest wall. Inspection of the chest wall can reveal asymmetry in chest expansion, accessory muscle use, contusions, penetrating chest wounds, open or sucking chest wounds, and distended neck veins. Auscultation of breath sounds can help diagnose pneumo- or hemothorax by detecting differences in breath sounds between the left and right chest. Palpation of the chest wall can be used to diagnose an unstable chest wall, tenderness, crepitance, deformity, or subcutaneous air. Finally, percussion has been suggested to identify hyperesonance, dullness, or tympany. Due to an often noisy resuscitation area, it is rarely helpful in diagnosing or differentiating chest trauma. Breathing problems can be life-threatening. A tension pneumothorax develops from either blunt or penetrating injury where air continuously enters the pleural space from the trachea, bronchi, or chest wall causing the lung to collapse. Clinical signs include shifting of the mediastinum with deviation of the trachea away from the affected side, distended neck veins, respiratory distress, decreased venous return due to elevated intrathoracic pressure with low cardiac output, hypotension, and shock. Tension pneumothorax is a clinical diagnosis and a chest x-ray should be obtained after treatment by chest tube insertion. Differentiation between a tension pneumothorax and cardiac tamponade may be difficult. Neck veins may not be distended secondary to hypovolemic shock. Heart sounds are usually muffled with the latter but this may be difficult to appreciate in a noisy trauma bay. Absent breath sounds may be the only differentiating sign. A massive hemothorax can also cause mediastinal shift due to blood instead of air and circulatory compromise. Fortunately, the treatment is similar and involves tube thoracostomy.
Ultrasound may be extremely useful in the rapid detection of pneumothorax, hemothorax, and cardiac tamponade. Accuracy for diagnosis of pneumo- and hemothoraces compares favorably with portable chest radiograph, and it can be performed much more quickly. The diagnosis of cardiac tamponade is also done efficiently by ultrasound, although the presence of a left hemothorax decreases accuracy.21–23
A flail chest can also cause breathing problems. The definition of a flail segment is three or more consecutive ribs broken in at least two places each, or one or more rib fractures along with a costochrondral separation or fracture of the sternum. A flail chest is most often associated with underlying hemo- or pneumothorax and/or pulmonary contusion, which is the usual cause of associated respiratory compromise.24
An open pneumothorax is defined as a chest wall defect greater than two thirds the diameter of the trachea. This is also known as a “sucking chest wound”. In an open pneumothorax air is drawn through the defect (the path of least resistance) into the chest. Larger defects cause greater respiratory distress. Treatment involves immediate temporary coverage of the defect on three sides, ipsilateral chest tube placement, and operative closure of the defect.25
Finally, a massive hemothorax (>1,200 mL of blood evacuated initially) can cause mediastinal shift, respiratory distress, and hypovolemic shock, which must be managed immediately. This is managed with tube thoracostomy, transfusion, and immediate operation.
Circulation with Hemorrhage Control
Hemorrhage is the leading cause of preventable death after injury. Shock is the result of inadequate oxygen delivery to tissues. Although hypovolemic shock from bleeding is the most common form of shock in trauma victims, other types of shock can occur in these patients, and occasionally a combination of several types of shock are simultaneously present. Treatment for shock begins with placement of two large-bore peripheral IVs (16-gauge or larger) and appropriate isotonic fluid replacement. There are four classes of shock based on initial blood loss and presentation (Table 10-2).
Table 10-2 Estimated Blood Lossa Based on Patient’s Initial Presentationch10tb2_02 |Favorite Table|Download (.pdf)
Table 10-2 Estimated Blood Lossa Based on Patient’s Initial Presentationch10tb2_02
|Class I||Class II||Class III||Class IV|
|Blood loss (mL)||Up to 750||750–1500||1,500–2,000||>2,000|
|Blood loss (% blood volume)||Up to 15%||15–30%||30–40%||>40%|
|Pulse pressure (mm Hg)||Normal or increased||Decreased||Decreased||Decreased|
|Urine output (mL/h)||More than 30||20–30||5–15||Negligible|
|CNS/mental status||Slightly anxious||Mildly anxious||Anxious/confused||Confused/lethargic|
|Fluid replacement||Crystalloid||Crystalloid||Crystalloid and blood||Crystalloid and blood|
STOP THE BLEEDING!!! The most important treatment for hemorrhage is control of bleeding.26,27 Hemorrhage in the adult trauma patient comes from one of five places—the thoracic cavity, abdominal cavity, pelvic fracture, long bones, or obvious external bleeding. The rapidity with which each source is investigated depends on the degree of shock. Some sources may be excluded by physical examination (external bleeding, thigh deformity), whereas others require the radiologic adjuncts to the primary survey. Bleeding into the chest and pelvis can be difficult to determine by physical examination alone, making early radiologic examinations essential in the patient in shock. The scalp is quite vascular and profuse bleeding from scalp wounds may require suture ligation or Raney clips to stop bleeding.28 For obvious external bleeding, direct pressure on the bleeding vessel is the most effective method of hemorrhage control. For less well-defined areas of bleeding, proximal pressure over the femoral artery in the groin or the brachial artery in the upper extremity can be used. Tourniquets are effective in massive exsanguination from an extremity, but run a high risk of ischemic injury to that extremity and should only be used when direct pressure is not effective.15 However, the use of tourniquets is increasing, especially in the prehospital phase. Kragh et al. investigated tourniquet use at a combat hospital in Baghdad. They found that tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; P<0.0001), that prehospital use was associated with survival, and no limbs were lost due to tourniquet use.29 Hemothorax is treated with tube thoracostomy and operative control, intra-abdominal hemorrhage in the setting of shock requires laparotomy, and bleeding from a significant pelvic fracture requires pelvic stabilization with a sheet or binder followed by angiography or pelvic packing if necessary.
The diagnosis of shock begins with a check of the patient’s pulse rate and character, skin color and temperature, and mental status. A slow, regular pulse suggests normovolemia, whereas a weak or thready pulse suggests hypovolemia. Patients with pink and warm skin and extremities are less likely to have a circulation problem. Mental status changes may be due to inadequate end organ perfusion caused by hypovolemia, brain injuries, or drug use. Blood pressure is an important indicator of response to resuscitation, but should not be relied upon during the initial evaluation for the presence of shock. Urine output and central venous monitoring may also be used later to assess volume status and response to resuscitation.
Tachycardia results from a compensatory response to intravascular volume depletion via stimulation of the sympathetic nervous system and should always raise the suspicion of hemorrhagic shock. This efferent response to low intravascular volume also results in vasoconstriction of peripheral arteries, making the skin cool and clammy to the touch. Certain medications common in the elderly may blunt the tachycardic response, including beta-blockers, calcium-channel blockers, and diuretics.
Although tachycardia is the most common compensatory response to hemorrhagic shock, paradoxical bradycardia has also been observed. Paradoxical bradycardia is associated with rapid large-volume hemorrhage. Bradycardia in hemorrhagic shock predicts a poor prognosis, and traditional teaching associates a decrease in heart rate with irreversible shock (terminal response). However, research has revealed that bradycardia as an acute response to hemorrhage is potentially reversible. The key to treatment is quick recognition that bradycardia is a sign of major bleeding requiring massive and rapid fluid loading. Administration of atropine can precipitate cardiac arrhythmias and is contraindicated.30
Traditional predictors of physiologic reserve such as age, injury severity, and lactic acidosis on admission have been criticized for lack of sensitivity and/or specificity in predicting trauma mortality. Heart rate variability (HRV) is a recently applied biomarker reflecting physiologic reserve and cardiac control and describes changes in the beat-to-beat interval rather than variations in the instantaneous heart rate. HRV may be measured using either time-domain or frequency-domain approaches. A Holter monitor or EKG may be used to measure the R-R interval in milliseconds, which can be used to derive the standard deviation of the normal RR interval (SDNN), an important and clinically useful time-domain measurement. The gold standard for time-domain measurements is to examine HRV over a 24-hour period, but a brief 5-minute assessment of HRV can also be clinically valid and meaningful. Reduced HRV reflects loss of physiologic reserve and control of the heart. This cardiac uncoupling has been used to predict severely injured patients in the prehospital setting and as a measure of a patient’s clinical course over the first 24 hours of intensive care unit (ICU) stay.31,32
Traumatic brain injury, metabolic causes such as intoxication, and shock can all cause mental status changes.33 Decreased cerebral blood flow from any cause leads to decreased cerebral perfusion and alteration of mental status. It is important to recognize and treat shock in brain-injured patients because mortality and morbidity in these patients doubles with concurrent hypotension, and there is a 3-fold increase in mortality and morbidity if both hypotension and hypoxia are present.34
Blood pressure can be a misleading sign in the shock patient. Hypotension may not be evident until 30% of blood volume is lost. The numeric difference between systolic and diastolic pressures (known as the pulse pressure) is a more sensitive indicator of blood loss. A narrowed pulse pressure is detectable after loss of as little as 15% of blood volume. In the adult trauma patient, a systolic blood pressure less than 90 mm Hg is considered shock until proven otherwise.35
Cardiogenic shock can occur as a result of cardiac tamponade or blunt myocardial injury. Cardiac tamponade may be caused by penetrating injuries to the “box,” a three-dimensional region bounded by the clavicles superiorly, the nipples inferiorly, and the mid-clavicular lines laterally. This life-threatening condition must be diagnosed and treated emergently. On clinical examination, jugular venous distension (JVD), muffled heart sounds, and hypotension are the classic signs known as Beck’s triad. Cardiac tamponade can be confused with tension pneumothorax but the latter causes diminished or absent breath sounds on the side of the pneumothorax as well as tracheal deviation. Temporary treatment of tamponade involves needle pericardiocentesis to relieve the tamponade, but definitive treatment with emergent sternotomy or thoracotomy may be necessary. Blunt myocardial injury may result from blunt chest trauma.36 Few patients with this injury have life-threatening cardiogenic shock. Blunt cardiac injury has a variable incidence depending on the method of diagnosis. It also has variable importance, ranging from clinically insignificant to life-threatening cardiac failure. In patients that sustain blunt chest trauma, a normal electrocardiogram is the only test necessary to exclude clinically significant blunt cardiac injury. Cardiac enzymes are not helpful, as troponin I and T have poor sensitivity and predictive value despite relatively high specificity.37 With no evidence of blunt cardiac injury and no respiratory distress, ICU admission for either telemetry or aggressive pulmonary therapy is also unnecessary.38 If blunt myocardial injury is present, treatment usually involves monitoring in the ICU and appropriate management of hypotension if present.39
Neurogenic shock results from spinal cord injury. It is not seen with traumatic brain injury alone unless there is imminent death from the brain injury and a state of preterminal shock. Hemorrhagic shock should be ruled out in these patients. The pathophysiology of neurogenic shock is loss of sympathetic tone due to spinal cord injury. Loss of sympathetic innervation to peripheral blood vessels and unopposed vagal stimulation of the heart lead to warm extremities and normocardia or even bradycardia with shock. This may be seen in patients with injuries at T6 or above.40 Injuries below T6 should prompt an aggressive search for alternative causes of the hemodynamic derangements. Treatment initially begins with fluid resuscitation, and vasoactive medications are usually necessary. Neurogenic shock differs from spinal shock, which refers to the temporary loss of muscle tone and reflexes occurring after total or near-total spinal cord injuries.
Septic shock is usually not seen in the acutely injured trauma patient, but may appear in hospitalized patients many hours to days after their injury due to causes such as missed hollow viscus injuries. Septic patients may be normovolemic with normal blood pressure or minimal hypotension, warm skin, and wide pulse pressure, or hypovolemic and displaying signs of shock. All patients with suspected serious injuries require the placement of two large-bore peripheral IVs. Higher flow rates are best achieved with short, large-diameter catheters. Peripheral IVs are usually placed in the upper extremities unless there is significant injury to the upper extremities or upper chest with vascular or soft tissue compromise. When peripheral IVs cannot be placed, the next preferred choice for access is a femoral central venous catheter. Use of the subclavian or jugular veins is not initially recommended because of the higher likelihood of complications such as a pneumothorax.41 Central venous catheter insertion should be performed by a physician trained in these procedures. A cutdown of the saphenous vein in the lower extremity or basilic or cephalic vein in the upper extremity can also be performed in difficult situations. In children under 6 years of age, intraosseous cannulation of the proximal tibia may be used until adequate volume resuscitation and circumstances allow venous access.42 In the out of hospital setting, intraosseous cannulation is now being used more frequently in adult patients as well (Fig. 10-2). As in the pediatric population, this access may be used in-hospital until intravenous access is obtainable.43,44 At the time of placement, blood should be drawn for basic hematologic and chemistry analysis and type- and cross-matching.
Demonstration of intraosseous puncture via the proximal tibial route. (Reproduced with permission from American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. 8th ed. Chicago, IL: American College of Surgeons Committee; 2008: p. 77.)
The treatment for hypovolemic shock is fluid resuscitation and hemorrhage control. Remember, STOP THE BLEEDING!!! Severely injured patients should receive a 2-L bolus of warm, isotonic fluid such as Ringer’s lactate. Patients whose blood pressure responds to this initial fluid bolus can undergo further work-up for potential injuries and continued crystalloid resuscitation. If blood pressure remains low, blood should be given. Historically, red blood cells were used alone, but recent studies have indicated that administering a combination of fresh frozen plasma and packed red blood cells during massive resuscitation is associated with improved mortality. The optimum ratio of fresh frozen plasma to packed red blood cells is still under investigation.45–47 O-negative blood should be used until type-specific blood becomes available. In hypotensive children a 20-mL/kg fluid bolus should be administered. Patient response to fluid can be categorized into three groups. Rapid responders have a return of normal vital signs after the 2-L bolus. Transient responders undergo transient normalization of blood pressure and heart rate followed by recurrence of hypotension and tachycardia. Patients who fall into the final category are referred to as minimal to no responders and their vital signs remain abnormal after the initial fluid resuscitation. These three categories correspond to minimal (10–20%), moderate and ongoing (20–40%), and severe (>40%) blood loss, respectively (Table 10-3).
Table 10-3 Responses to Initial Fluid Resuscitationa |Favorite Table|Download (.pdf)
Table 10-3 Responses to Initial Fluid Resuscitationa
|Rapid Response||Transient Response||Minimal or No Response|
|Vital signs||Return to normal||Transient improvement||Remain abnormal|
|Estimated blood loss||Minimal (10–20%)||Moderate and ongoing (20–40%)||Severe (>40%)|
|Need for more crystalloid||Low||High||High|
|Need for blood||Low||Moderate to high||Immediate|
|Blood preparation||Type and crossmatch||Type specific||Emergency blood release|
|Need for operative intervention||Possibly||Likely||Highly likely|
|Early presence of surgeon||Yes||Yes||Yes|
|aTwo liters of isotonic solution in adults; 20 mL/kg bolus of Ringer’s lactate in children.|
|Adapted with permission from American College of Surgeons Committee on Trauma: Advanced trauma life support for doctors. 8th ed. Chicago, IL: American College of Surgeons Committee; 2008: p. 65.|
For patients who present in extremis or after cardiac arrest from penetrating chest trauma, an ED thoracotomy performed by a trained surgeon may be life-saving. Resuscitation efforts may be withheld in any blunt trauma patient who is apneic, pulseless, and without organized ECG activity upon the arrival of Emergency Medical System (EMS) personnel at the scene. Termination of resuscitation efforts should be considered in blunt trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and cardiopulmonary resuscitation.48
Anticipating which patients will require blood can be challenging. In the case of patients who are hypotensive and tachycardic, the preparation is simplified by ensuring the availability of O-negative blood. However, the need for blood may be less obvious in patients with significant injury mechanisms such as high-speed crashes with prolonged extrication. These patients may initially be reported as awake and alert with minimal alterations in vital signs, but may have occult injuries. If the need for blood is not anticipated and blood is not readily available, the delay in appropriate resuscitation may affect morbidity and mortality.
Disability: Neurologic Status
Once life-threatening injuries are found and treated during the ABCs, a brief neurologic examination can be performed. The neurologic examination includes the GCS and pupil examination including size, symmetry, and reaction to light. A complete and detailed neurologic examination is not accurate or warranted until the patient is hemodynamically normal. The GCS is the sum of scores for three areas of neurologic evaluation: eye opening, verbal response, and best motor response. Abnormal pupillary size, asymmetry, or reaction to light can indicate a lateralizing brain lesion. The eye examination can be misleading if drugs, ocular prostheses, or direct injury to the globe are present.
The pupils and GCS should be frequently reevaluated to detect changes signaling deterioration of mental status. Accurate record keeping is important, particularly in those patients requiring transfer, as a change is GCS may be the earliest sign of increased intracranial pressure and worsening head injury. Computed tomography (CT) scanning should be used liberally in patients with suspected head injuries or signs or symptoms of trauma to the brain.49,50
Exposure and Environmental Control
The patient’s clothing must be completely removed for complete and adequate evaluation, while ensuring the patient does not become hypothermic. Clothing is cut when there is severe injury or risk of injury to the spine. During exposure of the patient, prevention of hypothermia with warmed air, fluids, oxygen, and blankets is necessary. The temperature of the patient should be obtained as soon as possible and reassessed frequently.51 In colder climates where the threat of hypothermia is more serious, the inaccuracy of standard thermometers below 30°C becomes an important consideration. In this situation, a temperature-sensing urinary catheter placed in the bladder is ideal. The best way to avoid hypothermia in the trauma patient is to stop bleeding. Prevention of hypothermia and rewarming of the patient are equally important parts of the primary survey and resuscitation.
Reevaluation throughout the primary survey is important to detect changes in the patient’s condition. If the patient is not responding to the treatment provided then revisiting the steps in the primary survey is crucial. In some cases, an operation is required to control circulation and the secondary survey is completed at a later time.
Adjuncts to the Primary Survey
Monitors should be placed on the trauma patient upon arrival. Heart rate, respiratory rate, temperature, and blood pressure should be checked as soon as possible. Continuous ECG monitoring of cardiac rhythm is essential. Arterial blood gas with base deficit and/or lactate measurements should be added in severely injured patients to identify presence and severity of shock.52,53
Continuous pulse oximetry provides a means to monitor the status of oxygenation and ventilation. When the patient arrives intubated, end-tidal CO2 can confirm tube position. An arterial or central venous line or pulmonary artery catheter may be useful in the seriously injured patient in the ICU, but their initial use is not indicated.
The main catheters and tubes are the Foley catheter and the nasogastric or orogastric tube. The Foley catheter is placed to monitor urine output. Certain injuries or signs may be a contraindication to placement of a Foley catheter.54 In the male patient, blood at the urethral meatus, a scrotal or penile hematoma, or a high-riding prostate on digital rectal examination are contraindications to placement of a Foley catheter. Placement should be deferred until a retrograde urethrogram (RUG) can be performed to rule out disruption of the urethra. If the urethrogram is normal, gentle placement of the Foley can be undertaken. If the RUG is abnormal, subspecialty consultation and placement of a suprapubic tube or definitive repair is necessary. The measurement of hourly urine output can be helpful in assessing volume status.
Decompression of the stomach is important, especially in patients where gastric distention can occur as a result of intubation. Children are especially sensitive to gastric distention, and decompression of the stomach may improve hemodynamics in this population. In the presence of severe maxillofacial trauma or the suspicion of a cribiform plate or basilar skull fracture with blood or cerebrospinal fluid (CSF) drainage from the nose or ears, placement of an orogastric tube is safer to avoid inadvertent insertion of the nasogastric tube into the brain, which is a potentially fatal injury.55 Blood return from the oro- or nasogastric tube is usually from swallowed blood but can be an indicator of traumatic injury to the upper gastrointestinal tract.
X-Rays and Other Diagnostic Studies
A chest radiograph is mandatory during the primary survey/resuscitation for both blunt and penetrating trauma. The chest x-ray can be used to identify rib fractures, pneumo- or hemothorax, and a widened mediastinum possibly indicative of blunt aortic injury. In the hemodynamically abnormal blunt trauma patient, a portable pelvic x-ray is also obtained as the physical examination of the pelvis may be misleading, particularly in the obtunded patient. Significant pelvic fractures or separation of the pelvic bones can explain blood loss in the patient in shock. The results of these tests frequently alter treatment plans.
In the hemodynamically normal patient with significant mechanism for injury, CT scans of the head, cervical spine, chest, abdomen, and pelvis are obtained after completion of the primary and secondary survey. The decision of which CT scans to obtain is based on mechanism of injury as well as the findings of the primary and secondary surveys. For example, a head CT should be obtained in patients with suspected head injuries, altered GCS, or anticoagulation use. A more recently recognized injury involves the use of seat belts with a shoulder strap. Significant deceleration with the harness belt in place can cause seatbelt marks on the neck and chest. In these situations, the physician should be concerned about blunt carotid, vertebral, or aortic injuries, and a CT angiogram of the neck and chest should be performed.56 Judicious selection of CT scans is important because CT contrast agents can interfere with the sequence of tests and lead to contrast nephropathy.57 In addition, the increased use of CT scans, especially of the chest and abdomen, has been linked to a higher incidence of cancer later in life.58
If the patient’s hemodynamics do not allow safe transport to the CT scanner, the abdomen must be evaluated for blood loss not explained by chest or pelvic radiographs. A FAST59,60 examination and/or diagnostic peritoneal lavage (DPL)61,62 may be performed to identify occult abdominal blood loss.63 During the FAST examination, an experienced physician uses an ultrasound machine to look for fluid, presumed blood, in the recesses of the peritoneal cavity. The four windows examined include the spaces between the liver and the kidney (Morison’s pouch), between the spleen and the kidney (splenorenal recess), over the bladder, and at the heart to identify fluid in the pericardial sac.64 In the case of a negative FAST, other sources for hemorrhage should be sought. An indeterminate result and persistent hypotension warrants a DPL as the next step. With a positive FAST, the patient is taken directly to the operating room for definitive control of hemorrhage.
Decision for Early Transfer
Early recognition of the patient that requires transfer is essential, as patient outcome is directly related to the time between injury and definitive care. The decision to transfer is based on patient injury and local resources. Once the decision is made to transfer the patient, the efforts of the team should be directed to resuscitation of the patient and restoration of normal perfusion. Any unnecessary diagnostic tests take up valuable time and should be avoided. Physician-to-physician contact should occur to relay vital information about the mechanism of injury, the injuries identified and their treatment so far, and to make arrangements for transportation, accompanying health professionals, and tasks that must be completed before and during transport. The selected mode of transport may carry its own set of risks. In recent years, the number of helicopter crashes during medical transport has risen. These crashes are often related to bad weather conditions or flight at night. Although seriously injured patients may need immediate flight transport, and “critical care” ground transport continues to evolve, older guidelines published by the National Association of EMS Physicians (consensus with American College of Surgeons) speak to the issues regarding air medical utilization. New guidelines through NAEMSP are still being drafted.65
The patient should be continuously monitored during transport. The evaluation and resuscitation of the patient continues throughout transport until safe arrival at the receiving facility. While waiting for transport, the secondary survey may be completed including a complete history, “head-to-toe” examination, laboratory tests, and only those x-ray studies that assist in treatment without adding delay. Once the patient arrives at the receiving hospital, the definitive care phase begins and treatment continues in the ED, operating room, or ICU. During direct physician-to-physician contact, arrangements are made at the receiving facility for surgical subspeciality care such as trauma surgeons, orthopedic surgeons, or neurosurgeons.