Although, the physical examination is an important component in the initial assessment, its limitations make it necessary to utilize adjunctive tests to fully identify serious and potentially life-threatening injuries. Adjuncts to the primary survey should be quick, reliable, be able to be performed in the trauma resuscitation bay and provide a high degree of specificity that positive test results are of unequivocal importance that demand attention. The primary adjuncts remain: chest and pelvic radiography, FAST or extended FAST (eFAST), and DPA (Fig. 10-3). While CT scanning revolutionized trauma care and is of undisputed importance in the complete identification of injures, we believe that physiologically unstable patients should not go to CT and therefore we consider it an adjunct to the secondary survey. While a complete review of all of these primary adjunctive modalities is beyond the scope of this chapter, the following outlines the major issues.
Algorithm showing a stepwise approach to a patient presenting in shock. As time is of the essence, ideally the overall assessment and investigation should take no more 10–15 minutes and should be monitored though performance improvement. While much has been written about responders and nonresponders to resuscitation, we contend that rapid identification of patients who require emergent intervention is more meaningful. Though nonresponders fit into this group, so do patient who have responded to blood and fluid but still need emergent OR or IR intervention without further radiologic or investigatory delay (eg, those with pericardial tamponade, exsanguinating extremity trauma or severe pelvic fractures). Patients who respond without obvious need for intervention may undergo complete trauma work-up as needed.
Although, not yet relegated to the historical scrap heap, the role of routine CXR has been questioned.24,25,26 While chest CT is superior for the total identification of thoracic injuries, lost in the debate is the true purpose of the plain CXR,27 which is a screening tool to quickly evaluate a patient for life-threatening conditions. In the patient with an abnormal chest physical examination (ie, tachypnea, desaturation, significant chest deformity) or hemodynamic instability, the CXR provides a rapid means of identifying hemo- or pneumothoraces, a ruptured diaphragm or the suggestion of aortic injury. Additionally, pulmonary contusions or multiple rib fractures that can be seen on the screening CXR may predict later respiratory failure and the need for admission to a monitored bed for more comprehensive care.28 Lastly, the CXR confirms placement of both endotracheal and chest tubes. Thus, while routine CXR may not be warranted in every hemodynamically stable patient with a normal physical examination, it remains an integral and invaluable part of the primary survey in patients with physiologic derangements or positive physical examination findings.
Similar and possibly to a greater extent than the discussion on screening CXR, there are multiple studies demonstrating lack of utility for routine pelvic x-ray (PXR) as a standard adjunct to the primary survey.29,30,31 This conclusion was reflected in the most recent edition of ATLS, where PXR is no longer considered a mandatory adjunct to the primary survey.23 In our own practice, we have now focused our efforts in those patients with unexplained hypotension in which a simple intervention such as pelvic binding might be beneficial or those with obvious skeletal injuries where a hip dislocation may be considered.
Focused Assessment of Sonography in Trauma
The standard FAST exam (four views examining the pericardium, right and left upper quadrants and the bladder) has been shown to be a useful adjunct in the hemodynamically unstable blunt trauma patient (see Chapter 36).32,33,34 Its use has essentially replaced (DPA/DPL) as the prime adjunct for triage of the abdomen in the unstable patient. Recently, however, there have been questions as to the role this modality plays in certain subgroups such as those with penetrating trauma or the hemodynamically stable patient. Multiple studies have demonstrated that sensitivity and specificity decrease significantly in the patient who is stable or may have other injuries.35,36,37 Unlike plain radiography, the reliability of the FAST exam is related to operator experience, patient’s body habitus, underlying bowel gas, or the machine itself. The inability to get the critical views makes the scan unreliable and the examination should not be considered “negative.” Thus, in the hemodynamically unstable patient without external signs of bleeding and a “clean CXR and PXR” a negative FAST should be interpreted with caution.
The last decade has seen an expansion in the use of ultrasound to include evaluation of the thorax for pneumothorax.38 The eFAST has been shown in multiple studies to be equal or more reliable in detection of pneumothoraces than CXR.39,40,41,42,43 Although, operator experience always comes into play with ultrasound, the eFAST has the advantage of rapidity and decreased ionizing radiation. However, the true role for eFAST in the trauma patient has not yet been clearly defined. Because the eFAST can detect occult pneumothoraces that might not be found on CXR, caution should be utilized in making decisions about a tube thoracostomy in those patients.
Diagnostic Peritoneal Lavage
Though the diagnostic peritoneal lavage (DPL) has been utilized for nearly 50 years in evaluation of the trauma patient with suspected intra-abdominal trauma, the adoption of FAST as a noninvasive means of evaluation has called some to question whether it still has any role in trauma care.44 However as the use of FAST has become widespread, potential limitations due to patient, machine, and operator factors have become more apparent and the role of the DPL in the hemodynamically unstable patient has re-emerged.45 We would submit that there is no longer a need for the actual lavage portion of the procedure and as currently practiced it is a direct aspirate of the peritoneal cavity designed to look for gross blood in the face of hemodynamic instability. Eliminating the lavage mitigates some of the reported disadvantages to the DPL including lack of ability to repeat the study, possibility of altering/skewing CT or ultrasound results with installation of fluid and high negative laparotomy rate due to its inherent sensitivity. We strongly believe that DPA should not be eliminated from the trauma surgeon’s armamentarium. In those instances where the FAST is “negative” in a patient with unexplained hypotension, a DPA should be strongly considered a part of abdominal triage.
With significant improvements in technology, CT scanning of the trauma patient has become ubiquitous. As an adjunct to the secondary survey, for the hemodynamically stable patient, there is no doubt that modern CT scanning provides the most accurate means of injury identification over a broad spectrum of possibilities. There is some evidence that the liberal use whole body scanning identifies clinically significant abnormalities.46,47 An additional advantage of the “pan-scan” is the ability to discharge patients safely when the scan is negative.21 There should however be some caution in liberally and routinely prescribing total body CT scans for all trauma patients. In addition to the cumulative radiation over a patient’s lifetime, there is risk for contrast-induced nephropathy, especially in the geriatric trauma patient.48 The provider should take into account all factors, such as mechanism of injury/suspected injury, cooperation of the patient, clinical exam findings, and patient flow, when making decisions as to what scans are needed.
Although, there are multiple studies that demonstrate a low utility for certain standard screening laboratory panels in trauma patients, there may be some tests of value depending on the nature of the trauma.49,50,51 Although, decisions as to appropriate testing can be made based on the severity/perceived severity of the patient, it is often useful to have a “trauma panel” that includes a CBC, coagulation profile, and alcohol level. Point of care testing should be considered as the results are more rapidly available. All patients should have a type and cross match sent. After that, there may be some utility in obtaining an arterial blood gas in those patients meeting the highest level of trauma activation.52,53,54,55 This should ideally be able to provide the standard values like pH and base deficit but lactate as well. A venous lactate may also provide similar information.56 For those in shock, TEG/Rotem have shown some promise in helping guide resuscitation.57,58
Medical Record and Performance Improvement
With increasing emphasis on short- and long-term outcomes, clinicians taking care of trauma patients should create performance improvement methodology which allows for a thoughtful analysis of each trauma encounter. It should include review of the team’s performance during the initial assessment and management of the trauma patient and can begin with identification of appropriate triage of the trauma patient. Flow in the trauma bay, specifically evaluating times to accomplish certain tasks (ie, movement to the operating room or interventional radiology) and timely response of consultants can also be measured. While there is no perfect system of recording the events in the trauma bay, the backbone of most PI programs is the trauma flow sheet. These should be completed in sufficient detail that allows the trauma center staff to do a thorough review of any case. As the primary individuals responsible for charting are the trauma nursing staff, seeking their input in the creation of an institution’s trauma flow sheet is invaluable.
First described in 1988, Trauma Video Review has been utilized in many institutions (Fig. 10-4) and found to be an effective performance improvement tool.59,60,61 Although, there are medicolegal considerations to its use, trauma video review provides an opportunity to improve performance by highlighting team cooperation, error identification, and educating the entire trauma team.
Small, wide angled cameras can provide a full field of view during trauma resuscitation for later video review. These devices can be mounted unobtrusively and operated remotely such that the trauma team is unaware of their presence or operations and performs their tasks in a routine manner.