Overview

Trauma is the leading cause of death for people aged 1-44 years and is exceeded only by cancer and atherosclerotic disease in all age groups. Orthopedic surgery plays a key role in the treatment of the polytraumatized patient. In a study at Brown University, gunshot wounds (see images below) required more orthopedic trauma resources than other surgical areas.^[1] The orthopedic surgeon is a member of a team consisting of many specialists, including emergency medicine physicians, trauma surgeons, neurosurgeons, and other surgical subspecialists. Each person on that team should be familiar with the basics of trauma resuscitations, outlined below.^{[2, 3]}

All resuscitations should be performed using Advanced Trauma Life Support (ATLS) guidelines.^[4] For the individual physician, assessment of the polytraumatized patient is performed using a stepwise longitudinal approach, in which the airway is handled first and no procedures are initiated until the airway is secured. Then, breathing and circulation are addressed. In the trauma team approach, each team member should be assigned a specific task or tasks so that each of these can be performed simultaneously to ensure the most rapid treatment possible.^[5]

Birdshot from a shotgun. Birdshot from a shotgun. Next

Primary Survey

Assessment

In the primary survey, airway, breathing, and circulation are assessed and immediate life-threatening problems must be diagnosed and treated. An easy-to-remember mnemonic is ABCDE: airway, breathing, circulation, disability, and exposure/environment control.

The primary survey usually takes no longer than a few minutes, unless procedures are required. The primary survey must be repeated any time a patient's status changes, including changes in mental status, changes in vital signs, or the administration of new medications or treatments.

Airway (with Cervical Spine Protection)

An obstructed airway is one of the most immediate and deadliest threats to life. The goals are to provide a patent airway while maintaining in-line cervical stabilization and to protect the airway from future obstruction by blood, edema, vomitus, or other possible causes of blockage.

Diagnosis

• Ask the patient a question; for example, ask how he or she is feeling. If the patient responds verbally, he or she has an intact airway, is breathing, is thinking, and, therefore, has a pulse. Also, the patient's level of consciousness can be briefly assessed.
• If the patient is unresponsive, check airway patency by looking at the patient's chest while leaning the ear toward the patient's mouth. Look for chest expansion, listen, and feel for air movement. This may be performed while using the jaw-thrust (or head-tilt/chin-lift maneuver if cervical injury has been ruled out).
• Anticipate potential problems. If the patient is breathing spontaneously, listen to the quality of the breathing. Snoring or gurgling suggests partial airway obstruction. A hoarse voice, subcutaneous emphysema of the anterior part of the neck, or a palpable thyroid cartilage crepitus may indicate laryngeal trauma.
• Assess the ability of an unconscious victim to protect the airway by checking the gag reflex. Touch the posterior pharynx with a tongue blade to initiate the gag response. If the patient is alert, the best way to check for the ability to protect the airway is to witness swallowing. Patients without a gag reflex cannot protect themselves from aspirating secretions into the lungs; these patients should be intubated.

Treatment

• The jaw-thrust maneuver may be necessary. The most common airway obstruction is due to the base of the tongue falling backward into the posterior pharynx. The jaw thrust is performed by placing the fingers behind the angle of the mandible and lifting anteriorly. This is uncomfortable and may awaken an obtunded patient.
• A possible alternative to the jaw thrust is the chin-lift maneuver. The chin of the patient is lifted superiorly, hyperextending the neck and opening the airway. This is dangerous in trauma patients because it may exacerbate a cervical spine injury. Its use is restricted to those patients in whom cervical spine injury has been excluded.
• Remove any foreign bodies that are seen, including dentures. Do not perform a blind mouth sweep because this may push the blocking object(s) farther down the pharynx.
• Suction to remove secretions and blood.
• An oropharyngeal airway is for use only in unconscious patients. It is easy to insert to ensure airway patency while using a bag-valve mask ("bagging" the patient) or while preparing for endotracheal intubation.
• A nasopharyngeal airway is useful in partially conscious, intoxicated, or seizing patients to ensure a patent airway. It is contraindicated in patients with facial trauma or coagulopathy.
• A laryngeal mask airway is an airway device inserted through the mouth, with a mask that covers the larynx. It comes in different sizes, so check the package to choose the appropriate size for the weight of the patient. After inflating the cuff, the airway is secured. A laryngeal mask airway is very effective as a rescue airway, but it does not protect the patient from aspiration and should be considered only a temporary measure until definitive airway management is possible.

Definitive airway management

Definitive airway management achieves the 3 P' s: airway patency, aspiration protection, and positive pressure ventilation.

• Orotracheal intubation is the criterion standard of airway management. An endotracheal tube is placed between the vocal cords under direct visualization. Immediately afterward, the physician must (1) check breath sounds bilaterally, (2) check for gastric distention/borborygmi, (3) check for exhaled carbon dioxide using an end-tidal carbon dioxide detector, (4) ensure that the oxygen saturation by pulse oximetry remains at 95-100%, and (5) obtain a chest radiograph to confirm proper positioning of the tip 2-3 cm above the carina.
• Nasotracheal intubation is indicated for a spontaneously breathing patient. It may be associated with bleeding from trauma to the nasal passages, but once in place, it is better tolerated by an awake patient because it is more comfortable and less likely to induce vomiting than orotracheal intubation. It is contraindicated in patients with facial trauma or basilar skull fractures. Check tube placement afterward, as with the orotracheal tube.
• Surgical airway is usually a last resort and is indicated when orotracheal intubation is unsuccessful, obstruction of the trachea (by edema, blood) is complete, or the airway is totally transected. Surgical cricothyroidotomy is indicated in patients older than 5-12 years. Needle-jet insufflation may be used in pediatric patients by experienced personel.

Intubation can be extremely difficult in the trauma setting. In-line cervical stabilization must be maintained, and the airway frequently is obscured by edema, blood, or vomitus.

Intubation may be performed without medication in polytraumatized, obtunded, or comatose patients. Sedation with etomidate may be sufficient to relax the muscles of the jaw and neck. Rapid sequence intubation with paralytics is used with adequate precautions because paralyzing the patient means he or she cannot breathe independently or protect the airway if intubation is unsuccessful.

Any time intubation is considered, failure is a possibility. Prepare for this inevitable situation by having backup personnel or airway devices and a cricothyroidotomy tray available. Lack of an airway is one of the few situations in medicine in which seconds count.

Adjuncts to orotracheal intubation

If a difficult airway is predicted or multiple attempts at laryngoscopic intubation have failed, the following adjuncts may be useful in performing intubation:

• Fiberoptic intubation: A fiberoptic scope is inserted and guided under direct visualization into the larynx, and then the endotracheal tube is fed over it.
• Retrograde intubation: Puncture the cricothyroid membrane with a large-bore needle aimed cephalad, and then feed the guidewire through up to the mouth. Feed the endotracheal tube down the guidewire, which is held taut at both ends.
• Light wand: A lighted stylet assembly is inserted blindly into the mouth. When the tip is visible transilluminating through the cricothyroid membrane, it is in the correct location and the endotracheal tube is fed down the stylet.

Cervical spine protection

The physician must assure that in-line cervical stabilization is maintained for any patient with suspected or confirmed cervical spine fracture. The mechanism of injury must be considered to predict danger to the cervical spine. A history of the ability to walk or move all 4 limbs following an injury does not rule out the possibility of an unstable cervical spine fracture. Any patients with facial injuries, significant blunt trauma (including falls and motor vehicle accidents), or neurologic deficits must be assumed to have a cervical injury until proven otherwise.

Protection is initially provided by holding the head in a neutral position facing forward. It can be temporarily maintained with a hard cervical collar and taping of the forehead to the gurney to prevent rotation within the collar. When intubating a patient with possible cervical spine injury, the head is kept in a neutral position. The patient must lie immobile with a hard collar in place until vertebral or spinal cord injury is excluded clinically or with radiography (see Cervical spine clearance). Precautions against decubitus pressure injury must be taken.

Breathing

Any immediate life-threatening obstacles to breathing, namely tension pneumothorax, open pneumothorax, flail chest, or massive hemothorax, must be identified and treated quickly.

Diagnosis

• Watch the patient breathe, listen to the lungs, and feel with both hands for equal bilateral chest expansion. Look at the skin, lips, and tongue for cyanosis.
• Monitor the pulse oximetry; however, remember that pulse oximetry can be unreliable in patients with poor peripheral perfusion after trauma. Arterial blood gas sampling may be indicated, which allows a more accurate reading of the oxygenation, as well as carbon dioxide elimination and acid-base status.

Treatment

• Oxygen at 6-10 L/min via a nonrebreathing face mask is indicated for polytrauma patients able to maintain the airway and breathe (ventilate). Beware of potential for vomiting.
• Ventilate the patient with rescue breaths, a bag-valve device (bagging the patient), or a ventilator.
• Treat open pneumothorax, tension pneumothorax, flail chest, and massive hemothorax.

Open pneumothorax (sucking chest wound)

Any chest wound with a diameter of more than two thirds of the trachea can become a sucking chest wound. Air moves preferentially through the wound orifice rather than through the trachea (due to less air flow resistance), and the ipsilateral lung deflates. Emergency treatment is with a bandage taped on 3 sides so that air can escape but cannot be sucked into the chest, followed as soon as possible by tube thoracostomy.

Tension pneumothorax

Tension pneumothorax is a deadly condition in which a defect in the lung allows air into the pleural space but does not allow air to escape. First, the lung collapses, but eventually, the pressure inside the hemithorax builds up and pushes the mediastinum into the opposite hemithorax. The contralateral lung is compressed, and the great vessels may be kinked. Severe perfusion-ventilation mismatch ensues, and the patient may go into shock in minutes. Tension pneumothorax frequently is caused by positive pressure ventilation with a lung injury, but it can result from any thoracic trauma.

Tension pneumothorax is a clinical diagnosis; do not wait for radiographs. The classic signs of tension pneumothorax are chest pain, respiratory distress, shock refractory to fluids and pressors, decreased breath sounds and tympany of the affected hemithorax, jugular venous distension, cyanosis, and tracheal deviation to the opposite side. However, because the classic signs may be hard to detect, suspect tension pneumothorax in any patient who is hypoxic or in shock, especially if the patient has air crepitus or evidence of trauma to the ipsilateral chest wall. Auscultation may be difficult in a noisy trauma resuscitation, breath sounds can be transmitted from the opposite side, jugular venous distention may be absent in the presence of hypovolemia, and tracheal deviation is a late sign.

Treatment is a 16-gauge needle inserted into the second intercostal space in the midclavicular line to immediately decompress the thorax, quickly followed by chest tube insertion into the fifth intercostal space in the midclavicular line to reexpand the lung.

Flail chest

Flail chest is defined as 3 or more consecutive ribs fractured at 2 sites. This creates a floating section of chest wall that does not move with the rib cage during ventilation. Flail chest may be associated with hypoxia secondary to severe underlying lung contusion, resulting in significant morbidity and mortality.^[6]

Trauma to the chest wall and lungs causes hypoxia in a number of ways. Rib pain from contusion or fracture may cause the patient to hold the chest still, which causes hypoventilation. Paradoxical breathing may be observed when multiple continuous rib fractures cause the injured segment of the chest to no longer expand with inspiration but collapse inward. Pulmonary contusion causes extravasation of fluid and blood into the alveoli, limiting oxygen diffusion.

Flail chest is a clinical diagnosis. The physician must (1) maintain a high index of suspicion in any thoracic injury, (2) begin treatment immediately, and (3) confirm the diagnosis as soon as possible with chest radiography. Treatment involves maximizing oxygenation of the lungs, using positive pressure ventilation if necessary. Effective pain control, including opiates and intercostal nerve blocks, is important to prevent splinting and further hypoxia. Judicious fluid management is required to avoid turning pulmonary contusion into pulmonary edema. Sandbags, taping the chest, or other historical methods of external splinting are not indicated and can worsen respiratory distress.

Massive hemothorax

A small hemothorax does not compromise breathing, but a massive hemothorax can cause problems with breathing and circulation. Several liters of blood can be exsanguinated into each hemithorax. Massive hemothorax is defined as 1500 mL of blood in the chest cavity, usually caused by disruption of an intercostal systemic or hilar vessel.

Clinically, a massive hemothorax can manifest with both respiratory and circulatory collapse. Breath sounds are reduced, and percussion is dull on the affected side. The chest can accommodate the entire circulating volume of blood; therefore, hemorrhagic shock may be severe.

Treatment is evacuation of blood with a large-bore (36-40F) chest tube and collection of blood for possible autotransfusion, while intravascular volume is replaced intravenously with fluids and blood. Patients who continue to bleed, defined as a flow of 200 mL/h for 2-4 hours, or who persistently need blood transfusions may require a thoracotomy to control the bleeding vessel.

Circulation and Hemorrhage Control

Diagnosis

• The level of consciousness, skin temperature and color, nail bed capillary refill time, and rate and quality of the pulses are all clinical markers for blood circulation and tissue perfusion.
• Identify and control external bleeding with direct pressure. Include a log roll of the patient to identify posterior bleeding.
• Cardiac and blood pressure monitoring is instituted.
• Draw blood for basic laboratory studies, including hematocrit and a pregnancy test for all females of childbearing age.

Treatment

• Resuscitate with 2 large-bore (14- to 16-gauge) intravenous catheters, using warmed fluids and packed RBCs if necessary.
• Control hemorrhage.
• Treat cardiac tamponade, cardiac arrest, and massive hemothorax; consider immediate resuscitative thoracotomy.
• Use the left lateral recumbent position for pregnant patients at more than 20 weeks of gestation. If this positioning is impossible, push the uterus laterally to relieve pressure on the inferior vena cava, which may be responsible for decreased venous return.

Fluid and blood resuscitation

All patients who experience trauma should have 2 large-bore peripheral intravenous lines placed in the primary survey. Shock should be treated with rapid infusion of warmed isotonic fluids (either normal saline or lactated Ringer solution). Young, previously healthy patients who undergo trauma can be administered 2 L (or 20 mL/kg in pediatric patients) immediately. Older patients, especially those with congestive heart failure or renal failure, should receive smaller boluses (250-500 mL) to prevent fluid overload. Assess the response to resuscitation by monitoring vital signs, clinical status, base deficit, and serum lactate levels. Patients who do not improve should receive cross-matched packed RBCs with more fluids. If in extremis, unmatched O-negative blood is used for female patients of child-bearing age. 0 Rh+ blood is acceptable for male patients (see Blood transfusions).

Hemorrhage control

During the primary survey, the physician identifies and controls serious sources of bleeding. Even soft-tissue and musculoskeletal injuries can involve major vessels and can cause life-threatening exanguination. External bleeding is treated with direct pressure. Use of hemostats is to be avoided as blind clamping can cause damage to adjacent vessels or nerves. Tourniquets should be considered only in limited circumstances (eg, traumatic amputation). Quickclot, a biologically and chemically inert zeolite powder, has been approved by the US Food and Drug Administration to control bleeding in external wounds. It promotes coagulation by absorbing water, but it produces an exothermic reaction that could result in burns.

Intra-abdominal hemorrhage is a common life-threatening source of bleeding, and it must be considered in any hypotensive patient. Besides splenic rupture and extensive hepatic lacerations, major vascular injuries could be the culprit. Direct surgical control of the bleeding in the operative room is an integral part of shock resuscitation of patients who do not respond to the initial fluid infusion (nonresponders). Intra-abdominal bleeding can be assessed quickly with focused abdominal sonography for trauma (FAST) (or diagnostic peritoneal lavage (DPL) if ultrasonography is not available).

Fractures can cause serious bleeding. Tibia and humerus fractures may be associated with up to 750 mL of blood loss, femur fractures with up to 1500 mL of hemorrhage, and pelvic fractures with several liters of blood loss. Temporary stabilization by splinting can be lifesaving in these patients. In the primary survey, presumed bleeding from pelvic fractures should be controlled with noninvasive techniques, such as a pelvic binder or a sheet wrapped about the pelvic region. Military antishock trousers or a pneumatic antishock garment may also be considered in efforts to tamponade bleeding from pelvic fractures.

Bleeding from pelvic fractures is frequently retroperitoneal and must be distinguished from intraperitoneal bleeding from a ruptured solid organ. This is usually performed using FAST or DPL, but it can be difficult and may require CT scanning, angiography, or even emergent exploratory laparotomy.

The use of skeletal traction may be beneficial to control hemipelvic displacement. This can be applied at the end of the primary survey. More definitive treatment of the pelvic fracture is handled during the secondary survey.

Cardiac tamponade

Cardiac tamponade is the result of an increased amount of fluid or blood in the pericardium, which compresses the heart, prevents venous return, and causes pump failure.

Suspect cardiac tamponade in any patient with penetrating trauma to the left chest, left upper abdomen, or back. As little as 150-200 mL of blood can cause significant cardiac compromise. Clinical signs of tamponade are shock refractory to fluids and pressors or pulseless electrical activity, jugular venous distension, muffled heart sounds, the Kussmaul sign (ie, increased jugular venous pulsation on inspiration), pulsus paradoxus, or electrical alternans on ECG tracings.

Pericardial effusion is detected by transthoracic ultrasonography as a strip of hypoechoic fluid between the myocardium and the pericardium.

Treatment is immediate pericardiocentesis or pericardial window (a surgical opening in the subxiphoid area) in the operating room. Aspiration of even 10-15 mL of blood can relieve cardiogenic shock and gain time for more definitive management.

Cardiac arrest

Any patient without a pulse should immediately be assessed with defibrillator paddles or a cardiac monitor. Unstable arrhythmias must be treated by electrical cardioversion to prevent them from becoming terminal rhythms such as pulseless electrical activity, ventricular fibrillation, or asystole.

Resuscitative thoracotomy

Witnessed loss of vital signs associated with penetrating thoracic injury constitutes an indication for a resuscitative thoracotomy. Endotracheal intubation with mechanical ventilation is performed, and the intravascular volume is concurrently replenished. After gaining access to the chest, the qualified surgeon or emergency physician may (1) treat cardiac tamponade, (2) gain direct control of intrathoracic hemorrhaging vessels, (3) perform open cardiac massage or defibrillation, and (4) cross-clamp the aorta to slow blood loss distally and increase perfusion to the heart and brain proximally. Resuscitative thoracotomy has not been found to be beneficial for blunt trauma.

Disability

Perform a quick neurologic examination by assessing the patient's level of consciousness, pupillary size and reaction, and gross motor functioning. The Glasgow Coma Scale (GCS) is the most commonly used rating system. The GCS is used to measure eye opening, gross motor function, and verbalization of the patient. Each category has a point score, and the sum of the 3 scores is the total GCS rating. The GCS is as follows:

• Eye opening (E)
  • Spontaneous - 4 points
  • To speech - 3 points
  • To painful stimulus - 2 points
  • No response - 1 point
• Movement (M)
  • Follows commands - 6 points
  • Localizes to painful stimulus - 5 points
  • Withdraws from painful stimulus - 4 points
  • Decorticate flexion - 3 points
  • Decerebrate extension - 2 points
  • No response - 1 point
• Verbal response (V)
  • Alert and oriented - 5 points
  • Disoriented conversation - 4 points
  • Nonsensical words - 3 points
  • Incomprehensible sounds - 2 points
  • No response - 1 point

Altered level of consciousness can be due to multiple factors, including drug or alcohol intoxication, hypoxia, hypotension, or cerebral injury. Hypoxia, hypotension, hypothermia or hyperthermia, and hypoglycemia are treatable conditions, and should be addressed first in a polytrauma patient. After oxygenation and perfusion are normalized, an altered level of consciousness should be assumed to be due to traumatic brain injury (TBI) and is assessed in the secondary survey.

Exposure/Environment Control

Expose the patient by removing all clothes. Hypothermia is a frequent complication of trauma and is due to waiting on scene and peripheral vasoconstriction. Keeping the patient warm is often forgotten during the trauma resuscitation. Control hypothermia with adequate warming or blankets.

Adjuncts to the Primary Survey

See the list below:

• Radiography: The "trauma triple" is a portable cervical spine, anteroposterior chest, and anteroposterior pelvis radiographs. These provide the maximum amount of information about potentially dangerous conditions in a minimum amount of time.
• Laboratory studies: Obtain a complete blood cell count and chemistry, including a sodium level, potassium level, renal function assessment, urinalysis, urinary toxicology screen, and a beta-human chorionic gonadotropin value in all females of childbearing age.
• Blood preparations: Order a type and screen, and consider cross-matching 2-4 units of RBCs, depending on the severity of the trauma and shock.
• Urinary and gastric catheterization
• Temperature, ECG and oxygen saturation monitoring

Consider Transfer

At this point, the physician should have enough knowledge of the patient's status to consider transfer to a higher level of care if the appropriate care is not available at the current facility. All cities or counties in the United States have a system to determine which patients require transfer to a trauma center.

Summary of the Primary Survey

See the list below:

• Airway - Airway opened, airway obstruction treated, possible definitive airway placed
• Breathing - Breathing assessed, tension pneumothorax and massive hemothorax treated, oxygen and assisted ventilation provided as needed
• Circulation - Blood circulation and tissue perfusion assessed, intravascular volume loss replaced with fluids and blood, cardiac tamponade and cardiac arrest treated, emergency thoracotomy performed if indicated, and external hemorrhage controlled
• Disability - Neurologic status assessed
• Exposure/environment - Patient fully undressed and environment controlled to protect from hypothermia or hyperthermia
• Adjuncts - Trauma triple radiographs, laboratory studies, urinary or gastric catheters, temperature, ECG and oxygen saturation monitoring, consider blood transfusion
• Consider transfer - For higher level of care if necessary

Shock In The Polytraumatized Patient

Hemorrhagic shock

In the trauma patient, shock is assumed to be caused by hemorrhage until proven otherwise. Hemorrhagic shock is a clinical diagnosis based on vital signs and physical examination findings. The hematocrit value drops but does not equilibrate fully in the face of acute bleeding until several hours have passed to allow interstitial fluid to flow into the intravascular space. Also, remember that fluid resuscitation dilutes the blood and lowers the hematocrit value.

Treat hemorrhagic shock initially with warmed isotonic crystalloid fluids and packed RBCs if necessary. The use of albumin is controversial and has not been proven beneficial. Surgical control of the source of bleeding is an integral part of resuscitation and must not be delayed by full reestablishment of intravascular volume.^[7] Treatment is aimed towards normalization of physiologic parameters: pulse rate (60-100 beats per minute), blood pressure (mean arterial pressure 90-100 mm Hg), pH (7.35-7.45), urine output (>0.5 mL/kg/h for adults, 1 mL/kg/h for children, 2 mL/kg/h for neonates), mental status, serum lactate level, and no base deficit. For patients with invasive monitoring devices in place, normalization of the central venous or mixed venous oxygen extraction ratio (65-70%) should be considered.

Neurogenic shock

Neurogenic shock is insufficient tissue perfusion secondary to a high spinal cord injury that causes disruption of the sympathetic outflow to the heart and blood vessels. Do not confuse this with "spinal shock," which is a neurologic condition referring to the transient areflexia and flaccidity observed in the initial stage of a spinal cord injury (which constitutes a lower motor neuron lesion associated later with hyperreflexia and spasticity). Consider neurogenic shock in any patient with a slow pulse, warm and dry extremities, and hypotension, especially those with direct trauma to the upper spine, acute paraplegia, or quadriplegia. Resuscitate with fluids and vasopressors if needed, and immediately consult a neurosurgeon.

Hypoxic shock

Remember to frequently reassess the airway, breathing, and circulation for airway compromise, mucous plug, equipment failure, apnea, pneumothorax, hemothorax, or flail chest. Provide sufficient oxygen and positive pressure ventilation if necessary.

Also consider comorbid conditions such as sepsis, dehydration, congestive heart failure, and anaphylaxis that may cause shock. Head trauma is rarely a cause of hypotension in adults. Any patient with hypotension and head injuries is usually bleeding from another source, often the abdomen.

Table. Classes of Hemorrhagic Shock (Open Table in a new window)

Class Blood Loss,



% Volume



Pulse,



Beats per Minute



Blood Pressure Capillary Refill,



Seconds



Mental Status Initial Treatment Class I < 15 < 100 Normal < 2 Anxious Intravenous fluids Class II 15-30 < 120 Red pulse pressure >2 Very anxious Intravenous fluids Class III 31-40 < 140 Red systolic blood pressure >2 Combative Intravenous fluids plus blood Class IV 41+ >140 Red systolic blood pressure >2 Obtunded Intravenous fluids plus blood

Blood transfusions

Consider transfusion of blood or packed RBCs for any patient who sustained trauma and has severe blood losses or unstable vital signs that do not respond to initial fluid resuscitation. Fully cross-matched blood is best, but most laboratories need 1 hour of preparation time. Type-specific blood is usually available in 10 minutes. Type O blood should be reserved for true emergencies. Rh-negative blood should be used in women of childbearing age; otherwise, Rh-positive blood is acceptable.

Remember to ask the patient about previous transfusions and transfusion reactions. If the patient develops a hemolytic reaction, characterized by chest or flank pain, nausea and vomiting, fever, and dark urine, stop the transfusion immediately and provide fluids, urine alkalinization with bicarbonate, and mannitol. Minor allergic or febrile reactions can be treated with antipyretics and antihistamines, without the need to stop the transfusion.

If post-traumatic coagulopathy is suspected, emergently consult a hematologist.^[8]

Secondary Survey

Specialized Tests

The secondary survey is performed only after the primary survey has been finished and all immediate threats to life have been addressed. The secondary survey is a head-to-toe examination designed to identify any injuries that might have been missed.

Specialized diagnostic tests are performed to confirm potentially life-threatening injury only after the primary survey has been completed, all immediate threats to life are treated or stabilized, and hemodynamic and ventilation status are normalized. These tests include CT scanning, extremity radiography, endoscopy, and formal ultrasonography.^{[9, 10, 11]}

Recent reports on the use of ultrasonography to measure optic nerve sheath diameter for the detection of raised intracranial pressure suggest a good correlation, with a sensitivity of 90% and a specificity of 85%. This bedside diagnostic tool is operator dependent but can provide additional clinical data points to help decide on the next appropriate diagnostic or therapeutic approach, including early transfer to a higher level of care for suspected raised intracranial pressure.^[12]

The trauma patient must be reevaluated constantly to identify trends in physical examination and laboratory findings. Administer intravenous opiates or anxiolytics in small doses to minimize pain and anxiety without obscuring subtle injuries or causing respiratory depression.

Focused Patient History

The history in the secondary examination is focused on the trauma and pertinent information if the patient is to be sent to surgery. The mnemonic SAMPLE covers the basics.

• Symptoms - Pain, shortness of breath, other symptoms
• Allergies to medications
• Medications taken
• Past medical/surgical history
• Last meal - Important to determine risk of aspiration
• Events leading up to trauma

Head and Skull Examination

Head trauma is responsible for 50% of trauma deaths and therefore should be of the highest priority during the secondary survey. Intracranial bleeding, including subarachnoid hemorrhage, intracranial hemorrhage, subdural hematoma, and epidural hematoma all can be identified by a neurologic examination and noncontrast head CT scanning. Suspect intracranial injury in any patient with focal neurologic signs, altered mental status, loss of consciousness, persistent nausea and vomiting, or headache, even if those symptoms may be explained easily by other intoxications or injuries. Any patient with suspected intracranial injuries should undergo head CT scanning as soon as he or she is hemodynamically stable.

Examination of the head involves assessing the level of consciousness, eyes, and skull. The level of consciousness can be quickly quantified using the GCS. The eyes are inspected for visual acuity, pupillary size, and extraocular movements. Funduscopy is used to evaluate preretinal hemorrhage. The skull is examined and palpated for lacerations, tenderness, or fractures. Look for signs of basilar skull fracture, such as the Battle sign (ie, bruising at the mastoid area), raccoon eyes (ie, periorbital ecchymoses), or cerebrospinal fluid rhinorrhea or otorrhea.

Head injury management involves aggressive treatment of hypoxia and hypotension to prevent secondary brain injury and an immediate consultation with a neurosurgeon. Maintain the mean arterial blood pressure at 90 mm Hg or above in patients with suspected intracranial injury in order to maintain cerebral perfusion pressure.^[13] Methods to treat intracranial hypertension, such as raising the head of the bed, hyperventilation, furosemide (Lasix), and mannitol, may be considered under the supervision of a neurosurgeon. The TBI scale is as follows:

• Mild TBI - GCS rating of 14-15
• Moderate TBI - GCS rating of 9-13; requires careful monitoring to avoid hypotension or hypoxia
• Severe TBI - GCS rating of 8 or less; requires careful monitoring to avoid hypotension or hypoxia, but also requires intubation and admission to an intensive care setting

Maxillofacial Examination

Injuries to the face are rarely life threatening unless they involve the airway. Look inside the mouth and nose for bleeding or hematomas. Examine the maxilla and mandible for instability associated with Le Fort fractures. Consider early intubation to protect the airway, which may become compromised later because of tracheal swelling or excessive secretions.

Neck Examination

The neck contains 3 very important structures anteriorly (ie, trachea, pharynx/esophagus, great vessels) and holds the spine posteriorly. All these structures must be evaluated in patients with penetrating trauma to the neck. Any patient with penetrating trauma to the neck in which the superficial fascia and muscles are penetrated should receive immediate consultation with an otolaryngologist or general trauma surgeon.

Chest Examination

Thoracic injuries account for 25% of the trauma-related mortality rate. Of thoracic injuries, 10% are fatal. Only 10% of blunt injuries and 15-30% of penetrating trauma injuries require thoracotomy and/or specialized surgical procedures; thus, most cases of thoracic trauma can be managed by any ATLS-trained physician.

Inspect the chest for bruising, deformity, and motion of the chest wall during respiration. Auscultate the heart for muffled heart sounds or murmurs associated with traumatic valvular damage. Auscultate the lungs for breath sounds. Palpate the chest for subcutaneous emphysema or bony crepitus, which may indicate tracheobronchial disruption or rib fractures, respectively.

Injuries that Must Be Considered in the Secondary Examination

See the list below:

• Traumatic rupture of the aorta
  • Diagnosis: Use chest radiography to screen for a widened mediastinum or other signs of rupture. Aortography is cumbersome and is used infrequently. The definitive diagnosis is made with CT angiography of the chest, or transesophageal echocardiography.^[14]
  • Treatment: Use an interpositional graft or repair the rupture.
• Tracheobronchial disruption
  • Diagnosis: Consider this diagnosis if a collapsed lung does not expand after chest tube insertion, a massive air leak persists, or progressive subcutaneous emphysema is noted.
  • Treatment: Perform bronchoscopy and surgical repair.
• Diaphragmatic disruption
  • Diagnosis: Stomach (gastric bubble) and/or bowel can be seen in the thorax on chest radiographs, CT scans, or laparotomy findings.
  • Treatment: Insert a nasogastric tube to decompress the stomach; then, perform surgery.
• Blunt cardiac injury
  • Significance: This may cause contusion, chamber rupture, or valvular disruption.
  • Diagnosis: ECG and cardiac echo aid in diagnosis.
  • Treatment: Consult with a cardiothoracic specialist for rupture, valve disruption, or contusion; monitor the patient for 6-24 hours for arrhythmias.
• Pulmonary contusion
  • Diagnosis: Pulmonary opacities can be seen on chest radiographs.
  • Treatment: Avoid fluid overload if the patient is fluid-resuscitated. Administer oxygen and analgesia, and consider intubation.
• "Blast lung": Blast lung is seen with high-energy explosive injuries, such as terrorist bombings. As reported from Israel, the strength of explosives strapped to an individual limits the occurrence of fatal blast lung to within 6 meters of the detonation. According to the US Centers for Disease Control and Prevention Injury Center, blast lung is the most common fatal primary blast injury among initial survivors. Signs may be immediate or may be delayed up to 48 hours. The triad of apnea, bradycardia, and hypotension is characteristic. Blast lung should be suspected in victims of explosive injury who have dyspnea, cough, hemoptysis, or chest pain.
• Simple pneumothorax
  • Significance: This can develop into tension pneumothorax, especially if intubation and positive pressure ventilation are used.
  • Treatment: Chest tube placement is indicated.
• Hemothorax
  • Significance: This may become a massive hemothorax, may clot, and may cause lung entrapment or become an empyema.
  • Treatment: Chest tube placement is indicated.
• Mediastinal traversing wounds
  • Significance: This may cause damage to the heart, great vessels, tracheobronchial tree, or esophagus.
  • Treatment: Patients with symptomatic, hemodynamically unstable, and mediastinal traversing wounds are immediately taken to the operating room. Patients with stable mediastinal traversing wounds undergo an extensive workup with CT angiography, esophagraphy, and bronchoscopy/endoscopy in consultation with a surgeon.

Abdominal Examination

Abdominal trauma is separated into blunt and penetrating injuries. Patients are immediately sent to the operating room for laparotomy if any of the following are present: evisceration; penetrating injuries caused by firearms or objects; and/or any injury accompanied by shock, free air under the diaphragm on chest radiographs, and/or peritoneal signs. Blunt abdominal injuries can be subtle. Solid organ damage that is causing occult bleeding into the abdomen can be overlooked in patients with other injuries that distract attention. Most patients with blunt abdominal trauma who are hemodynamically stable and have no evidence of intra-abdominal bleeding can undergo CT scanning, and many are treated with conservative measures.

Examine the abdomen for surgical scars, contusions (seatbelt sign), or lacerations. Listen for bowel sounds. Feel gently for tenderness, and then consider FAST or DPL to rule out intra-abdominal bleeding.

FAST is a quick, sensitive way to detect fluid in the abdominal cavity. FAST can detect as little as 300-500 mL of free fluid. FAST can be accurately performed by properly trained physicians or surgeons. The limitations of FAST are operator dependance; an inability to detect retroperitoneal blood (eg, from pelvic fractures); and an inability to differentiate blood from urine, ascites, or other abdominal fluid.

DPL is a sensitive technique for detecting intra-abdominal blood. The advantages over FAST include increased sensitivity and the ability to analyze the type of intraperitoneal fluid (eg, blood, ascites in cirrhotic patients, bowel contents). The disadvantage is that DPL takes longer than FAST and is invasive. With the advent of fast spiral CT scanners, DPL is infrequently resorted to.

In the presence of hypotension, a positive FAST or DPL result is an indication for immediate laparotomy.

Spinal Cord/Vertebral Column

Palpate spinous processes to assess for point tenderness. Any point tenderness, bony step-offs, or abnormalities should prompt immediate spinal radiography to evaluate the damage. Management of spinal fractures includes total immobilization of the spine and consultation with a spinal surgical specialist. The use of high-dose methylprednisolone is no longer recommended. Any patient with hypotension and a slow pulse should be assessed for neurogenic shock and a high spinal cord injury.

Afterwards, complete the neurologic examination, including motor and sensory examinations and reflexes.

[#cervical]

Cervical spine clearance

All patients with any possibility of cervical spine fracture based on history, physical examination findings, or mechanism of injury must be immobilized with a hard collar until a proper examination can be performed.^[15] Patients who can be considered for clinical cervical spine clearance must meet the following criteria:

• No focal neurologic deficits
• No distracting injuries, eg, gunshot wound, pelvic fracture, long bone fracture
• No intoxications (eg, alcohol, opiates)
• Full orientation and awareness
• No midline neck tenderness

Instruct the patient to slowly rotate the head from side to side. If this is performed without pain or tingling sensations or numbness of the extremities, that patient almost certainly does not have a cervical spine fracture (99.8% negative predictive value). Other patients must have a minimum of 3 cervical spine radiographs (ie, lateral, anteroposterior, and open-mouth odontoid views) and potentially other imaging studies to rule out cervical spine involvement.

Do not leave patients on the long board with a hard collar in place longer than necessary. The limitation of movement causes both anxiety and musculoskeletal pain, which distress the patient and can obscure follow-up examinations. Continuous pressure from the backboard may cause decubitus ulcers to the posterior skull and other posterior bony prominences.

Genitourinary Examination

Perform a rectal examination, examine the perineum, and perform a genital/vaginal examination. Rectal tone is an indicator of spinal cord function, and a patient with poor rectal tone should be considered to have a spinal cord injury until proven otherwise. The stool is assessed for fresh blood that might indicate an open pelvic fracture or other injury that has lacerated the rectum. A vaginal or genital examination is performed. A Foley catheter is placed unless contraindicated by signs of urethra injury, such as a high-riding prostate, blood at the meatus, or scrotal/perineal hematoma.

Summary of the Secondary Survey

See the list below:

• Focused patient history - Symptoms, allergies, medications, past medical/surgical history, last meal, events leading up to trauma
• Head/skull - Eyes, skull, tympanic membrane, and pupils evaluation
• Maxillofacial - Palpation for instability; inspection for intraoral bleeding or nasal septal hematoma
• Neck - Midline position of the trachea
• Chest - Chest inspection, palpation, and auscultation
• Abdomen - Inspection, auscultation, palpation, and percussion (Consider FAST and/or DPL.)
• Spine/vertebrae - Palpation of the spinal column, neurologic examination, clearing the cervical spine
• Genitourinary - Perineal examination, rectal examination, genital/vaginal examination
• Musculoskeletal - Palpation of the pelvis, extremities, and splint fractures (Consider immediate reduction of dislocations.)

Immediate Management Of Musculoskeletal Injuries

The secondary survey ends with the assessment of the musculoskeletal system, and this is when the orthopedist's skills are required.^{[16, 17, 18]} Palpate all joints and long bones, and assess pulses, capillary refill, sensation, and motor strength. Also determine whether different limb lengths may indicate hip fracture or dislocation or pelvic fracture. Splint all fractures above and below the joint after realignment of the limb. Perform immediate reduction of dislocations, especially if neurovascular compromise is present.

Surgical priorities - Damage control versus early total care

Splinting is always indicated in the polytrauma patient. Better healing is observed in cases in which early surgical immobilization of fractures is performed, but this intervention can actually be harmful if performed too early on unstable trauma patients. Patients who are underresuscitated, as evidenced by increased serum lactate levels or base deficit, should have early splinting or skeletal traction until adequately resuscitated. If the patient is in the operating room for life-saving surgery, temporary external fixation also may be used, especially for the patient's lower-extremity long bone fractures. Definitive surgical repair is delayed until the patient is stable and adequately resuscitated.^{[19, 20]}

Early definitive stabilization can be used after ensuring optimal resuscitation and the absence of impending life-threatening conditions. A retrospective study of 750 femoral fractures treated from 1999-2006 in Cleveland, Ohio found 656 definitive stabilizations were safely used within 24 hours of injury.^[21]

Pelvic fractures

Pelvic fracture must be suspected in any patient with an appropriate mechanism of injury, pain in the pelvic region, or leg-length discrepancies. Other signs are the Destot sign (ie, hematoma of scrotum or inguinal ligament), the Earle sign (ie, hematoma or tenderness along bones on rectal examination), and the Roux sign (ie, asymmetry in the distances between the greater trochanter and the pubic spine on each side).^{[22, 23]}

Test for pelvic stability (by pushing posteriorly and then medially on the iliac crests and downward on the symphysis pubis) only if the clinician believes that the pelvis is intact. If a pelvic fracture is suspected on clinical grounds, this exam is discouraged as it can exacerbate pain and hemorrhage. Instead, order anteroposterior pelvic radiographs as soon as the primary survey is completed. Pay careful attention to the rectal examination findings, which may be the only indication of a dangerous open pelvic fracture impinging on the rectum.

Pelvic fractures result from high-energy trauma such as motorcycle accidents, accidents involving vehicles hitting pedestrians, or falls from higher than 12 feet. Pelvic fractures can cause considerable morbidity and mortality from bleeding, damage to nerves, and damage to genitourinary structures and the rectum.

Pelvic fractures can bleed from the pelvic venous plexus or, occasionally, the internal iliac arteries and its branches. Shock and hypotension may be the only indicators of pelvic hemorrhage in polytrauma patients.

The mechanism of injury can provide clues as to the type of pelvic injury. Anteroposterior trauma opens the pelvic ring and increases the volume of blood that can be held in the cavity. Initial treatment must include stabilization of the pelvis to reduce this volume. Lateral trauma tends to close the pelvis and cause bladder and/or urethral injury.

Treatment is temporary stabilization by noninvasive methods, such as a sheet or pelvic binder. These temporary methods may cause pressure ulcerations of the skin over the bony prominences of the pelvis. Consequently, external fixation should be applied early in the acute care phase to avoid this complication. This will usually require orthopedic surgical expertise and an operating room with general anesthesia.

Open fractures

Any open wound reaching a fracture is an open fracture. Open fractures must be treated aggressively to prevent infection, which can easily spread to soft tissues or to bone. All open fractures are treated initially with immobilization, irrigation of the wound, debridement of devitalized tissue, and prophylactic antibiotics (often a first-generation cephalosporin). Surgical debridement may be delayed depending on the patient's physiologic response to the injury and resuscitation. If unstable, irrigation and a sterile wound dressing, along with splinting or traction, are required until the patient is able to proceed to the operating room for definitive debridement and fracture stabilization. Depending on the severity of the injury, external or internal fixation, flap construction, or vascular repair may be required afterwards.

The Gustilo and Anderson classification of long bone open fractures is as follows:

• Class I - Less than 1 cm, low energy, often simple fractures
• Class II - Greater than 1 cm, often comminuted fractures with some crushing component
• Class III - Greater than 1 cm wound or significant soft-tissue injury or fracture comminution, high energy (eg, gunshot wounds, motor vehicle accidents, falls from height), subdivided based on management required
  • Class IIIA - Extensive soft-tissue damage but has adequate periosteal bone coverage and usually does not require major reconstructive surgery
  • Class IIIB - Extensive soft-tissue damage with periosteal stripping that leaves bone exposed, requires flap placement for soft tissue coverage
  • Class IIIC - Vascular injury to a named artery requiring repair

Soft-tissue and joint injuries

All soft-tissue injuries should be treated with copious irrigation. Debridement is necessary if any devitalized tissue remains, in order to prevent dead tissue from becoming a nidus of infection. Cover open wounds with sterile dressings soaked in saline.

Serious soft-tissue destruction (including Gustilo/Anderson class IIIB/IIIC) may require flap construction. Immediate free flap construction may be performed within 48 hours of the trauma if the patient is stable. Radical debridement is performed at the site of injury, and a free flap is inserted. If debridement is not performed, reconstruction should be delayed until the tissues have healed at the margins and no evidence of infection is noted. Flaps are most commonly harvested from the latissimus dorsi, gracilis, serratus anterior, or rectus abdominus muscles for medium- to large-sized wounds.

Injuries that may compromise the joint space should be thoroughly evaluated. Arthroscopic irrigation and wound debridement should be performed to ensure healing and lessen the chance for infection.

Crush syndrome (traumatic rhabdomyolysis)

Crush injury of an extremity may release large amount of myoglobin and potassium or other toxic by-products of muscle breakdown. This can lead to renal failure and electrolyte abnormalities, lethal dysrhythmias, and disseminated intravascular coagulopathy. Intravascular fluid is shifted by osmotic pressure into the muscle compartments, which causes compartment syndrome locally and hypovolemic shock with an added contribution to renal insufficiency systemically.^[24]

Any limb that has been compressed or crushed should not be reperfused until vigorous fluid resuscitation is initiated to protect the kidneys and heart. Sodium bicarbonate therapy may be considered to alkalinize the urine and prevent precipitation of myoglobin in the renal tubules. Mannitol, 1-2 mg/kg of a 20% solution administered over 4 hours, may also be considered, but hard evidence supporting its use is lacking.

Evaluation of gunshot wounds

Avoid underestimating the damage caused by gunshot wounds because the injuries occur beneath the skin. Splint extremities until underlying fractures have been ruled out with appropriate radiographs. With low-velocity gunshot wounds from civilian arms, the damage is usually limited to the path of the bullet. High-velocity weapons such as assault rifle rounds cause shockwave damage as the bullet enters the flesh and, therefore, are more complicated because adjacent tissues are potentially injured. Surgical intervention is based on the clinical assessment of the wound. Remember to report all gunshot wounds to the police.

Special Patient Populations

Geriatric polytrauma

Patients older than 65 years account for 36% of ambulance transports and 25% of total trauma costs. Elderly patients are less likely to be involved in trauma but are more likely to die from trauma. Falls are the most common accident in people aged 75 years or older and are the second most common accident in people aged 65-74 years. Most fall on a level surface, and most sustain an isolated orthopedic injury. Motor vehicle accidents are the leading mechanism that brings elderly patients to a trauma center.

Vital signs may be difficult to assess in elderly patients. Elderly patients may not be able to mount a tachycardic response to shock because of medications or reduced sensitivity to sympathetic outflow. A seemingly normal blood pressure might actually be dangerously low in a patient with baseline hypertension. Consider invasive monitoring, such as a central venous line or Swan-Ganz catheter, because fluid overload can be just as dangerous as hypovolemia in these patients.

Elderly patients are predisposed to hip fractures because of osteopenic and osteoporotic changes. Long bone fractures can cause significant morbidity with loss of mobility. Consider early placement of intramedullary rods in these patients to facilitate mobility later. They also have an increased prevalence of rib fractures and increased respiratory complications from trauma and recovery, such as pulmonary contusion or pneumonia.

Polytrauma in children

Trauma is the leading cause of death in childhood. Each year, 22 million children are injured, which is 1 in 3 children. Falls and motor vehicle accidents cause 90% of cases of pediatric multisystem trauma, but motor vehicle accidents are the leading cause of death. Children are not simply small adults; they require special care.

Immediately assess the child's weight, either by a scale or the Broselow pediatric measuring tape. Accurate dosing of medications and fluids is essential. Children have larger surface area–to–mass ratios, so keeping the child warm to prevent hypothermia is even more important.

Children have increased blood loss associated with long bone and pelvic fractures compared with adults; therefore, early splinting and stabilization are even more important. The clinical examination is of the utmost importance because radiographs are difficult to interpret as a result of incomplete ossification.

Children have tremendous reserves to compensate for hypovolemia, so when they start to show signs of shock, it may already be at an advanced stage. Children initially respond to hypovolemia with tachycardia and may not drop their blood pressure until they have lost 45% of their circulating volume. Consider early transfer to a pediatric trauma center.

Polytrauma in pregnant patients

Trauma is the largest cause of nonobstetric morbidity and mortality in pregnant women. Significant trauma complicates 6-7% of pregnancies.^[25]

Pregnant women tolerate blood loss because of a large circulating blood volume and may not initially show signs of shock. Pregnant patients are at high risk for aspiration during anesthesia. This is because of the reduction of gastric motility by progesterone and increased intragastric pressure from the enlarged uterus. Consider early nasogastric tube placement and suction.

The fetus must also be considered a patient. The bony pelvis tends to protect the fetus up to 12 weeks' gestation, but afterward, it is vulnerable to abdominal trauma incurred by the mother. Estimation of fetal age and viability becomes part of the primary survey in pregnant patients. If the gestation is greater than 22 weeks, fetal viability must be determined with fetal heart tones and an ultrasonic biophysical profile. Early consultation with an obstetrician-gynecologist is recommended.

Child, domestic, and elder abuse victims

Be aware of the possibility of child, elder, and spouse abuse in traumatized patients. Be suspicious of any inconsistent stories between different parties, signs of partially healed trauma, and trauma inconsistent with the mechanism described by the patient and relatives. If necessary, separate the child, spouse, or elderly patient from the family. Do not be hesitant to involve social services or the police. Physicians are required to notify the proper authorities in any case of suspected child abuse, as well as with domestic and elder abuse in many states.

Risk Management: Missed Injuries

Born et al reported 39 missed fractures in 26 of 1006 consecutive blunt trauma patients seen at a level I trauma center over an 18-month period.^[26] No serious adverse outcomes were reported in this study, but missed injuries have been called the trauma surgeon's nemesis by Enderson and Maull.^[27]

Tertiary Survey

A tertiary trauma survey, including a detailed history and physical examination, and a review of written radiology reports on all studies ordered has been recommended. Evaluate for potential abdominal compartment syndrome due to bowel and mesentery swelling and resulting high intra-abdominal pressure. The tertiary survey is performed 24 hours after the polytrauma patient has been admitted to the ward or ICU or 24 hours after the initial surgery, except if it was considered a "damage control" operation.^{[28, 29]}