Adult Trauma Resuscitation

I. Introduction

A.

Resuscitation is an intense period of medical care in which initial and continuous patient assessment guides concurrent diagnostic and therapeutic procedures. As a dynamic period, resuscitation requires the trauma team to rapidly develop a differential diagnosis based on mechanism of injury, effectiveness of treatment, and results of available diagnostic studies. When possible, the attending surgeon and emergency physician should direct this crucial activity. The supervising physician must ensure that the optimal resuscitation space, personnel, and equipment are present.

B.

Resuscitation of the trauma patient requires an organized, systematic approach utilizing a well-rehearsed protocol. Advanced Trauma Life Support (ATLS) is a single-physician resuscitation course of the American College of Surgeons that prescribes an initial approach to an unstable patient with life-threatening injury (Table 10-1). The principles of ATLS resuscitation are also applicable to the trauma center environment and should be supplemented by a team approach to the trauma patient. The approach of a trauma team should be multispecialty and protocol driven based on patient “stability” and mechanism of injury (blunt vs. penetrating) (Fig. 10-1). This chapter presents a team-oriented approach for trauma resuscitation.

II. Patient Stability

A.

The term “unstable” has classically referred to physiologic parameters such as vital signs (pulse, blood pressure, and respiratory rate). Patients with abnormalities of these vital signs in essence are sending out a clear distress signal. However, in the context of trauma resuscitation, the definition of unstable can be expanded to include patients who are considered metastable (the capacity to change at any time). These patients exhibit subjective, objective, or anatomical findings that may predict need for specialized trauma care in the trauma center. These expanded criteria for instability and metastability are liberal and refer to the potential need for surgery or the intensive care unit (Table 10-2). Patients who meet these expanded criteria usually have injuries that are life or limb threatening. A subcat-egory of unstable patients, those who present in extremis (sometimes referred to as “agonal”), requires a tailored approach. All interventions in the patient in extremis must be therapeutic, rather than simply diagnostic. For example, evaluation of thoracic cavities in the multiply injured patient in extremis is best done with bilateral chest tube placement rather than chest radiograph. Chest tube placement is more expedient and will diagnose the presence of hemothorax or pneumothorax, but more importantly be definitive treatment for a tension pneumothorax.

B.

Blood pressure response to initial fluid challenge is also a measure of stability. Hypotensive patients who sustain a normotensive response to the first 1 to 2 liters of fluid are responders and considered stable. Transient responders and nonresponders are unstable and should be treated accordingly. Their failure to correct abnormal physiology in response to treatment generally implies ongoing blood loss. Other causes for persistent hypotension despite fluid resuscitation include tension pneumothorax, cardiac tamponade, or neurogenic shock.

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TABLE 10-1 Phases of Initial Assessment

Primary Survey (15 seconds) Airway with C-spine control → Voice, air exchange, patency, cervical immobilization Breathing → Breath sounds, chest wall, neck veins Circulation → Mentation, skin color, pulse, blood pressure, neck veins, external bleeding Disability (neurologic) → Pupils, extremity movement (site and type), voice Expose the patient Resuscitation Generic—ECG leads, pulse oximetry, IV, draw labs Concurrent with life-threatening injuries identified on primary survey Include gastric and urethral catheters, or perform with secondary survey Secondary Survey Head-to-toe examination (including spine) AMPLE history (A = allergies, M = medications currently taken, P = past illness, L = last meal, E = events related to injury) Imaging Second survey may be delayed until after OR in unstable patient or patient in extremis Definitive Care Surgery (may be in resuscitation phase) Splinting Medications (3 A's): analgesics, antibiotics, antitetanus Consultants Transfer Tertiary Survey Repeat primary and secondary surveys within 24 hours for occult or missed injuries. Create injury “problem” list with specific identification of physician handling each. (Modified from American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Manual. Chicago, Ill: American College of Surgeons; 2001.)

Figure 10-1. Initial emergency department triage.

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TABLE 10-2 Criteria for Adult Unstable (and Metastable) Trauma Patient* (Blunt or Penetrating Trauma)

Altered Physiology Glasgow Coma Scale (GCS) score ≤14 Pulse <60 or >120 beats/min Blood pressure <90 mmHg after 2-L fluid challenge Blood pressure >190 mmHg systolic Respiratory rate <12 or >24 breaths/min Poor gas exchange (e.g., SaO2 <90%) Temperature <92°F (33°C) Altered Physical Findings Paralysis Hoarseness/inability to talk Labored respirations Severe pain External hemorrhage site(s) Combative Altered Anatomic Findings Severe deformit(ies): spine, neck, chest, extremities Penetrating wound from head to popliteal fossa *Increased index of suspicion: Age >55 y Coronary artery disease Obstructive lung disease Liver disease Insulin-dependent diabetes mellitus Anticoagulation or history of coagulopathy History of mental illness Pregnancy

C.

Significant injury may also be suspected from interpretation of key phrases verbalized by patients.

• “I'm choking”—airway dysfunction
• “I can't swallow”—airway dysfunction
• “I can't breathe”—ventilatory dysfunction
• “Let me sit up”—ventilatory dysfunction, hypoxia, cardiac tamponade
• “Please help me”—blood loss, hypoxemia
• “I'm going to die”—blood loss, hypoxemia
• “I'm thirsty”—blood loss
• “My belly hurts”—peritoneal irritation
• “I need to have a bowel movement”—hemoperitoneum
• “I can't move my legs”—spinal cord injury
• “Please do something for my pain”—significant injury

III. Management of the Stable Adult with Blunt Trauma

A.

Assess for airway, breathing, circulation, and neurologic disability.

B.

Immobilize cervical spine.

C.

Administer O₂ nasally or by mask.

D.

Insert at least one peripheral intravenous (IV, 18 gauge or larger).

E.

Perform “stable patient” laboratory studies.

F.

Splint deformed extremities.

G.

Assess for occult injury.

• Head, neck, chest, abdomen, pelvis, spine, and extremities
• Selective rectal and pelvic examinations

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H.

Consider insertion of a nasogastric tube (unnecessary in most stable patients).

I.

Insert urinary catheter (consider retrograde urethrogram prior to catheter insertion if patient is unable to void or pelvic fracture).

J.

Limit IV fluid (e.g., 1 L in first 30 min). Fluid resuscitate the patient based on physiologic response to treatment.

K.

Perform select radiologic studies as indicated by mechanism of injury and physical examination.

• Chest x-ray (usually routine)
• Cervical spine (C-spine)—no x-ray if no symptoms or signs and not intoxicated (Chapter 18)
• Pelvis—no x-ray if no symptoms or signs in an alert patient
• CT scan of head with any alteration in consciousness, headache, or history of anticoagulation
• CT scan of abdomen—if tenderness, macroscopic hematuria, or microscopic hematuria with signs and symptoms (Chapter 30)
• Ultrasound of abdomen (selective)—if abdominal tenderness
• CT chest (with CTA) if history of acceleration/deceleration injury (e.g., MVC >25 mph, fall >10 ft)
• CT angiogram of the neck (or carotid ultrasound) if seat-belt sign to neck
• Spine and extremity films (selective)—if tenderness

IV. Management of the Unstable Adult with Blunt Trauma

A.

Assess airway (with C-spine immobilization).

• Patency, voice, stridor, foreign body, tongue, lacerations, O₂ saturation
• Treatment options (Chapter 11 gives specific indications)
  • Administration of 100% O₂ (by mask)
  • Suction
  • Chin lift
  • Oral airway (if obtunded)
  • Nasopharyngeal airway
  • Laryngeal mask airway (LMA)—very selective
  • Endotracheal intubation
  • Surgical airway

B. Assess breathing.

• Facial expression (distress, anguish, flat), depth and quality of respiration (shallow or labored), skin pallor or cyanosis, use of accessory muscles (neck and abdomen)
• Trachea (midline, crepitus), neck veins (flat or distended), breath sounds (diminished or absent), chest symmetry (look for anterior or lateral flail, or splinting), respiratory rate, central cyanosis, O₂ saturation (pulse oximetry)
• Treatment options (Chapter 11 gives specific indications)
  • Endotracheal tube
  • Needle decompression of chest, unilateral or bilateral
  • Chest tube(s), unilateral or bilateral
  • Ventilator (manual or mechanical)
  • Analgesia (systemic titrated opioids, inhalational opioids, intercostal block, epidural)
  • Thoracotomy

C. Assess circulation.

• Skin color, mentation, palpable pulse
• Quality of pulse, blood pressure, capillary refill, peripheral cyanosis, skin temperature, external hemorrhage, agitation, ECG monitoring, O₂ saturation
• Treatment options (Chapters 5 and 12 give specific indications)
  • Two large-bore peripheral IVs, draw “unstable patient” labs.
  • Central line if peripheral access unavailable—subclavian or femoral.
  • If no IV access, consider adult IO (intraosseous) or cutdown at ankle or groin.
  • One to 2 L of warmed Ringer's lactate IV as fast as possible (monitor response).
  • With profound or persistent hypotension, early blood transfusion.
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  • Consider rapid focused abdominal ultrasound for trauma (FAST).
  • If signs of persistent hypovolemia (e.g., thirst, base deficit, tachycardia, or hypotension), check for occult blood loss in one of six areas:
    • External: (look under dressings), back, buttocks, occiput, axillae
    • Thoracic cavity: trachea, neck veins, stethoscope, early chest x-ray, chest tube
    • Abdominal cavity: palpation, ultrasound, diagnostic peritoneal lavage (DPL), exploratory laparotomy
    • Pelvis: physical examination, perineal laceration, unstable pelvic ring, pelvic binder, pelvic x-ray, arteriogram, or external fixation
    • Extremities: fractures, particularly if bilateral or femoral
    • Spine: extensive fractures with hemorrhage (lumbar)
• If the search for bleeding is unrevealing, other causes of hypotension include the following:
  • Tension pneumothorax
  • Cardiac rupture and tamponade
  • Neurogenic (e.g., spinal cord injury)
  • Severe blunt cardiac injury with acute heart failure (very uncommon)

D. Neurologic disability

• Perform and document focused neurologic examination (Chapters 17 and 18) before patient is intubated and paralyzed: Glasgow Coma Scale (GCS) score, pupils, movement, and gross sensation of all extremities.
• Palpate head and spine (log roll).
• Treatment options (Chapters 17 and 18 give specific indications)
  • Administration of O₂
  • Intubation
  • Mannitol
  • Consider methylprednisolone (for blunt spinal cord injury with neurologic deficit)
  • Emergency imaging of brain and/or spine
  • Intracranial pressure monitoring
  • Ventriculostomy
  • Craniotomy

E. Extremities

• Palpate extremities and joints.
• Palpate pulses (Doppler if not palpable).
• Perform focused motor and sensory examination.
• Treatment options (Chapter 31 gives specific indications)
  • Cover open wounds with sterile dressing.
  • Apply direct pressure to control hemorrhage.
  • Consider hemostatic composite pack for large bleeding wounds.
  • Realign gross deformities and dislocated joints.
  • Splint.
  • Apply traction (femur fractures).

F.

Place nasogastric or orogastric tube and urinary catheter at earliest opportunity if not contraindicated or interfering with assessment or stabilization of airway, breathing, circulation, or neurologic dysfunction.

G. Imaging in the unstable blunt trauma patient

• Suggested as time and clinical situation permit (in resuscitation area)
  • Chest x-ray: Cassette under patient is preferred rather than under backboard; camera at maximal distance (lower resuscitation litter); inspiratory-hold.
  • Cervical spine: If time permits, perform lateral (to rule out gross deformity only), delay full C-spine until stable.
  • Pelvis: Anteroposterior (AP) to rule out site of occult hemorrhage.
• Selective (based on assessment and patient stability)
  • Extremities
  • Thoracic and lumbar spine
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• In general, imaging should be delayed until airway, breathing, and circulatory dysfunctions have been stabilized. Exceptions occur when chest x-ray or pelvic x-ray are needed to identify “occult” blood loss as previously stated.
  • CT scan (if stabilized hemodynamically). Sending the trauma patient if unstable for CT scan is dangerous. Studies in the metastable trauma patient should be done only in CT scan units with full monitoring capability, easy full patient body viewing, and a nurse-physician team capable of performing any and all lifesaving procedures should a crisis arise (e.g., cricothyroidotomy, chest decompression, decision to operate). There is always risk in attempting to perform CT studies on the metastable trauma patient. Underestimating the patient's abnormal physiology will result in a patient decompensating in CT; never a good situation. Newer rapid helical or spiral scanners can image the head, chest, and abdomen rapidly allowing studies to be performed in select transient responders to fluid challenge when supported by clinical judgment and logistics.
    • Head: if GCS <15
    • Chest: if suspected contusion or mediastinal anatomy uncertainty
    • Abdomen and pelvis: if signs or symptoms or unable to examine
    • Spine: if suspected by plain films or physical examination

V. Management of the Stable Adult with Penetrating Trauma

A.

Assess patient for airway, breathing, circulatory, and neurologic dysfunction.

B.

Document number and sites of penetrating wounds.

C.

Determine trajectory—this is vital in determining anatomic structures at risk from missiles, realizing that bullets often take an unpredictable course.

D. Treatment options

• Administer O₂.
• Secure at least one peripheral IV.
• Selectively place nasogastric tube and urinary catheter (e.g., penetrating torso wound).
• Perform “stable patient” laboratory studies.

E.

Assess the patient for significant injury, depending on injury sites: physical examination and x-ray. Both plain film and CT are complementary to accurately determine precise trajectory. Diagnostic options include:

• Head: CT scan without contrast.
• Neck: CT scan with IV and oral contrast, AP and lateral x-rays, contrast swallow study, endoscopy, arteriogram, neck exploration. (Caution: check airway repeatedly during diagnostic evaluations with low threshold for intubation.)
• Chest: chest x-ray; if transmediastinal, CT with IV and oral contrast, or angiography, bronchoscopy, esophageal contrast, cardiac window, echocar-diography.
• Abdomen, back, or flank: local wound exploration, DPL, ultrasound, CT scan with IV and oral contrast (including rectal), laparoscopy, laparotomy.
• Extremities: pulses, motor and sensory examination, ankle brachial index, Duplex ultrasound, arteriogram, operative exploration.

VI. Management of the Unstable Adult with Penetrating Trauma

A.

Assess patient for airway, adequate gas exchange, circulatory or neurologic dysfunction.

B.

Assess number and sites of penetrating wounds.

C.

Determine trajectory—this is vital in determining anatomic structures at risk from missiles.

D. Treatment options

• Airway (Chapter 11)
  • Administration of 100% O₂
  • Suction
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  • Chin lift
  • Oral airway (if obtunded)
  • Nasopharyngeal airway
  • Endotracheal intubation
  • Surgical airway (i.e., for shotgun wounds to face)
• Breathing
  • Needle decompression of chest, unilateral or bilateral
  • Chest tube(s), unilateral or bilateral
  • Ventilator (manual or mechanical)
  • Thoracotomy or sternotomy
• Circulatory
  • Insert two large-bore IVs, draw unstable patient laboratory studies, consider large-bore central line, 1 to 2 L of warmed Ringer's lactate IV, blood transfusion with profound or persistent hypotension.
  • IV access above and below diaphragm in penetrating torso trauma.
  • Avoid IV placement such that the bullet wound is between the IV site and the heart.
  • If signs of hypovolemia occur (e.g., thirst, base deficit, tachycardia, or hypotension), search for sites of blood loss.
    • Thoracic cavity: tracheal deviation, neck veins, bilateral equal breath sounds, ultrasound, chest x-ray, chest tubes (bilateral if precise trajectory not known).
    • Abdominal cavity: exploratory laparotomy, ultrasound, or DPL (stab wounds).
    • If hypotension continues, look for cardiac tamponade, tension pneumothorax.
    • Occult spinal cord injury.
• Place nasogastric or orogastric tube and urinary catheter at earliest convenience.

E.

Hemodynamically unstable patient with a penetrating wound to the chest may require chest tube(s) and thoracotomy in emergency department (ED) or operating room (OR).

• Chest tube may be diagnostic or therapeutic.
• If patient is hemodynamically unstable after chest tubes, perform thoracotomy in ED or OR.
• If stable after chest tubes and mediastinal or transmediastinal trajectory (Chapters 24 and 25), then perform the following:
  • Ultrasound or pericardial window (repeat)
  • Echocardiogram (transthoracic or transesophageal)
  • Aortogram
  • Bronchoscopy
  • Esophageal contrast study
  • CT scan with contrast in selected patients

F.

The hemodynamically unstable patient with a penetrating wound to the neck, abdomen, or extremity requires prompt control of hemorrhage in the OR.

VII. Management of the Patient in Extremis

A.

The patient in extremis presents with anatomic or physiologic findings that will result in death within minutes if not immediately corrected. These patients usually have signs of life such as reactive pupils, spontaneous respiratory efforts, spontaneous movement, or a palpable pulse, but otherwise present with profound shock or respiratory failure. This requires a treat, then diagnose approach (meaning OR now!).

B.

If not intubated, intubate.

• If unable to intubate, obtain a surgical airway.

C.

Penetrating injury, patient in extremis (Fig. 10-2)

• Neck
  • Direct digital pressure if expanding hematoma or active bleeding
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  • IV fluid and blood

    Figure 10-2. Penetrating trauma patient in extremis.

  • OR
• Chest
  • Bilateral chest tubes
  • IV fluid and blood
  • Left thoracotomy or bilateral thoracotomy
  • OR
• Abdomen
  • IV fluid and blood (avoid systolic blood pressure >80 mmHg until in the OR).
  • Move to OR immediately.
    • Left thoracotomy for aortic control within the chest if abdomen is expanding and blood pressure remains low despite volume resuscitation. Some prefer control of the aorta through a high midline abdominal incision.
• Groin and extremities
  • Applied pressure if expanding hematoma or active bleeding
  • IV fluid and blood
  • OR
• Multiple penetrating wounds
  • Applied pressure to sites of active bleeding
  • Bilateral chest tubes
  • IV fluid and blood
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  • OR

    Figure 10-3. Blunt trauma patient in extremis.

  • Left thoracotomy (Section C.3 above)

D.

Blunt injury, patient in extremis (Fig. 10-3)

• Applied pressure to external hemorrhage (consider hemostatic composite pack for large wounds)
• IV fluid and blood
• Bilateral chest tubes
  • If ongoing hemorrhage or > 1,500 mL initial insertion of chest tubes, perform OR or resuscitative thoractomy.
• Ultrasound (US) or DPL of abdomen
  • If grossly positive, move to OR.
  • If negative DPL aspirate or US minimal or if no fluid, x-ray pelvis.
• X-ray of pelvis. One needs to identify the exsanguinating patient with pelvic fracture. (A small proportion of patients with major associated vascular injury must be taken to the OR.)
  • If positive, place pelvic binder and move to angiography (consider aortography after pelvis).
  • External fixation not usually appropriate for patient in extremis.
• Priorities with multiple injuries
  • First → active thoracic hemorrhage or cardiac tamponade
  • Second → abdominal hemorrhage
  • Third → pelvic hemorrhage
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  • Fourth → extremity hemorrhage
  • Fifth → intracranial injury
  • Sixth → spinal cord injury

VIII. Laboratory Studies

A.

Recent data have suggested a more selective and cost-effective approach to laboratory studies in both blunt and penetrating trauma.

• Stable patient
  • Hemoglobin (Hb) and hematocrit (Hct)
  • Blood ethanol (ETOH), depending on hospital protocol
  • Urine dipstick for blood, human chorionic gonadotrophin (HCG) in women of childbearing age (urine or blood)
  • Blood screening without cross-match unless condition changes
  • Other studies as indicated by disease history
• Unstable patient
  • Required
    • Blood type and cross-match
    • Arterial blood gas and serum lactate
    • Hemoglobin/hematocrit
    • Prothrombin time, partial thromboplastin time, platelet count
    • Urine dipstick for blood, HCG for women of childbearing age
    • ECG
  • Selective (based on hospital protocol)
    • Na, K, CO₂, Cl, blood urea nitrogen (BUN), creatinine, Ca²⁺⁺, Mg^{2+ +}
    • Serum amylase or lipase
    • Serum ETOH
  • Point of care testing—available in many trauma centers

IX. Multiple Victims

A.

When several trauma victims arrive in the resuscitation area simultaneously, priority should be given to the unstable trauma victims.

B.

Trauma team leader (most senior physician) should assign physicians and nurses to specific areas, and designees should not cover several areas simultaneously.

C.

The trauma team leader should rotate from patient to patient to oversee management, prioritize care, and supervise actions of individual trauma teams.

D.

The team leader should decide the need for backup assistance or calling a disaster plan when demand outstrips immediate resources. The team leader should err on the side of calling for additional assistance.

Axioms

• The unstable trauma patient can be defined by potential requirement for surgery or the ICU as well as cardiopulmonary dysfunction.
• The trauma patient who remains unstable after initial resuscitation usually requires operative intervention.
• The trauma patient in extremis may require treatment before diagnosis.