Chapter 73 Evaluation and Acute Resuscitation of the Trauma Patient
INTRODUCTION
Although not all trauma patients need surgical intervention, they do require immediate evaluation and resuscitation. Therefore, trauma continues to be a surgical disease. Early intervention in critically injured patients can significantly influence mortality, morbidity, and disability after major trauma. Patients have improved outcomes when treated at these specialized centers1–3 and when additional resources and commitment are dedicated to trauma care.4–6
The Advanced Trauma Life Support (ATLS) course sponsored by the American College of Surgeons Committee on Trauma is the “gold standard” for teaching trauma management and heavily emphasizes the importance of the initial trauma resuscitation.7 This chapter utilizes the ATLS framework to highlight the essentials and potential pitfalls in the evaluation and resuscitation of the injured patient.
PRIMARY SURVEY
Airway
Loss of Airway
• Consequence
Loss of airway during trauma resuscitation can rapidly lead to respiratory and then cardiopulmonary arrest and death.
• Prevention
All potential alternatives must be anticipated. Do not assume that the first attempt at endotracheal intubation will be immediately successful. If endotracheal intubation cannot be done expeditiously, advanced airway manipulation (e.g., fiberoptic intubation, laryngeal mask airway) may be the next attempted maneuver. The ultimate backup is surgical airway by cricothyrotomy, which should be in the armamentarium of every surgeon treating trauma patients (Fig. 73-1). Occasional providers still attempt to achieve emergency surgical airway by means of a tracheostomy. This dangerous practice ignores the anatomic fact that the cricothyroid membrane is the most superficial access point to the airway and the trachea immediately dives deep into the mediastinum.
Conversion of a Metastable Airway to an Unstable Airway
• Consequence
Conversion of a metastable airway to an unstable airway can rapidly change a difficult situation into an impossible one. Death from airway loss is never a pretty sight.
• Prevention
Before dosing a patient with paralytics for rapid-sequence intubation, consider the potential consequences in a patient with a metastable airway. Paralytics may convert a patient who is protecting her or his own airway and able to oxygenate and ventilate to a patient who is no longer breathing and is unable to be intubated. Consider letting the patient sit up to help clear blood and secretions, rather than making her or him lay flat and possibly inducing aspiration.
Causing Worse Neurologic Injury with Spine Manipulation
• Consequence
Exacerbating neurologic deficits by not immobilizing the cervical spine can have long-lasting devastating consequences. Patients with spinal column injuries may have no neurologic deficit or only an incomplete spinal cord injury. It is incredibly tragic when patients such as this have worsening of their injury from inappropriate cervical spine immobilization.
• Prevention
Cervical spine stabilization is emphasized during airway management by ensuring that the head stays in neutral position. Hyperextending the neck in a patient with an unstable cercival spine injury may change a patient’s functional outcome significantly by exacerbating neurologic injury. A patient may be rendered permanently quadriplegic with even small manipulations of the neck.
Breathing
Missed Tension Pneumothorax on Physical Examination
• Consequence
Missing tension pneumothorax on physical examination or waiting for a confirmatory chest x-ray can lead to an unnecessary prolonged period of hypotension, shock, hypoperfusion, anoxic brain injury, and/or death.
• Prevention
Decreased breath sounds on one side should lead to an immediate chest tube before radiographic evaluation in patients with significant respiratory distress or shock. In this case, treatment of a tension pneumothorax can be life saving. Tension pneumothorax should be a clinical diagnosis made by physical examination, not radiographically. Tracheal deviation (away from the tension pneumothorax) helps confirm the diagnosis in patients with decreased breath sounds and hypotension.
Placing an Unnecessary Chest Tube
• Consequence
Tube thoracostomy is not a benign procedure. It is associated with injury to structures within the chest and abdomen and has the potential to cause infection. Appropriate tube thoracostomy placement can be necessary; however, if a patient does not need a chest tube, we should not place one.
• Prevention
In the hemodynamically stable patient who is physiologically normal from a respiratory standpoint (e.g., no hypoxia, shortness of breath, use of accessory muscles), consider getting an early chest x-ray to clearly define whether a hemo- and/or pneumothorax is present before intervention. Providers must always be cognizant of the benefit of listening very closely with an unbiased stethoscope. Often, when there is a wound over one hemithorax, we expect (and subsequently believe we find) decreased breath sounds when there may be no anatomic pathology. An early chest x-ray can save the patient a potentially unnecessary chest tube placed for “unequal breath sounds” in the physiologically normal trauma patient. However, this recommendation should not be taken as a suggestion to wait for a chest x-ray in an unstable patient with signs of respiratory distress or tension pneumothorax.
Conversion of Simple Pneumothorax to Tension Pneumothorax with Positive-Pressure Ventilation
• Consequence
Trauma patients may have a small pneumothorax, which may be too small to see on chest x-ray or computed tomography (CT) scan. These may be of no consequence and heal on their own without intervention. However, if there is a hole in the visceral pleura over the lung, this simple pneumothorax can be converted to a tension pneumothorax with positivepressure ventilation.
• Prevention
Ventilation may rapidly deteriorate with endotracheal intubation and positivepressure ventilation owing to a worsening pneumothorax. In patients with known pneumothorax, consider placing a chest tube as soon as the patient is intubated, rather than waiting until a confirmatory chest x-ray is performed.
Main Stem Intubation Leading to Unnecessary Chest Tube
• Consequence
Straightforward successful intubation is the expected outcome after plans for controlling the airway. Main stem intubation is a common minor complication of endotracheal intubation. In and of itself, it does not cause major problems. However, if unrecognized, it may lead the team to perform further procedures (e.g., tube thoracostomy for presumed hemo- or pneumothorax owing to decreased or absent breath sounds) before the simple diagnosis is made.
• Prevention
Main stem intubation (more commonly into the right main stem bronchus) can give the appearance of chest pathology owing to absent or decreased breath sounds. Always consider this possibility rather than assuming another lung pathology (such as hemo- or pneumothorax). Confirming endotracheal tube placement by early chest x-ray or pulling the endotracheal tube back may avoid an unnecessary tube thoracostomy.
Air Embolism
• Consequence
Intubation and positivepressure ventilation may cause air embolism. Hypovolemic patients whose penetrating injuries produce direct communications between the small airways and the pulmonary venous tributaries are at particularly high risk. When positive pressure is applied to the bronchial tree, air may go through these abnormal connections and eventually enter the left side of the heart. Air can then flow to the brain causing stroke or the coronary arteries causing myocardial infarction.
• Prevention
Air embolism is difficult to prevent. Key maneuvers include minimizing the time of positivepressure ventilation before attempting surgical control of a penetrating lung injury. Prompt hydration and fluid resuscitation will also help ensure a full venous system, which may help prevent air embolism as well.
Circulation
Uncontrolled External Hemorrhage
• Prevention
External bleeding is best controlled by direct digital pressure. Frequently, a patient with a small head laceration presents to the trauma center with a large, loosely wrapped, bulky gauze dressing saturated with blood. When the trauma team removes this dressing and sees a 2-cm laceration, digital pressure from one finger can completely stop this external hemorrhage and save multiple units of blood transfusions for this patient.
Exacerbating a Vascular Injury by Blind Clamping
• Consequence
Blindly placing a clamp into a bleeding wound has considerable potential to enlarge a small arterial or venous injury. This may change the necessary surgical procedure significantly. What may have taken one or two simple sutures may now require a complex vascular repair.
• Prevention
In the extremities, external bleeding is often best controlled with digital pressure directly on the bleeding wound. Blind clamping should be avoided to prevent further major vascular injury. Imprecise clamp placement can convert a small partial-thickness arterial injury to a complete transaction requiring a larger, more complex arterial reconstruction. Although there is con troversy about their use, tourniquets may be considered if direct pressure does not stop the ongoing hemorrhage.8 A blood pressure cuff placed directly over the wound and inflated to above the arterial blood pressure should temporize the situation and control external hemorrhage while the rest of the ABCDEs are addressed. The primary and secondary surveys can be finished expeditiously while a definitive plan (surgical exploration) for hemorrhage control is undertaken.
Assuming that a Normal Heart Rate or Blood Pressure Ensures that a Patient Is Not in Shock
• Consequence
Making a false assumption such as this will ultimately delay the diagnosis of shock. This may allow a patient enough time to continue to exsanguinate. Hemorrhage is a major cause of death after trauma. In a recent review of 2594 deaths at a large regional trauma center, delayed intervention for hemorrhage accounted for the largest percentage of preventable death.9
• Prevention
Early consideration of control of internal hemorrhage is important, although this often falls into the secondary survey in hemodynamically stable patients. Pitfalls during this portion of resuscitation can occur in specific patient populations. Young, well-trained athletes and patients who are well β-blocked will continue with a normal heart rate (or bradycardia), even after significant blood loss has occurred. Patients in class II hemorrhagic shock (blood loss of 15%–30% of blood volume or 750–1500 ml) will compensate with tachycardia and vasoconstriction but may still have “normal” vital signs. The only physical examination finding may be a narrow pulse pressure. Take the example of a patient whose baseline blood pressure is 120/80 mm Hg and heart rate is 60. His or her vital signs after trauma (blood pressure 110/90 mm Hg and pulse 90) may be in the overall “normal” range but represent a 50% decrease in pulse pressure and a 50% increase in heart rate.
Elderly patients also may not exhibit typical signs and symptoms of hemorrhage and shock (e.g., tachycardia, hypotension) after major trauma. These patients may not have the physiologic reserve that their younger counterparts do. Extra vigilance must be used in elderly trauma patients to ensure timely diagnosis and treatment because elderly patient may not be able to recover if the therapy is delayed. Trauma team activation and early intensive monitoring may improve outcomes in trauma patients older than 70 years.10,11
Assuming Hemodynamic “Stability” Excludes Significant Hemorrhage after Penetrating Abdominal Trauma
• Consequence
Delay in laparotomy once the diagnosis of peritonitis is made can allow a longer period of bleeding and abdominal contamination. This may lead to the need for more extensive surgery, higher rates of abdominal sepsis, and death.
• Prevention
In the modern era of selective management of penetrating abdominal trauma, not all patients with stab or gunshot wounds require mandatory laparotomy, as was the practice pattern for many years. Patients with a completely benign abdominal examination and normal vital signs may be safely treated expectantly, but the trauma team should be ready and willing to operate immediately at the first sign of clinical deterioration.
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