Key points
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Trauma is the leading cause of death for individuals in the United States up to the age of 45, and is the third leading cause of death overall for all ages.
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The most widely accepted standard of care for initial assessment and treatment of injured casualties is the Advanced Trauma Life Support (ATLS) program.
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Regardless of the injuries sustained or the capabilities of the treating facility, the principles described in ATLS should guide the initial assessment, resuscitation, and treatment of the multiply injured patient.
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The primary and secondary survey should be continually repeated to identify deterioration in the patient’s condition and to make appropriate interventions.
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The use of a prioritized and systematic approach to initial management of the trauma patient ensures that optimal care is delivered and the best possible outcome is achieved.
Introduction
Trauma is the leading cause of death for individuals in the United States up to the age of 45, and is the third leading cause of death overall for all ages. Worldwide, trauma is responsible for more than 3 million deaths and 300 million injuries annually, making it a significant, yet preventable global public health issue.
The most widely accepted standard of care for initial assessment and treatment of injured casualties is the Advanced Trauma Life Support (ATLS) program, developed by the American College of Surgeons. It places priority on diagnosis and management of the injuries that are the greatest threat to life first, using a simple ABCDE mnemonic as follows: A irway with C-spine protection, B reathing and ventilation, C irculation with hemorrhage control, D isability–neurologic status, and E xposure and environmental control.
This article focuses on the initial evaluation of the trauma patient, incorporating many of the recent significant changes in management, and addresses the common injuries that may be evaluated by the oral and maxillofacial surgeon.
Introduction
Trauma is the leading cause of death for individuals in the United States up to the age of 45, and is the third leading cause of death overall for all ages. Worldwide, trauma is responsible for more than 3 million deaths and 300 million injuries annually, making it a significant, yet preventable global public health issue.
The most widely accepted standard of care for initial assessment and treatment of injured casualties is the Advanced Trauma Life Support (ATLS) program, developed by the American College of Surgeons. It places priority on diagnosis and management of the injuries that are the greatest threat to life first, using a simple ABCDE mnemonic as follows: A irway with C-spine protection, B reathing and ventilation, C irculation with hemorrhage control, D isability–neurologic status, and E xposure and environmental control.
This article focuses on the initial evaluation of the trauma patient, incorporating many of the recent significant changes in management, and addresses the common injuries that may be evaluated by the oral and maxillofacial surgeon.
Airway with C-spine protection
Airway assessment
Verification of a patent airway is paramount during initial evaluation of the trauma patient, because all other resuscitative efforts are futile without adequate oxygenation and ventilation. All patients should receive high-flow oxygen on initial arrival, and the cervical spine should be immobilized by use of a hard collar or in austere settings, using sand bags secured with tape.
Assessment of the airway typically begins by encouraging the patient to speak, commonly performed by asking “What is your name?” Not only does this allow the physician to evaluate the airway status, but in addition it provides a rapid assessment of mentation if the patient answers in a logical manner. Signs of airway obstruction including stridor, gurgling, agitation, and hoarseness should be quickly assessed. In addition, the physician should evaluate for possible facial, mandibular, or tracheal or laryngeal fractures, which may compromise the airway and eventually lead to obstruction. The presence of blood, vomit, fractured teeth, or other debris in the oral cavity is concerning for potential airway compromise and should be monitored closely.
Neck trauma
All patients with penetrating injury to the neck should be assessed for airway compromise, because potential vascular injury can lead to significant hemorrhage resulting in airway displacement and obstruction. Signs of direct airway injury can include shortness of breath and hemoptysis, and a large neck hematoma with tracheal deviation should prompt urgent intubation before loss of airway.
Maxillofacial trauma
Trauma to the maxillofacial region can cause airway compromise because of hemorrhage, tissue swelling, and fractures leading to loss of facial architecture. Midface injuries can compromise the nasopharynx and oropharynx as a result of fractures and dislocations. Severely comminuted or bilateral mandibular fractures may cause airway obstruction because of collapse of the glottic structures on the posterior pharynx. Dentoalveolar fractures, in addition to being associated with hemorrhage, can be problematic if teeth are dislodged because these can be easily aspirated. Therefore, all teeth should be accounted for to ensure none have been aspirated.
Airway management
Indications for intubation of the trauma patient include airway obstruction; shock; altered mental status (Glasgow Coma Scale [GCS] ≤8); and occasionally combativeness requiring sedation for evaluation. Initial management of the patient with airway compromise who requires intubation consists of a chin-lift or jaw-thrust maneuver, which is maintained until intubation is achieved. Oropharyngeal airways can serve as helpful adjuncts, but these cannot be used in conscious patients because of potential gagging, vomiting, and aspiration. Nasopharyhgeal airways are more tolerable in the awake patient and may transiently aid in maintaining airway patency.
When a decision has been made to initiate a definitive airway, orotracheal intubation is typically performed, although this can be difficult in the setting of bleeding or vomiting because of lack of clear visualization of the cords. It is imperative that all intubation equipment is readily available during initial examination because the need for an emergency airway can develop quickly during initial evaluation. In the urgent setting where orotracheal intubation is unsuccessful, prompt transition to a surgical airway (cricothyroidotomy) is recommended.
Breathing and ventilation
Assessment of breathing and ventilation includes inspection, palpation, and auscultation of the neck, thoracic region, and upper abdomen and back. Injuries that can be identified during the primary survey and may restrict adequate ventilation include tension pneumothorax; flail chest (three or more consecutive ribs fractured in two places) with underlying pulmonary contusions; open pneumothorax; and massive hemothorax. Inspection identifies contusions, penetrating injuries, open wounds and soft tissue defects, flail segments, and asymmetry in chest expansion during inspiration. Palpation may elicit areas of tenderness, subcutaneous emphysema, abnormal chest wall motion, and bony abnormalities. Auscultation, although sometimes difficult in a noisy resuscitation area, can confirm the presence of bilateral breath sounds and when abnormal, can suggest the possibility of a pneumothorax or hemothorax.
Perhaps the most critical abnormality to recognize during this phase is a tension pneumothorax, a true emergency that clinically presents with unilateral absence of breath sounds, tracheal deviation, distended neck veins, and hypotension. A tension pneumothorax develops when air enters the pleural space from the trachea, bronchi, lungs, or chest wall. The air cannot escape, and the progressive increase in pressure in the affected side collapses the lung and mediastinal structures to the contralateral side. As air accumulates and the intrathoracic pressure increases, the mediastinal structures including the heart, superior vena cava, and inferior vena cava are compressed; venous return decreases; and hypotension ensues. Treatment of a tension pneumothorax is relatively simple, consisting of needle decompression above the rib in the second intercostal space along the midclavicular line. This relieves the increased pressure in the pleural cavity, and is confirmed by a rush of air on needle insertion. A thoracostomy tube is then placed to manage the resulting simple pneumothorax, and to prevent reaccumulation of air leading to another tension pneumothorax.
A simple pneumothorax is caused by the entry of air into the thoracic cavity from the chest wall, lung, or trachea, which removes the normal negative pleural pressure maintaining lung expansion and causes the lung to collapse. Clinical findings include decreased breath sounds on the affected side, but physical findings may be subtle if the pneumothorax is small. Pneumothoraces with minimal findings are usually identified on subsequent chest radiograph, and treatment consists of tube thoracostomy.
Similarly, a hemothorax (blood accumulated in the pleural cavity) presents with decreased breath sounds on the affected side because the contained blood prevents full expansion of the lung during inspiration. In the setting of significant bleeding over 1500 mL, patients can present with hypotension in addition to abnormal breath sounds, and this is defined as a massive hemothorax. In patients presenting with stable vital signs, diagnosis is usually made during radiologic evaluation, including chest radiograph or CT scan. In both situations, treatment is tube thoracostomy.
Circulation with hemorrhage control
Shock
After the airway is secured and ventilation has been assessed, the patient’s circulatory status is addressed. Shock, defined as inadequate tissue perfusion, can be categorized into four types: (1) hemorrhagic (or hypovolemic); (2) cardiogenic; (3) septic; and (4) neurogenic. The most common cause of shock in the injured patient is hemorrhagic in nature, although neurogenic shock can also be present in the setting of spinal cord injury, and cardiogenic or septic shock can occasionally be seen. It is of utmost importance to recognize the patient in the shock state, because early recognition and treatment is crucial during the primary survey.
Clinical signs of shock include tachycardia; dyspnea; cool and clammy skin; mental status changes; decreased pulse pressure; and in more severe cases, hypotension. Estimations of overall blood loss using vital signs has been suggested by ATLS to assist in determining optimal resuscitation strategies for patients in shock, and degree of shock has been classified into four classes (Classes 1–4) ( Table 1 ). As the severity of shock increases, recommendations for fluid replacement change from crystalloids to packed red blood cells (PRBC) and fresh frozen plasma (FFP).
| Class | Blood Loss | Findings | Fluid Replacement |
|---|---|---|---|
| I | <15% (<750 mL) | P < 100, normal BP, normal PP | Crystalloid |
| II | 15%–30% (750–1500 mL) | P = 100–120, normal BP, decreased PP | Crystalloid |
| III | 30%–40% (1500–2000 mL) | P = 120–140, decreased BP, decreased PP | Crystalloid and blood |
| IV | >40% (>2000 mL) | P > 140, decreased BP, decreased PP | Crystalloid and blood |
Identification and control of bleeding source
The circulation and hemorrhage control phase of the primary survey centers around identification of the source of blood loss, controlling ongoing hemorrhage, and replacing the volume loss ( Fig. 1 ). Two large-bore intravenous (IV) lines are initially placed, and bleeding from external wounds is typically controlled with direct pressure. Tourniquets, used much more frequently in military settings, are an excellent adjunct to control severe bleeding from extremities, and have been shown to be extremely effective.
In addition to obvious bleeding from external sources, other sources of bleeding need to be considered during initial evaluation of the patient in shock. These include bleeding from the thorax (massive hemothorax, vascular injury, penetrating cardiac injury); abdomen (solid organ injury [liver, spleen, or kidney], major vessel injury, or mesenteric bleeding); retroperitoneum (pelvic fracture); or long bone fractures (eg, femur). Chest radiograph is a readily obtainable diagnostic study that provides significant information regarding thoracic sources of shock, because a large hemothorax can be easily recognized on a plain film. A focused abdominal sonographic examination for trauma (FAST) is a sensitive procedure used to determine the presence of fluid in the abdominal cavity, which is typically assumed to be blood until proved otherwise. In a patient with hypotension and a positive FAST, a laparotomy is indicated to identify and control the source of abdominal bleeding. A pelvic plain film radiograph can identify a pelvic fracture with possible retroperitoneal hemorrhage, and either physical examination findings or extremity radiographs can detect the presence of long bone fractures.
Volume replacement
Volume replacement is initiated after securing IV access, and typically consists of a warmed 1- to 2-L bolus of lactated Ringer solution or normal saline. Depending on the patient’s response, further resuscitation fluids may consist of more crystalloid, PRBC, or FFP. The amount of fluid or blood products required is difficult to determine on initial evaluation, and therefore the response to fluid challenges is a major determinant of further infusion of crystalloid or blood products. Parameters that are important to observe after administration of resuscitation fluids include improvement of tachycardia, normalization of blood pressure, clearing of mental status, improved urine output, and overall evidence of improved end-organ perfusion. If the patient only experiences a minimal response or a transient response to fluid administration, this is evidence of ongoing bleeding and further resuscitative strategies should consist of blood products instead of crystalloid fluids.
When a decision has been made to provide blood products, O-positive blood for men or O-negative blood for women is usually readily available for immediate infusion until type-specific, crossmatched blood is obtained from the blood bank. Based largely on military experience during Operation Iraqi Freedom, PRBC, plasma, and platelets are now provided in a 1:1:1 manner (6 U PRBC:6 U FFP:6-pack platelets or 1 U apheresis platelets) to better replace the components that are being lost during hemorrhage.
Hemostatic resuscitation and permissive hypotension
Hemostatic resuscitation refers to the use of restrictive fluid therapy to maintain a blood pressure that provides adequate end-organ perfusion, but does not increase the blood pressure excessively to dislodge blood clots and cause further unnecessary bleeding before surgical control. General guidelines recommend a goal systolic blood pressure of 80 to 100 mm Hg, or enough to maintain a palpable radial pulse. This permissive hypotension avoids the use of aggressive high-volume fluid replacement to obtain normal vital signs until surgical control can be obtained. After the bleeding source is identified and controlled, normal blood pressures are then established. Hemostatic resuscitation and permissive hypotension are major aspects of the concept known as damage control resuscitation (DCR), which is described later in this article.
Tranexamic acid
Tranexamic acid (TXA), a synthetic derivative of the amino acid lysine, is an antifibrinolytic agent commonly used in cardiac surgery. Largely based on the results of a recent large, prospective, randomized study evaluating the use of TXA in trauma patients, TXA has been advocated as an important intervention that can significantly reduce the risk of death in bleeding patients. In the original CRASH-2 study, mortality was markedly improved in trauma patients with the use of TXA (14.5% vs 16%). However, in a subsequent analysis of the CRASH-2 data, the mortality benefit was only present if TXA was administered less than 3 hours after injury, and mortality actually increased if TXA was given after 3 hours (4.4% vs 3.1%). Clinical studies are currently underway to further delineate the benefit of TXA, although many major trauma centers are currently using TXA early after initial injury.
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