The initial management of the severely injured patient requires the surgeon to make rapid choices between various diagnostic and therapeutic interventions. In patients with a single severe injury there is a single set of priorities. In sharp contrast, a patient with critical injuries to several different organ systems often presents conflicting priorities in management. The thoughtful and accurate ordering of diagnostic and therapeutic interventions is critical to provide the optimal outcome and is perhaps the most important task of the trauma surgeon.[13]
Priorities in Initial Management
It is essential to begin with the assumption that the physiologic state of the patient is likely to deteriorate, perhaps abruptly, and that there is more than one serious injury present. It is also essential to realize that the most obvious or most dramatic injury may not be the most critical one. The trauma surgeon must adopt a very focused approach in which problems are addressed in strict order of their threat to life and function. Even a small delay for the treatment of a more minor injury cannot be tolerated. Within this focused approach, the surgeon must be constantly reassessing the situation as new data are obtained and be able to instantly change the focus and the order of priorities as new injuries or new findings are brought to light. The necessity to balance various conflicting priorities and accurately direct the initial diagnosis and treatment requires an approach to the patient as a whole, not as isolated organ systems. The overall management of the patient is best directed by one person who has the experience and authority to make difficult immediate decisions under stressful circumstances.
The correct prioritization of diagnostic and therapeutic interventions requires an assessment of the criticality of the intervention, the time frame in which action must be taken, and the cost of delay imposed on other injured systems. In general, establishing a patent airway with adequate oxygenation and ventilation are the primary concerns during resuscitation. Next the physiologic stabilization of the patient and control of significant hemorrhage must be addressed. Under these circumstances, optimal resuscitation of the patient is the best resuscitation for any specific organ system. Once immediately life-threatening problems have been controlled, management of possible brain injury is the next priority. Patients with a high likelihood of intracranial mass lesion requiring surgical intervention should undergo computed tomography (CT) of the head as soon as practicable. This group would include patients with Glasgow Coma Scale (GCS) score less than 8, especially in the presence of lateralizing signs. After management of brain injury has been undertaken, injuries causing less immediate threat to life and function should be addressed. Damage-control laparotomy for control of visceral injury, angiography for control of pelvic bleeding or to assess potential aortic injury, revascularization of an ischemic extremity, or management of a contaminated open fracture are examples of this type of problem. Treatment of injuries that present no immediate threat to life or function should be deferred until all other more critical issues have been resolved. This group of injuries is often orthopedic and includes closed-extremity fractures, spine fractures without neurologic compromise, facial fractures, and most soft tissue injuries.
The initial evaluation of the trauma patient consists of a rapid primary survey, aimed at identifying and treating immediately life-threatening problems. The primary survey should be completed in no more than 5 to 10 minutes. After all critical issues in the primary survey have been addressed, a full head-to-toe secondary survey is undertaken, with the goal of carefully examining the entire patient and identifying all injuries. The primary survey is conducted according to the mnemonic ABCDE: Airway, Breathing, Circulation, Disability, Exposure.
The crucial first step in managing an injured patient is securing an adequate airway. The mechanical removal of debris and the chin lift or jaw thrust maneuver, both of which pull the tongue and oral musculature forward from the pharynx, are often useful in clearing the airway of less severely injured patients. However, if there is any question about the adequacy of the airway, if there is evidence of severe head injury, or if the patient is in profound shock, more definitive airway control is necessary and appropriate. In the majority of patients this is accomplished by endotracheal intubation. Endotracheal intubation must be done rapidly, under the assumption of cervical spine instability, and in a fashion that does not induce increased intracranial pressure (ICP) in patients with head injury. This is best accomplished through a technique borrowed from surgical anesthesia known as rapid-sequence induction. In rapid-sequence induction, the patient is given a fast-acting anesthetic agent followed by a neuromuscular blocking agent. This combination of deep sedation and muscular relaxation allows careful intubation without cervical hyperextension and with minimal physiologic impact. The technique can be used with a number of different pharmacologic agents, depending on the knowledge and preferences of the individual practitioner. It is incumbent on the individual responsible for the procedure to be fully aware of the dosage, risks, and indications associated with the agents chosen. Excessive ventilation must be avoided after intubation, particularly in the hypovolemic patient, because it will increase mean intrathoracic pressures and compromise cardiac filling.
Although nasotracheal intubation has been widely suggested as a central modality, if not the primary modality, for emergency airway control in the past, we believe that nasotracheal intubation now should be used only rarely in the initial management of the injured patient. Nasotracheal intubation has a number of drawbacks, and the goal of safe endotracheal intubation with cervical spine precautions can be better accomplished using orotracheal intubation after rapid-sequence induction.
In a few patients, endotracheal intubation is either impractical or impossible and a surgical airway is required. Indications for a surgical airway include massive maxillofacial trauma, anatomic distortion due to neck injury, and inability to visualize the vocal cords because of the presence of blood, secretions, or airway edema. Cricothyroidotomy is the preferred emergency procedure in the majority of circumstances. Actual tracheotomy may be indicated in select patients, such as those with laryngeal injuries. Either surgical procedure may be preceded by needle cricothyroidotomy with jet insufflation to improve oxygenation and allow the surgical procedure to be performed in a more orderly fashion. Emergency airway procedures are one of the few immediately lifesaving interventions that a surgeon is likely to be called on to perform. By their nature, such procedures are always done under suboptimal conditions and under high stress. It is important for the trauma surgeon to have fully planned the approach to secure a surgical airway before being called on to actually perform the procedure.
After a secure airway has been established, the nature and adequacy of tidal ventilation is assessed. Inspection, palpation, and auscultation of the chest will demonstrate the presence of normal, symmetrical ventilatory effort and adequate bilateral tidal exchange. A supine anteroposterior chest radiograph is the primary diagnostic adjunct, demonstrating chest wall, pulmonary parenchymal, and pleural abnormalities. If there is decreased respiratory drive or severe chest wall injury, assisted ventilation is usually necessary. In addition to these mechanical factors, pulmonary parenchymal injury may lead to poor gas exchange and inadequate oxygenation, which necessitates mechanical ventilation. In either circumstance, the decision to provide assisted ventilation should be made early, as soon as it appears likely that the patient will not be able to sustain adequate oxygenation and ventilation, rather than at the point of overt ventilatory failure. Serial measurement of arterial blood gases should be used to monitor patients who are at risk and to assist in appropriate adjustment of the ventilator. It is especially important to prevent episodes of hypoxemia and hypoventilation in patients with associated head injury. There is also a body of evidence that suggests that hyperventilation may be detrimental to cerebral perfusion, accentuating the need for accuracy in ventilator management and vigilance in monitoring pH and Paco2.
Once the airway is secured, and adequate breathing has been established, the focus shifts to the circulatory system. The primary goal is the identification and control of the hemorrhage. External hemorrhage is controlled by direct pressure on the wound, while the possibility of hemorrhage into the chest, abdomen, or pelvis is rapidly assessed. In patients with known pelvic fracture, a pneumatic antishock garment may be applied or circumferential compression can be accomplished with a bed sheet wrapped around the pelvis. While steps are being taken to control hemorrhage, at least two large-bore intravenous lines should be placed to allow fluid resuscitation. These lines are usually placed percutaneously in the vessels of the arm. If peripheral upper extremity access is inadequate, alternative routes include the placement of a large-bore venous line in the femoral vein at the groin or cutdown on the greater saphenous vein at the ankle. The subclavian vein is a poor site for emergency access in the hypovolemic patient and should be used only when other sites are not available. In small children, intraosseous infusion is the preferred alternative route if peripheral access cannot be established. Fluid resuscitation begins with a 1000-mL bolus of lactated Ringer’s solution for an adult or 20 mL/kg for a child. Response to therapy is monitored by clinical indicators, including blood pressure, skin perfusion, urinary output, and mental status. If there is no response or only transient response to the initial bolus, a second bolus should be given. If ongoing resuscitation is required after two boluses, it is likely that transfusion will be required, and blood should be administered early. The primary goal is the control of hemorrhage, and fluid resuscitation is of value only if active measures to control hemorrhage are in progress.
The clinician must be vigilant for possible causes of hypotension that require immediate intervention during the primary survey, such as pericardial tamponade or tension pneumothorax. If the pattern of injury and clinical presentation raise suspicion of such injuries, immediate steps must be taken, often before the chest radiograph is available. For example, if a patient presents with profound hemodynamic instability and there is a high suspicion of tension pneumothorax, a needle catheter decompression of the affected hemithorax should be performed immediately, without radiologic confirmation. Needle catheter decompression can be done with relative impunity, even bilaterally, in patients who are intubated and on positive-pressure ventilation. Much greater care must be taken in patients who are breathing spontaneously, because the process of needle catheter decompression can induce pneumothorax and worsen ventilatory dysfunction, especially if done on both sides of the chest.
The next step is a rapid examination to determine the presence and severity of neurologic injury. Level of consciousness measured by the Glasgow Coma Scale (GCS) score ( Table 20–2 ), pupillary response, and movement of extremities are evaluated and recorded. The assessment of neurologic function can be complicated by endotracheal intubation and administration of neuromuscular blocking agents. Pupillary response still can be assessed in the paralyzed patient, but the GCS measured under these circumstances is of no value. Intubation interferes with the assessment of the verbal component of the GCS, and there is no standard method for interpretation. If the GCS is used in intubated and paralyzed patients, notation should be made about the circumstances of the assessment to signify that the score may be inaccurate.
Eye Opening
| |
No response
|
1
|
To painful stimulus
|
2
|
To verbal stimulus
|
3
|
Spontaneous
|
4
|
Best Verbal Response
| |
No response
|
1
|
Incomprehensible sounds
|
2
|
Inappropriate words
|
3
|
Disoriented, inappropriate content
|
4
|
Oriented and appropriate
|
5
|
Best Motor Response
| |
No response
|
1
|
Abnormal extension (decerebrate posturing)
|
2
|
Abnormal flexion (decorticate posturing)
|
3
|
Withdrawal
|
4
|
Purposeful movement
|
5
|
Obeys commands
|
6
|
Total
|
3–15
|
The final step in the primary survey is to completely undress the patient and do a rapid head-to-toe examination to identify any injuries to the back, perineum, or other areas that are not easily seen in the supine, clothed position. Evidence of blunt trauma, fracture, and unexpected penetrating injuries is likely to be discovered.
After completion of the primary survey and after all immediately life-threatening injuries have been addressed, a complete physical examination is performed. This secondary survey is often done in a head-to-toe manner and includes ordering and collecting data from appropriate laboratory and radiologic tests. This time period also allows for the placement of additional lines, catheters (e.g., nasogastric tube or Foley), and monitoring devices. Data accumulated then can be used to reset priorities and plan definitive management of all injuries.
A number of minor injuries may not become apparent until the patient has been under medical care for 12 to 24 hours. By this time, competing pain from other major injuries has often subsided, and the patient has had an opportunity to take inventory of all bodily complaints. It is very important for the physician to return and perform a tertiary survey, which is another complete head-to-toe physical examination aimed at identifying injuries that may have escaped notice in the first several hours.
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