Initial Management of Trauma in Adults - UpToDate

17/1/2017
InitialmanagementoftraumainadultsUpToDate
OfficialreprintfromUpToDate
www.uptodate.com2017UpToDate
Initialmanagementoftraumainadults
Authors: AliRaja,MD,MBA,MPH,RichardDZane,MD
SectionEditor: MariaEMoreira,MD
DeputyEditor: JonathanGrayzel,MD,FAAEM
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2016.|Thistopiclastupdated:Sep19,2016.
INTRODUCTIONTraumaticinjuriescanrangefromminorisolatedwoundstocomplexinjuriesinvolving
multipleorgansystems.Alltraumapatientsrequireasystematicapproachtomanagementinorderto
maximizeoutcomesandreducetheriskofundiscoveredinjuries.
Thisreviewwilldiscusstheinitialmanagementofadulttraumapatients.Themanagementofpediatrictrauma
patientsandspecificinjuriesarereviewedseparately.(See"Traumamanagement:Approachtotheunstable
child"and"Traumamanagement:Uniquepediatricconsiderations"and"Initialevaluationandmanagementof
shockinadulttrauma".)
EPIDEMIOLOGYTraumaisaleadingcauseofmortalityglobally[1].Worldwide,roadtrafficinjuriesarethe
leadingcauseofdeathbetweentheagesof18and29,whileintheUnitedStates,traumaistheleadingcause
ofdeathinyoungadultsandaccountsfor10percentofalldeathsamongmenandwomen[2].Over45million
peoplesustainmoderatetoseveredisabilityeachyearduetotrauma[1].IntheUnitedStatesalone,more
than50millionpatientsreceivesomeformoftraumarelatedmedicalcareforannually,andtraumaaccounts
forapproximately30percentofallintensivecareunit(ICU)admissions[3,4].
AccordingtotheWorldHealthOrganization(WHO),roadtrafficinjuriesaccountedfor1.25milliondeathswin
2014,andtraumaisexpectedtorisetothethirdleadingcauseofdisabilityworldwideby2030[1,5].Outside
areasofarmedconflict,penetratinginjuriesareresponsibleforfewerthan15percentoftraumaticdeaths
worldwide[6],buttheseratesvarybycountry.Asexamples,whilehomicideaccountsforasmanyas45
percentofdeathsinLosAngeles,penetratinginjuriesaccountforonly13percentofdeathsinNorway[7].
Approximatelyhalfoftraumaticdeathsresultfromcentralnervoussystem(CNS)injury,whileathirdfrom
exsanguination[8].
Patientswithserioustraumaticinjurieshaveasignificantlylowerlikelihoodofmortalityormorbidity(10.4
versus13.8percentrelativerisk[RR]0.75,95%CI0.600.95)whentreatedatadesignatedtraumacenter
[9].Olderage,obesity,andmajorcomorbiditiesareassociatedwithworseoutcomesfollowingtrauma[1018].
Intraumapatientswithsignificanthemorrhage,alowerscoreontheGlasgowComaScale(GCS)andolder
agearebothindependentlyassociatedwithincreasedmortality,accordingtomultivariablelogisticregression
analysisoftwolargedatabases[19].InalargeretrospectivestudyfromtheUnitedStatesNationalTrauma
DataBank,warfarinusewasassociatedwithanapproximately70percentincreasedriskofmortalityfollowing
trauma,afteradjustingforotherimportantriskfactors(oddsratio[OR]1.7295%CI1.631.81)[20].
Whilethemostcommoncausesofmortalityfromtraumaarehemorrhage,multipleorgandysfunction
syndrome,andcardiopulmonaryarrest[21],themostcommonpreventablecausesofmorbidityare
unintendedextubation,technicalsurgicalfailures,missedinjuries,andintravascularcatheterrelated
complications[22].
Relativelyfewpatientsdieafterthefirst24hoursfollowinginjury.Rather,themajorityofdeathsoccureitherat
thesceneorwithinthefirstfourhoursafterthepatientreachesatraumacenter[23,24].
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The"goldenhour"concept,whichemphasizedtheincreasedriskofdeathandtheneedforrapidintervention
duringthefirsthourofcarefollowingmajortrauma,wasdescribedinearlytraumastudiesandhasbeen
promulgatedintextbooksandinstructionalcourses[25].Undoubtedly,thereareinstanceswhenrapid
interventionimprovestheoutcomeofinjuredpatients(eg,obstructedairway,tensionpneumothorax,severe
hemorrhage),especiallyinbattlefieldinjuries[26].However,therelationshipbetweentimingandmortalitymay
bemorecomplexthanoncethought.Inalargestudyusingregistriesfrommultipletraumacentersacross
NorthAmerica,noassociationbetweenemergencymedicalservices(EMS)intervals(eg,onsceneand
transporttimes)andtraumapatientmortalitywasfound[27,28].
MECHANISMParticularmechanismspredisposepatientstospecificinjuries.Commonblunttrauma
mechanismsandtheirmostfrequentlyassociatedinjuriesaredescribedintheaccompanyingtable(table1).
Inaddition,certainhighriskbluntmechanisms,includingpedestriansstruckbyautomobiles,motorcycle
accidents,severemotorvehicleaccidents(eg,extensivedamageleadingtoprolongedextricationtime),and
fallsgreaterthan20feet,havebeenassociatedwithgreatermorbidityandmortality[2932].
PREPARATION
PrearrivalpreparationWheneverpossible,emergencymedicalservices(EMS)shouldnotifythe
receivinghospitalthatatraumapatientisenroute.Thisprovidesthereceivinghospitalwithinformationand
timethatcanbecrucialtothemanagementoftheseverelyinjuredpatient.
Ideally,theinformationprovidedbyEMSincludes:
Patientageandsex
Mechanismofinjury
Vitalsigns(somecliniciansaskforthelowestbloodpressureandhighestpulse)
Apparentinjuries
Earlynotificationenablesemergencydepartment(ED)stafftodothefollowing:
Notifyadditionalpersonnel(eg,EDstaff,traumasurgery,obstetrics,orthopedics,radiology,interpreter
services)
Assureresourcesareavailable(eg,ultrasound,CT,operatingroomspace)
Prepareforanticipatedprocedures(eg,trachealintubation,chesttube)
Prepareforbloodtransfusion
Inaddition,informationprovidedbyEMSpriortoarrivalcanhelphospitalbasedcliniciansfocusonmorelikely
injuries(table1).Asanexample,adescriptionofafeetfirstfallfromgreatheightraisessuspicionfor
fracturesofthecalcaneus,lowerextremity,andlumbarspinesimilarly,reportofaprolongedmotorvehicle
extricationduetocollapseofthedriver'ssidecompartmentraisesconcernforinjuriessuchasribfractures,
pulmonarycontusion,andlacerationsofthespleenandkidney.
Universalprecautionsagainstbloodandfluidbornediseasesshouldbepartofthetraumateam'spreparation.
Theseincludegloves,gowns,masks,andeyeprotectionforallmembersoftheteaminvolvedinthe
resuscitation.Leadshieldsforstaffshouldbeavailableifportablexraysaretobeperformedduring
resuscitationefforts.
TraumateamInruralhospitals,thetraumateammaybelimitedtoonephysicianandanurse.Insuch
settings,theteammightenlisthelpfromEMSpersonnelorotherclinicianstomanagecriticallyillormultiple
patients.Teamsatmajortraumacentersmayincludeemergencyphysicians,traumasurgeons,subspecialist
surgeons,emergencynurses,respiratorytherapists,technicians,andsocialworkers.Regardlessofthe
setting,allteamsmusthaveaclearlydesignatedleaderwhodeterminestheoverallmanagementplanand
assignsspecifictasks.Whileleadersofsmallerteamsmightfindthemselveshavingtoperformproceduresin
ordertocareeffectivelyfortheirpatients,leadersoflargerteamsshouldavoidperformingprocedures.This
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allowstheleadertoremainfocusedontheirsupervisoryresponsibilitiesandonthepatientandpossible
changesintheircondition.
Regardlessofsettingorteamcomposition,optimalcareofatraumapatientrequireseffectiveandefficient
communicationandteamworkamongallmembers[33,34].Goodcarebeginswithaprearrivalbriefingand
theassignmentofgeneralrolesandspecifictasks,andcontinuesthroughouttheresuscitationastheteam
usesclosedloopcommunicationandmaintainsacommonvisionoftheplanofcare.
Breakdownsinthecareplanandmedicalmismanagementtypicallyoccurduetooneormoreoffourpotential
problems[34]:
Communicationbreakdowns(eg,changesinthepatient'sphysiologicstateorcriticaltestresultsarenot
effectivelycommunicated,overallmanagementplanorpriorityoftasksisnotconveyedclearlybythe
teamleader)
Failuresinsituationalawareness(eg,failuretorecognizeshock,failuretoanticipatebloodtransfusion
needs,failuretomodifystandardmanagementforhigherriskpatients)
Staffingorworkloaddistributionproblems(eg,insufficientlytrainedstaffconductingaprocedure,
inadequatestaffforpatientvolume)
Unresolvedconflicts(eg,unresolvedhostilityaboutotherteammembersperceivedtobeperforming
inadequately,disagreementaboutoverallmanagementplan,disagreementamongseniorcliniciansvying
forteamleadership)
PRIMARYEVALUATIONANDMANAGEMENT
OverviewAclear,simple,andorganizedapproachisneededwhenmanagingaseverelyinjuredpatient.
TheprimarysurveypromulgatedinAdvancedTraumaLifeSupport(ATLS)providessuchanapproach
[25].Theprimarysurveyisorganizedaccordingtotheinjuriesthatposethemostimmediatethreatstolifeand
isperformedintheorderdescribedbelow.Insettingswithlimitedresources,theprimarysurveysimplifies
prioritiesandanyproblemsidentifiedshouldbemanagedimmediatelybeforemovingontothenextstepof
thesurvey.However,atmajortraumacenters,manycapablecliniciansmaybepresent,allowingtheteamto
addressmultipleproblemssimultaneously.
Theprimarysurveyconsistsofthefollowingsteps:
Airwayassessmentandprotection(maintaincervicalspinestabilizationwhenappropriate)
Breathingandventilationassessment(maintainadequateoxygenation)
Circulationassessment(controlhemorrhageandmaintainadequateendorganperfusion)
Disabilityassessment(performbasicneurologicevaluation)
Exposure,withenvironmentalcontrol(undresspatientandsearcheverywhereforpossibleinjury,while
preventinghypothermia)
Keepthefollowingpointsinmindwhileperformingtheprimarysurvey:
Airwayobstructionisamajorcauseofdeathimmediatelyfollowingtrauma[27,33].Theairwaymaybe
obstructedbythetongue,aforeignbody,aspiratedmaterial,tissueedema,orexpandinghematoma.
Definitiveguidelinesfortrachealintubationintraumadonotexist.Whenindoubt,itisgenerallybestto
intubateearly,particularlyinpatientswithhemodynamicinstability,orthosewithsignificantinjuriestothe
faceorneck,whichmayleadtoswellinganddistortionoftheairway.
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Onceanairwayhasbeenestablished,itisimportanttosecureitwellandtoensureitisnotdislodgedany
timethepatientismoved.Unintendedextubationisthemostcommonpreventablecauseofmorbidityin
traumapatients[22].
Unconsciouspatientswithsmallpneumothoracesthatarenotvisibleormissedontheinitialchest
radiographmaydeveloptensionphysiologyaftertrachealintubationfrompositivepressureventilation.It
isimportanttoreauscultatethelungsoftraumapatientswhodevelophemodynamicinstabilityafterbeing
intubatedandtobeattentivetoventilatorpressurealarms.
Hemorrhageisthemostcommonpreventablecauseofmortalityintrauma[21].Bealertforsubtlesigns
ofhemorrhagicshock,particularlyintheelderly,whomaybeoncardiovascularmedicationsthatblunt
suchsigns,andyoung,healthyadultswhomaynotpresentwithobviousmanifestations.Hypotension
generallydoesnotmanifestuntilatleast30percentofthepatient'sbloodvolumehasbeenlost[35].
Suchpatientsareathighriskofdeath.Elderlypatientsmaybehypotensiverelativetotheirbaseline
bloodpressurebutstillhavebloodpressuremeasurementsinthe"normal"range.Asingleepisodeof
hypotensionsubstantiallyincreasesthelikelihoodthataseriousinjuryhasoccurred[36,37].(See"Initial
evaluationandmanagementofshockinadulttrauma",sectionon'Recognition'and"Geriatrictrauma:
Initialevaluationandmanagement".)
Braininjuriesarecommoninpatientswhohavesustainedsevereblunttraumaandevenasingleepisode
ofhypotensionincreasestheirriskofdeath[35,38].
AirwaySeverelyinjuredpatientscandevelopairwayobstructionorinadequateventilationleadingto
hypoxiaanddeathwithinminutes.Observationalstudiessuggestthatairwayobstructionisamajorcauseof
preventabledeathamongtraumapatients[39,40].Therefore,airwayevaluationandmanagementremainthe
criticalfirststepsinthetreatmentofanyseverelyinjuredpatient[25].
Severalstudiessuggestthatchecklistsimprovetheefficiencyandreducethecomplicationsassociatedwith
airwaymanagementoftraumapatients[4144].Inaprospectivestudyof141intubatedtraumapatients,
implementationofprearrivalandpreinductionpreparationchecklistsreducedintubationrelatedcomplication
ratesby7.7percent(95%CI0.514.8)[41].Asamplechecklistisprovidedintheaccompanyingtable(table
2).
Maintainingthepatientsstretcherataslightanglewiththeheadslightlyelevated(reverseTrendelenburg
position)orelevatingjusttheheadtoabout30degreesifcervicalspineprecautionsarenotrequiredcanhelp
todecreasetheriskofaspirationandimprovelungcapacitybyreducingabdominalpressureonthechest.
AssessmentInaconsciouspatient,initialairwayassessmentcanbeperformedasfollows[45]:
Beginbyaskingthepatientasimplequestion(eg,"Whatisyourname?").Aclearaccurateresponse
verifiesthepatient'sabilitytomentate,phonate,andtoprotecttheirairway,atleasttemporarily.
Observetheface,neck,chest,andabdomenforsignsofrespiratorydifficulty,includingtachypnea,
accessoryorasymmetricmuscleuse,abnormalpatternsofrespiration,andstridor.
Inspecttheoropharyngealcavityfordisruptioninjuriestotheteethortongueblood,vomitus,orpooling
secretions.Noteifthereareobstaclestotheplacementofalaryngoscopeandendotrachealtube.
Inspectandpalpatetheanteriorneckforlacerations,hemorrhage,crepitus,swelling,orothersignsof
injury.Palpationoftheneckalsoenablesidentificationofthelandmarksforcricothyrotomy.
Intheunconsciouspatient,theairwaymustbeprotectedimmediatelyonceanyobstructions(eg,foreignbody,
vomitus,displacedtongue)areremoved.Managementoftheairwaygenerallyandinapatientwithdirect
airwaytraumaisdiscussedseparately.(See"Emergencyairwaymanagementintheadultwithdirectairway
trauma"and"Penetratingneckinjuries:Initialevaluationandmanagement"and"Advancedemergencyairway
managementinadults"and"Rapidsequenceintubationforadultsoutsidetheoperatingroom".)
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Airwaymanagementinatraumapatientunabletoprotecthisorherairwayiscompletedinanexpedientyet
controlledfashion.Whenpossible,performabriefpreintubationassessmenttogaugethepotentialdifficultyof
intubationanddeterminebasicbaselineneurologicfunction(eg,pupillarylightreflex,movementof
extremities).Methodsandmnemonicstoassessairwaydifficultyarereviewedseparately,buttheapplication
oftheLEMONmnemonictotraumapatientsisdescribedhere.(See"Approachtothedifficultairwayinadults
outsidetheoperatingroom".)
L:LOOK:Facialandneckinjuriescandistortexternalandinternalstructuresmakingitdifficulttovisualize
theglottisorinsertanendotrachealtube.
E:EVALUATE332:Thisreferstotheintraoral,mandibular,andhyoidtothyroidnotchdistances
(picture1).Thecervicalcollarmustbeopenedtomaketheseassessments.Thedistancesreferredto
canbenarrowedbyfracture,hematoma,orotheranatomicdistortions(eg,softtissueswelling).
M:MALLAMPATI:AstandardcalculationoftheMallampatiscorecannotbeperformedinmanytrauma
patientsinjuredpatientsrequiringemergentintubationoftencannotopentheirmouthsspontaneously
(figure1).Nevertheless,aneffortshouldbemadetodeterminehowmuchoftheretropharynxcanbe
seenandwhetherinjuriesoftheoropharynxorpooledblood,vomitus,orsecretionsarepresent.
O:OBSTRUCTION/OBESITY:Eitherfactorcaninterferewithvisualizationandmanagementofthe
traumatizedairway.Anynumberofinjuriescanobstructtheairwayincludinginternalorexternal
hematomasorsofttissueedemafromsmokeinhalation.Obesitycomplicatesperformanceof
cricothyrotomy.
N:NECKMOBILITY:Inlinestabilizationisnecessaryinmosttraumapatients.Oncethecervicalcollaris
removedbyasecondskilledprovider,thatprovidershouldstabilizethespinewhileorotrachealintubation
isperformed.Itisimportanttonotethattheriskofneurologicinjuryfromhypoxemiaismuchgreaterthan
theriskofspinalinjuryduetoneckextensionduringintubation.Judiciousrelaxationofimmobilizationmay
benecessaryinsomecases[45].
DifficultairwaydevicesDevicesfordifficultairwaymanagementarediscussedseparately.(See
"Devicesfordifficultemergencyairwaymanagementinadults".)
Anumberofairwaytoolsandrescueairwayscanbehelpfulwhenmanagingatraumapatient.Devicesthat
shouldbeavailableatthebedsideinclude:
Suction(ie,multiplepumpsandtips)
Bagvalvemaskattachedtohighflowoxygen
Oralandnasalairways
Rescueairways(eg,Combitube,Laryngealmaskairway)
Endotrachealtubeintroducer(ie,gumelasticbougie)
Videolaryngoscope,ifavailable
Cricothyrotomykit
Endotrachealtubesinarangeofsizes
Laryngoscopes,includingarangeofdifferentsizedbladesandhandles
Preferredadjunctintubatingdevices(eg,lightwand)
Directlaryngoscopyreliesondirectvisualizationoftheglottis,whichisoftendifficultintheseverelyinjured
patientwhoseairwaymaybeobstructedandwhoseneckcannotbemanipulated.Incontrast,video
laryngoscopesprovideanexcellentviewoftheglottiswithminimalmovementofthecervicalspineandappear
tobewellsuitedforairwaymanagementinthetraumapatient[4648].Largerstudiesintraumapopulations
areneededtoconfirmtheseinitialimpressions.
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Theendotrachealtubeintroducer(orgumelasticbougie)isanotherinvaluabletoolforairwaymanagementin
thetraumapatient,particularlywhentheglotticviewislimited.Itsuseisdiscussedseparately.(See"Devices
fordifficultemergencyairwaymanagementinadults",sectionon'Endotrachealtubeintroducers(gumelastic
bougie)'.)
IntubationTrachealintubationoftheinjuredpatientisoftencomplicatedbytheneedtomaintain
cervicalimmobilization,thepresenceofobstructionssuchasblood,vomitus,anddebris,andpossiblyby
directtraumatotheairway[49].Nevertheless,manytraumapatientsrequireintubationforimmediateairway
protectionorbecauseoftheprojecteddiseasecourse.Intubationimprovesoxygenation,therebyhelpingto
meetincreasedphysiologicdemands,andallowsfortestingandprocedurestobeperformedmoreeasilyand
withlesspatientdiscomfort.(See"Thedecisiontointubate".)
Ideally,airwaymanagersshouldhaveapredeterminedbackupplanwithallnecessarytoolsatthebedside,
includingrescueairwaysandacricothyrotomykit,beforeproceedingwithintubation.Incrashscenarios,this
maynotbepossible.Asamplechecklisttoassistwithairwaymanagementoftheadulttraumapatientis
providedintheaccompanyingtable(table2).
Cliniciansshouldconsidertheexpectedcourseofdiseaseandneedforinterventionswhendecidingtosecure
anairway.Asexamples,apatientwhoishemodynamicallystableforthemomentbutatriskofdeterioration
andwhorequiresacomplexdiagnosticstudythatmustbeperformedinaremoteradiologysuite,orapatient
withsignificantinjuryinimminentneedofanorthopedicorotherpainfulprocedure,oftenwarrantearly
intubationtoensureairwayprotectionandtoallowfordeepersedationandpaincontrol.
Theperformanceofrapidsequenceintubationanddirectlaryngoscopyarediscussedseparately.(See"Rapid
sequenceintubationforadultsoutsidetheoperatingroom"and"Directlaryngoscopyandendotracheal
intubationinadults".)
CricothyrotomyClinicianswhomanagetraumamustbepreparedtoperformacricothyrotomywhen
orotrachealintubationcannotbeaccomplished.Theperformanceofcricothyrotomyandtheapproachtothe
failedairwayarediscussedseparately.(See"Thefailedairwayinadults"and"Emergencycricothyrotomy
(cricothyroidotomy)".)
Intraumapatientswithapotentiallydifficultairway,adoublesetup,inwhichsimultaneouspreparationis
madetoperformorotrachealintubationandcricothyrotomy,maybethebestapproach.Thisenablesthe
cliniciantotransitionimmediatelytoacricothyrotomyifattemptsatoralintubationareunsuccessful.
Traumapatientsmayhavesustainedinjuriestotheneckthatmakecricothyrotomydifficulttoperform,and
therefore,itisimportanttooptimizeanyattemptatorotrachealintubation.
CervicalspineimmobilizationAssumethataninjurytothecervicalspinehasoccurredinallblunt
traumapatientsuntilprovenotherwise.Conversely,patientswithisolatedpenetratingtrauma,nosecondary
bluntinjury,andanintactneurologicexaminationtypicallydonothaveanunstablespinalcolumninjury[45].
Spinalimmobilizationmaybeharmfultothesepatientsinsomecircumstancesandisunnecessarywhen
managingtheirairway[50].(See"Evaluationandacutemanagementofcervicalspinalcolumninjuriesin
adults".)
Theanteriorportionofthecervicalcollarshouldbetemporarilyremovedandmanualinlinestabilization
maintainedforallpatientswithblunttraumaticinjuriesreceivingairwayinterventions,includingbagmask
ventilation[51,52].Preintubationairwayinterventionsareassociatedwithasmuchspinalcolumnsubluxation
asintubation[51,52].
Trachealintubationshouldnotbeattemptedwiththeanteriorportionofthecervicalcollarinplace.
Intubationsperformedwiththecompletecervicalcollarinplaceareassociatedwithgreaterspinalsubluxation
thanthoseperformedwiththeanteriorportionremovedandmanualinlinestabilizationmaintained[53].
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Thesafetyofmanualinlinestabilizationforpatientswithblunttraumaticinjuriesneedingintubationiswell
established.Fewcasereportsdescribespinalinjuryduringintubation,andinallcases,thespinewasnot
manuallystabilized[5456].
BreathingandventilationOnceairwaypatencyisensured,assesstheadequacyofoxygenationand
ventilation[25].Chesttraumaaccountsfor20to25percentoftraumarelateddeaths,inlargepartduetoits
harmfuleffectsonoxygenationandventilation[24].Themanagementofbluntchesttraumaisdiscussed
separately.(See"Initialevaluationandmanagementofbluntthoracictraumainadults".)
Inspectthechestwalllookingforsignsofinjury,includingasymmetricorparadoxicalmovement(eg,flail
chest),auscultatebreathsoundsattheapicesandaxillae,andpalpateforcrepitusanddeformity.Inunstable
patients,obtainaportablechestradiograph.Tensionpneumothorax,massivehemothorax,andcardiac
tamponadeareimmediatethreatstolifethatshouldbeidentifiedatthisstageoftheprimarysurvey.
Ultrasoundcanprovideimportantinformationaboutallthesediagnosesduringthisportionoftheassessment.
(See'Ultrasound(FASTexam)'belowand"Emergencyultrasoundinadultswithabdominalandthoracic
trauma".)
Presumptivelytreatpatientsexhibitingsignsoftensionpneumothorax,includinghypotension,dyspnea,and
ipsilateraldecreasedbreathsounds,withneedledecompressionbeforeobtainingimaging.Delaystoobtaina
portablechestradiographcancausesignificantmorbidity.Ifconfirmationisneededpriortotreatment,
ultrasoundcanbeperformedrapidlyatthebedside,anditismoresensitivethanplainradiographfor
detectingpneumothorax[57].Needledecompressionisperformedwithalargebore(14gaugeorlarger)
angiocatheter,eitherinthesecondintercostalspaceinthemidclavicularlineorinthefifthintercostalspacein
themidaxillaryline.Ifequipmentisimmediatelyavailable,itisappropriatetoproceeddirectlytochesttube
insertionwithoutinterveningneedledecompression.
Ofnote,astandard14gaugeangiocathetercannotpenetratethechestwallandreachthepleuralspacein10
to33percentoftraumapatients[58].A10gauge,7.5cm(3inch)armoredangiocatheterisabletopenetrate
thepleuralspaceinmostinstances.Needledecompressionisfollowedimmediatelybytubethoracostomy.
(See"Initialevaluationandmanagementofbluntthoracictraumainadults",sectionon'Initialmanagement'
and"Placementandmanagementofthoracostomytubes".)
Tubethoracostomyinanunstabletraumapatientisplacedinanticipationofbothhemothoraxand
pneumothoraxusingachesttubeofatleast32Frenchindiameter.Agenerousskinincisionshouldbemade
inthefifthintercostalspaceinthemidaxillarylineallowingforplacementofthetubeintheinferiorportionof
theinterspaceanddigitalguidancetowardstheposteriorapicalportionofthehemithorax.
Circulation
RecognitionandmanagementofhemorrhageOncetheairwayandbreathingarestabilized,perform
aninitialevaluationofthepatient'scirculatorystatusbypalpatingcentralpulses.Ifacarotidorfemoralpulse
isverifiedandnoobviousexsanguinatingexternalinjuryisnoted,circulationmaymomentarilybeassumedto
beintactcompletionoftheprimarysurveyshouldnotbedelayedbythedeterminationofanexactblood
pressure.
Whilecirculationisassessed,twolargebore(16gaugeorlarger)intravenous(IV)cathetersareplaced,most
oftenintheantecubitalfossaofeacharm,andbloodisdrawnfortesting,particularlyforbloodtypingand
crossmatch.Intraosseouscannulationorcentralvenouscatheterplacement(ideallyunderultrasound
guidance)canbeperformedifthereisdifficultyestablishingperipheralIVaccess.(See"Intraosseous
infusion".)
Lifethreateninghemorrhagemustbecontrolled.Acombinationofmanualpressure,proximalcompression
witheitheratourniquetoramanualbloodpressurecuff,andelevationistypicallysufficienttocontrolexternal
arterialhemorrhage.Whentheseareunsuccessful,hemostaticagentsmaybeused,ifavailable.Venous
bleedingiscontrolledwithdirectpressure.Bleedingfromseverepelvicinjuriesmayrequiretheapplicationof
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apelvicbinder.(See"Initialevaluationandmanagementofshockinadulttrauma",sectionon'Hemostatic
agents'and"Pelvictrauma:Initialevaluationandmanagement",sectionon'Management'.)
Emergencythoracotomymaybeneededfortraumapatientswithoutfemoralorcarotidpulses.Theprocedure
ismosteffectiveforvictimsofstabwoundstothechestwhohavepulsesorotherwitnessedsignsoflife(eg,
voluntarymovement)initially.Itisrarelybeneficialinpatientswithblunttraumaorwhenperformedinfacilities
withoutreadyaccesstoappropriatesurgicalcare.Emergencythoracotomyisdiscussedingreaterdetail
separately.(See"Initialevaluationandmanagementofbluntthoracictraumainadults",sectionon'Emergent
thoracotomy'.)
Inpatientsinextremiswithimpendingarrest,placementofaresuscitativeballoonforocclusionoftheaorta
(REBOA)bythosetrainedinthistechniquemaybelifesaving.Useofthisdeviceismosteffectiveto
temporizepatientswithintraabdominalorretroperitonealsourcesofhemorrhageuntilmoredefinitivetherapy
withsurgeryorangioembolizationispossible,andsorapidtransporttotheoperatingroomand/or
angiographicsuiteisessential.REBOAisnotappropriateforuseinthosewithsuspectedthoracicsourcesof
exsanguinationorinpatientsincardiacarrest,inwhomEDTshouldbeperformedinstead.(See
"Endovascularmethodsforaorticcontrolintrauma",sectionon'REBOAtechnique'.)
Mosttraumapatientswithhypotensionorsignsofshock(eg,pale,cool,moistskin)arebleeding,andpatients
withseverehemorrhagehavesignificantlyhighermortality(table3)[59].Initialfluidresuscitationforthese
patientsmayconsistofabolusofintravenouscrystalloid(eg,20mL/kgisotonicsaline).However,patientswith
obvioussevereorongoingbloodlossshouldbetransfusedimmediatelywithtypeOblood(womenof
childbearingageshouldbetransfusedwithOnegativeblood).Whilemildlyunstablepatientsmaybetreated
withisotoniccrystalloidinlieuofblood,unnecessaryinfusionofcrystalloidshouldbeavoided[60].Fluid
resuscitation,includingtheappropriateuseofdelayedfluidresuscitationandtransfusionofthetraumapatient
inshockarediscussedseparately.(See"Initialevaluationandmanagementofshockinadulttrauma".)
Patientswithpersistenthemodynamicinstabilitydespiteaninitialfluidbolusgenerallyrequireblood
transfusionanddefinitivecontrolofthebleedingsource.Significanthemorrhageoccursinanyoffivesites:
external,intrathoracic,intraperitoneal,retroperitoneal,andpelvicorlongbonefractures.Iftransfusionis
required,a1:1:1ratioofplasma,platelets,andredcellsshouldbetargeted.Patientsrequiringtransfusion
maybenefitfromtreatmentwithtranexamicacidifitisgivenwithinthreehoursofinjury.Transfusionofthe
traumapatientandtheuseofantifibrinolyticagentssuchastranexamicacidarediscussedindetail
separately.(See"Initialevaluationandmanagementofshockinadulttrauma",sectionon'Transfusionof
bloodproducts'and"Initialevaluationandmanagementofshockinadulttrauma",sectionon'Antifibrinolytic
agents'.)
Itisimportanttoobtainmanualbloodpressuremeasurementsintraumapatientswithsystolicbloodpressures
below90mmHg,asautomatedbloodpressurecuffsoftenoverestimatevaluessignificantlyinthesepatients
[61].Furthermore,datasuggestthatthetraditionalthresholdofasystolicbloodpressurebelow90mmHgto
defineshockisinaccurate[6265].Theappropriatesystolicormeanarterialbloodpressurethresholdfor
definingshockvariesbyage.Asignificantproportionoftraumapatientswithhemorrhagicshockhavea
systolicbloodpressureabove90mmHgusingacutoffof110mmHgislikelytobemoreappropriateinthe
elderly.(See"Geriatrictrauma:Initialevaluationandmanagement".)
ReversalofanticoagulationSometraumapatients,particularlyelderswithcomorbidities,maybe
takinganticoagulants.Providedbelowareseveraltablesoutliningmethodsforreversingparticular
anticoagulantsincasesoflifethreateningbleeding,aswellaslinkstomoredetaileddiscussionsofhowto
managebleedingassociatedwiththesemedications:
Warfarin(see"ManagementofwarfarinassociatedbleedingorsupratherapeuticINR",sectionon
'Serious/lifethreateningbleeding').Initialemergencytreatmenttoreverseanticoagulationduetowarfarin
inpatientswithseverehemorrhageisoutlinedinthefollowingtable(table4).
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Directthrombininhibitors(eg,dabigatran)andfactorXainhibitors(eg,rivaroxaban,apixaban,edoxaban)
(see"Managementofbleedinginpatientsreceivingdirectoralanticoagulants").Initialemergency
treatmenttoreverseanticoagulationduetodirectoralanticoagulantsinpatientswithseverehemorrhage
isoutlinedinthefollowingtable(table5).
Heparin(see"HeparinandLMWheparin:Dosingandadverseeffects",sectionon'Bleeding').
Lowmolecularweightheparin(see"HeparinandLMWheparin:Dosingandadverseeffects",sectionon
'Bleeding').
NonhemorrhagiccausesofshockInadulttraumapatients,nonhemorrhagiccausesofshockinclude
tensionpneumothoraxandcardiactamponade.Theseinjuriesarebestdetectedbyphysicalexaminationor
ultrasoundassessment(ie,FAST).Particularlyinolderpatients,theclinicianmayneedtoconsidermedical
causesofhypotensionthatprecededandpossiblycausedthetrauma,suchasmyocardialinfarction,
arrhythmia,malfunctioningpacemakerorleftventricularassistdevice(LVAD),orgastrointestinalbleeding.
(See'Ultrasound(FASTexam)'belowand"Emergencyultrasoundinadultswithabdominalandthoracic
trauma"and"Geriatrictrauma:Initialevaluationandmanagement"and"Initialevaluationandmanagementof
shockinadulttrauma",sectionon'Differentialdiagnosis'.)
DisabilityandneurologicevaluationOnceproblemsrelatedtotheairway,breathing,andcirculationare
addressed,performafocusedneurologicexamination.Thisshouldincludeadescriptionofthepatient'slevel
ofconsciousnessusingtheGlasgowComaScale(GCS)score,andassessmentsofpupillarysizeand
reactivity,grossmotorfunction,andsensation(table6).Alsonoteanylateralizingsignsandthelevelof
sensationifaspinalcordinjuryispresent.Acuteneurologicinjury,includingimagingrecommendationsand
medicalandsurgicalmanagement,isdiscussedindetailseparately.(See"Managementofacutesevere
traumaticbraininjury"and"Acutetraumaticspinalcordinjury".)
TheGCSscoreiswidelyusedandcanbeemployedtofollowthepatient'sneurologicstatus.Unfortunately,a
numberofstudiessuggestthattheinitialGCSscoreisnotpredictiveofoutcomeinpatientswithseverebrain
injury,andintubation,sedatives,andalcoholorotherdrugintoxicationmayinterferewithitsapplication[66
68].
Maintainspinalimmobilizationforallpatientswiththepotentialforspinalcordinjury.Thepresenceofamotor
deficitoraspinalcordsensorylevelindicatestheneedforimagingofthebrain,spinalcord,andtheirvascular
supply.
ExposureandenvironmentalcontrolBecertainthatthetraumapatientiscompletelyundressedand
thathisorherentirebodyisexaminedforsignsofinjuryduringtheprimarysurvey.Missedinjuriesposea
gravethreat[69].Regionsoftenneglectedincludethescalp,axillaryfolds,perineum,andinobesepatients,
abdominalfolds.Penetratingwoundsmaybepresentanywhere.Whilemaintainingcervicalspineprecautions,
examinethepatient'sbackdonotneglectexaminationoftheglutealfoldandposteriorscalp.
Hypothermiashouldbepreventedifpossibleandtreatedimmediatelyonceidentified.Hypothermia
contributestobothcoagulopathy[70]andthedevelopmentofmultipleorgandysfunctionsyndrome[71].
Duringwintermonthsandwheneverahypothermictraumapatientisbeingtreated,theresuscitationroom
shouldbeheatedtheUnitedStatesMilitaryJointTheaterTraumaSystemClinicalPracticeGuidelineon
hypothermiapreventionrecommendsemergencydepartment(ED)andoperatingroom(OR)temperaturesof
atleast29.4C(85F)duringthetreatmentofthesepatients[72].Rapidlyremovewetclothing,makeliberal
useofwarmblanketsandactiveexternalwarmingdevices,andwarmIVfluidsandblood.Treatmentsfor
hypothermiaarediscussedseparately.(See"Accidentalhypothermiainadults".)
Diagnosticstudies
PortableradiographsPlainradiographsplayanimportantroleintheprimaryevaluationofthe
unstabletraumapatient.Screeningradiographsshouldbeobtained,eitherintheemergencydepartment(ED)
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ortheoperatingroom(OR),eveninhemodynamicallycompromisedpatientswhoaresentdirectlytotheOR
duringoraftertheirprimarysurvey.Promptimagingofthelateralcervicalspine,chest,andpelviscandetect
lifethreateninginjuriesthatmightotherwisebemissed.However,thesensitivityofthelateralcervicalspine
radiographisonly70to80percent[7375],andsomesacralandiliacfracturescanbemissedonplainpelvic
radiographs.
Clinicaldecisionrules(eg,NEXUS)canbeusedtodeterminetheneedforcervicalspineimagingin
hemodynamicallystabletraumapatients.Assessmentofthespinalcolumninjuriesintrauma,includingthe
selectionofimagingstudies,isdiscussedseparately.(See"Evaluationandacutemanagementofcervical
spinalcolumninjuriesinadults".)
PlainradiographyofthechestandpelvisisoftenobtainedfortraumapatientsnotthoughttorequireCT
imaging.Thedecisiontoobtaintheseimagesshouldbemadebasedupontheinjurymechanismandclinical
findings.Theevaluationofpatientswithpenetratingtraumaoftenincludesimagesoftheregionofpenetration
eveninstablepatients,theseradiographscandetectretainedforeignbodiesorfragments.Ontheother
hand,patientswithblunttraumashouldundergoimagingwithplainradiographsonlyifclinicalfindingssuggest
thepresenceofinjury[76,77].Plainradiographscanbeomittedaltogetherifthereisnoclinicalsuspicionof
injuryandthestudiesareunlikelytoalteremergentmanagement.(See"Pelvictrauma:Initialevaluationand
management",sectionon'Plainradiograph'.)
Aplainradiographofthechestshouldbeobtainedinpatientswithpenetratinginjuriesofthechest,back,or
abdomenregardlessoftheneedforCT.Plainfilmsmayrevealsubdiaphragmaticfreeair,aforeignbody,ora
pneumothoraxorhemothorax.
IfthecliniciandeterminesthatCTimagingisneededbaseduponthemechanismorclinicalsuspicion,thereis
noroleforeitheraplainradiographofthechestorpelvisinhemodynamicallystablepatientswithblunttrauma
[76,7881].
Ultrasound(FASTexam)FocusedAssessmentwithSonographyforTrauma(FAST)isanessential
partoftheprimarycirculationsurveyforunstablepatients,inwhomitoftendeterminesmanagement[8286].
FASTisusedprimarilytodetectpericardialandintraperitonealblood,anditismoreaccuratethanany
physicalexaminationfindingfordetectingsignsofintraabdominalinjury.Inhemodynamicallystablepatients,
FASTcanbedelayeduntilthesecondarysurveyandisideallyperformedbyasecondoperatorwhilethe
remainderofthesecondarysurveyiscompleted.TheperformanceoftheFASTexaminationandevidence
supportingitsusearediscussedseparately.(See"Emergencyultrasoundinadultswithabdominaland
thoracictrauma".)
TheaccuracyandroleofFASTmaybemorelimitedinpatientswithsignificantpelvicfracturesbecauseitis
lesssensitivefordetectingpelvicbleedingandcannotdifferentiatebetweenbloodandurine.Retroperitoneal
bleedingisalsonotreliablyvisualizedwithultrasound.Themanagementofsuchpatientsisdiscussed
separately.(See"Pelvictrauma:Initialevaluationandmanagement",sectionon'Initialmanagement'.)
FASTislesssensitiveforinjuryinpenetratingtraumathanblunttrauma,andtheresultsofultrasound
examinationsinpenetratingtraumapatients,particularlynegativeresults,mustbeinterpretedwithgreater
caution.(See"Emergencyultrasoundinadultswithabdominalandthoracictrauma",sectionon'Clinical
studies'.)
TheExtendedFAST(EFAST)includesexaminationsofthethoraciccavitylookingforpneumothoraces.
PreliminarystudiessuggestthesensitivityofEFASTisbetterthanplainradiographforthisinjury[87].
Emergencycomputedtomography(CT)Traumapatientsfoundtobehemodynamicallyunstable
duringtheprimarysurveyareaggressivelyresuscitatedwhilecliniciansattempttodeterminethemostlikely
causesoftheirinstability.Ifthesourceofhemorrhageinanunstabletraumapatientcannotbedetermined
usingdiagnosticimagingstudiesimmediatelyavailableatthebedside,orifadditionalinformationisneededto
directoperativecare,inmostcasesthetreatingemergencyphysicianandsurgeonmustdecidewhetherto
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performemergencyCTimagingfirstortotakethepatientdirectlytotheoperatingroom.Thisdecisionis
baseduponthepatient'sresponsetoinitialresuscitationmeasures,theirprobableinjuriesandanticipated
operativeintervention,andtheproximityoftheCTscannertotheresuscitationbay.TheissueoftotalbodyCT
isdiscussedseparately.(See'Computedtomography,includingtotalbodyCT'below.)
Imagingmustnotdelaytransferinsituationswhenpatientsrequirehigherlevelsofcarethancanbeprovided
attheinitialfacility.Iftransferwillbeneeded,theprocessshouldbeinitiatedasearlyaspossible(insome
cases,immediatelyuponpatientarrivalandassessment).IfCTimagingisneededandcansafelyand
reasonablybedonewithoutdelayingtransfer,itmaybeobtained.(See'Patienttransfer'below.)
Inrareinstances,patientsmayhaveknownandpotentiallylifethreateningallergiestoIVcontrast[88].In
suchcases,assessmentoptionsinclude:noncontrastCT,ultrasound,exploratorysurgery,and(whenpatient
stabilityandresourcesallow)MRIorradionuclideredcellscan[89].
DiagnosticperitonealtaporlavageDiagnosticperitonealtap(DPT)orlavage(DPL)hasarole
similartoFASTintheunstablepatientinwhomasourceofbleedinghasnotbeenfound[90].Itcanbe
performedtodetectintraperitonealbloodwhenFASTisunavailableorindeterminateinhemodynamically
unstablepatients,todeterminethetypeofintraperitonealfluidwhenitisimportanttodoso(eg,bloodversus
urineinthesettingofapelvicfracture),oratphysiciandiscretion.(See"Initialevaluationandmanagementof
bluntabdominaltraumainadults",sectionon'Diagnosticperitoneallavage(DPL)'.)
ElectrocardiogramAnelectrocardiogram(ECG)shouldbeobtainedforallpatientsinjuredby
mechanismswiththepotentialtocausecardiacinjury.Signsofbluntcardiacinjurycanincludearrhythmias,
significantconductiondelays,orSTsegmentchanges.Findingsconsistentwithpericardialtamponadeinclude
tachycardia,lowvoltage,andelectricalalternans.IfECGfindingsconsistentwithcardiacinjuryarepresent,
formalechocardiography(inadditiontotheFASTexamination)shouldbeperformed.Inaddition,cardiac
monitoringshouldcontinuethroughoutthetraumaevaluationandresuscitation,includingduringdiagnostic
testing,aschangesinheartrateandbloodpressuremayheraldrapidclinicaldeterioration.(See"Cardiac
injuryfromblunttrauma"and"Cardiactamponade".)
LaboratorytestsThepracticeofobtainingroutinescreening"laboratorytestsontraumapatientsis
neitherusefulnorcosteffective[91,92].Testingshouldbeperformedbaseduponclinicalsuspicionand
shouldbelimitedtothoseteststhatmayaltermanagement.Asexamples,apregnancytest(eg,urinehCG)
shouldalwaysbeperformedonwomenofchildbearingage,andabloodtypeandscreenorcrossmatch
shouldbeobtainedforpatientswithsignificanttraumawhomayreasonablybeexpectedtorequire
transfusion.
Clinicalcircumstancesdeterminetheneedforfurthertesting.Asexamples,patientstakingwarfarinlikelyneed
coagulationstudies(eg,prothrombintime)andpatientsfoundonthegroundforanundeterminedtimeneed
studies(eg,creatinekinase)todetermineifrhabdomyolysisispresent.(See"Clinicalfeaturesanddiagnosis
ofhemepigmentinducedacutekidneyinjury(acuterenalfailure)".)
Atinitialpresentation,theneedfortransfusionofbloodproductsintheseverelyinjuredtraumapatientis
determinedonclinicalgrounds,andmayinvolvemassivetransfusionprotocols.Thereafter,routine
coagulationstudiesdonotpredictcoagulopathyaccuratelyintheacutetraumapatientwhereavailable,
thromboelastographyprovidesafasterandmoreaccuratemeansfordetectingimbalancesinthehemostatic
systemandassessingongoingneedsfortreatment.(See"Coagulopathyassociatedwithtrauma".)
Commonlyobtainedbutrarelyhelpfultestsincludethemetabolicpanel(afingerstickbloodsugarwilloften
suffice,providedthepatientisnotexhibitingsignsofelectrolyteabnormalityoracidosis),alcohollevelina
patientwhoisclearlyintoxicated,toxicologicscreenwhenitisnotrelevanttoclinicalcare,andcardiac
biomarkers,unlesscardiaccontusionorischemiaissuspected[93].(See"Cardiacinjuryfromblunttrauma",
sectionon'Diagnostictests'.)
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Elevationofboththeserumlactateconcentrationandbasedeficitcorrelateswithincreasedmortalityin
traumapatients[9497].However,thebasedeficitisessentiallyasurrogateforlactateandanelevatedbase
deficitintheabsenceofanelevatedlactateisnotpredictiveofincreasedmortality[98].Furthermore,while
elevatedlevelsshouldheightensuspicionforsevereinjury,anormallactateandbasedeficitdonotensurethe
absenceofsignificantinjury,especiallyingeriatrictraumapatients.Inaddition,laboratoryvalueslagbehind
clinicalimprovementafteraggressiveresuscitation.Thus,thepatientmaynolongerbeinshockdespitean
elevatedlactatesuggestingotherwise[99,100].(See"Geriatrictrauma:Initialevaluationandmanagement".)
Thewhitebloodcell(WBC)countisnonspecificandoflittlevalueduringtheinitialevaluationofthetrauma
patient[92].Thepositiveandnegativepredictivevalueof,respectively,anelevatedornormalWBCispoor.
EpinephrinereleasefromtraumacancausedemarginationandmayelevatetheWBCto12,000to
20,000/mm3withamoderateleftshift.Solidorhollowviscusinjurycancausecomparableelevations[101].
PATIENTTRANSFERCliniciansathospitalswithlimitedresourcestomanagetraumashouldconsultthe
nearesttraumacenterassoonasitbecomesapparentthatapatienthassustainedinjuriesbeyondthe
managementcapacityoftheirhospital.Patientsshouldbestabilizedaswellaspossiblewithoutdelaying
transferdelaysareassociatedwithincreasedmortality[102,103].Criteriafortransferarebaseduponthe
patient'sdemographics,mechanismofinjury,andclinicalfindings.Itcannotbeoveremphasizedthata
completeworkupisnotarequirementfortransferpostponingtransfertoobtainlaboratoryresultsorimaging
studiesonlydelaysdefinitivetreatment.Oftensuchstudiesmustberepeatedatthereceivingfacility.
Computedtomography(CT)imagingshouldonlybeobtainedinpatientswhomightotherwisebe
appropriatelytreatedattheinitialfacility.IfanegativeCTwouldallowthepatienttobedischarged,itshould
beperformed,butifthatpatientrequirestransferregardlessoftheresults,thentransfershouldnotbe
delayed.Likewise,proceduresandotherinterventionsshouldonlybeperformedtotreatemergency
conditionsorpreventpossiblepatientdeteriorationduringtransport.Endotrachealintubation,tube
thoracostomy,andpelvisfracturestabilizationarecommonexamplesofnecessaryinterventionslaceration
repair,unlessitisperformedtopreventexsanguination,isnot.Forhemodynamicallyunstablepatients,blood
ifavailableshouldbetransfused.Transfusioncanbeginattheinitialfacilityorbeperformedduring
transportbysendingunitsofbloodwiththeemergencytransportteam.
Thedecisionofwhentotransferanunstablepatientshouldideallybemadebythetransferringandreceiving
physiciansincollaboration.Clearcommunicationiscritical:thetransmissionofvitalinformationallows
receivingclinicianstomobilizeneededresourceswhiletheinadvertentomissionofsuchinformationcandelay
definitivecare.Informationshouldbeconveyedinbothverbalandwritten(viathepatientrecord)formand
shouldincludethepatient'sidentifyinginformation,relevantmedicalhistory,prehospitalcourse,andED
evaluationandtreatment(includingproceduresperformedandimagingobtained)[25].Theuseofatransfer
checklistcanhelptoensurethatimportantinformationisnotomitted.
SECONDARYEVALUATIONDefinitivemanagementofahemodynamicallyunstabletraumapatientmust
notbedelayedtoperformamoredetailedsecondaryevaluation.Suchpatientsaretakendirectlytothe
operatingroom(OR)orangiographysuite,ortransferredtoamajortraumacenter.
Acareful,headtotoesecondaryassessment(ie,secondarysurvey)isperformedinalltraumapatients
determinedtobestableuponcompletionoftheprimarysurvey.Thesecondarysurveyincludesadetailed
history,athoroughbutefficientphysicalexamination,andtargeteddiagnosticstudies,andplaysacrucialrole
inavoidingmissedinjuries.Commonlymissedinjuriesinclude[104106]:
Bluntabdominaltrauma:Hollowviscusinjury,pancreatoduodenalinjuries,diaphragmaticrupture
Penetratingabdominaltrauma:Rectalandureteralinjuries
Thoracictrauma:Aorticinjuries,pericardialtamponade,esophagealperforation
Extremitytrauma:Fractures(especiallyindistalextremities),vasculardisruption,compartmentsyndrome
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Delayedreevaluationofthetraumapatient(ie,tertiarysurvey)isalsousefulforpreventingmissedinjuriesand
fordetectinginjuriesthatpresentlate[104].Itismosthelpfulifthepatientisreevaluatedwhenfullyalert.Any
memberofthetraumateamwithadvancedassessmentskillscanperformthetertiarysurveyhowever,itis
bestifthesameclinicianperformsallserialexaminationsforagivenpatientinordertodetectsubtlechanges.
HistoryThemechanismofinjurycanincreasesuspicionforcertaininjuries.Prehospitalpersonneloften
knowimportantinformationandshouldbequeriedregardingthemechanismandhistoryoftheinjury.Ifthis
cannotbedoneimmediatelyuponarrivalbecauseofthepatient'sstatus,asktheprehospitalprovidersto
remainintheemergencydepartment(ED)untilthiscanbeaccomplished.Oftenthehistoryisconveyedwhile
medicsandhospitalclinicianstransferthepatientandimportantinformationmaybeforgottenormissed.
Whilelisteningtothehistory,keepinmindthatthescenesofaccidentscanbechaoticandnotallinformation
willbereliable.Asanexample,apatientdescribedas"founddown"mayhavebeenassaultedorstruckbya
car.
Mechanismrelatedinformationtobeobtainedfromprehospitalpersonnelincludes[107]:
Blunttrauma
Seatbeltuse
Steeringwheeldeformation
Airbagdeployment
Directionofimpact
Damagetotheautomobile(especiallyintrusionintothepassengercompartment)
Distanceejectedfromthevehicle
Heightoffall
Bodypartlandedupon
Penetratingtrauma
Typeoffirearm
Distancefromfirearm
Numberofgunshotsheard
Typeofblade
Lengthofblade
Inquirealsoaboutthepatient'smedications,allergies,andmedicalandsurgicalhistory.Ifthisinformationis
unknown,itcanbehelpfultoassignsomeonethetaskofcontactingfamilymemberstoobtainit.Theuseof
anticoagulantandantiplateletmedicationsissteadilyrisingandincreasestheriskofinternalbleedingin
traumapatients,andthereforetheseagentsshouldspecificallybediscussed[108110].
Asanexampleoftherisksassociatedwithanticoagulants,aretrospectivestudyof11,374adulttrauma
patientsreportedthattheuseofantiplateletdrugswasassociatedwithanincreasedriskofdeath(propensity
adjustedoutcome9.4versus8percentmortality)andmajormorbidityamongthe1327(11.7percent)patients
takingthematthetimeoftheirinjury[108].Patientstakingmultipleantiplateletmedicationswereatgreater
riskthanthosetakingasingledrug.
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Whilesuchquestionsdonottypicallyaffecttheimmediatetreatmentoftraumaticinjuries,itisimportanttoask
traumapatientsaboutpossibledomesticviolence.Thereportedprevalenceofdomesticviolencecontinuesto
increaseamongbothchildrenandadults,andcanleadtoapatternofrepeatedtraumaticinjury[111].(See
"Intimatepartnerviolence:Diagnosisandscreening"and"Intimatepartnerviolence:Childhoodexposure"and
"Eldermistreatment:Abuse,neglect,andfinancialexploitation"and"Peerviolenceandviolenceprevention".)
Ahistoryofmentalillness,includingthoughtsorattemptsatsuicide,maybesignificant,particularlyinthe
settingofsinglecaraccidentsorfallsfromaheight,whichmaybeinitiallyunrecognizedsuicideattempts.
Knowledgeofalcoholordrugabusemayhelptodetectorpreventwithdrawalduringhospitaladmission.
PhysicalexaminationThegoalofthesecondarysurveyistoidentifyinjuries.Thisincludesthe
performanceofathoroughbutefficientphysicalexamination.Usestandardprecautionsagainstbloodorfluid
borneinfection.
HeadandfaceInspectandpalpatetheentirebonystructureoftheheadandfacefortenderness,
deformity(eg,stepoff),andbleeding.Scalplacerationsareeasilymissedvisuallybutoftenfoundby
palpation.Beattentiveforforeignbodies,suchasglassinthescalpafteracaraccident.
Noteanysignssuggestingbasilarskullfracture(eg,hemotympanum).Retroauricular(Battle'ssign)and
periorbitalecchymosis(raccoon'seyes)arealsoindicativeofbasilarskullfracturebutgenerallydonotappear
untilatleast24hoursafteraninjury.Lookfornasalseptalhematomas.(See"Skullfracturesinadults"and
"Initialevaluationandmanagementoffacialtraumainadults".)
Performanocularexaminationincludinganevaluationofpupillarysize,shape,reactivity,andextraocular
movement.Lookforsignsofgloberuptureandintraocularhemorrhage.(See"Openglobeinjuries:Emergent
evaluationandinitialmanagement"and"Orbitalfractures"and"Retinaldetachment"and"Traumatic
hyphema:Clinicalfeaturesanddiagnosis".)
Patientswithmildtraumaticbraininjurymaynothaveexternalsignsoftrauma.Validateddecisiontools,
includingtheNewOrleansCriteria[112]andtheCanadianCTHeadRule[113],canbeusedtodeterminethe
needforneuroimaging[114]withcomputedtomography(CT).(See"Concussionandmildtraumaticbrain
injury".)
NeckAssumethatallpatientswithblunttraumahavesustainedaninjurytothecervicalspine.This
assumptioncanbedisprovedbyappropriateapplicationofclinicaldecisionrules,suchasNEXUSorthe
CanadianCSpineRule,orbyradiologicevaluationusingplainradiographsorCT.Assessmentofthecervical
spinefollowingtraumaisdiscussedseparately.(See"Evaluationandacutemanagementofcervicalspinal
columninjuriesinadults".)
Inspectandpalpatetheentireneckforsignsofinjury.Themanagementofpenetratingnecktraumais
discussedseparately.(See"Penetratingneckinjuries:Initialevaluationandmanagement".)
ChestInspectandpalpatetheentirechestwall.Payparticularattentiontothesternumandclavicles.
Injuriesatthesesitesareoftenmissed,andfracturesofthesebonessuggestthepresenceoffurtherinjury,
includingofintrathoracicstructures.Carefulauscultationcandetectapreviouslymissedsmallhemothorax,
pneumothorax,orpericardialeffusionnotyetcausingtamponade.TheNEXUSChestcriteriamaybeusedto
determinewhetherchestimagingisnecessaryinanadultfollowingblunttrauma[115].(See"Initialevaluation
andmanagementofbluntthoracictraumainadults".)
AbdomenPerformanddocumentacarefulabdominalexamination.Inspecttheabdomenandflanksfor
lacerations,contusions(eg,seatbeltsign),andecchymosispalpatefortendernessandrigidity.Thepresence
ofaseatbeltsign,reboundtenderness,abdominaldistension,orguardingallsuggestintraabdominalinjury.
Notethattheabsenceofabdominaltendernessdoesnotruleoutsuchinjury.
Keepinmindthattheabdominalexaminationisoftenunreliable,particularlyintheelderly,patientswith
distractinginjuriesoralteredmentalstatus,andpatientslateinpregnancy,andcanchangedramaticallyover
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time.(See"Geriatrictrauma:Initialevaluationandmanagement"and"Initialevaluationandmanagementof
bluntabdominaltraumainadults"and"Initialevaluationandmanagementofpregnantwomenwithmajor
trauma".)
RectumandgenitourinaryInspecttheperineumofallpatientsforsignsofinjury.(See"Straddle
injuriesinchildren:Evaluationandmanagement".)
Traditionally,thedigitalrectalexamination(DRE)wasconsideredanessentialpartofthephysicalexamination
foralltraumapatients.However,thesensitivityoftheDREforinjuriesofthespinalcord,pelvis,andbowelis
poor,andfalsepositiveandnegativeresultsarecommon[107,116118].Thus,routineperformanceis
unnecessaryandgenerallyunhelpful.Theexaminationiswarrantedincaseswhereurethralinjuryor
penetratingrectalinjuryissuspected.Iftheexaminationisperformed,checkforthepresenceofgrossblood
(signofbowelinjury),ahighridingprostate(signofurethralinjury),abnormalsphinctertone(signofspinal
cordinjury),andbonefragments(signofpelvicfracture).(See"Bluntgenitourinarytrauma:Initialevaluation
andmanagement"and"Penetratingtraumaoftheupperandlowergenitourinarytract:Initialevaluationand
management"and"Evaluationandacutemanagementofcervicalspinalcolumninjuriesinadults",sectionon
'Secondarysurvey'and"Pelvictrauma:Initialevaluationandmanagement".)
Performavaginalexaminationonallpatientsatriskforvaginalinjury(eg,thosewithlowerabdominalpain,
pelvicfracture,orperineallaceration)[25].Takecaretoavoidinjuryfrombonefragmentsifapelvicfractureis
knownorsuspected.
MusculoskeletalInspectandpalpatetheentirelengthofallfourextremitieslookingforareasof
tenderness,deformity,ordecreasedrangeofmotion.Alsoassessanddocumenttheneurovascularstatusof
eachextremity.Manipulatealljointsthoughttobeuninjuredbothpassivelyandactivelytoverifytheirintegrity
immobilizeandobtainradiographsofanyareawithasuspectedfracture.
Noteallpenetratingwounds,especiallythoseoverlyingsuspectedfractures,suggestinganopeninjury.The
treatmentofopenfracturesincludesirrigationanddebridement,applicationofacleandressing,and
prophylacticantibiotics.Preliminarylowpressurewoundirrigationcanbeperformedinthetraumabay,but
definitiveirrigationanddebridementisperformedintheoperatingroom(OR).(See"Treatmentand
preventionofosteomyelitisfollowingtraumainadults".)
Posttraumaticcompartmentsyndromeisanimportantsourceofpatientmorbidity.Increasingpain,tense
compartments,andpainwithpassivestretchingofthemusclescontainedwithinthecompartmentshould
promptimmediatemeasurementofintracompartmentalpressures.(See"Acutecompartmentsyndromeofthe
extremities".)
Inspectandpalpatethepelvis.Ecchymosisoverthepelvisortendernessalongthepelvicringwarrants
diagnosticimaging.Examinationfindings(eg,instability)orimagingstudiesconsistentwithpelvicring
disruptionindicatetheneedforpelvicimmobilizationandemergentorthopedicevaluation.Repeat
examinationstoassesspelvicstabilityareunnecessaryandlikelytoexacerbatebleeding.(See"Pelvic
trauma:Initialevaluationandmanagement".)
NeurologicThetraumapatient'sneurologicstatuscanchangedramaticallyovertime(eg,fromthe
effectsofanexpandingsubduralhematoma).Serialexaminationsshouldbeperformedandcarefully
documented.Duringthesecondarysurvey,performadetailedassessmentofthesensorimotorfunctionofthe
extremitiesandrepeatanassessmentofthepatient'sGlasgowComaScale(GCS)score(table6).(See"The
detailedneurologicexaminationinadults".)
SkinExaminationoftheskinmayreveallacerations,abrasions,ecchymosis,hematoma,orseroma
formation.Lookcloselyatareaswherelesionsmaybemissed,suchasthescalp,axillaryfolds,perineum,
and,particularlyinobesepatients,abdominalfolds.Donotneglectexaminationoftheback,glutealfold,and
posteriorscalp.Penetratingwoundsmaybepresentanywhere.Themanagementofskinwoundsisdiscussed
separately.(See"Clinicalassessmentofwounds"and"Basicprinciplesofwoundmanagement".)
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Appropriatetetanusprophylaxisshouldbegivenasappropriatetopatientswithbreaksintheirskin(table7).
(See"Infectiouscomplicationsofpuncturewounds",sectionon'Tetanusimmunization'.)
Additionalimaging
PlainradiographsPlainradiographsareusedduringthesecondarysurveyprimarilytoevaluatethe
spine,pelvis,andextremitiesforfractures,dislocations,andforeignbodies.
Computedtomography,includingtotalbodyCTMultidetectorcomputedtomography(MDCT)has
becomethemodalityofchoiceforimagingtraumapatientsbecauseofitsspeedandaccuracy.However,most
studiesofcomprehensivewholebodyCTscanning("panscan")forallpatientswithsignificanttraumaare
methodologicallylimited,andhavereachedcontradictoryconclusions[119129].Pendingfurtherresearch,we
donotadvocatecomprehensiveCTscanninginpatientswithoutsignificantalterationsinmentalstatusand
believeimagingstudiesshouldbeperformedselectivelybaseduponclinicalassessmentandthemechanism
ofinjury.WhilewholebodyCTscanningmayimproveoutcomesfollowingcertainhighrisktrauma,suchas
explosions,highspeedmotorvehiclecollisions,andfallsfromgreatheights[86,130],webelieveitshouldnot
beusedindiscriminatelygiventheshorttermriskofcontrastrelatedrenalinjuryandthelongtermriskof
radiationinducedcancer,aswellasthesubstantialcosts[131].(See"Pathogenesis,clinicalfeatures,and
diagnosisofcontrastinducednephropathy"and"Radiationrelatedrisksofimagingstudies".)
Inaninternational,multicentertrial,adulttraumapatientswithevidenceofsevereinjurywererandomly
assignedtoeitherwholebodyCT(n=541)orselectiveCTimaging(n=542)[132].Inhospitalmortalitydid
notdifferbetweengroups(wholebodyCT86[16percent]versusselectiveCT85[16percent]),nordidit
differsignificantlyamongpatientswithpolytraumaorbraininjury.
SomeauthorsadvocatewholebodyCTforseverelyinjuredpatientswithalterationsinmentalstatus.Ina
retrospectivedatabaseanalysisof5208patientsinJapanwithscoresontheGlasgowComaScale(GCS)
rangingfrom3to12,decreasedmortalitywasnotedinpatientswhoreceivedwholebodyCTscans[133].
AlthoughfurtherstudyoftheoutcomesandcosteffectivenessofwholebodyCTisneeded,theapproachmay
bebeneficialinsuchpatients,inwhomexaminationfindingsareoftenlimitedorunclear.
ItshouldbenotedthatwhileCTmaybeusefulintheevaluationofpatientswithblunttrauma[134],ithas
limitedutilityforevaluatingthetrajectoryandeffectsoflowvelocitypenetratinginjury(eg,stabwounds)
becauseofthelackoftissuedisruptionandgasdispersion(seenwithhighvelocityinjuries)[135],and
becauseinjuriestoluminalstructuresareoftendifficulttodetect[136].Diagnosticlaparoscopymaybeuseful
inpatientswithpenetratinginjuryandsignsofperitonealpenetrationdespitenegativeCTimaging.Although
improving,theaccuracyofCTfordetectingdiaphragminjuriesisalsolimited,anddependingonthenatureof
thepatientsinjuriesadditionaldiagnosticstudiesmaybeneeded.TheuseofCTforspecificinjuriesis
discussedindetailseparately,includingtopicsdevotedtoparticularinjuries.(See"Initialevaluationand
managementofabdominalstabwoundsinadults"and"Initialevaluationandmanagementofabdominal
gunshotwoundsinadults"and"Pelvictrauma:Initialevaluationandmanagement"and"Recognitionand
managementofdiaphragmaticinjuryinadults".)
MostpatientsshouldbehemodynamicallystablebeforeCTimagingisperformed,andresuscitationshouldbe
sufficienttominimizetheriskofdecompensationwhilethepatientisintheCTscanner.Ifthepatientis
unstable,CTimagingisusuallydeferred.(See'Emergencycomputedtomography(CT)'above.)
PITFALLSANDPEARLSThesystematicevaluationofthetraumapatientoutlinedaboveisdesignedto
helpcliniciansfocusonlifethreateningproblemsandminimizetheriskofmissedinjuries.Nevertheless,one
systematicreviewnotedthatupto39percentoftraumapatientshaveinjuriesthatareinitiallymissedandup
to22percentofthesemissedinjuriesareclinicallysignificant(definedasinjuriesassociatedwithincreased
mortality,requiringadditionalproceduresoralterationsintreatment,orresultinginsignificantpain,
complications,orresidualdisability)[69].
Potentialpitfallsintraumamanagementandwaystoavoidthemarediscussedbelow:
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EsophagealintubationsBetween0.5and6percentofprehospitalintubationsareesophagealdueto
airwaydifficultyordisplacementduringtransport.Verifythepositionofallendotrachealtubeseitherbydirect
visualizationoruseofanendtidalcarbondioxide(ETCO2)detector.(See"Prehospitalcareoftheadult
traumapatient",sectionon'Airwaysupport'.)
HemorrhagicshockApproximately30percentofthecirculatingbloodvolumemaybelostbeforethe
onsetofhypotension[25].Atransientresponsetooneormorefluidbolusesmeansthepatientlikelyhas
ongoinghemorrhageandisinapersistentstateofshock.Ahighindexofsuspicionshouldbemaintainedand
anaggressivesearchforthesourceofongoinghemorrhageiswarranted.(See"Initialevaluationand
managementofshockinadulttrauma".)
CardiactamponadeAssumethatelevatedjugularvenouspressure(JVP)inatraumapatientiscaused
bypericardialtamponade.However,hypovolemicpatientswithtamponademaynothaveelevatedJVP.
PerformtheFASTexamearlyinthecirculationevaluationoftheunstablepatientandbeginbylookingatthe
heart.(See"Cardiactamponade".)
ThoracoabdominalinjuryAssumethatanypenetratingwoundofthethoraxorabdomeninvolvesboth
compartmentsuntilprovenotherwise.
PenetratingbowelinjuryDuringtheinitialresuscitation,injuriescausedbylowvelocitypenetrating
wounds(typicallystabwounds)areeasilymissedbybothultrasound,becausethereistoolittleintraperitoneal
bloodtobedetected,andCT,becausethereisinadequatetissuedestruction.Forstabwounds,highclinical
suspicionmaywarrantfurtherevaluationbyDPLorlaparotomy,despiteinitiallynegativeimagingstudies.
Alternatively,atraumasurgeonmayopttoperformserialobservationsofpatientswithabdominalstab
wounds(andsomeextraperitonealgunshotwounds)overa12to24hourperiod.
Gunshotwoundstypicallyrequiretherapeuticlaparotomyandshouldbedistinguishedfromthe
aforementionedstabwoundsthesehighvelocityinjuriesareassociatedwithamuchgreatermorbidityand
mortalitythantheirlowvelocitycounterparts.(See"Initialevaluationandmanagementofabdominalgunshot
woundsinadults"and"Initialevaluationandmanagementofabdominalstabwoundsinadults".)
OpenbookpelvicfracturesTheunstablepelvisshouldnotbemanipulatedmultipletimesadditional
manipulationexacerbateshemorrhage.Oncesuspected,openorunstablepelvicfracturesshouldbe
stabilizedusingapelvicbinder,orasheetifnobinderisavailable.Ifthepatientishemodynamicallystable,
computedtomography(CT)imagingisobtained.Theunstablepatientrequireseithersurgeryorangiography.
(See"Pelvictrauma:Initialevaluationandmanagement".)
OcularinjuriesPeriorbitalswellingandecchymosisdoesnotprecludeperforminganocularexamination.
Patientswithsuchfindingsareathigherriskofocularinjury.Inaddition,injuriessuchasagloberuptureor
retroorbitalhematomamustbediagnosedquicklyinordertomaximizetheopportunitytosalvagevision.
(See"Overviewofeyeinjuriesintheemergencydepartment"and"Approachtoeyeinjuriesintheemergency
department"and"Openglobeinjuries:Emergentevaluationandinitialmanagement"and"Orbitalfractures"
and"Retinaldetachment"and"Traumatichyphema:Clinicalfeaturesanddiagnosis".)
ElderpatientsAssumethatolderpatientsinvolvedintraumahavesustainedasignificantinjury,evenif
theyappearwell.Theparadoxofeldertraumapatientsisthattheirphysiologyandmedicalinterventionscan
bothmaskandexacerbatetheseverityofinjuries.Medicationsarebutoneexample:betablockersmaymask
theeffectsofshockbysuppressingtachycardia,whilewarfarinandotheranticoagulantsincreasetheriskof
severehemorrhage.Atablesummarizingimportantconsiderationsintheeldertraumapatientisattached
(table8).(See"Geriatrictrauma:Initialevaluationandmanagement".)
CommoncognitiveerrorsSeveralcognitiveerrorsappeartoberelativelycommonduringtheinitial
managementofinjuredpatients,particularlythosewhodonotlooksickinitially.Amongtheseare[34]:
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PrematurediagnosisThehemodynamicstatusoftraumapatientsisoftendynamicandtheresultsof
theirinitialdiagnosticstudiespreliminary.Avoidmakingprematureassumptionsaboutpatients'injuries
andstability.
OverrelianceuponearlynegativeresultsNostudyisperfectandinitialstudiesmaynotrevealthe
fullextentofapatient'sinjuriesorindeedanyinjury.Reassessthepatient.Reevaluationmayinclude
serialeFASTexaminationsifthepatientsstatushaschanged.
AttributingabnormalfindingstobenigncausesTraumapatients,particularlyyounghealthyadults,
maynotimmediatelymanifestsignsofsevereinjury.Whenabnormalfindingsarise,assumetheyreflect
injury.
DistractionsDramaticorobviousinjuries,performanceofcriticalprocedures,andotheraspectsof
traumacarecandistractclinicians,causingthemtoneglectseriousbutlessapparentinjuriesorchanges
inpatientstatus.
AnalgesiaandsedationInjuredpatientsareinpain.Donotneglecttoprovidethemwithappropriate
analgesiaandsedation.Shortactingagents,suchasfentanylandmidazolam,aregenerallypreferredto
avoidadversehemodynamiceffects,buttheserequiremorefrequentmonitoringandadministration.(See
"Paincontrolinthecriticallyilladultpatient"and"Managementofacuteperioperativepain".)
VictimsofcrimeClinicalevaluationandtreatmentofinjuriesistheforemostresponsibilityoftheclinician
caringforatraumapatient.Whenpossible,caretakersshouldconsiderandactontheneedtopreserve
potentialevidenceifthetraumamaybeconnectedtoacrime.Asexamples,placingremovedclothinginto
paperbags,avoidingcuttingthroughholesinclothingcreatedbypenetratinginjuries,andcareful
documentationofinjuriesmayallbesignificant.
SUMMARYANDRECOMMENDATIONS
Traumaisaleadingcauseofmortalityglobally.Alltraumapatientsrequireasystematicapproachto
managementinordertomaximizeoutcomesandreducetheriskofundiscoveredinjuries.Optimalcare
requireseffectiveandefficientcommunicationandteamworkamongclinicians.Commonbreakdownsin
teammanagementaredescribedinthetext.(See'Epidemiology'aboveand'Traumateam'above.)
Particularmechanismspredisposepatientstospecificinjuries.Commonblunttraumamechanismsand
theirmostfrequentlyassociatedinjuriesaredescribedintheaccompanyingtable(table1).
TheprimarysurveyusedinAdvancedTraumaLifeSupportisorganizedaccordingtotheinjuriesthat
posethemostimmediatethreatstolife.Problemsaremanagedimmediatelyintheordertheyare
detected.Theindividualsteps(includingassessmentsoftheairway,breathing,circulation,andneurologic
injury)andimportantprinciplesoftheprimarysurveyaredescribedinthetext.(See'Primaryevaluation
andmanagement'above.)
Observationalstudiessuggestthatairwayobstructionisamajorcauseofpreventabledeathamong
traumapatients.Therefore,airwayevaluationandmanagementremainthecriticalfirststepsinthe
treatmentofanyseverelyinjuredpatient.(See'Airway'aboveand'Breathingandventilation'above.)
Hemorrhageisthemostcommonpreventablecauseofmortalityintrauma.Mosttraumapatientswith
signsofshock(eg,pale,cool,moistskin)arebleeding.Bealertforsubtlesignsofhemorrhagicshock,
particularlyintheelderlyandyoung,healthyadultswhomaynotpresentwithobviousmanifestations.
Hypotensiongenerallydoesnotmanifestuntilatleast30percentofthepatient'sbloodvolumehasbeen
lost.(See'Circulation'above.)
Diagnostictestingplaysanimportantroleintraumamanagement.Theappropriateuseofstudiesis
describedinthetext.(See'Diagnosticstudies'above.)
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Cliniciansathospitalswithlimitedresourcesfortraumamanagementshouldconsultthenearesttrauma
centerassoonasitbecomesapparentthatapatienthassustainedinjuriesbeyondthemanagement
capacityoftheirhospital.Itcannotbeoveremphasizedthatacompleteworkupisnotarequirementfor
transfer.(See'Patienttransfer'above.)
Asecondarysurveyisperformedinalltraumapatientsdeterminedtobestableuponcompletionofthe
primarysurvey.Thesecondarysurveyincludesadetailedhistory,athoroughbutefficientphysical
examination,andtargeteddiagnosticstudies,andplaysacrucialroleinavoidingmissedinjuries.The
secondarysurveyisdescribedindetailabove.(See'Secondaryevaluation'above.)
Upto39percentoftraumapatientshaveinjuriesthatareinitiallymissed,andupto22percentofthese
areclinicallysignificant.Commonpitfallsandguidanceforavoidingmissedinjuriesareprovidedinthe
text.(See'Pitfallsandpearls'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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JTrauma200457:288.
88.BrockowK,RingJ.Anaphylaxistoradiographiccontrastmedia.CurrOpinAllergyClinImmunol2011
11:326.
89.ZamanSR.Previousiodinatedcontrastanaphylaxisinbluntabdominaltrauma:managementoptions.
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90.DannePD,PiasioM,ChampionHR.Earlymanagementofabdominaltrauma:theroleofdiagnostic
peritoneallavage.AustNZJSurg198858:879.
91.TasseJL,JanzenML,AhmedNA,ChungRS.Screeninglaboratoryandradiologypanelsfortrauma
patientshavelowutilityandarenotcosteffective.JTrauma200865:1114.
92.AsimosAW,GibbsMA,MarxJA,etal.Valueofpointofcarebloodtestinginemergenttrauma
management.JTrauma200048:1101.
93.SloanEP,ZalenskiRJ,SmithRF,etal.Toxicologyscreeninginurbantraumapatients:drugprevalence
anditsrelationshiptotraumaseverityandmanagement.JTrauma198929:1647.
94.HusainFA,MartinMJ,MullenixPS,etal.Serumlactateandbasedeficitaspredictorsofmortalityand
morbidity.AmJSurg2003185:485.
95.PaladinoL,SinertR,WallaceD,etal.Theutilityofbasedeficitandarteriallactateindifferentiating
majorfromminorinjuryintraumapatientswithnormalvitalsigns.Resuscitation200877:363.
96.OdomSR,HowellMD,SilvaGS,etal.Lactateclearanceasapredictorofmortalityintraumapatients.J
TraumaAcuteCareSurg201374:999.
97.BaxterJ,CranfieldKR,ClarkG,etal.Dolactatelevelsintheemergencydepartmentpredictoutcomein
adulttraumapatients?Asystematicreview.JTraumaAcuteCareSurg201681:555.
98.MartinMJ,FitzSullivanE,SalimA,etal.Discordancebetweenlactateandbasedeficitinthesurgical
intensivecareunit:whichonedoyoutrust?AmJSurg2006191:625.
99.DavisJW,MackersieRC,HolbrookTL,HoytDB.Basedeficitasanindicatorofsignificantabdominal
injury.AnnEmergMed199120:842.
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100.DavisJW,KaupsKL,ParksSN.BasedeficitissuperiortopHinevaluatingclearanceofacidosisafter
traumaticshock.JTrauma199844:114.
101.SchnrigerB,InabaK,BarmparasG,etal.Serialwhitebloodcellcountsintrauma:dotheypredicta
hollowviscusinjury?JTrauma201069:302.
102.NirulaR,MaierR,MooreE,etal.Scoopandruntothetraumacenterorstayandplayatthelocal
hospital:hospitaltransfer'seffectonmortality.JTrauma201069:595.
103.SampalisJS,DenisR,FrchetteP,etal.Directtransporttotertiarytraumacentersversustransferfrom
lowerlevelfacilities:impactonmortalityandmorbidityamongpatientswithmajortrauma.JTrauma
199743:288.
104.EndersonBL,MaullKI.Missedinjuries.Thetraumasurgeon'snemesis.SurgClinNorthAm1991
71:399.
105.HoushianS,LarsenMS,HolmC.MissedinjuriesinalevelItraumacenter.JTrauma200252:715.
106.BrooksA,HolroydB,RileyB.Missedinjuryinmajortraumapatients.Injury200435:407.
107.ShlamovitzGZ,MowerWR,BergmanJ,etal.Poortestcharacteristicsforthedigitalrectalexamination
intraumapatients.AnnEmergMed200750:25.
108.FerrarisVA,BernardAC,HydeB.Theimpactofantiplateletdrugsontraumaoutcomes.JTrauma
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109.BeynonC,HertleDN,UnterbergAW,SakowitzOW.Clinicalreview:Traumaticbraininjuryinpatients
receivingantiplateletmedication.CritCare201216:228.
110.NishijimaDK,OffermanSR,BallardDW,etal.Immediateanddelayedtraumaticintracranial
hemorrhageinpatientswithheadtraumaandpreinjurywarfarinorclopidogreluse.AnnEmergMed
201259:460.
111.JosephB,KhalilM,ZangbarB,etal.PrevalenceofDomesticViolenceAmongTraumaPatients.JAMA
Surg2015150:1177.
112.HaydelMJ,PrestonCA,MillsTJ,etal.Indicationsforcomputedtomographyinpatientswithminorhead
injury.NEnglJMed2000343:100.
113.StiellIG,WellsGA,VandemheenK,etal.TheCanadianCTHeadRuleforpatientswithminorhead
injury.Lancet2001357:1391.
114.EasterJS,HaukoosJS,MeehanWP,etal.WillNeuroimagingRevealaSevereIntracranialInjuryin
ThisAdultWithMinorHeadTrauma?:TheRationalClinicalExaminationSystematicReview.JAMA
2015314:2672.
115.RodriguezRM,AnglinD,LangdorfMI,etal.NEXUSchest:validationofadecisioninstrumentfor
selectivechestimaginginblunttrauma.JAMASurg2013148:940.
116.EspositoTJ,IngrahamA,LuchetteFA,etal.Reasonstoomitdigitalrectalexamintraumapatients:no
fingers,norectum,nousefuladditionalinformation.JTrauma200559:1314.
117.GuldnerGT,BrzenskiAB.Thesensitivityandspecificityofthedigitalrectalexaminationfordetecting
spinalcordinjuryinadultpatientswithblunttrauma.AmJEmergMed200624:113.
118.HankinAD,BarenJM.Shouldthedigitalrectalexaminationbeapartofthetraumasecondarysurvey?
AnnEmergMed200953:208.
119.GuptaM,SchrigerDL,HiattJR,etal.Selectiveuseofcomputedtomographycomparedwithroutine
wholebodyimaginginpatientswithblunttrauma.AnnEmergMed201158:407.
120.SalimA,SangthongB,MartinM,etal.Wholebodyimaginginbluntmultisystemtraumapatientswithout
obvioussignsofinjury:resultsofaprospectivestudy.ArchSurg2006141:468.
121.MilloNZ,PlewesC,RoweBH,LowG.AppropriatenessofCTofthechest,abdomen,andpelvisin
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197:1393.
122.SierinkJC,SaltzherrTP,ReitsmaJB,etal.Systematicreviewandmetaanalysisofimmediatetotal
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123.StengelD,OttersbachC,MatthesG,etal.Accuracyofsinglepasswholebodycomputedtomography
fordetectionofinjuriesinpatientswithmajorblunttrauma.CMAJ2012184:869.
124.SiseMJ,KahlJE,CalvoRY,etal.Backtothefuture:reducingrelianceontorsocomputedtomography
intheinitialevaluationofblunttrauma.JTraumaAcuteCareSurg201374:92.
125.HealyDA,HegartyA,FeeleyI,etal.SystematicreviewandmetaanalysisofroutinetotalbodyCT
comparedwithselectiveCTintraumapatients.EmergMedJ201431:101.
126.SurendranA,MoriA,VarmaDK,GruenRL.Systematicreviewofthebenefitsandharmsofwholebody
computedtomographyintheearlymanagementofmultitraumapatients:arewegettingthewhole
picture?JTraumaAcuteCareSurg201476:1122.
127.CaputoND,StahmerC,LimG,ShahK.Wholebodycomputedtomographicscanningleadstobetter
survivalasopposedtoselectivescanningintraumapatients:asystematicreviewandmetaanalysis.J
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128.VanVugtR,KeusF,KoolD,etal.Selectivecomputedtomography(CT)versusroutine
thoracoabdominalCTforhighenergyblunttraumapatients.CochraneDatabaseSystRev2013
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survival:aretrospective,multicentrestudy.Lancet2009373:1455.
131.InabaK,BrancoBC,LimG,etal.Theincreasingburdenofradiationexposureinthemanagementof
traumapatients.JTrauma201170:1366.
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trial.Lancet2016388:673.
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traumapatientswithmoderatetosevereconsciousnessdisturbance:amulticenter,retrospectivestudy.
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134.BenjaminER,SiboniS,HaltmeierT,etal.NegativeFindingFromComputedTomographyofthe
AbdomenAfterBluntTrauma.JAMASurg2015150:1194.
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136.NgAK,SimonsRK,TorreggianiWC,etal.Intraabdominalfreefluidwithoutsolidorganinjuryinblunt
abdominaltrauma:anindicationforlaparotomy.JTrauma200252:1134.
Topic13854Version56.0
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GRAPHICS
Blunttraumamechanismsandassociatedinjuries
Mechanismofinjury
Additionalconsiderations
Potentialassociated
injuries
Motorvehiclecollisions
Headoncollision
Facialinjuries
Lowerextremityinjuries
Aorticinjuries
Rearendcollision
Hyperextensioninjuriesofcervical
spine
Cervicalspinefractures
Centralcordsyndrome
Lateral(Tbone)collision
Thoracicinjuries
Abdominalinjuries:spleen,liver
Pelvicinjuries
Clavicle,humerus,ribfractures
Rollover
Ejectedfromvehicle
Greaterchanceofejection
Crushinjuries
Significantmechanismofinjury
Compressionfracturesofspine
Likelyunrestrained
Spinalinjuries
Significantmortality
Windshielddamage
Likelyunrestrained
Closedheadinjuries,coupand
countercoupinjuries
Facialfractures
Skullfractures
Steeringwheeldamage
Likelyunrestrained
Thoracicinjuries
Sternalandribfractures,flail
chest
Cardiaccontusion
Aorticinjuries
Hemo/pneumothoraces
Dashboardinvolvement/damage
Pelvicandacetabularinjuries
Dislocatedhip
Restraint/seatbeltuse
Properthreepointrestraint
Decreasedmorbidity
Sternalandribfractures,pulmonary
contusions
Lapbeltonly
Chancefractures,abdominalinjuries,
headandfacialinjuries/fractures
Shoulderbeltonly
Cervicalspineinjuries/fractures,
"submarine"outofrestraintdevices
(possibleejection)
Frontendcollisions
Upperextremitysofttissue
injuries/fractures
Airbagdeployment
Lessseverehead/uppertorso
injuries
Lowerextremityinjuries/fractures
Noteffectiveforlateralimpacts
Moresevereinjuriesinchildren
(improperfrontseatplacement)
Pedestrianversusautomobile
Lowspeed(brakingautomobile)
Tibiaandfibulafractures,knee
injuries
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Highspeed
Waddle'striadtibia/fibulaorfemur
fractures,truncalinjuries,
craniofacialinjuries
"Thrown"pedestriansatriskfor
multisysteminjuries
Bicycle
Automobilerelated
Closedheadinjuries
"Handlebar"injuries
Spleen/liverlacerations
Additionalintraabdominal
injuries
Considerpenetratinginjuries
Nonautomobilerelated
Extremityinjuries
"Handlebar"injuries
Falls
Verticalimpact
LD 50 36to60feet(11to18m)
Calcanealandlowerextremity
fractures
Pelvicfractures
Closedheadinjuries
Renalandrenalvascularinjuries
Horizontalimpact
Craniofacialfractures
Handandwristfractures
Abdominalandthoracicvisceral
injuries
Aorticinjuries
From:GrossE,MartelM.Multipletrauma.In:Rosen'sEmergencyMedicine:ConceptsandClinicalPractice,7thed,Marx
JA,HockbergerRS,WallsRM,etal(Eds),MosbyElsevier,Philadelphia2010.TableusedwiththepermissionofElsevier
Inc.Allrightsreserved.
Graphic50454Version5.0
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Checklistsforairwaymanagementinadulttrauma
Prearrivalchecklistinpreparationforairwaymanagementofadulttraumapatient*
Oxygenmaskandnasalcannulaavailableandconnectedtooxygen
BagvalvemaskwithETCO2attachmentavailable
Oralairwaysavailable
Suctionavailableandworking
Directlaryngoscopehandleandbladesavailableandfunctional(lightworks)
Trachealtubes(multiplesizes)andstyletavailabletubeshapedstraighttocuff
Trachealtubeintroducer("bougie")available
Rescueairwaydevicesavailable(eg,laryngealmaskairway,Kingairway)
Cricothyrotomykitavailable
Videolaryngoscopeavailablemonitorpositionedappropriately
IVcathetersandisotonicfluidsavailable
Individualsdesignatedtoprovidecervicalspinestabilizationandairwayassistance
Airwayplanverbalized(primaryplanandbackupplan)
Respiratorytherapistnotifiedmechanicalventilatorbroughttobedside
Preinductionchecklistforintubationofadulttraumapatient*
Prearrivalchecklistcompleted
AirwayplanconfirmedbetweentraumaandEDattendingphysicians(ifnecessary)
IVlinesfunctioning
InductionandNMBAmedicationsanddosesconfirmed,anddrawnupinlabeledsyringes
Cervicalspinestabilizationinitiated(ifnecessary)
Preoxygenationunderway:maskat15L/minuteandnasalcannulaat5L/minute
Patientpositioningoptimized
BloodpressurecuffplacedonarmoppositethatofIVlineandpulseoximetryprobe
ETCO2:endtidalcarbondioxideIV:intravenousNMBA:neuromuscularblockingagentED:emergencydepartment.
*AllitemsmustbeverbalizedbytheNurseScribeandconfirmedbythephysicianorclinicianresponsibleforairway
management.
Adaptedfrom:SmithKA,HighK,CollinsSP,SelfWH.Apreproceduralchecklistimprovesthesafetyofemergency
departmentintubationoftraumapatients.AcadEmergMed201522:989.
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The332ruleforidentifyingadifficultairway
Thespatialrelationshipsdepictedhereareimportantdeterminantsofsuccessfuldirect
laryngoscopy.
(A)Thepatientcanopenhis/hermouthsufficientlytoadmitthreeofhis/herownfingers.
(B)Thedistancebetweenthementumandtheneck/mandiblejunction(nearthehyoidbone)isthe
lengthofthreeofthepatient'sfingers.
(C)Thespacebetweenthesuperiornotchofthethyroidcartilageandtheneck/mandiblejunction,
nearthehyoidbone,isthelengthoftwoofthepatient'sfingers.
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ThemodifiedMallampaticlassificationfordifficultlaryngoscopyand
intubation
ThemodifiedMallampaticlassification [1]isasimplescoringsystemthatrelatestheamountof
mouthopeningtothesizeofthetongue,andprovidesanestimateofspaceavailablefororal
intubationbydirectlaryngoscopy.AccordingtotheMallampatiscale,classIispresentwhenthesoft
palate,uvula,andpillarsarevisibleclassIIwhenthesoftpalateandbaseoftheuvulaarevisible
classIIIwhenonlythesoftpalateisvisibleandclassIVwhenonlythehardpalateisvisible.
Reference:
1.SamsoonGL,YoungJR.Difficulttrachealintubation:aretrospectivestudy.Anaesthesia1987
42:487.
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Differentialdiagnosisofshockintrauma
I.LowCVP
A.Hypovolemia
1.Hemorrhage
a.External(compressible)
i.Lacerations
ii.Contusions
iii.Fractures(partlycompressible)
b.Internal(noncompressible)
i.Intrathoracic
ii.Intraperitoneal
iii.Retroperitoneal(partlycompressible)
c.Fractures(partlycompressible)
2.Thirdspacing(eg,burns)
B.Neurogenic(highcervicalcordinjury)
II.HighCVP
A.Pericardialtamponade
B.Tensionpneumothorax
C.Myocardialcontusion
III.Otherdiagnosestoconsider
A.Pharmacologicortoxicologicagents
B.Myocardialinfarction(severe)
C.Diaphragmaticrupturewithherniation
D.Fatorairembolism
CVP:centralvenouspressure.
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Emergentreversalofanticoagulationfromwarfarinforlifethreatening
hemorrhageinadults:Suggestedapproachesbaseduponavailableresources
A.4factorprothrombincomplexconcentrate(4FPCC)isavailable(preferredapproach):
1.Give4FPCC*1500to2000units IVover10minutes.CheckINR15minutesaftercompletionofthe
infusion.IfINRisnot1.5,giveadditional4FPCC(refertotopicordrugreferencefordetails).
2.GivevitaminK10mgIVover10to20minutes.
B.3factorprothrombincomplexconcentrate(3FPCC)isavailablebut4FPCCisnotavailable:
1.Give3FPCC*1500to2000units IVover10minutes.CheckINR15minutesaftercompletionofthe
infusion.IfINRisnot1.5,giveadditional3FPCC(refertotopicordrugreferencefordetails).
2.GiveFactorVIIa20mcg/kgIVORgiveFFP2unitsIVbyrapidinfusion.FactorVIIamaybepreferredif
volumeoverloadisaconcern.
C.Neither3FPCCnor4FPCCisavailable:
1.GiveFFP2unitsIVbyrapidinfusion.CheckINR15minutesaftercompletionofinfusion.IfINR1.5,
administer2additionalunitsofFFPIVrapidinfusion.RepeatprocessuntilINR1.5.Maywishtoadminister
loopdiureticbetweenFFPinfusionsifvolumeoverloadisaconcern.
Theseproductsanddosesareforuseinlifethreateningbleedingonly.Evidenceoflifethreateningbleedingand
overanticoagulationwithavitaminKantagonist(eg,warfarin)arerequired.Anaphylaxisandtransfusionreactions
canoccur.
ItmaybereasonabletothawfourunitsofFFPwhileawaitingthePT/INR.Thetransfusionservicemaysubstitute
otherplasmaproductsforFFP(eg,PlasmaFrozenWithin24HoursAfterPhlebotomy[PF24])theseproductsare
consideredclinicallyinterchangeable.PCCwillreverseanticoagulationwithinminutesofadministrationFFP
administrationcantakehoursduetothevolumerequiredvitaminKeffecttakes12to24hours,but
administrationofvitaminKisneededtocounteractthelonghalflifeofwarfarin.Subsequentmonitoringofthe
PT/INRisneededtoguidefurthertherapy.Refertotopicsonwarfarinreversalinindividualsituationsforfurther
management.
PCC:unactivatedprothrombincomplexconcentrate4FPCC:PCCcontainingcoagulationfactorsII,VII,IX,X,proteinS
andproteinC3FPCC:PCCcontainingfactorsII,IX,andXandonlytracefactorVIIFFP:freshfrozenplasmaPT:
prothrombintimeINR:internationalnormalizedratioFEIBA:factoreightinhibitorbypassingagent.
*Beforeuse,checkproductlabeltoconfirmfactortypes(3versus4factor)andconcentration.Activatedcomplexesand
singlefactorIXproducts(ie,FEIBA,AlphaNine,Mononine,Immunine,BeneFix)areNOTusedforwarfarinreversal.
PCCdosesshownarethosesuggestedforinitialtreatmentofemergencyconditions.Subsequenttreatmentisbasedon
INRandpatientweightifavailable.RefertotopicandLexicompdrugreferenceincludedwithUpToDateforINRbased
dosing.
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Directoralanticoagulantassociatedbleedingreversalstrategies
Typeofbleeding
Majorbleeding(eg,
intracranial,
retroperitoneal,
compartmentsyndrome,
massivegastrointestinal)
Agent
Dabigatran(Pradaxa)
Possibleinterventions
Idarucizumab
ActivatedPCC*(eg,FEIBA)
Antifibrinolyticagent(eg,tranexamicacid,epsilon
aminocaproicacid)
Oralactivatedcharcoal(iflastdosewithinpriortwo
hours)
Hemodialysis
RBCtransfusionsifneededforanemia
Platelettransfusionsifneededforthrombocytopenia
orimpairedplateletfunction(eg,duetoaspirin)
Surgical/endoscopicinterventionifappropriate
Rivaroxaban(Xarelto),
apixaban(Eliquis),
edoxaban(Lixiana)
4factorunactivatedPCC*(eg,Kcentra)
Antifibrinolyticagent(eg,tranexamicacid,epsilon
aminocaproicacid)
Oralactivatedcharcoal(iflastdoserecentenough)
RBCtransfusionsifneededforanemia
Platelettransfusionsifneededforthrombocytopenia
orimpairedplateletfunction(eg,duetoaspirin)
Surgical/endoscopicinterventionifappropriate
Minorbleeding(eg,
epistaxis,uncomplicated
softtissuebleeding,minor
[slow]gastrointestinal
bleeding)
Dabigatran(Pradaxa)
Localhemostaticmeasures
Possibleanticoagulantdiscontinuation
Halflife(normalrenalfunction ):12to17hours
Possibleantifibrinolyticagent(eg,tranexamicacid,
epsilonaminocaproicacid)
Rivaroxaban(Xarelto),
apixaban(Eliquis),
edoxaban(Lixiana)
Localhemostaticmeasures
Possibleanticoagulantdiscontinuation
Halflives(normalrenalfunction ):
Rivaroxaban5to9hours
Apixaban8to15hours
Edoxaban6to11hours
Possibleantifibrinolyticagent(eg,tranexamicacid,
epsilonaminocaproicacid)
Thetabledescribesmeasuresthatmaybeusedtomanagebleedingassociatedwithdirectoralanticoagulants
(DOACs).ClinicaljudgmentisessentialinallcasesofDOACassociatedbleedinginordertoassesstherisksof
bleedingandweightheseagainsttherisksofthrombosisifanticoagulationisdiscontinuedorreversed.Referto
UpToDatetopicsontheuseofdirectthrombininhibitorsanddirectfactorXainhibitors,andmanagementofDOAC
associatedbleedingforfurtherdetailsanddosing.Theonsetofalloftheagentsdiscussedhereinisapproximately
2to4hours.
DOAC:directoralanticoagulantPCC:prothrombincomplexconcentrateFEIBA:factoreightinhibitorbypassing
activityRBC:redbloodcell.
*UsePCCproductonlyifcontinuedbleedingisreasonablylikelytobefatalwithinhours.
Theanticoagulanteffectoftheseagents(especiallydabigatran)willdissipatemoreslowlyasrenalfunctiondeclines.
Severehepaticfailuremayalsoprolongthehalflifeforrivaroxaban,apixaban,andedoxaban.
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GlasgowComaScale(GCS)
Score
Eyeopening
Spontaneous
Responsetoverbalcommand
Responsetopain
Noeyeopening
Bestverbalresponse
Oriented
Confused
Inappropriatewords
Incomprehensiblesounds
Noverbalresponse
Bestmotorresponse
Obeyscommands
Localizingresponsetopain
Withdrawalresponsetopain
Flexiontopain
Extensiontopain
Nomotorresponse
Total
TheGCSisscoredbetween3and15,3beingtheworstand15thebest.Itiscomposedofthreeparameters:best
eyeresponse(E),bestverbalresponse(V),andbestmotorresponse(M).ThecomponentsoftheGCSshouldbe
recordedindividuallyforexample,E2V3M4resultsinaGCSscoreof9.Ascoreof13orhighercorrelateswithmild
braininjury,ascoreof9to12correlateswithmoderateinjury,andascoreof8orlessrepresentsseverebrain
injury.
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Woundmanagementandtetanusprophylaxis
Allotherwounds
Cleanandminorwound
Previousdoses
oftetanus
toxoid*
Tetanustoxoid
containing
vaccine
Humantetanus
immuneglobulin
Tetanustoxoid
containing
vaccine
Humantetanus
immuneglobulin
<3dosesor
unknown
Yes
No
Yes
Yes
3doses
Onlyiflastdose
given10yearsago
No
Onlyiflastdose
given5yearsago
No
Appropriatetetanusprophylaxisshouldbeadministeredassoonaspossiblefollowingawound,butshouldbegiven
eventopatientswhopresentlateformedicalattention.Thisisbecausetheincubationperiodisquitevariable
mostcasesoccurwithineightdays,buttheincubationperiodcanbeasshortasonedayoraslongasseveral
months.
*Tetanustoxoidmayhavebeenadministeredasdiphtheriatetanustoxoidsadsorbed(DT),diphtheriatetanuswholecell
pertussis(DTP,DTwPnolongeravailableintheUnitedStates),diphtheriatetanusacellularpertussis(DTaP),tetanus
diphtheriatoxoidsadsorbed(Td),boostertetanustoxoidreduceddiphtheriatoxoidacellularpertussis(Tdap),or
tetanustoxoid(TT).
Suchas,butnotlimitedto,woundscontaminatedwithdirt,feces,soil,orsalivapuncturewoundsavulsions
woundsresultingfrommissiles,crushing,burns,orfrostbite.
Thepreferredvaccinepreparationdependsupontheageandvaccinationhistoryofthepatient:
<7years:DTaP
Underimmunizedchildren7and<11yearswhohavenotreceivedTdappreviously:Tdap.Childrenwhoreceive
Tdapbetweenage7and11yearsdonotrequirerevaccinationatage11years.
11years:AsingledoseofTdapispreferredtoTdforallindividualsinthisagegroupwhohavenotpreviously
receivedTdap.PregnantwomenshouldreceiveTdapduringeachpregnancy.
TdispreferredtoTTforthosewhoreceivedTdappreviouslyandwhenTdapisnotavailable.
250unitsintramuscularlyatadifferentsitethantetanustoxoidintravenousimmuneglobulinshouldbeadministered
ifhumantetanusimmuneglobulinisnotavailable.
Thevaccineseriesshouldbecontinuedthroughcompletionasnecessary.
Boosterdosesgivenmorefrequentlythaneveryfiveyearsarenotneededandcanincreaseadverseeffects.
Datafrom:
1.AdvisoryCommitteeonImmunizationPractices.Recommendedadultimmunizationschedule:UnitedStates,
2012.AnnInternMed2012156:211.
2.CentersforDiseaseControlandPrevention(CDC).Updatedrecommendationsforuseoftetanustoxoid,reduced
diphtheriatoxoidandacellularpertussis(Tdap)vaccinefromtheAdvisoryCommitteeonImmunizationPractices,
2010.MMWRMorbMortalWklyRep201160:13.
3.CentersforDiseaseControlandPrevention.Updatedrecommendationsforuseoftetanustoxoid,reduced
diphtheriatoxoid,andacellularpertussis(Tdap)vaccineinadultsaged65yearsandolderAdvisoryCommittee
onImmunizationPractices(ACIP),2012.MMWRMorbMortalWklyRep201261:468.
4.CentersforDiseaseControlandPrevention(CDC).Updatedrecommendationsforuseoftetanustoxoid,reduced
diphtheriatoxoid,andacellularpertussisvaccine(Tdap)inpregnantwomenAdvisoryCommitteeon
ImmunizationPractices(ACIP),2012.MMWRMorbMortalWklyRep201362:131.
Adaptedfrom:AmericanAcademyofPediatrics.Tetanus(lockjaw).In:RedBook:2015ReportoftheCommitteeon
InfectiousDiseases,30thEdition,KimberlinDW,BradyMT,JacksonMA,LongSS(Eds),AmericanAcademyof
Pediatrics,ElkGroveVillage,IL2015.
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Potentialpitfallsinthemanagementoftheelderlytraumapatient
Whattheinjuredelderly
wouldtellyou(ifthey
could)
Relatedphysiologyandrationale
"Icangofromnormotensiveto
hypotensiveinaheartbeat."
Profound,lifethreateninghypovolemiamayoccurinthesettingofnormal
bloodpressure.Physiologicreserveisminimal,andhemodynamic
decompensationcanoccurquickly.
"Irespondpoorlytotoomuchor
toolittlefluid."
Thetherapeuticwindowforcardiacpreloadisnarrow,andinadequatepreload
monitoringmayleadtoerrorsinvolumeresuscitation.
"Mysubduralhematomahasn't
expandedenoughyettoreally
affectmylevelofconsciousness."
Corticalatrophy,commonintheelderly,mayacttodelaytheclinical
manifestationsofseriousintracranialhemorrhage.Thishemorrhagemaybe
clinicallyoccult.
"Traumaisnotreallymymajor
problem."
Stroke,myocardialinfarction,andseizuresmayresultfromfallsormotor
vehiclecrashesanddelayeddiagnosisoftheprincipalunderlyingproblem.
"IonlylooklikeIhaveadequate
ventilatoryreserve."
Ventilatoryfailureandrespiratoryarrestmayoccursuddenlyinconjunction
withchestorabdominalinjuriesdespiteabenignoutwardclinicalappearance.
"IgetdemandischemiaifIhave
toomuchpainormyhematocrit
dropsbelow29."
Myocardial(demand)ischemiamayresultfromsevereorprolongedpainor
fromtransfusionthresholdsthathavenotbeenappropriatelyliberalizedinthe
settingofcoronaryarterydisease.
"Ican'tstandevenalittleshock
orhypoxia...andneithercanmy
myocardium."
Evenminorperturbationsinperfusion,oxygenation,orvasoconstrictionmay
leadtomajorcardiaccomplications.
"Myconnectivetissuejustain't
whatitusedtobe..."
Decreaseinconnectivetissueintegritywithless"tamponadeeffect"for
hemorrhageintosofttissues.Bloodlossintosofttissuespaces,including
subcutaneousloss,maybeexcessiveandisoftenoverlooked.
"Thesensitivityofmyabdominal
examinationisbetterthanflipping
acoin...butnotmuch."
Clinicalmanifestationsofseriousabdominalinjuryinelderlypatientsareoften
minimal.Relianceontheabdominalexaminationoftenleadstomissed
abdominalinjuries.
"Mybonesarebrittle...myhip
bone,myshinbone,andmy
aorticbone!"
BAImayoccurintheelderlyintheabsenceofconventionalsignsor
symptoms.AlowthresholdforCTimagingshouldexist.
"Alittlemedicationgoesalong
waywithme..."
Failuretoadjustmedicationdosage,particularlysedativehypnoticsand
analgesics,mayresultinseriouscomplications.
"Ijusthaven'tbeeneatingsowell
lately."
Chronicmalnutritioniscommonandoftenundiagnosed.
"Myinjuriesweren'taccidental."
Elderabuseiscommonandoftenunreportedandundiagnosed.
"Majortrauma?Heck,Iwouldn't
eventolerateabriskhaircut..."
Underestimatingandundermanagingcomorbidities(eg,chronicobstructive
pulmonarydisease,coronaryarterydisease,smoking,ethylalcohol[ETOH]
consumption)mayresultinpreventablemorbidity/mortality.
Reproducedfrom:Mackersie,RC.Pitfallsintheevaluationandresuscitationofthetraumapatient.EmergMedClin
NorthAm201028:1.TableusedwiththepermissionofElsevierInc.Allrightsreserved.
36/37
17/1/2017
ContributorDisclosures
AliRaja,MD,MBA,MPH Nothingtodisclose RichardDZane,MD Nothingtodisclose MariaEMoreira,
MD Nothingtodisclose JonathanGrayzel,MD,FAAEM Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.
Conflictofinterestpolicy
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