Crit Care Clin 20 (2004) 1 11

Initial management of the trauma patient

Christopher F. Richards, MDa,b,*,
John C. Mayberry, MD, FACSc
a
Center for Policy and Research in Emergency Medicine, Oregon Health & Science University,
3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
b
Department of Emergency Medicine, Oregon Health & Science University,
3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
c
Division of General Surgery, Oregon Health & Science University,
3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA

The management of severely injured patients can be complex and requires a

familiarity with a large body of clinical information that encompasses several
specialties. Thus, organized trauma systems with designated trauma centers and
trauma specialists have proven valuable for managing the multiply injured patient
[1,2]. Unfortunately, only 35 states have formal trauma systems [3]. Critical care of
the severely injured patient may therefore, at many centers, fall to other critical care
physicians. This article discusses the prehospital and initial management steps of
the multiply injured patient, focusing on established principles of therapy with
which a critical care specialist should be familiar.

Epidemiology
Trauma is one of the leading causes of critical illness and death in the United
States. In 2001, injury trailed only heart disease and deliveries as the most common
first-listed discharge diagnosis category at nonfederal hospitals (over 2.4 million
patients) [4]. In 2000, unintentional injury was the fifth leading cause of death
(97,900 people) [5]. The leading cause of injury in the United States is the motor
vehicle crash (MVC), which resulted in 3,033,000 injuries and 42,116 fatalities in
2001 [6]. About one third of trauma patients evaluated at a level 1 trauma center
will be admitted to a critical care unit, with a mean length of stay of 5 days [7].
Several reports have documented a trend toward increased age and comorbidities

* Corresponding author. Center for Policy and Research in Emergency Medicine, Oregon Health
& Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239.
E-mail address: richarch@ohsu.edu (C.F. Richards).

0749-0704/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0704(03)00097-6
2 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111

among trauma patients, both of which are known to increase the risk of trauma
morbidity and death [8].

Prehospital care
Regionalized trauma systems have a mandated ambulance destination policy
that instructs prehospital personnel to transport seriously injured patients to a
designated trauma center. Nontrauma designated medical facilities are bypassed
even when they are closer in proximity to the scene of the injury. Prehospital
personnel use well-defined mechanistic, anatomic, and physiologic criteria for
trauma system entry (Table 1). Most trauma systems allow paramedics consider-
able discretion to overtriage. Scoring systems such as the revised trauma score
(RTS) and the injury severity score (ISS) have not always been shown to be
superior to paramedic judgment [9]. Trauma systems use quality assurance
programs to periodically re-evaluate their entry criteria with the goal of minimizing
undertriage. Trauma systems have been shown to decrease morbidity and mortality
in urban areas, but the benefits have been harder to describe in rural areas [10].
The scope of care that paramedics deliver at the scene of the injury is
controversial. Mainstays of prehospital care include airway management, control
of external bleeding, immobilization of the spine, needle decompression of
suspected tension pneumothorax, and splinting of major extremity fractures. On-
scene delay usually is discouraged for interventions of unproven benefit [11 15].

Table 1
Oregon Health and Science University trauma activation criteria
Full trauma teama response Modified trauma teamb response
Airway problems (intubated or attempted intubation) GCS > 10 or GCS < 13
Breathing difficulty (RR < 10 or > 29) Two or more long bone fractures
Systolic BP < 90 Fall > 20 feet
GCS < 11 Ejection from vehicle
Penetrating injury to the head, neck or torso Death in same passenger compartment
Flail chest Extrication time > 20 minutes
Paralysis Rollover motor vehicle crash
Pelvic instability High-speed motor vehicle crash
Amputation proximal to the wrist or ankle Automobile versus pedestrian > 5 mph
Major crush injury to torso or upper thigh Special consideration age < 5 or > 65
Paramedic discretion
MCC, ATV, bike crash
Significant intrusion/impact
Hostile environment (cold, heat)
Pre-existing medical illness
Presence of intoxicants
Pregnancy
Abbreviations: ATV, all terrain vehicle crash; MCC, motorcycle crash; RR, respiratory rate.
a
The full trauma team includes the trauma surgeon, emergency medicine physician, critical
response nurse, anesthesiologist, and respiratory therapist.
b
The modified trauma team excludes the anesthesiologist and the respiratory therapist.
 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111 3

For example, the application of military antishock trousers (MAST) by paramedics,

once a standard component of prehospital care, did not prove beneficial in
randomized trial [16]. Many, but not all, trauma systems encourage endotracheal
intubation of the comatose trauma patient. Although more study is needed, recent
prospective studies of field intubation of patients with severe traumatic brain injury,
however, have uncovered a potentially harmful effect [17,18]. Prehospital intra-
venous (IV) crystalloid resuscitation of bluntly injured patients is recommended,
but aggressive IV fluid administration is discouraged in patients with penetrating
injury unless the patient manifests severe shock, or prolonged transport (more than
30 minutes) is expected [19].

Initial management
Optimal care of multiply injured patients includes a preplanned emergency
department (ED) phase. Predetermined response teams with defined roles and
expectations are necessary so that multiple therapeutic and diagnostic procedures
can be performed simultaneously. A physician team leader assesses the patient,
orders and interprets diagnostic studies, and prioritizes diagnostic and therapeutic
concerns. The team leader helps the team focus on the injuries that are immediately
life-threatening and formulates the plan for the evaluation of less threatening
injuries in sequence. Dividing the ED phase into the Advanced Trauma Life
Support (ATLS) recommended stages of the primary survey, initial imaging tests,
secondary survey, and transfer to definitive care is a well-tested means of
determining these priorities [20].

The primary survey

The primary survey is defined by the mnemonic ABCDE: Airway, Breath-
ing, Circulation, Disability and Exposure/Environment [20]. Although these com-
ponents are described sequentially, some components may be performed
simultaneously. Problems identified during this portion of the evaluation are
managed immediately.

Airway
The airway always is assessed immediately for patency, protective reflexes,
foreign body, secretions, and injury. This assessment may range from asking the
patient to open the mouth and phonate to suctioning secretions and assessing the
stability of midface, mandible, or dental injuries. Suction or manual clearing of
foreign bodies or vomitus is followed by careful inspection and palpation of the
facial structures, oropharynx, and neck. The patients level of consciousness is also
a primary indicator of airway stability. Patients with a Glasgow Coma Score (GCS)
of 8 or less are at risk for aspiration and hypoventilation.
4 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111

If for any reason the clinician is not convinced of the patients ability to maintain
his or her own airway, the clinician proceeds to artificial airway control. The
appropriate method of establishing an airway depends upon the specific situation,
but some general rules apply. All trauma patients need manual cervical immobi-
lization during airway management to prevent movement of a potentially unstable
cervical spine injury. Rapid sequence induction is preferred in all but the most
moribund patients and oro tracheal intubation is the preferred route. Naso
tracheal intubation no longer is encouraged because of its difficulty to performance
and higher complication rate [21]. The concern that clinicians have had that oro
tracheal intubation is potentially harmful in patients with potential cervical spine
fractures has been refuted by prospective studies [22 24]. Urgent or emergent
intubation should not be delayed to obtain radiographs of the cervical spine.
Stridor, hoarseness, or neck subcutaneous empysema are signs of a possible
laryngo tracheal injury. Although many of these patients can be managed without
an airway, they all demand close observation in an ICU. If intubation is required
and time allows, a physician experienced in difficult intubations should be chosen.
Unsuccessful endotracheal intubation of a partial laryngo tracheal tear may
transform it to a complete transection. Fiberoptic nasotracheal intubation should
be attempted only by experienced clinicians with the necessary equipment
immediately available. Even in this ideal situation, blood and secretions often
render fiberoptic intubation difficult or impossible.
Surgical airway management is indicated when either the oral route has failed or
is in the situation of massive facial injury. Percutaneous transtracheal ventilation
can be a temporizing measure before performance of tracheostomy or cricothy-
rotomy. Cricothyrotomy is easier to perform and is preferred over tracheostomy in
most situations; however, if there is a suspicion of a laryngeal fracture or tracheal
transection, tracheostomy is the method of choice [25 27].

Breathing
Breathing is assessed by determining the patients respiratory rate and by
subjectively quantifying the depth and effort of inspiration. Breath sounds should
be carefully auscultated bilaterally. Pulse oximetry is a mandatory adjunct and
end tidal carbon dioxide monitoring is becoming a useful adjunct. Rapid respi-
ratory effort, the use of accessory muscles of respiration, hypoxia, hypercapnia,
asymmetric chest wall excursions, and diminished or absent breath sounds all
require treatment before proceeding. Needle decompression of tension pneumo-
thorax can be completed quickly at this stage with definitive tube thoracostomy
performed after completion of the primary survey.

Circulation
Assessment of the circulation begins with a quick evaluation of the patients
mental status, skin color, and skin temperature. Patients in significant hemorrhagic
shock will progress from anxiety to agitation and finally coma if their blood loss is
not abated. Because one of the immediate responses of the body to hemorrhage is
 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111 5

the activation of the sympathetic nervous system, the peripheral skin of a bleeding
patient will become pale, cool, and sweaty. Cyanotic or mottled peripheral skin is a
sign of severe hemorrhagic shock. Sluggish capillary refill of the toes and the
absence of blood in the superficial veins of the feet and hands also may be apparent.
Unfortunately, the traditional vital signs, heart rate, blood pressure, and respiratory
rate, are neither sensitive nor specific for hemorrhagic shock [28]. Young, healthy
patients in compensated shock may not be significantly tachycardic or hypotensive
until they have lost up to 30% of their blood volume. In addition, because of the
pain and anxiety that many injured patients experience, tachycardia and tachypnea
are common regardless of whether there is significant hemorrhage.
Direct pressure should be applied to external bleeding. Physicians should resist
the urge to clamp bleeding vessels, since significant additional damage can result,
and direct pressure is usually effective. A tourniquet will be required only in cases
of near or complete amputation with massive external bleeding.
The primary survey of circulation is not complete until adequate venous access
is obtained. If two large bore (16 14 gauge) IV lines cannot be obtained within
several minutes, a femoral venous central line should be inserted. If the patient is in
shock, an 8 French single lumen catheter should be placed, but the smaller diameter
triple lumen catheter is adequate for more stable patients. Because of the risk of
lower extremity deep venous thrombosis and central line infection, femoral venous
catheters placed in the ED should be removed within 24 hours.
Choices of fluids for resuscitation include crystalloid, colloid, and blood
products. Initial fluids should be crystalloids, either normal saline or Ringers
lactate. Ringers lactate is preferred when large volumes are required, as acidosis
can result from large volumes of normal saline [29]. Ringers lactate, however, is
hypotonic and hyponatremic compared with plasma and therefore may be contra-
indicated in cases of brain injury. Hypertonic saline (7.5% salt in 6% Dextran) in
small volumes has been used and shown to improve survival in hypotensive trauma
patients [30,31]; however, its use is not common.
Patients who do not respond to 1 to 2 L of crystalloid resuscitation or who appear
moribund should be transfused with type O uncross-matched blood. O-positive
blood can be used for most patients so that O-negative blood can be reserved for use
in women of child-bearing age. Because of the time delay, type-specific or fully
cross-matched blood is only indicated in less urgent situations.
Once therapy for shock has been initiated and external bleeding control initiated,
the search for sources of internal hemorrhage must begin. The three body regions
that will hide significant amounts of blood in cases of blunt injury include the chest,
abdomen, and pelvis. Chest and pelvic radiographs and a focused assessment with
sonography for trauma (FAST) or a diagnostic peritoneal lavage (DPL) are
mandatory screening studies for patients in shock. Computed tomography (CT)
scanning of patients in hemorrhagic shock is discouraged. Long bone fractures can
cause bleeding, but absent open fractures with significant external blood loss rarely
result in shock. Neurogenic shock is entertained as a diagnosis only after causes of
hemorrhagic shock have been eliminated. Patients with torso-penetrating injury
and shock should be taken urgently to the operating room by a qualified surgeon.
6 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111

Selected patients with hypovolemic shock with circulatory collapse that is

unresponsive to fluid resuscitation can be considered for ED thoracotomy. This
procedure should be performed only by a qualified and experienced emergency
physician or surgeon. Only patients with a penetrating mechanism of injury and
loss of vital signs en route or after arrival should be considered. Patients with stab
wounds, gunshot wounds, and blunt mechanisms of injury have 16.8%, 4.3%, and
1.4% survival rates, respectively [32].

Disability
Disability should be assessed early so as to document neurologic deficits before
giving IV sedation or paralytics. The GCS and the gross motor and sensory status of
all four extremities should be determined and recorded. The physician also should
recognize the need for cerebro-protection measures in cases of brain injury. Brain
injured patients who are intubated should be sedated with a rapidly reversible agent
such as midazolam or propofol. Aggressive hyperventilation is not indicated, but it
is the most rapid method of transiently lowering the intracranial pressure (ICP) in
patients suspected of near-herniation [33]. Mannitol in a dose of 1.0 g/kg IV is
indicated in patients with low GCS and asymmetric pupils who are not in shock
[34,35].

Exposure/environment
The final portion of the primary survey is exposure and environmental control.
Exposure is particularly important in the patient with a traumatic mechanism of
injury where failure to identify a second or third injury may result in mis-
assessment of the clinical picture. Environmental control involves assessing the
core body temperature and preventing hypothermia. At a minimum, the room
should be maintained at a temperature as warm as possible and the patient covered
with blankets. Rapid infusion of blood products and crystalloid solutions should be
accomplished by way of a Level 1 (Level 1, Inc., Rockland, Massachusetts) fluid
warmer. Patients in shock may be normothermic initially, but nevertheless, they
will require active warming during the resuscitation phase.

Initial radiographs and procedures

Depending upon findings during the primary survey, initial portable radiographs
and indicated procedures should be performed immediately and not be delayed for
the secondary survey. A portable chest film is usually the only radiograph
necessary in cases of penetrating torso trauma. The placement of a chest tube on
the side of the penetrating wound before chest film is routine if the patient has of
shortness of breath, diminished breath sounds, or shock. Relatively routine
emergent radiographs in bluntly injured patients are the lateral cervical spine,
chest, and pelvis. The FAST exam can be used as a substitute for the DPL in a
 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111 7

patient who is in shock, but it should not be routine, as it has a low sensitivity in
hemodynamically stable patients [36].

Secondary survey
The secondary survey is a complete re-assessment of the patient and injuries. A
more complete and traditional history and physical exam is performed. Multiple
sources (friends, relatives, law enforcement, and emergency services personnel)
often are required to obtain a complete history. Much can be learned from the
mechanism of injury. The type and magnitude of the potential energy transfer
provides many clues to potential injury patterns. Patients with a history of high
energy transfer (eg, high speed crashes, falls from great heights) are at higher risk
for occult injury regardless of their initial clinical presentation. Single vehicle
crashes, unexplained falls, or potentially self-inflicted injuries will require assess-
ment of the patients underlying mental state and potential for further self-harm.
The physical examination commences at the head of the patient and proceeds
toward the toes. The experienced trauma specialist realizes that painful, distracting
injuries and a less than precise examination may leave some injuries unidentified.
Throughout this portion of the evaluation, the patient should be monitored
with continuous cardiac rhythm with pulse oximetry, frequent blood pressure
measurements, mental status exam, and clinical assessments of peripheral
perfusion. End tidal carbon dioxide monitoring can be useful also. Invasive
monitoring by means of pulmonary artery catheters is rarely feasible in an ED
setting. If at any time during the secondary survey the patients clinical status
deteriorates, the examiner should return to the elements of the primary survey.
Once the secondary survey is completed, more specific imaging and diagnostic
studies can be obtained. If the patient is hemodynamically stable, and the physician
has a low concern for life-threatening injury, transport to the radiology department
or CT scanner for more accurate diagnostic testing is reasonable. The patient should
be accompanied and monitored by a nurse at all times until the initial evaluation
is complete.

Geriatric trauma
Because the general population of the United States is continuing to age, and
more Americans are remaining active for many years after they retire, trauma
centers are expected to admit increasing numbers of elderly patients. Most trauma
systems recognize that advanced age should lower the threshold for field triage
directly to a trauma center. The age cut-off for geriatric trauma has not been
standardized, but it generally ranges from age 55 or certainly beyond age 65. Age,
and especially comorbid medical conditions, are well-recognized risk factors for
adverse outcomes following trauma [8]. In spite of the risk of increased morbidity,
however, advanced age should not be used as the sole criteria for limiting trauma
8 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111

resuscitation and procedures. Most elderly trauma patients admitted to trauma

centers will return to independent function.
Whether geriatric trauma patients should receive more aggressive invasive
monitoring in the ICU than younger, similarly injured patients is not clear. There
are insufficient data to support a level 1 evidence-based medicine recommendation
for the use or nonuse of a pulmonary artery catheter during resuscitation based on
age alone [8]. If the older patient has evidence of shock associated with a significant
injury, however, a pulmonary artery catheter-directed resuscitation is probably
wise, especially when chronic cardiovascular or renal disease is present. Older
patients with blunt thoracic trauma are certainly at risk for pulmonary deterioration
even if they initially appear compensated [37]. Pain control with an epidural
catheter and ICU-monitored pulmonary toilet for the first 48 hours is recommended
for any patient older than 65 years of age with multiple rib fractures [38].

Tertiary survey
Performing a tertiary survey on injured patients admitted to the ICU is necessary
to completely identify all of the potentially multiple injuries. [39] Injuries that have
not yet been detected or that have been set aside while more life-threatening issues
are managed are common, especially in blunt trauma. In addition, patients who are
intoxicated with alcohol or other chemicals and are unable to cooperate with the
diagnosis and management of their potential injuries may require rapid sequence
induction and endotracheal intubation just to facilitate their secondary survey and
diagnostic imaging. The tertiary survey consists of yet another head to toe physical
examination, an assessment of the patients response to resuscitation thus far, a
review of current radiographic studies with radiologist interpretation, a review of
all laboratory studies, and a effort if necessary to obtain a pre-injury medical history
from family and friends who by this time should be arriving. Typically this would
be performed upon the patients arrival to the ICU. It is reasonable at this point to
order a new panel of labs that in the case of a multiply injured patient that would at
the least consist of a complete blood count, coagulation panel, arterial blood gas,
and serum lactate. The trauma specialist or intensive care specialist then decides
what invasive monitoring and IV access and what further radiographic studies are
necessary. A plan for sedation and analgesia is formulated.
Because delays in detecting all injuries are common in multiply injured
patients, the injury should not be considered significantly delayed or missed if
found within the first 24 hours. The experienced trauma specialist will suspect
fractures that are hidden easily from view (eg, in the cervical, thoracic, or lumber
spine). The authors routine practice is to obtain a cervical spine CT scan during
the patients second trip to the CT scanner (eg, during the second serial head CT
scan for patients with brain injury). A low threshold for a chest CT scan will
detect occult pneumothoraces, pulmonary contusion, and even aortic injury. The
potential development of extremity compartment syndrome should be considered
around all extremity fractures or soft-tissue injuries. Intra-abdominal pressure
 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111 9

should be measured on admission to the ICU and every 6 hours in the critically ill
trauma patient regardless of whether there is a known abdominal injury. The
aggressive fluid resuscitation associated with traumatic shock will lead to total
body edema and even ascites [40].
Two complications that will occur simultaneously and synergistically and that
should be expected during the tertiary survey are hypothermia and coagulopathy.
Hypothermia as the result of environmental exposure or shock complicates
resuscitation and treatment of trauma patients and increases morbidity and
mortality [41]. Iatrogenic causes of hypothermia include massive fluid resuscita-
tion and prolonged surgical procedures. Hypothermia exacerbates acidosis,
increases blood viscosity, decreases microvascular blood flow, and reduces platelet
aggregation. IV fluids should be warmed with a Level 1 transfuser (Level 1, Inc.,
Rockland, Massachusetts) beginning in the ED, and the patient should be covered
with a Bair Hugger (Arizant Health Care, Inc., Eden Prairie, Minnesota) and
blankets as much as possible. The combination of hypothermia and massive
transfusion may result in an uncorrectable coagulopathy unless both of these
problems are anticipated and treated. Most trauma centers initiate a massive
transfusion protocol as soon as it is predicted that more than ten units of packed
red cells will be transfused [42,43]. A clinical pathologist should come to the
patients bedside and directly assist the surgeon and intensive care specialist with
the ordering and delivering of procoagulation products.

Summary
Critical care specialists should be familiar with the initial management of
injured patients. Dividing the evaluation and treatment of the patient into the pri-
mary, secondary, and tertiary surveys ensures that the multiply injured patient will
be managed expeditiously. The primary survey identifies the acute life-threatening
problems that must be managed immediately. The secondary survey identifies the
remaining major injuries and sets priorities for definitive management. The tertiary
survey identifies occult injuries before they become missed injuries.

References
[1] Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review of published
evidence regarding trauma system effectiveness. J Trauma 1999;47(Suppl 3):S25 33.
[2] Mullins RJ, Mann NC, Hedges JR, Worrall W, Jurkovich GJ. Preferential benefit of implemen-
tation of a statewide trauma system in one of two adjacent states [discussion]. J Trauma 1998;
44(4):609 17.
[3] MacKenzie EJ, Hoyt DB, Sacra JC, Jurkovich GJ, Carlini AR, Teitelbaum SD, et al. National
inventory of hospital trauma centers. JAMA 2003;289(12):1515 22.
[4] Hall MJ, DeFrances CJ. 2001 National hospital discharge survey. Hyattsville (MD): National
Center for Health Statistics; 2003.
[5] Anderson RN. Deaths: leading causes for 2000. Hyattsville (MD): National Vital Statistics Re-
ports; 2002.
10 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111

[6] Traffic Safety Facts 2001. Washington (DC): National Center for Statistics & Analysis; 2001.
[7] Report of the Trauma Service. Washington (DC): Oregon Health & Science University; 2002.
[8] Jacobs DG, Plaisier BR, Barie PS, Hammond JS, Holevar MR, Sinclair KE, et al. Practice manage-
ment guidelines for geriatric trauma: the EAST practice management guidelines work group.
J Trauma 2003;54(2):391 416.
[9] Emerman CS, Shade B, Kubincanek J. A comparison of EMT judgment and prehospital trauma
triage. J Trauma 1991;31(10):1369 75.
[10] Esposito TJ, Sanddal TL, Reynolds SA, Sanddal ND. Effect of a voluntary trauma system on
preventable death and inappropriate care in a rural state. J Trauma 2003;54(4):663 9.
[11] Demetriades D, Chan L, Cornwell E, Belzberg H, Burne TV, Asensio J, et al. Paramedic vs private
transportation of trauma patients. Effect on outcome. Arch Surg 1996;131(2):133 8.
[12] Copass MK, Oreskovich OR, Bladergroen MR, Carrico CJ. Prehospital cardiopulmonary resus-
citation of the critically injured patient. Am J Surg 1984;148(1):20 6.
[13] Pepe PE, Copass MK, Joyce TH. Prehospital endotracheal intubation: rationale for training
emergency medical personnel. Ann Emerg Med 1985;14(11):1085 92.
[14] Eckstein M, Alo K. The effect of a quality improvement program on paramedic on-scene times for
patients with penetrating trauma. Acad Emerg Med 1999;6(3):191 5.
[15] Eckstein M, Chan L, Schneir A, Palmer R. Effect of prehospital advanced life support on out-
comes of major trauma patients. J Trauma 2000;48(4):643 8.
[16] Mattox KL, Bickell W, Pepe PE, Burch J, Feliciano D. Prospective MAST study in 911 patients.
J Trauma 1989;29(8):1104 11.
[17] Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. Endotracheal intubation in the field
does not improve outcome in trauma patients who present without an acutely lethal traumatic
brain injury. J Trauma 2003;54(2):307 11.
[18] Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, et al. The effect of para-
medic rapid sequence intubation on outcome in patients with severe traumatic brain injury.
J Trauma 2003;54:444 53.
[19] Martin RR, Bickwell WH, Pepe PE, Burche JM, Mattox KL. Prospective evaluation of pre-
operative fluid resuscitation in hypotensive patients with penetrating truncal injury: a preliminary
report. J Trauma 1992;33(3):354 61.
[20] Krantz BE. Advanced trauma life support for doctors. Chicago (IL): The American College of
Surgeons; 1997.
[21] Holley J, Jorden R. Airway management in patients with unstable cervical spine fractures. Ann
Emerg Med 1989;18(11):1237 9.
[22] Rhee KJ, Green W, Holcroft HW, Mangili JA. Oral intubation in the multiply injured patient: the
risk of exacerbating spinal cord damage. Ann Emerg Med 1990;19(5):511 4.
[23] Gerling MC, Davis DP, Hamilton RS, Morris GF, Vike GM, Garfin SR, et al. Effects of cer-
vical spine immobilization technique and laryngoscope blade selection on an unstable cervical
spine in a cadaver model of intubation. Ann Emerg Med 2000;36(4):293 300.
[24] Walls RM. Airway management in the blunt trauma patient: how important is the cervical spine?
Can J Surg 1992;35(1):27 30.
[25] Holmes JF, Panacek EA, Sakles JC, Brofeldt BT. Comparison of two cricothyrotomy techniques:
standard method versus rapid four-step technique. Ann Emerg Med 1998;32(4):442 6.
[26] Gussack GS, Jurkovich GJ. Treatment dilemmas in laryngotracheal trauma. J Trauma 1988;
28(10):1439 44.
[27] Fuhrman GM, Stieg 3rd FH, Buerk CA. Blunt laryngeal trauma: classification and management
protocol. J Trauma 1990;30(1):87 92.
[28] Victorino GP, Battistella FD, Wisner DH. Does tachycardia correlate with hypotension after
trauma? J Am Coll Surg 2003;196(5):679 84.
[29] Brill SA, Stewart TR, Brundage SI, Schreiber MA. Base defect does not predict mortality when
secondary to hyperchloremic acidosis. Shock 2003;17(6):459 62.
[30] Mattox KL, Maningas PA, Moore EE, Mateer JR, Marx JA, Aprahamian C, et al. Prehospital
 C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 111 11

hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multi-center Trial.
Ann Surg 1991;213(5):482 91.
[31] Maningas PA, Mattox KL, Pepe PE, Jones RL, Feliciano DV, Burch JM. Hypertonic saline
dextran solutions for the prehospital management of traumatic hypotension [discussion]. Am J
Surg 1989;157(5):528 34.
[32] Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency depart-
ment thoracotomy: review of published data from the past 25 years. J Am Coll Surg 2000;
190(3):288 98.
[33] Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, et al. Adverse effects of
prolonged hyperventilation in patients with severe head injury: a randomized clinical trial.
J Neurosurg 1991;75(5):731 9.
[34] Schrot RJ, Muizelaar JP. Mannitol in acute traumatic brain injury. Lancet 2002;359(9318):
1633 4.
[35] The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint
Section on Neurotrauma and Critical Care. Use of mannitol. J Neurotrauma 2000;17:521 5.
[36] Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so fast. J Trauma 2003;54(1):
52 9.
[37] Bulger EN, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma
2000;48(6):1040 6.
[38] Wisner DH. A step-wise logistic regression analysis of factors affecting morbidity and mortality
after thoracic trauma: effect of epidural analgesia. J Trauma 1990;30:799 804.
[39] Biffl WL, Harrington DT, Cioffi WG. Implementation of a trauma survey decreases missed
injuries. J Trauma 2003;54(1):38 43.
[40] Mayberry JC, Welker KJ, Goldman RK, Mullins RJ. Mechanism of acute ascites formation after
trauma resuscitation. Arch Surg 2003;138(7):773 6.
[41] Ferrara A, MacArthur JD, Wright HK, Modlin IM, McMillen MA. Hypothermia and acidosis
worsen coagulopathy in the patient requiring massive transfusion. Am J Surg 1990;160(5):
515 8.
[42] Vaslef SN, Knudsen NW, Neligan PJ, Sebastian MW. Massive transfusion exceeding 50 units
of blood products in trauma patients [discussion]. J Trauma 2002;53(2):291 6.
[43] Lapointe LA, Von Rueden KT. Coagulopathies in trauma patients. AACN Clin Issues 2002;
13(2):192 203.