In the fast-paced world of emergency medicine, the ability to effectively manage trauma situations can make the difference between life and death. Whether it’s a car accident, a fall, or a workplace injury, trauma requires swift and precise intervention to stabilize patients and prevent further harm. In this comprehensive guide, we’ll delve into the basic principles of trauma management, covering everything from initial assessment to advanced life support.

Understanding Trauma

Trauma refers to any physical mechanisms of injury or wound caused by an external force. It can range from minor cuts and bruises to severe life-threatening conditions like traumatic brain injury or massive hemorrhage. Effective trauma management begins with a systematic approach to assessment and specialist treatment.

The first step in trauma management is conducting a rapid intervention yet thorough assessment of the patient’s condition. This includes evaluating the airway, breathing, circulation, disability (neurological status), and exposure (undressing to assess for other injuries).

The primary survey follows the ABCDE mnemonic:

1. Airway Management
2. Breathing
3. Circulation and Hemorrhage Control
4. Disability
5. Exposure

Let’s look into the initial assessment elaborately:

1. Airway Management: Ensure the patient’s airway is open and not obstructed.

• Airway patency threats:
  • Blood clots, teeth, or foreign bodies in the oropharynx.
  • Soft-tissue laxity and posterior retraction of the tongue due to obtundation.
  • Edema or hematoma from direct neck trauma.
• Assessment:
  • Direct inspection of the mouth or neck.
  • Patient speaking to confirm airway safety.
• Intervention:
  • Removal of blood and foreign material by suction or manual means.
  • Endotracheal intubation for obtunded patients or those with significant oropharyngeal injury.
  • Drugs administered for unconsciousness and paralysis before intubation.
• Tools for airway management:
  • Extraglottic devices
  • Airway bougie
  • Video laryngoscopy
• Confirmation of endotracheal tube placement:
  • Carbon dioxide colorimetric device
  • Waveform capnography
• Alternatives to endotracheal intubation:
  • Surgical or percutaneous cricothyrotomy.
  • Indicated if intubation is not possible (e.g., due to airway edema from thermal burn) or contraindicated (e.g., severe maxillofacial injury).
• Cervical spine immobilization:
  • It’s crucial to maintain cervical spine immobilization during airway management until cervical spine injury is ruled out by thorough examination or imaging studies.

2. Breathing: Assess breathing for rate, depth, and symmetry.

• Threats to adequate ventilation:
  • Decreased central respiratory drive (e.g., severe head injury, intoxication, shock)
  • Chest injury (e.g., hemothorax, pneumothorax, rib fractures, pulmonary contusion)
• Assessment:
  • Full exposure of the chest wall to:
    • Evaluate chest wall expansion
    • Look for external signs of trauma
    • Identify paradoxical wall motion (indicative of flail chest)
  • Palpation of the chest wall for:
    • Rib fractures
    • Presence of subcutaneous air (a potential sign of pneumothorax)
  • Auscultation for:
    • Breath sounds
    • Signs of tension pneumothorax (e.g., decreased breath sounds, distended neck veins, tracheal deviation)
• Management:
  • Decompression of pneumothorax by chest tube insertion.
  • Confirmation of pneumothorax with a chest x-ray or bedside ultrasonography before positive-pressure ventilation.
• Decompression of tension pneumothorax with:
  • Finger thoracostomy
  • Needle thoracostomy (e.g., a 14-gauge needle inserted in midaxillary line, 5th intercostal space).
• Treatment of inadequate ventilation with:
  • Endotracheal intubation
  • Mechanical ventilation
• Management of open pneumothorax:
  • Covering with an occlusive dressing attached on 3 sides.
  • Leaving the 4th side untaped to release pressure and prevent tension pneumothorax.

3. Circulation and hemorrhage control: Check for signs of shock and assess pulse and blood pressure.

• Assessment:
  • Assess BP, heart rate and evidence of bleeding.
  • Control any external bleeding by direct pressure.
  • In penetrating injuries of the neck, where venous injuries are suspected, put the patient in the Trendelenburg position, (head down) to prevent air embolism.
  • If there is shock, insert one or two large intravenous lines and start fluid resuscitation.
• Signs of shock:
  • Tachypnea
  • Dusky color
  • Diaphoresis
  • Altered mental status
  • Poor capillary refill
• Physical signs of internal hemorrhage:
  • Abdominal distention and tenderness
  • Pelvis instability
  • Thigh deformity and instability
• Following trauma there are different groups or conditions, which can cause shock:
  • Significant external hemorrhage from any major vessel
  • Life-threatening internal hemorrhage, often less obvious, occurring in body compartments such as the chest, abdomen, retroperitoneum, and soft tissues of the pelvis or thigh.
• Management of Trauma Patients:
  • Control of hemorrhage (external) by direct pressure.
  • Application of tourniquets for extremity bleeding if direct pressure fails.
  • Initiation of two large-bore IVs with 0.9% saline or lactated Ringer’s solution.
  • Rapid infusion of 1 L (20 mL/kg for children) for signs of shock and hypovolemia.
  • Consideration of early administration of blood component therapy.
  • Bedside measurement of lactate or arterial blood gases for assessment of tissue hypoperfusion and shock severity.
  • Consideration of massive blood transfusion protocols for patients.
  • Evaluation of coagulation with thromboelastography or rotational thromboelastography.
  • Early administration of tranexamic acid.
  • Immediate laparotomy for patients with strong clinical suspicion of serious intra-abdominal hemorrhage.
  • Placement of a resuscitative balloon for aortic occlusion to stabilize the patient before surgery.
  • Immediate thoracotomy for patients with massive intrathoracic hemorrhage, possibly followed by autotransfusion of recovered blood via tube thoracostomy.

4. Disability: Evaluate neurological status using the Glasgow Coma Scale

• Evaluation of neurologic function:
  • Use of Glasgow Coma Scale (GCS) and pupillary response to light for assessing level of consciousness and intracranial injury severity.
  • Screening for serious spinal cord injury via gross motor movement and sensation in each extremity.
  • Palpation of the cervical spine for tenderness and deformity, followed by stabilization with a rigid collar until cervical spine injury is ruled out.
• Logrolling of the patient onto a side for:
  • Palpation of thoracic and lumbar spine
  • Inspection of the back.
  • Rectal examination if indicated (checking tone, prostate position, presence of blood).
• Glasgow Coma Scale (GCS):
  • Used for assessing the level of consciousness and severity of intracranial injury.
  • Divided into three components: eye-opening, verbal response, and motor response, with scores ranging from 3 to 15.
  • Lower scores indicate more severe impairment.

• Modified Glasgow Coma Scale for Infants and Children:
  • Adaptation of the GCS for assessing consciousness and intracranial injury severity in pediatric patients.
  • Utilizes age-appropriate criteria for eye opening, verbal response, and motor response, with scores ranging from 3 to 15.

5. Exposure: Examine the patient for any additional injuries.

• Undress the patient completely for a thorough examination.
• Keep the patient warm with blankets and warm IV fluids.
• Trauma patients become hypothermic very quickly.
• Severe blood loss, elderly patients, and pediatric trauma patients are at high risk for hypothermia.

Secondary Survey of Injured Patients

• The secondary survey follows completion of the primary survey (ABC’s) and initiation of resuscitation.
• It may be performed after life-saving interventions for critical injuries.
• Includes a comprehensive examination from head to toe:
  • Examination of head and neck
  • Assessment of chest
  • Examination of abdomen
  • Inspection of the back
  • Rectal and vaginal examinations if indicated
  • Evaluation of musculoskeletal system

Note: During the secondary assessment, exercise caution to prevent exacerbation of potential spinal cord injuries by avoiding excessive manipulation or movement of the patient. Utilize appropriate spinal injury precautions, such as logrolling, to minimize the risk of further injury.

In critical care and related medical fields, ongoing advancements are commonplace, reflecting the dynamic nature of healthcare. To stay informed about the latest developments in treating conditions within critical care settings, it’s essential to regularly consult recent critical care literature, track ongoing clinical trials, participate in relevant webinars, or enroll in online courses led by leading critical care specialists. These resources provide valuable access to the most current information on available treatments and emerging therapeutic standardized approaches.

Checklist for a Critical Care student to have a comprehensive understanding of the condition:

• Resuscitation efforts and Initial Management of Acutely Ill Patients
• Diagnosis: Assessment, Investigation, Monitoring, and Data: Interpretation of the Acutely Ill Patients
• Disease Management
• Organ System Failure
• Therapeutic Interventions/Organ System Support in Single or Multiple Organ Failure
• Peri-operative Care
• Critical Care of Children
• Transportation
• Physical & Clinical Measurement
• Research Methods (Includes Data Collection and Statistics)

Remember to stay updated with the latest literature and attend relevant conferences or seminars to enhance your knowledge. Critical care is a complex and evolving field, and staying informed will contribute to your effectiveness as a future healthcare professional.

Frequently Asked Questions (FAQs)

Q1. What are the key components of the primary survey in trauma management?

Ans. The primary survey in trauma management follows the ABCDE mnemonic: Airway, Breathing, Circulation, Disability (neurological status), and Exposure/Environmental control. Each component is systematically assessed to identify and address life-threatening injuries promptly.

Q2. How is airway management approached in trauma patients?

Ans. Airway management involves ensuring airway patency by removing obstructions such as blood clots or foreign bodies, assessing for signs of airway compromise, and intervening with measures like suctioning, intubation, or surgical airway access if necessary. Continuous monitoring and confirmation of proper endotracheal tube placement are essential.

Q3. What are the priorities in the secondary survey of injured patients?

Ans. The secondary survey is conducted after the primary survey and resuscitation. It involves a comprehensive head-to-toe examination to identify any additional injuries that may not have been initially apparent. Priorities include examining the head, neck, chest, abdomen, back, and performing rectal and vaginal examinations if indicated, as well as assessing the musculoskeletal system.