Chapter 41

• The initial assessment of the trauma patient can be divided into primary, secondary, and tertiary surveys. The primary survey should take 2–5 min and consists of the ABCDE sequence of trauma: Airway, Breathing, Circulation, Disability, and Exposure. Resuscitation and assessment proceed simultaneously. Trauma resuscitation includes two additional phases: control of hemorrhage and definitive repair of the injury. More comprehensive secondary and tertiary surveys of the patient follow the primary survey.
• Five criteria increase the risk for potential instability of the cervical spine: (1) neck pain, (2) severe distracting pain, (3) any neurological signs or symptoms, (4) intoxication, and (5) loss of consciousness at the scene. A cervical spine fracture must be assumed if any one of these criteria is present. Even with these criteria, the incidence of cervical spine trauma is approximately 2%. The incidence of cervical spine instability increases up to 10% in the presence of a severe head injury.
• Neck hyperextension and excessive axial traction must be avoided whenever cervical spine instability is suspected. Manual immobilization of the head and neck by an assistant should be used to stabilize the cervical spine during laryngoscopy (“manual in-line stabilization” or MILS).
• The mainstay of therapy of hemorrhagic shock is intravenous fluid resuscitation and transfusion. Multiple short (1.5–2 in), large-bore (14–16 gauge or 7–8.5F) catheters are placed in whichever veins are easily accessible.
• Rapid-infusion systems that use large-bore tubing and rapidly warm fluids are invaluable during massive transfusions. A convection forced-air warming blanket and heated humidifier will also help maintain body temperature. Hypothermia worsens acid–base disorders, coagulopathy, and myocardial dysfunction.
• Hypotension in patients with hypovolemic shock should be aggressively treated with intravenous fluids and blood products, not vasopressors unless there is profound hypotension that is unresponsive to fluid therapy, coexisting cardiogenic shock, or cardiac arrest.
• Commonly used induction agents for trauma patients include ketamine and etomidate. Even after adequate fluid resuscitation, the induction dose requirements for propofol are greatly (80–90%) reduced in patients with major trauma. Even drugs such as ketamine and nitrous oxide that normally indirectly stimulate cardiac function can display cardiodepressant properties in patients who are in shock and already have maximal sympathetic stimulation. Hypotension may also be encountered following etomidate.
• Invasive monitoring (direct arterial, central venous, and pulmonary artery pressure monitoring) can be extremely helpful in guiding fluid resuscitation but insertion of these monitors should not detract from the resuscitation itself. Serial hematocrits (or hemoglobin), arterial blood gas measurement, and serum electrolytes (particularly K+) are invaluable in protracted resuscitations.
• Any trauma victim with altered consciousness must be considered to have a brain injury. The level of consciousness is assessed by serial Glasgow Coma Scale evaluations.

Trauma is the leading cause of death in Americans from the first to the thirty-fifth year of age. Up to one-third of all hospital admissions in the United States are directly related to trauma. Fifty percent of trauma deaths occur immediately, with another 30% occurring within a few hours of injury (the “golden hour”). Because many trauma ...

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