- 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
- 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
- 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 ...