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InitialEvaluationoftheTraumaPatient

InitialEvaluationoftheTraumaPatient
Author:DavidJDries,MD,MSE,FACS,FCCP,FCCMChiefEditor:JohnGeibel,MD,DSc,MAmore...
Updated:Jan31,2014

Overview
Theinitialevaluationofapersonwhoisinjuredcriticallyfrommultipletraumaisachallengingtask,andevery
minutecanmakethedifferencebetweenlifeanddeath.
Overthepast50years,assessmentoftraumapatientshasevolvedbecauseofanimprovedunderstandingofthe
distributionofmortalityandthemechanismsthatcontributetomorbidityandmortalityintrauma.
Mortalitycanbegroupedintoimmediate,early,andlatedeaths.Immediatedeathsarecausedbyafatalinjuryof
thegreatvessels,heart,orneurologicsystem. [1]Immediatemortalityoccursatthesceneofinjury,asshowninthe
imagebelow.

Immediatemortalityintraumaoccursatthesceneoftheinjury.Preventionofthesedeathsrequiresamultidisciplinarypublichealth
systemsapproach.CourtesyofKevinKilgore,MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

Earlydeathsmayoccurfromminutestohoursaftertheinjury.Thesepatientsfrequentlyarriveatahospitalbefore
death,whichusuallyoccursbecauseofhemorrhageandcardiovascularcollapse.Latetraumamortalitypeaksfrom
daystoweeksaftertheinjuryandisprimarilyduetosepsisandmultipleorganfailure.Organizedsystemsfor
traumacarearefocusedonthesalvageofapatientfromearlytraumamortality,whereascriticalcareisdesignedto
avertlatetraumamortality. [2,3]
Earlytraumadeathsresultfromfailedoxygenationofthevitalorgans,massivecentralnervoussysteminjury,or
both.Themechanismsoffailedtissueoxygenationincludeinadequateventilation,impairedoxygenation,circulatory
collapse,andinsufficientendorganperfusion.Massivecentralnervoussystemtraumaleadstoinadequate
ventilationand/ordisruptionofbrainstemregulatorycenters.Injuriesthatcauseearlytraumamortalityoccurin
predictablepatternsbasedonthemechanismofinjurythepatient'sage,sex,andbodyhabitusorenvironmental
conditions.
RecognitionofthesepatternsledtothedevelopmentoftheAdvancedTraumaLifeSupport(ATLS)approachby
theAmericanCollegeofSurgeons. [4]ATLSisthestandardofcarefortraumapatients,anditisbuiltarounda
consistentapproachtopatientevaluation.Thisprotocolensuresthatthemostimmediatelifethreateningconditions
arequicklyidentifiedandaddressedintheorderoftheirriskpotential.
Theobjectivesoftheinitialevaluationofthetraumapatientareasfollows:(1)torapidlyidentifylifethreatening
injuries,(2)toinitiateadequatesupportivetherapy,and(3)toefficientlyorganizeeitherdefinitivetherapyortransfer
toafacilitythatprovidesdefinitivetherapy.

TriageandOrganizationofCare
Theobjectiveoftriageistoprioritizepatientswithahighlikelihoodofearlyclinicaldeterioration.Triageoftrauma
patientsconsidersvitalsignsandprehospitalclinicalcourse,mechanismofinjury,patientage,andknownor
suspectedcomorbidconditions.Findingsthatleadtoanacceleratedworkupincludemultipleinjuries,extremesof
age,evidenceofsevereneurologicinjury,unstablevitalsigns,andpreexistingcardiacorpulmonarydisease. [5]
Whenperformingatriagewithpatientswhohavedifferenttypesofinjuries,theprioritiesoftheprimarysurvey(see
InitialAssessment)helptodetermineprecedence(eg,apatientwithanobstructedairwayreceivesgreaterpriority
forinitialattentionthanarelativelystablepatientwithatraumaticamputation).Intraumacenters,ateamof
providersevaluatespatientswhoarecriticallyinjuredandsimultaneouslyperformsdiagnosticprocedures(seethe
imagebelow).Thisparallelprocessingapproachcandramaticallyreducethetimerequiredtoassessandstabilizea
patientwithmultipleinjuries. [6]

Traumaresuscitationsinvolvingsimultaneousdiagnosisandtreatmentbymultipleprovidersdemandleadershipandorganizationto
functioneffectively.CourtesyofKevinKilgore,MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

Theteamapproachtotraumaisresourceintensive[7]however,theavailablepersonnelandresourcescanbecome
overwhelmedquicklyinnonhospitalsettings,insmallerinstitutions,andinmasscasualtysituations.Underthese
conditions,additionalfactorsaffectthetriageprocess,includingthenumberandskilllevelsofavailableproviders,

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theavailableequipment,andtheprovider'sestimateoftheclinicalprobabilityofeachpatient'ssurvival.Thetriage
objectivebecomeshowtomaximizethenumberofpatientswhoaresalvagedundertheprevailingconditions.This
processcanresultinbypassingseriouslyinjuredpatientsuntillesscriticalpatientshavebeenstabilized.Triage
underconditionsoflimitedresourcesisdifficult. [8]
Regardlessoftheclinicalsetting,thecareteamshouldbeorganizedbeforepatientarrival.Leadershipandunityof
commandareessentialfordirectingarapidandefficientworkup.Inlargerinstitutionswithdedicatedtrauma
services,generalsurgeonsformthecoreofthetraumateaminclosecooperationwiththeemergencydepartment
staff.Aphysicianfromeitherservicewhoisexperiencedinthecareoftraumapatientsservesastheteamleader
anddirectsevaluationandresuscitation.
Additionalphysiciansormidlevelprovidersareresponsibleformanagingtheairway,conductingtheprimaryand
secondarysurveys,andperformingotherproceduresasneeded.Nursesandtechniciansmonitorvitalsigns,gain
intravenous(IV)access,andobtainbloodsamples.Respiratorytherapistsandradiologytechnologistsshouldalso
bepresent.Asconsultants,neurosurgeonsandorthopedicsurgeonsmustbeavailableimmediatelytothetrauma
team.Earlyconsultationwithaneurosurgeonismandatorywhensignificantcentralnervoussysteminjuryispresent.
Specificproceduresperformedbybothneurosurgeonsandorthopedistscanbelifesaving.

InitialAssessment
[#target9]Theinitialevaluationfollowsaprotocolofprimarysurvey,resuscitation,secondarysurvey,andeither
definitivetreatmentortransfertoanappropriatetraumacenterfordefinitivecare. [4]Thisapproachistheheartof
theATLSsystem,whichisdesignedtoidentifylifethreateninginjuriesandtoinitiatestabilizingtreatmentina
rapidlyefficientmanner.Absolutediagnosticcertaintyisnotrequiredtotreatcriticalclinicalconditionsidentified
earlyintheprocess.Whenresourcesarelimited(eg,oneclinician),donotperformsubsequentstepsintheprimary
surveyuntilafteraddressinglifethreateningconditionsintheearliersteps.

Primarysurvey
ThestepsoftheprimarysurveyareencapsulatedbythemnemonicABCDE(airway,breathing,
circulation/hemorrhage,disability,andexposure/environment).
Theairwayisthefirstpriority.Assessitbydeterminingtheabilityofairtopassunobstructedintothelungs.Critical
findingsincludeobstructionoftheairwayduetodirectinjury,edema,orforeignbodiesandtheinabilitytoprotect
theairwaybecauseofadepressedlevelofconsciousness(seetheimagebelow).Treatmentsimplymaybe
secretioncontrolwithsuctioningormayrequireendotrachealintubationorplacementofasurgicalairway(eg,
cricothyroidotomy(seethevideobelow),emergenttracheostomy). [9,10]

Establishmentofadefinitiveairwaymayrequireemergencyplacementofasurgicalairwaywhenfacialtraumaprecludes
orotrachealintubation.CourtesyofKevinKilgore,MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.
SurgicalcricothyroidotomySeldinger.VideocourtesyofThereseCanares,MD,andJonathanValente,MD,RhodeIslandHospital,
BrownUniversity.

Next,evaluatethebreathingtodeterminepatientabilitytoventilateandoxygenate.Criticalfindingsincludethe
absenceofspontaneousventilation,absentorasymmetricbreathsounds(consistentwitheitherpneumothoraxor
endotrachealtubemalposition),dyspnea,hyperresonanceordullnesstochestpercussion(suggestingtension
pneumothoraxorhemothorax),andgrosschestwallinstabilityordefectsthatcompromiseventilation(eg,flailchest,
suckingchestwound).Treatpneumothorax,hemothorax,tensionpneumothorax,andsuckingchestwoundswitha
tubethoracostomy.Initialtreatmentforaflailchestismechanicalventilation,whichfrequentlyisrequiredforother
injuriesassociatedwithventilationandoxygenationdeficits.
Evaluatethecirculationbyidentifyinghypovolemia,cardiactamponade,andexternalsourcesofhemorrhage.
Inspectneckveinsfordistensionorcollapse,determinewhetherthehearttonesareauscultated,anddetermine
whethertheexternalhemorrhageisidentifiedandcontrolled.Initiatetreatmentofhypovolemiabyrapidlyinfusinga
lactatedRingersolutionvia2largebore,peripheral,IVcatheters.Placethempreferentiallyintheupperextremities.
Treatcardiactamponadebypericardiocentesis,orplaceasubxiphoidpericardialwindow,followedimmediatelyby
surgerytoexploreandrepairthesourceofbleeding. [11]Controlanyexternalbleedingwithdirectpressureor
surgery.
Determinethedisabilityofthepatientbyperforminggrossmentalstatusandmotorexaminations.Determine
whetheraseriousheadorspinalcordinjuryexists.AssessthegrossmentalstatususingtheGlasgowComaScale
(seetheGlasgowComaScalecalculator).Examinethepupilsforsize,symmetry,andreactivenesstolight.Obtain
anearlyassessmentofspinalcordinjurybyobservingspontaneousmovementoftheextremitiesandspontaneous
respiratoryeffort.
Pupillaryasymmetryordilation,impairedorabsentlightreflexes,andhemiplegiaorweaknesssuggestimpending
herniationofthecerebrumthroughthetentorialincisuraduetoanexpandingintracranialmassordiffusecerebral
edema. [12]Thesefindingsindicatetheneedforemergencytreatmentofintracranialhypertension,including
administrationofIVmannitol,hypertonicsaline,sedatives,andmusclerelaxants,afterobtainingadefinitiveairway.
Urgentneurosurgicalconsultationismandatory.
Intheabsenceofadepressedlevelofconsciousness,paraplegiaorquadriplegiaindicatesspinalcordinjury.
Possibilityofaspinalcordinjuryrequiresfullspinalimmobilization.Ifinspiratoryeffortsareweakorwhenahigh

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cervicalcordlesionissuspected,performanendotrachealintubation. [13,14]
Thefinalstepintheprimarysurveyincludespatientexposureandcontroloftheimmediateenvironment.
Completelyremovepatientclothesforathoroughphysicalexamination.Simultaneously,initiatetreatmentto
preventhypothermia,aconditionthatisfrequentlyiatrogenicintheexposedpatientinanairconditionedemergency
department.TreatprophylacticallywiththeadministrationofwarmedIVfluids,blankets,heatlamps,andwarmed
aircirculatingblanketsasneeded.

Otherprocedures
Performseveralmonitoringanddiagnosticadjunctsinconcertwiththeprimarysurvey. [4]PlaceECGandventilatory
monitoringleads,andstartcontinuouspulseoximetryassoonaspossible.Monitorsprovidedatathatarecriticalto
guidingresuscitation.Ifthepatientrequiresanartificialairway,performagastricintubationtodecompressthe
stomachandtolessenthelikelihoodofaspirationofgastriccontents.Duringtheresuscitationphase,inserta
urinarycathetertofacilitatemeasuringtheresponsetofluidresuscitation.PlacementofaFoleycatheteris
contraindicatedifurethralinjuryisevident.Signsofurethralinjuryincludebloodatthemeatus,ecchymosisinthe
scrotumorlabiummajora,orahighridingprostate,whichcanbeidentifiedduringarectalexamination.Anyof
thesefindingsmandatearetrogradeurethrogramtoexcludeurethralinjurypriortobladdercatheterization.

ResuscitationandComprehensiveAssessment
ResuscitationPhase
Duringtheprimarysurvey,whenmakingdiagnosesandperforminginterventions,continueuntilthepatientcondition
isstabilized,thediagnosticworkupiscomplete,andresuscitativeproceduresandsurgeriesarecomplete.This
ongoingeffortinvolvesmonitoringpatientvitalsigns,protectingtheairwaywithassistedventilationandoxygenation
asrequired,andprovidingresuscitationwithIVfluidsandbloodproducts.
Patientswithmultipleinjuriesmayrequireseverallitersofcrystalloidoverthefirst24hourstosustainintravascular
volume,tissueandvitalorganperfusion,andurineoutput.Administerbloodforhypovolemia,whichisunresponsive
tocrystalloidbolus. [15]Ifongoingbloodlossisnotcontrolledbydirectpressureandtransfusionwithbloodorblood
products,surgeryorimagingbasedproceduresmayberequiredtoattainhemostasis.Theendpointsofresuscitation
arenormalvitalsigns,absenceofbloodloss,adequateurineoutput(0.51cc/kg/h),andnoevidenceofendorgan
dysfunction.Parameters,suchasbloodlactatelevelsandbasedeficitonanarterialbloodgas,maybehelpfulwith
patientswhoareseverelyinjured. [16]
Anabundanceofstandardvitalsigndataguidesevaluationandresuscitationoftheinjuredpatient.
TheCommitteeonTraumafortheAmericanCollegeofSurgeonshaslongpublishedcategoriesofshockthatallow
thecliniciantopredictthelikelihoodofsignificantbloodlossandtoanticipatethetypeandamountoffluid
requirements. [4]
Theshockclassification,asshownintheTablebelow,allowsthecliniciantocharacterizethepatientsresponseto
injury,asbloodlossassociatedwithinjuryprogresses,mentalstatusdeteriorates,heartrateincreases,blood
pressurefalls,andoliguriaisapparent. [4]Thepatientwithpersistentvitalsignevaluationsuggestinghypotensionis
atsignificantriskforlossof3040%ofbloodvolumeonpresentation.
Table.EstimatedFluidandBloodLossesBasedonPatientsInitialPresentation[4](OpenTableinanewwindow)
ClassI

ClassII

ClassIII

ClassIV

Upto750

7501500

15002000

>2000

BloodLoss(%bloodvolume) Upto15%

1530%

3040%

>40%

PulseRate

<100

>100

>120

>140

BloodPressure

Normal

Normal

Decreased

Decreased

PulsePressure(mmHg)

Normalorincreased Decreased

Decreased

Decreased

RespiratoryRate

1420

2030

3040

>35

UrineOutput(mL/h)

>30

2030

515

Negligible

CNS/MentalStatus

Slightlyanxious

Mildlyanxious Anxious,confused

BloodLoss(mL)

FluidReplacement(3:1rule) Crystalloid

Crystalloid

Confused,lethargic

Crystalloidandblood Crystalloidandblood

SecondarySurvey
Formallybeginthissurveyaftercompletingtheprimarysurveyandafterstartingtheresuscitationphase.Atthis
time,identifyallinjuriesbyconductingathoroughheadtotoeexamination.
Reviewthepatient'svitalsigns,andperformaquickrepeatoftheprimarysurveytoassesspatientresponsetothe
resuscitationeffortandtoidentifyanydeterioration.
Then,reviewthepatient'shistory,includingreportsfromprehospitalpersonnelandfromfamilymembersorother
victims.
Ifthepatientisableorotherinformationsourcesareavailable,collectcriticaldata,includingpreexistingmedical
problems,currentmedicationsandallergies,tetanusimmunizationstatus,timeoflastmeal,andeventssurrounding
theinjury.Thesedataassistwithfocusingthesecondarysurveybyidentifyingthemechanismofinjury,the
likelihoodofcoldorheatinjury,andthepatient'sgeneralphysiologicstatus.

SubsequentPhysicalExamination
Thedictum"fingersortubesineveryorifice"guidesthisexamination.
Examineeachregionofthebodyforsignsofinjury,bonyinstability,andtendernesstopalpation.

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Evaluatetheheadandfaceformaxillofacialfractures,ocularinjury,andanopenorclosedheadinjury,includinga
basilarskullfracture.

Periorbitalecchymosis,or"raccooneyes,"isaclassicdiagnosticsignofbasilarskullfracture.CourtesyofKevinKilgore,MD
CarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

Performadetailedcranialnerveexaminationaspartofathoroughneurologicevaluation.
Inspecttheneckanteriorlyforevidenceofairwayorgreatvesselinjury,andpalpateposteriorlyforbonyabnormality
ortendernesssuggestiveofcervicalspineinjury.
Inpatientswithblunttraumaandpatientswithanunknownmechanismofinjury(eg,"founddown"),observefull
spineprecautionsuntilinjurytothespinalcolumnisexcluded.

Chestexamination
Palpatethechestwallfortenderness,instability,orcrepitation,followedbyauscultationofthelungsandheart.
Inthepatientwithpenetratingtrauma,performathoroughsearchforadditionalentryorexitwounds,including
examiningtheaxillaeandback.
Assesschesttubesforoutputandairleaks,andusetheportablechestxraytoevaluateforbonyabnormalities,
persistentpneumothorax,evidenceofmediastinalinjury,andplacementoftubesandlines.

Abdomenandpelvisexamination
Inspecttheabdomenfordistensionorotherevidencesuggestinggrossintraabdominalbleedingorinjury.
Inpatientswithpenetratingtrauma,locallyexplorelowvelocitywoundstodetermineifthemuscularfasciais
penetrated.
Urgentlyexplorehighvelocitypenetratinginjuriesintheoperatingroom.
Palpatetheiliaccrestsonceforinstabilitytodetectsignificantpelvicfractures.Useaportableanteroposterior(AP)
radiographtoaidindetectingthesefractures.Ifafractureisdiagnosed,avoidadditionalmanipulationofthepelvis
topreventexacerbationofpelvicbleeding,whichisnotoriouslydifficulttocontrol. [17]
Inspectforevidenceofbleeding(ecchymosis)ontheperineum,grossbloodonthevaginalandrectalexaminations,
andurethralinjury,followedbyplacementofaFoleycatheter.
Inpatientswithasuspectedspinalcordinjury,recordtheanalsphinctermotortone.

Extremityevaluation
Inthisevaluation,identifylongbonefracturesthatrequirestabilization,maycausevascularcompromise,andshow
evidenceofamajornerveinjury.
Performplainxrayfilmstoidentifydeformity,tenderness,orinstability.
Conducttemporarysplintstabilizationpriortomovingthepatientfromtheemergencydepartment.
Immediatelyactonanyevidenceofvascularcompromise,sinceischemicinjurytoanextremitycanbecome
irreversibleinhours.

Neurologicexamination
Theelementsoftheneurologicexaminationfrequentlyarecompletedduringtheregionalportionsofthesecondary
surveyhowever,includeaformalassessmentofthespinetocompletetheneurologicassessment.
Logrollthepatientwithinlinestabilizationoftheheadandneck.
Inspecttheentirespinefromtheocciputtothesacrumforbonyabnormalities,deformities,andtenderness.Atthe
sametime,performadetailedsurveyofthebacktoidentifypenetratinginjuries,ecchymoses,orotherinjuries.Back
injuriesfrequentlyaremissed.

ImagingandLaboratoryStudies
Radiographicimagingstudiesprovidecrucialdiagnosticdatathatguidetheinitialevaluation.Thesequenceand
timingofthesestudiesareimportant.Stagetheimagingstudiessothatlifesavinginterventionsidentifiedinthe
primarysurveyandresuscitationphasesarenotimpeded.Also,ensurethatthepatientishemodynamicallystable
enoughfortransfertotheradiologysuite.

Anteroposteriorradiographs
TheAPchestradiographisthemostcommonimagingstudyperformedontraumapatients.Itcanbeeasily
obtainedduringtheresuscitationphase,anditprovidesinformationonthepresenceofahemothorax,
pneumothorax,orpulmonarycontusion.TheAPchestradiographalsoaidsintheplacementofchestand
endotrachealtubes,whicharecriticaltotheresuscitationeffortandtheprimarysurvey. [18]

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Thischestradiographdemonstratesbilateralpulmonarycontusionsinatraumapatient.CourtesyofKevinKilgore,MDCarson
Harris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

Forpatientswithblunttrauma,aportableAPpelvisfilmcaneasilybeobtainedduringtheresuscitationphase.This
filmcanhelpconfirmthepresenceofsignificantpelvicfractures(asdepictedintheimagebelow),whichareoften
thesitesofhemorrhagethatrequireexternalfixationand/orangiographicembolizationforcontrol.

Theanteroposteriorpelvisradiographquicklyhelpsidentifymajorpelvicfracturesandjointdisruptions.CourtesyofKevinKilgore,
MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

Focusedabdominalsonogram
Thefocusedabdominalsonogramfortrauma(FAST)complementstheportablechestandpelvisfilms. [19]Atrauma
clinicianwhohasbeenformallytrainedinthetechniquequicklyandeasilyperformsthisportableultrasound
examinationinthetraumaresuscitationroom.Itisusedtoidentifyfreefluidintheperitonealcavity,pericardial
effusion,hemothorax,andpneumothorax. [19]Becauseofitsspeed,sensitivity,andnoninvasivecharacter,FAST
largelyhassupplantedothertechniquesforrapidassessmentofunstabletraumapatients.Thistechniquerequiresa
majorcommitmenttoattainproficiencytherefore,itisnotfrequentlyusedoutsideofmajortraumacenters. [20,21]
Generally,donotperformdiagnosticstudiesifthecapabilitytoactontheinformationgainedisnotimmediately
present.Forexample,patientswithblunttraumainitiallytransportedtosmallruralemergencydepartments
frequentlyhaveindicationsforadvancedimaging.Ifanappropriatelytrainedsurgeonisnotpresentintheinstitution,
thenthesestudiesareofquestionablevalue,sincetheymaydelaythetransferofthepatienttoatraumacenter.
Consequently,stageimagingstudiesandprioritizethembasedonpatientstability,thepracticalutilityofthedatato
beobtained,andtheimperativeneedforearlytransfertoobtaindefinitivecare.

CTscan
TheCTscanisthedefinitiveradiographicstudyinmostpatientswithtrauma.CTimagingoftheabdomen,pelvis,
chest,cervicalspine,andheadisthemostsensitiveandaccuratenoninvasivediagnostictoolforidentifyingmajor
injury.BedsideassessmentofblunttraumaticinjurywasrecentlyevaluatedtoassesstheimpactofCTscans. [22]
Bedsideevaluationwaseffectiveinrulingoutseriousinjuriesinpatientswithlowriskofseriousinjury.Overall
diagnosticaccuracyofbedsideassessmentwaslow,however,suggestingthatCTbeutilizedinhighacuitypatients
toavoidmissinginjuries. [22,23]
OverrelianceonCTimagingcanbedetrimentalifemergentoperationsaredelayed.Onereviewofpatients
presentingwithhypotension(systolicBP<90mmHg)andsignificantabdominalinjurydemonstratedgreater
mortalityifsurgerywasdelayedbyaCTscan. [24]Excessiveradiationexposureisalsoaconcern. [25]

CTscanoftheabdomenidentifiessignificantsofttissueinjurywithhighsensitivityandspecificity.Atraumaticliverlacerationdueto
blunttraumawithribfragmentpenetrationintotheliverparenchymaisshown.CourtesyofKevinKilgore,MDCarsonHarris,MD
andDavidHale,MD,RegionsHospital,StPaul,Minn.

ObtainaCTscanoftheheadtoidentifyintracranialbleeding(asseenintheimagebelow)andtoguide
neurosurgicalintervention. [26]ObtainaheadCTscanfortraumawithoutIVcontrast,andperformitfirstwhen
indicated,priortotheinjectionofanIVcontrastforabdominalandpelvicscans.Manycentersscanthecervical
spineatthesamesettinginpatientsreceivingCTevaluationofthehead.

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TheheadCTscanfortraumaidentifiesspaceoccupyinglesionsanddirectsoperativeevacuation.Thelenticularshapeofthislesion
identifiesitasanepiduralhematoma.CourtesyofKevinKilgore,MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,St
Paul,Minn.

ObtainaCTscanofthechesttoevaluatemediastinalinjuries. [27]CTscanningisreplacingaortographyasthe
stateoftheartstudyforimagingmediastinalvascularstructures,particularlytheaorta. [28]CTscanningisalsomore
sensitivethanAPchestradiographyinthedetectionofpneumothorax,ribfractures,pulmonarycontusion,and
hydrothorax.Formostpatientswithtrauma,CTscansofthehead,chest,abdomen,andpelvisaresufficientto
guideoperativeandnonoperativemanagementofinjuriesintheirrespectiveregionsofthebody. [29]
CTscansoftheabdomenandpelvisusuallyareperformedtogether,usingbothIVandoralcontrast. [30]Usethis
studytoidentifyinjuriestoabdominalandpelvicorgansandtoidentifybleedingintheretroperitoneumandpelvis.
AsthequalityofCTscanscontinuestoincrease,theroleofangiographycontinuestofocustoagreaterdegreeon
interventionsratherthanondiagnosis. [31]
AgrowingvolumeofdatasupportstheaggressiveuseofCTscanningintheevaluationofblunttrauma. [32,33]For
example,abdominalinjurybecomesmorelikelywithvelocitychangesofgreaterthan20km/h.Extremesofageor
extremity,head,orspineinjuriesarepredictiveofabdominaltraumaaswell.Theabsenceofcoincidentinjury
decreasestheriskofabdominalinjury. [34]Onereviewofaorticinjuriesrevealsanincreasedriskwithlateralimpacts
andlackofseatbeltuse.Associatedinjurieswerepoorpredictors. [35]
SeveralreportsfrommajortraumacentersemphasizethevalueofCTscanningtoevaluatepenetratingtorso
injuries.Patientsrequiringhospitalizationorextendedperiodsofobservationintheemergencydepartmentmaynow
besenthomewithalategenerationCTscanthatdemonstratesthebenigntrackofabulletwoundorstabbing
injury. [36,37,38,39]Withincreasingresolution,evensmallbowelandmesentericinjuriesarenowreadilyidentified.
Theseinjurieswerepreviouslydifficulttodetectandcanbeasourceoflatemorbidityforpatients. [40]
ApracticeofearlycomprehensivemultisliceCTisrapidlyevolvinginurbantraumacenters.Thisuseofadvanced
CTtechnologyleadstoamoreaccurateandfasterdiagnosiswithareductioninresourceutilization.Whether
increasingradiationexposurewiththeuseofadvancedCTtechnologywillbecomeaclinicalandsocialissueis
unclear.

Spineevaluation
CTscanningisreplacingplainradiographsinmanypatientsbeingevaluatedforspinetrauma. [41,42]Current
scannersofferthecapabilitytoreconstructspineimagesatthesametimethatscansareobtainedofthechest,
abdomen,andpelvis. [43]Manyclinicianswillscanthecervicalspineinpatientswithotherindicationsforscansof
theheadortheheadandtorso.OrthopedicandneurosurgicalconsultantsaremakingincreaseduseofCTin
evaluationofthespine.
Obtainplainxrayfilmsofthespineinpatientswithhighenergyblunttraumaandinothertraumapatientswith
knownorsuspectedneurologicdeficitsifCTscanningisunavailableorifacomplimentaryimageisdesired. [44]
Forpatientswithalowlikelihoodofspinalinjury,defermostorallofthespinalradiographseriesuntilthe
resuscitationphaseiswellunderwayand,ifnecessary,afterperformingalifesavingemergentlaparotomy,
craniotomy,orotheroperations.
Ifagreaterthanroutineneedtoexcludecervicalspineinjuryexists,performaportablelateralcervicalspine(C
spine)filmduringtheresuscitationphase.AnadequatelateralCspinexray(eg,visualizingfromtheskullbaseto
T1)helpsidentifymostCspinefracturesandsubluxations.Ultimately,afullCspineseries(ie,AP,lateral,and
odontoidviews)mustbeperformedtoexcludeinjury,andvirtuallyalltraumaclinicianswillrequestCTifanydoubt
exists.
TheAdvancedTraumaLifeSupportcurriculumpointsoutthat,withidentificationofacervicalspinefracture,the
likelihoodofanotherbreakinthespinalcolumnis10%.ControversyexistswhethercompleteCTimagingis
sufficienttoruleoutcervicalspineinjury.Ifthepatientcannotcooperatewithaphysicalexaminationtoallowan
assessmentofligamentousstability,manycenterswillperformMRItoruleoutligamentousinjuryofthecervical
spine,evenifhighquality,multislice,multidetectorCTimagesfailtoidentifythisinjury.
ForpatientswithaneurologicdeficitbutnegativeplainfilmsandCTscans(formerlycalledspinalcordinjurywithout
radiographicabnormality),conductanMRIofthespinalcolumnandnerveroots.AnMRIisthemostsensitive
methodfordetectingthistypeofsofttissueinjury,althoughCTscanninghasbecomethestandardforacute
evaluationofthevastmajorityofspinalcolumninjuries. [14,21,45]

Angiography
Angiographycanbebothadiagnosticprocedureandatherapeuticprocedure,anditisvaluableinselectedtrauma
patients.Themostcommonindicationforemergentangiographyintraumaistoidentifyandcontrolarterial
bleedingfrompelvicfracturesorintheretroperitoneum.Contemplateemergentthoracicaorticangiographywhen
plainxrayfilmsoraCTscanofthechestrevealsevidenceofatypicalmediastinalbleeding.CTisnowthe
diagnosticmodalityandstentgraftingthetreatmentforbluntaorticinjury. [46,47,48]Inaorticinjury,angiographyis
thehistoricalstandardfordiagnosisandoperativeplanning. [48]Withsuspectedbleedingintheretroperitoneumand

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pelvis,anangiographicembolizationoftenisquickerandsaferthansurgicalapproachesinthesedifficultdifficultto
accessareashowever,thisisonlytruewitharterialbleeding,whilethemorecommoncaseofvenousbleeding
remainsadifficultmanagementproblem. [46]
Angiographyalsofacilitatesnonoperativemanagementofinjurytotheliver,spleen,andkidneyfollowingblunt
trauma.Specificcriteriaforangiographyandembolizationhavenotbeenagreedupon. [49]ACTscanofthe
abdomenwithintravenouscontrastfrequentlydemonstratesareasofactivebleeding,whichmaybetargetedbythe
interventionalradiologistinthepatientwhoissufficientlystabletotoleratethetimedelayrequiredtoobtain
angiographyandorganspecificembolizationofbleedingpoints.

Labstudiesduringtheinitialevaluation
Themostimportantlabstudyisthetypeandcrossmatch,whichoftencanbecompletedwithin20minutesof
receiptofthebloodsample.
Arterialbloodgasesarealsousefulintheinitialassessmentperiod,althoughtheiruseforserialmonitoringhas
declinedsincetheintroductionofcontinuouspulseoximetry.
Abaselinehemoglobinorhematocritdeterminationisusefulonarrival,withtheunderstandingthatinacute
hemorrhage,afallinhematocritmaynotbeapparentuntilautogenousmobilizationofextravascularfluidor
administrationofIVresuscitationfluidscommences.
Urinescreensfordrugsofabusecommonlyareorderedintraumacenters.Forsimilarreasons,checkbloodalcohol
andglucoselevelstoidentifycorrectablecausesofadecreasedlevelofconsciousness.Arecentreviewfromthe
dataoftheNationalTraumaDataBankoftheUnitedStatesrevealsadisturbingdeclineinsubstanceuse
screening,despitetheimportanceofsubstanceuseasacontributiontoinjury. [50]Earlyhyperglycemiahasbeen
linkedtoanincreasedriskofinfectiouscomplicationsandmortalityafterinjury. [51]
Formosttraumapatients,serumelectrolytes,coagulationparameters,cellbloodcounts,andothercommon
laboratorystudiesarelessusefulduringthefirst12hoursthantheyareafterstabilizationandresuscitation.

SpecialInjuries
Theforegoingdiscussionisapplicabletomosttraumapatientswitheitherblunttraumaorpenetratingtrauma
however,patientswithburns,coldinjuries,andelectricalinjurieshavespecialconsiderationsthatmustbe
addressedduringtheinitialassessmentandresuscitation.

Burns
Anearlyimperativeistostoptheburningprocess,especiallyinthecaseofchemicalburns,inwhichthecontinued
contactoftheagentwiththepatient'sskinmaynotbereadilyapparent.Thisprocessmayrequirerepeatedtesting
ofthepatient'sskin,specificchemicalneutralization,andextensivelavageoftheaffectedareas.Iffullthickness
burnsofanextremityorthethoraxaresuspected,escharotomiesmayberequiredtopreventcompartment
syndromeandimpairedventilation,respectively. [52]
Iftheclinicalhistoryorthephysicalexaminationsuggeststhatupperairwayburnsorinhalationinjurymaybe
present,thenearlyintubationandmechanicalventilationareindicated.
Finally,patientswithlargeburnsrequirelargevolumesofIVcrystalloidresuscitationfluids.Whilethisresuscitation
canbedelayedbrieflywhileperforminglifesavinginterventions,earlycommencementisbeneficial.

Coldinjuries
Thedominantimperativeisrewarming,particularlyinthecaseofsystemichypothermia,butitisequallyapplicable
tocoldinjuriestotheextremities(eg,frostbite). [53]Whilemildhypothermiaismanagedasdescribedaboveforthe
primarysurvey(seePrimarysurveyinInitialAssessment),treatseverecoldinjurieswithimmersioninwaterwarmed
to40C.AdministerIVfluidsonlyasindicated,basedonthepatient'sphysiologicstatus(notonthewoundsize).In
thecaseofseverehypothermiawithcardiacarrestand/orapnea,donotstopresuscitationeffortsuntilthepatientis
rewarmedthoroughly. [54]

Highvoltageelectricalinjuries
Althoughsometimesconsideredasburninjuries,highvoltageelectricalinjuries(eg,lightningstrikes,powerlines)
presentadifferentsetofproblems. [52]First,muchofthetissueinjuryfromelectricalinjuriesmaynotbeapparent
onphysicalexamination.Massivemyonecrosisanddamagetobothsofttissueandbonemaybeconcealedbeneath
normalappearingskinbetweentheentranceandexitwoundstherefore,maintainalowthresholdformeasurement
ofcompartmentpressuresandperformanceofdecompressivefasciotomies.Carefullyandcontinuouslymonitorthe
urineoutputforevidenceofmyoglobinuria,whichcanleadtoacuterenalfailureifuntreated.Likewise,provide
continualcardiacmonitoringtothepatientbecauseoftherisksofdirectmyocardialinjuryandhyperkalemiaarising
frommyonecrosis.

Perils,Pitfalls,andControversies
Asudden,expecteddeteriorationofaninitiallystablepatientisacommonproblemencounteredduringthecareof
multipletraumapatients.Thissituationisespeciallyproblematicafterperformingthoroughprimaryandsecondary
surveysandinstitutingaresuscitationplan.ThesolutiontothesecrisesliesintheABCs(airway,breathing,and
circulation)oftheprimarysurvey. [55]
Injuriescanevolvefromsubclinicaltoclinicallyapparentoverthecourseofarapidtraumaworkup,andeventhe
bestdiagnosticworkupisnotperfecttherefore,itisnecessarytoensurethattheairwayisclear,thatventilationis
adequate,andthatthebloodpressureandendorganperfusionaresufficient.Byrapidlyrecheckingtheelementsof
theprimarysurveyfirst,easilycorrectedproblems(eg,malpositionedendotrachealtubes,tensionpneumothorax,
unsuspectedhemorrhage)canberapidlyidentifiedandaddressed.
Nevertheless,thesurveymaymissinjuries,especiallyinseriouslyinjuredpatientswhorequireintensiveresuscitative

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and/orsurgicalprocedurestostabilize.Thistendencyisexacerbatedbythefocusedprioritiesoftheprimarysurvey
andresuscitationphase.Asimpleremedyforthisproblemisfrequentandthoroughreassessment.Performa
formaltertiarysurveywithin1836hoursafteradmission.Itconsistsofathoroughheadtotoeexaminationin
conjunctionwithareviewofalllaboratorydataandimagingstudiesobtainedsinceadmission.Whilethetertiary
surveydoesnotreducetheincidenceofinjuriesmissedduringtheprimaryandsecondarysurveys,itdecreasestheir
morbidityandmortalitybyearlieridentificationandtreatment.
Adifficultaspectoftreatingmultipletraumapatientsisprioritizingbetweencompetinginjuriesinthesamepatient.
The3examplesthatfollowillustrateclinicaldilemmasindecisionmakingfacedbysurgeonscaringfortrauma
victims.

Patient1
Arelativelystraightforwardexampleisanindividualwithaposteriordislocationofthekneejointandconcomitant
vascularcompromisebelowtheknee.Inthiscase,thecompetinginterestsaretheorthopedicrepairoftheknee
jointversustherepairofdamagedvessels,presumablyincludingthepoplitealartery.Althoughadisruptedknee
jointisclearlyanurgentproblem,especiallyifthejointspaceisopen,theshortviabilityofadevascularizedlimb(3
4h)andtheincreasingriskofcompartmentsyndromewithincreasingtimeofischemiaaretheparamountissues.
Therefore,vascularrepairusuallyisperformedfirst,followedbytheorthopedicrepair.

Patient2
Amoredifficultdilemmaoccursintheunstablehypotensivepatientwithabdominalandheadinjuries.Theneedfor
operativeexplorationandcontrolofabdominalhemorrhagemustbebalancedagainsttheneedforaheadCTscan
toidentifyandlocalizepotentiallyfatalintracranialmasslesionsforneurosurgicaldrainage.Aruleofthumbin
situationssuchastheseisthatbluntheadtraumaaloneusuallydoesnotcausehypotension,andhypovolemiais
theprobableculprit.Preservingthebloodpressureandcerebralperfusionisessentialtopreventsecondarybrain
injurythus,measurestocontrolhypotensionandintraabdominalbleedingoftenareprioritizedearlierthanhead
injuries,whichareprognosticallymoreserious.

Patient3
Afinalexampleliesinthetimingofoperativeversusangiographictreatmentofbluntpelvictraumawithknownor
suspectedhemorrhagefrompelvicfractures.Thesafetyandefficacyofangiographicembolizationmustbebalanced
againsttheknowledgethatmostcausesofpelvichemorrhagearevenousinoriginand,therefore,arenotamenable
toangiographicembolization.Furthermore,theresuscitationoftheunstablepatientismuchmoredifficultinthe
angiographysuitethanintheICU.Nosimplerulesapply,andonlythegoodjudgmentoftheseniorclinician
responsibleforthepatientcanidentifythebestapproachineachcase.

ContributorInformationandDisclosures
Author
DavidJDries,MD,MSE,FACS,FCCP,FCCMProfessorofSurgeryandAnesthesiology,JohnFPerry,Jr,
ChairofTraumaSurgery,UniversityofMinnesotaMedicalSchoolAssistantMedicalDirectorforSurgicalCare,
HealthPartnersMedicalGroup
DavidJDries,MD,MSE,FACS,FCCP,FCCMisamemberofthefollowingmedicalsocieties:AirMedical
PhysicianAssociation,AlphaOmegaAlpha,AmericanAssociationfortheSurgeryofTrauma,AmericanBurn
Association,AmericanCollegeofChestPhysicians,AmericanCollegeofCriticalCareMedicine,American
CollegeofSurgeons,AmericanMedicalAssociation,AmericanSocietyforParenteralandEnteralNutrition,
AmericanThoracicSociety,AssociationforAcademicSurgery,ChicagoMedicalSociety,EasternAssociationfor
theSurgeryofTrauma,IllinoisStateMedicalSociety,PhiBetaKappa,ShockSociety,SocietyofCriticalCare
Medicine,SocietyofUniversitySurgeons,SurgicalInfectionSociety,andWoundHealingSociety
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
ErnestDunn,MDProgramDirector,SurgeryResidency,DepartmentofSurgery,MethodistHealthSystem,
Dallas
ErnestDunn,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,American
MedicalAssociation,AssociationforAcademicSurgery,SocietyofCriticalCareMedicine,andTexasMedical
Association
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
RobertLSheridan,MDAssistantChiefofStaff,ChiefofBurnSurgery,ShrinersBurnsHospitalAssociate
ProfessorofSurgery,DepartmentofSurgery,DivisionofTraumaandBurns,MassachusettsGeneralHospital
andHarvardMedicalSchool
RobertLSheridan,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,
AmericanAssociationfortheSurgeryofTrauma,AmericanBurnAssociation,andAmericanCollegeofSurgeons
Disclosure:Nothingtodisclose.
PaoloZamboni,MDProfessorofSurgery,ChiefofDaySurgeryUnit,ChairofVascularDiseasesCenter,
UniversityofFerrara,Italy
PaoloZamboni,MDisamemberofthefollowingmedicalsocieties:AmericanVenousForumandNewYork
AcademyofSciences
Disclosure:Nothingtodisclose.

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ChiefEditor
JohnGeibel,MD,DSc,MAViceChairandProfessor,DepartmentofSurgery,SectionofGastrointestinal
Medicine,andDepartmentofCellularandMolecularPhysiology,YaleUniversitySchoolofMedicineDirector,
SurgicalResearch,DepartmentofSurgery,YaleNewHavenHospital
JohnGeibel,MD,DSc,MAisamemberofthefollowingmedicalsocieties:AmericanGastroenterological
Association,AmericanPhysiologicalSociety,AmericanSocietyofNephrology,AssociationforAcademic
Surgery,InternationalSocietyofNephrology,NewYorkAcademyofSciences,andSocietyforSurgeryofthe
AlimentaryTract
Disclosure:AMGENRoyaltyConsultingArdelyxOwnershipinterestBoardmembership

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