1/29/2015 ThePolytraumatizedPatient

ThePolytraumatizedPatient
Author:ChatVDang,MDChiefEditor:MaryAnnEKeenan,MDmore...

Updated:Jul11,2013

Overview
Traumaistheleadingcauseofdeathforpeopleaged144yearsandisexceededonlybycancerandatherosclerotic
diseaseinallagegroups.Orthopedicsurgeryplaysakeyroleinthetreatmentofthepolytraumatizedpatient.Ina
studyatBrownUniversity,gunshotwounds(seeimagesbelow)requiredmoreorthopedictraumaresourcesthan
othersurgicalareas. [1]Theorthopedicsurgeonisamemberofateamconsistingofmanyspecialists,including
emergencymedicinephysicians,traumasurgeons,neurosurgeons,andothersurgicalsubspecialists.Eachperson
onthatteamshouldbefamiliarwiththebasicsoftraumaresuscitations,outlinedbelow. [2,3]

AllresuscitationsshouldbeperformedusingAdvancedTraumaLifeSupport(ATLS)guidelines. [4]Fortheindividual
physician,assessmentofthepolytraumatizedpatientisperformedusingastepwiselongitudinalapproach,inwhich
theairwayishandledfirstandnoproceduresareinitiateduntiltheairwayissecured.Then,breathingandcirculation
areaddressed.Inthetraumateamapproach,eachteammembershouldbeassignedaspecifictaskortasksso
thateachofthesecanbeperformedsimultaneouslytoensurethemostrapidtreatmentpossible. [5]

Birdshotfromashotgun.

Birdshotfromashotgun.

PrimarySurvey
Assessment
Intheprimarysurvey,airway,breathing,andcirculationareassessedandimmediatelifethreateningproblemsmust
bediagnosedandtreated.AneasytoremembermnemonicisABCDE:airway,breathing,circulation,disability,and
exposure/environmentcontrol.

Theprimarysurveyusuallytakesnolongerthanafewminutes,unlessproceduresarerequired.Theprimarysurvey
mustberepeatedanytimeapatient'sstatuschanges,includingchangesinmentalstatus,changesinvitalsigns,or
theadministrationofnewmedicationsortreatments.

Airway(withCervicalSpineProtection)

Anobstructedairwayisoneofthemostimmediateanddeadliestthreatstolife.Thegoalsaretoprovideapatent
airwaywhilemaintaininginlinecervicalstabilizationandtoprotecttheairwayfromfutureobstructionbyblood,
edema,vomitus,orotherpossiblecausesofblockage.

Diagnosis

Askthepatientaquestionforexample,askhowheorsheisfeeling.Ifthepatientrespondsverbally,heor
shehasanintactairway,isbreathing,isthinking,and,therefore,hasapulse.Also,thepatient'slevelof
consciousnesscanbebrieflyassessed.
Ifthepatientisunresponsive,checkairwaypatencybylookingatthepatient'schestwhileleaningtheear
towardthepatient'smouth.Lookforchestexpansion,listen,andfeelforairmovement.Thismaybe
performedwhileusingthejawthrust(orheadtilt/chinliftmaneuverifcervicalinjuryhasbeenruledout).
Anticipatepotentialproblems.Ifthepatientisbreathingspontaneously,listentothequalityofthebreathing.
Snoringorgurglingsuggestspartialairwayobstruction.Ahoarsevoice,subcutaneousemphysemaofthe
anteriorpartoftheneck,orapalpablethyroidcartilagecrepitusmayindicatelaryngealtrauma.
Assesstheabilityofanunconsciousvictimtoprotecttheairwaybycheckingthegagreflex.Touchthe
posteriorpharynxwithatonguebladetoinitiatethegagresponse.Ifthepatientisalert,thebestwayto
checkfortheabilitytoprotecttheairwayistowitnessswallowing.Patientswithoutagagreflexcannot
protectthemselvesfromaspiratingsecretionsintothelungsthesepatientsshouldbeintubated.

Treatment

Thejawthrustmaneuvermaybenecessary.Themostcommonairwayobstructionisduetothebaseofthe
tonguefallingbackwardintotheposteriorpharynx.Thejawthrustisperformedbyplacingthefingersbehind

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theangleofthemandibleandliftinganteriorly.Thisisuncomfortableandmayawakenanobtundedpatient.
Apossiblealternativetothejawthrustisthechinliftmaneuver.Thechinofthepatientisliftedsuperiorly,
hyperextendingtheneckandopeningtheairway.Thisisdangerousintraumapatientsbecauseitmay
exacerbateacervicalspineinjury.Itsuseisrestrictedtothosepatientsinwhomcervicalspineinjuryhas
beenexcluded.
Removeanyforeignbodiesthatareseen,includingdentures.Donotperformablindmouthsweepbecause
thismaypushtheblockingobject(s)fartherdownthepharynx.
Suctiontoremovesecretionsandblood.
Anoropharyngealairwayisforuseonlyinunconsciouspatients.Itiseasytoinserttoensureairwaypatency
whileusingabagvalvemask("bagging"thepatient)orwhilepreparingforendotrachealintubation.
Anasopharyngealairwayisusefulinpartiallyconscious,intoxicated,orseizingpatientstoensureapatent
airway.Itiscontraindicatedinpatientswithfacialtraumaorcoagulopathy.
Alaryngealmaskairwayisanairwaydeviceinsertedthroughthemouth,withamaskthatcoversthelarynx.
Itcomesindifferentsizes,socheckthepackagetochoosetheappropriatesizefortheweightofthepatient.
Afterinflatingthecuff,theairwayissecured.Alaryngealmaskairwayisveryeffectiveasarescueairway,
butitdoesnotprotectthepatientfromaspirationandshouldbeconsideredonlyatemporarymeasureuntil
definitiveairwaymanagementispossible.

Definitiveairwaymanagement

Definitiveairwaymanagementachievesthe3P's:airwaypatency,aspirationprotection,andpositivepressure
ventilation.

Orotrachealintubationisthecriterionstandardofairwaymanagement.Anendotrachealtubeisplaced
betweenthevocalcordsunderdirectvisualization.Immediatelyafterward,thephysicianmust(1)check
breathsoundsbilaterally,(2)checkforgastricdistention/borborygmi,(3)checkforexhaledcarbondioxide
usinganendtidalcarbondioxidedetector,(4)ensurethattheoxygensaturationbypulseoximetryremains
at95100%,and(5)obtainachestradiographtoconfirmproperpositioningofthetip23cmabovethe
carina.
Nasotrachealintubationisindicatedforaspontaneouslybreathingpatient.Itmaybeassociatedwith
bleedingfromtraumatothenasalpassages,butonceinplace,itisbettertoleratedbyanawakepatient
becauseitismorecomfortableandlesslikelytoinducevomitingthanorotrachealintubation.Itis
contraindicatedinpatientswithfacialtraumaorbasilarskullfractures.Checktubeplacementafterward,as
withtheorotrachealtube.
Surgicalairwayisusuallyalastresortandisindicatedwhenorotrachealintubationisunsuccessful,
obstructionofthetrachea(byedema,blood)iscomplete,ortheairwayistotallytransected.Surgical
cricothyroidotomyisindicatedinpatientsolderthan512years.Needlejetinsufflationmaybeusedin
pediatricpatientsbyexperiencedpersonel.

Intubationcanbeextremelydifficultinthetraumasetting.Inlinecervicalstabilizationmustbemaintained,andthe
airwayfrequentlyisobscuredbyedema,blood,orvomitus.

Intubationmaybeperformedwithoutmedicationinpolytraumatized,obtunded,orcomatosepatients.Sedationwith
etomidatemaybesufficienttorelaxthemusclesofthejawandneck.Rapidsequenceintubationwithparalyticsis
usedwithadequateprecautionsbecauseparalyzingthepatientmeansheorshecannotbreatheindependentlyor
protecttheairwayifintubationisunsuccessful.

Anytimeintubationisconsidered,failureisapossibility.Prepareforthisinevitablesituationbyhavingbackup
personnelorairwaydevicesandacricothyroidotomytrayavailable.Lackofanairwayisoneofthefewsituationsin
medicineinwhichsecondscount.

Adjunctstoorotrachealintubation

Ifadifficultairwayispredictedormultipleattemptsatlaryngoscopicintubationhavefailed,thefollowingadjuncts
maybeusefulinperformingintubation:

Fiberopticintubation:Afiberopticscopeisinsertedandguidedunderdirectvisualizationintothelarynx,and
thentheendotrachealtubeisfedoverit.
Retrogradeintubation:Puncturethecricothyroidmembranewithalargeboreneedleaimedcephalad,and
thenfeedtheguidewirethroughuptothemouth.Feedtheendotrachealtubedowntheguidewire,whichis
heldtautatbothends.
Lightwand:Alightedstyletassemblyisinsertedblindlyintothemouth.Whenthetipisvisible
transilluminatingthroughthecricothyroidmembrane,itisinthecorrectlocationandtheendotrachealtubeis
feddownthestylet.

Cervicalspineprotection

Thephysicianmustassurethatinlinecervicalstabilizationismaintainedforanypatientwithsuspectedor
confirmedcervicalspinefracture.Themechanismofinjurymustbeconsideredtopredictdangertothecervical
spine.Ahistoryoftheabilitytowalkormoveall4limbsfollowinganinjurydoesnotruleoutthepossibilityofan
unstablecervicalspinefracture.Anypatientswithfacialinjuries,significantblunttrauma(includingfallsandmotor
vehicleaccidents),orneurologicdeficitsmustbeassumedtohaveacervicalinjuryuntilprovenotherwise.

Protectionisinitiallyprovidedbyholdingtheheadinaneutralpositionfacingforward.Itcanbetemporarily
maintainedwithahardcervicalcollarandtapingoftheforeheadtothegurneytopreventrotationwithinthecollar.
Whenintubatingapatientwithpossiblecervicalspineinjury,theheadiskeptinaneutralposition.Thepatientmust
lieimmobilewithahardcollarinplaceuntilvertebralorspinalcordinjuryisexcludedclinicallyorwithradiography
(seeCervicalspineclearance).Precautionsagainstdecubituspressureinjurymustbetaken.

Breathing

Anyimmediatelifethreateningobstaclestobreathing,namelytensionpneumothorax,openpneumothorax,flail
chest,ormassivehemothorax,mustbeidentifiedandtreatedquickly.

Diagnosis

Watchthepatientbreathe,listentothelungs,andfeelwithbothhandsforequalbilateralchestexpansion.
Lookattheskin,lips,andtongueforcyanosis.
Monitorthepulseoximetryhowever,rememberthatpulseoximetrycanbeunreliableinpatientswithpoor
peripheralperfusionaftertrauma.Arterialbloodgassamplingmaybeindicated,whichallowsamore
accuratereadingoftheoxygenation,aswellascarbondioxideeliminationandacidbasestatus.

Treatment

Oxygenat610L/minviaanonrebreathingfacemaskisindicatedforpolytraumapatientsabletomaintain
theairwayandbreathe(ventilate).Bewareofpotentialforvomiting.
Ventilatethepatientwithrescuebreaths,abagvalvedevice(baggingthepatient),oraventilator.

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Treatopenpneumothorax,tensionpneumothorax,flailchest,andmassivehemothorax.

Openpneumothorax(suckingchestwound)

Anychestwoundwithadiameterofmorethantwothirdsofthetracheacanbecomeasuckingchestwound.Air
movespreferentiallythroughthewoundorificeratherthanthroughthetrachea(duetolessairflowresistance),and
theipsilaterallungdeflates.Emergencytreatmentiswithabandagetapedon3sidessothataircanescapebut
cannotbesuckedintothechest,followedassoonaspossiblebytubethoracostomy.

Tensionpneumothorax

Tensionpneumothoraxisadeadlyconditioninwhichadefectinthelungallowsairintothepleuralspacebutdoes
notallowairtoescape.First,thelungcollapses,buteventually,thepressureinsidethehemithoraxbuildsupand
pushesthemediastinumintotheoppositehemithorax.Thecontralaterallungiscompressed,andthegreatvessels
maybekinked.Severeperfusionventilationmismatchensues,andthepatientmaygointoshockinminutes.
Tensionpneumothoraxfrequentlyiscausedbypositivepressureventilationwithalunginjury,butitcanresultfrom
anythoracictrauma.

Tensionpneumothoraxisaclinicaldiagnosisdonotwaitforradiographs.Theclassicsignsoftension
pneumothoraxarechestpain,respiratorydistress,shockrefractorytofluidsandpressors,decreasedbreathsounds
andtympanyoftheaffectedhemithorax,jugularvenousdistension,cyanosis,andtrachealdeviationtotheopposite
side.However,becausetheclassicsignsmaybehardtodetect,suspecttensionpneumothoraxinanypatientwho
ishypoxicorinshock,especiallyifthepatienthasaircrepitusorevidenceoftraumatotheipsilateralchestwall.
Auscultationmaybedifficultinanoisytraumaresuscitation,breathsoundscanbetransmittedfromtheopposite
side,jugularvenousdistentionmaybeabsentinthepresenceofhypovolemia,andtrachealdeviationisalatesign.

Treatmentisa16gaugeneedleinsertedintothesecondintercostalspaceinthemidclavicularlinetoimmediately
decompressthethorax,quicklyfollowedbychesttubeinsertionintothefifthintercostalspaceinthemidclavicular
linetoreexpandthelung.

Flailchest

Flailchestisdefinedas3ormoreconsecutiveribsfracturedat2sites.Thiscreatesafloatingsectionofchestwall
thatdoesnotmovewiththeribcageduringventilation.Flailchestmaybeassociatedwithhypoxiasecondaryto
severeunderlyinglungcontusion,resultinginsignificantmorbidityandmortality.

Traumatothechestwallandlungscauseshypoxiainanumberofways.Ribpainfromcontusionorfracturemay
causethepatienttoholdthecheststill,whichcauseshypoventilation.Paradoxicalbreathingmaybeobservedwhen
multiplecontinuousribfracturescausetheinjuredsegmentofthechesttonolongerexpandwithinspirationbut
collapseinward.Pulmonarycontusioncausesextravasationoffluidandbloodintothealveoli,limitingoxygen
diffusion.

Flailchestisaclinicaldiagnosis.Thephysicianmust(1)maintainahighindexofsuspicioninanythoracicinjury,(2)
begintreatmentimmediately,and(3)confirmthediagnosisassoonaspossiblewithchestradiography.Treatment
involvesmaximizingoxygenationofthelungs,usingpositivepressureventilationifnecessary.Effectivepaincontrol,
includingopiatesandintercostalnerveblocks,isimportanttopreventsplintingandfurtherhypoxia.Judiciousfluid
managementisrequiredtoavoidturningpulmonarycontusionintopulmonaryedema.Sandbags,tapingthechest,
orotherhistoricalmethodsofexternalsplintingarenotindicatedandcanworsenrespiratorydistress.

Massivehemothorax

Asmallhemothoraxdoesnotcompromisebreathing,butamassivehemothoraxcancauseproblemswithbreathing
andcirculation.Severallitersofbloodcanbeexsanguinatedintoeachhemithorax.Massivehemothoraxisdefined
as1500mLofbloodinthechestcavity,usuallycausedbydisruptionofanintercostalsystemicorhilarvessel.

Clinically,amassivehemothoraxcanmanifestwithbothrespiratoryandcirculatorycollapse.Breathsoundsare
reduced,andpercussionisdullontheaffectedside.Thechestcanaccommodatetheentirecirculatingvolumeof
bloodtherefore,hemorrhagicshockmaybesevere.

Treatmentisevacuationofbloodwithalargebore(3640F)chesttubeandcollectionofbloodforpossible
autotransfusion,whileintravascularvolumeisreplacedintravenouslywithfluidsandblood.Patientswhocontinueto
bleed,definedasaflowof200mL/hfor24hours,orwhopersistentlyneedbloodtransfusionsmayrequirea
thoracotomytocontrolthebleedingvessel.

CirculationandHemorrhageControl

Diagnosis

Thelevelofconsciousness,skintemperatureandcolor,nailbedcapillaryrefilltime,andrateandqualityof
thepulsesareallclinicalmarkersforbloodcirculationandtissueperfusion.
Identifyandcontrolexternalbleedingwithdirectpressure.Includealogrollofthepatienttoidentifyposterior
bleeding.
Cardiacandbloodpressuremonitoringisinstituted.
Drawbloodforbasiclaboratorystudies,includinghematocritandapregnancytestforallfemalesof
childbearingage.

Treatment

Resuscitatewith2largebore(14to16gauge)intravenouscatheters,usingwarmedfluidsandpackedRBCs
ifnecessary.
Controlhemorrhage.
Treatcardiactamponade,cardiacarrest,andmassivehemothoraxconsiderimmediateresuscitative
thoracotomy.
Usetheleftlateralrecumbentpositionforpregnantpatientsatmorethan20weeksofgestation.Ifthis
positioningisimpossible,pushtheuteruslaterallytorelievepressureontheinferiorvenacava,whichmaybe
responsiblefordecreasedvenousreturn.

Fluidandbloodresuscitation

Allpatientswhoexperiencetraumashouldhave2largeboreperipheralintravenouslinesplacedintheprimary
survey.Shockshouldbetreatedwithrapidinfusionofwarmedisotonicfluids(eithernormalsalineorlactatedRinger
solution).Young,previouslyhealthypatientswhoundergotraumacanbeadministered2L(or20mL/kginpediatric
patients)immediately.Olderpatients,especiallythosewithcongestiveheartfailureorrenalfailure,shouldreceive
smallerboluses(250500mL)topreventfluidoverload.Assesstheresponsetoresuscitationbymonitoringvital
signs,clinicalstatus,basedeficit,andserumlactatelevels.Patientswhodonotimproveshouldreceivecross
matchedpackedRBCswithmorefluids.Ifinextremis,unmatchedOnegativebloodisusedforfemalepatientsof
childbearingage.0Rh+bloodisacceptableformalepatients(seeBloodtransfusions).

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Hemorrhagecontrol

Duringtheprimarysurvey,thephysicianidentifiesandcontrolsserioussourcesofbleeding.Evensofttissueand
musculoskeletalinjuriescaninvolvemajorvesselsandcancauselifethreateningexanguination.Externalbleedingis
treatedwithdirectpressure.Useofhemostatsistobeavoidedasblindclampingcancausedamagetoadjacent
vesselsornerves.Tourniquetsshouldbeconsideredonlyinlimitedcircumstances(eg,traumaticamputation).
Quickclot,abiologicallyandchemicallyinertzeolitepowder,hasbeenapprovedbytheUSFoodandDrug
Administrationtocontrolbleedinginexternalwounds.Itpromotescoagulationbyabsorbingwater,butitproduces
anexothermicreactionthatcouldresultinburns.

Intraabdominalhemorrhageisacommonlifethreateningsourceofbleeding,anditmustbeconsideredinany
hypotensivepatient.Besidessplenicruptureandextensivehepaticlacerations,majorvascularinjuriescouldbethe
culprit.Directsurgicalcontrolofthebleedingintheoperativeroomisanintegralpartofshockresuscitationof
patientswhodonotrespondtotheinitialfluidinfusion(nonresponders).Intraabdominalbleedingcanbeassessed
quicklywithfocusedabdominalsonographyfortrauma(FAST)(ordiagnosticperitoneallavage(DPL)if
ultrasonographyisnotavailable).

Fracturescancauseseriousbleeding.Tibiaandhumerusfracturesmaybeassociatedwithupto750mLofblood
loss,femurfractureswithupto1500mLofhemorrhage,andpelvicfractureswithseverallitersofbloodloss.
Temporarystabilizationbysplintingcanbelifesavinginthesepatients.Intheprimarysurvey,presumedbleeding
frompelvicfracturesshouldbecontrolledwithnoninvasivetechniques,suchasapelvicbinderorasheetwrapped
aboutthepelvicregion.Militaryantishocktrousersorapneumaticantishockgarmentmayalsobeconsideredin
effortstotamponadebleedingfrompelvicfractures.

Bleedingfrompelvicfracturesisfrequentlyretroperitonealandmustbedistinguishedfromintraperitonealbleeding
fromarupturedsolidorgan.ThisisusuallyperformedusingFASTorDPL,butitcanbedifficultandmayrequire
CTscanning,angiography,orevenemergentexploratorylaparotomy.

Theuseofskeletaltractionmaybebeneficialtocontrolhemipelvicdisplacement.Thiscanbeappliedattheendof
theprimarysurvey.Moredefinitivetreatmentofthepelvicfractureishandledduringthesecondarysurvey.

Cardiactamponade

Cardiactamponadeistheresultofanincreasedamountoffluidorbloodinthepericardium,whichcompressesthe
heart,preventsvenousreturn,andcausespumpfailure.

Suspectcardiactamponadeinanypatientwithpenetratingtraumatotheleftchest,leftupperabdomen,orback.
Aslittleas150200mLofbloodcancausesignificantcardiaccompromise.Clinicalsignsoftamponadeareshock
refractorytofluidsandpressorsorpulselesselectricalactivity,jugularvenousdistension,muffledheartsounds,the
Kussmaulsign(ie,increasedjugularvenouspulsationoninspiration),pulsusparadoxus,orelectricalalternanson
ECGtracings.

Pericardialeffusionisdetectedbytransthoracicultrasonographyasastripofhypoechoicfluidbetweenthe
myocardiumandthepericardium.

Treatmentisimmediatepericardiocentesisorpericardialwindow(asurgicalopeninginthesubxiphoidarea)inthe
operatingroom.Aspirationofeven1015mLofbloodcanrelievecardiogenicshockandgaintimeformore
definitivemanagement.

Cardiacarrest

Anypatientwithoutapulseshouldimmediatelybeassessedwithdefibrillatorpaddlesoracardiacmonitor.Unstable
arrhythmiasmustbetreatedbyelectricalcardioversiontopreventthemfrombecomingterminalrhythmssuchas
pulselesselectricalactivity,ventricularfibrillation,orasystole.

Resuscitativethoracotomy

Witnessedlossofvitalsignsassociatedwithpenetratingthoracicinjuryconstitutesanindicationforaresuscitative
thoracotomy.Endotrachealintubationwithmechanicalventilationisperformed,andtheintravascularvolumeis
concurrentlyreplenished.Aftergainingaccesstothechest,thequalifiedsurgeonoremergencyphysicianmay(1)
treatcardiactamponade,(2)gaindirectcontrolofintrathoracichemorrhagingvessels,(3)performopencardiac
massageordefibrillation,and(4)crossclamptheaortatoslowbloodlossdistallyandincreaseperfusiontothe
heartandbrainproximally.Resuscitativethoracotomyhasnotbeenfoundtobebeneficialforblunttrauma.

Disability

Performaquickneurologicexaminationbyassessingthepatient'slevelofconsciousness,pupillarysizeand
reaction,andgrossmotorfunctioning.TheGlasgowComaScale(GCS)isthemostcommonlyusedratingsystem.
TheGCSisusedtomeasureeyeopening,grossmotorfunction,andverbalizationofthepatient.Eachcategoryhas
apointscore,andthesumofthe3scoresisthetotalGCSrating.TheGCSisasfollows:

Eyeopening(E)
Spontaneous4points
Tospeech3points
Topainfulstimulus2points
Noresponse1point
Movement(M)
Followscommands6points
Localizestopainfulstimulus5points
Withdrawsfrompainfulstimulus4points
Decorticateflexion3points
Decerebrateextension2points
Noresponse1point
Verbalresponse(V)
Alertandoriented5points
Disorientedconversation4points
Nonsensicalwords3points
Incomprehensiblesounds2points
Noresponse1point

Alteredlevelofconsciousnesscanbeduetomultiplefactors,includingdrugoralcoholintoxication,hypoxia,
hypotension,orcerebralinjury.Hypoxia,hypotension,hypothermiaorhyperthermia,andhypoglycemiaaretreatable
conditions,andshouldbeaddressedfirstinapolytraumapatient.Afteroxygenationandperfusionarenormalized,
analteredlevelofconsciousnessshouldbeassumedtobeduetotraumaticbraininjury(TBI)andisassessedinthe
secondarysurvey.

Exposure/EnvironmentControl

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Exposethepatientbyremovingallclothes.Hypothermiaisafrequentcomplicationoftraumaandisduetowaiting
onsceneandperipheralvasoconstriction.Keepingthepatientwarmisoftenforgottenduringthetrauma
resuscitation.Controlhypothermiawithadequatewarmingorblankets.

AdjunctstothePrimarySurvey

Radiography:The"traumatriple"isaportablecervicalspine,anteroposteriorchest,andanteroposterior
pelvisradiographs.Theseprovidethemaximumamountofinformationaboutpotentiallydangerous
conditionsinaminimumamountoftime.
Laboratorystudies:Obtainacompletebloodcellcountandchemistry,includingasodiumlevel,potassium
level,renalfunctionassessment,urinalysis,urinarytoxicologyscreen,andabetahumanchorionic
gonadotropinvalueinallfemalesofchildbearingage.
Bloodpreparations:Orderatypeandscreen,andconsidercrossmatching24unitsofRBCs,dependingon
theseverityofthetraumaandshock.
Urinaryandgastriccatheterization
Temperature,ECGandoxygensaturationmonitoring

ConsiderTransfer

Atthispoint,thephysicianshouldhaveenoughknowledgeofthepatient'sstatustoconsidertransfertoahigher
levelofcareiftheappropriatecareisnotavailableatthecurrentfacility.AllcitiesorcountiesintheUnitedStates
haveasystemtodeterminewhichpatientsrequiretransfertoatraumacenter.

SummaryofthePrimarySurvey

AirwayAirwayopened,airwayobstructiontreated,possibledefinitiveairwayplaced
BreathingBreathingassessed,tensionpneumothoraxandmassivehemothoraxtreated,oxygenand
assistedventilationprovidedasneeded
CirculationBloodcirculationandtissueperfusionassessed,intravascularvolumelossreplacedwithfluids
andblood,cardiactamponadeandcardiacarresttreated,emergencythoracotomyperformedifindicated,
andexternalhemorrhagecontrolled
DisabilityNeurologicstatusassessed
Exposure/environmentPatientfullyundressedandenvironmentcontrolledtoprotectfromhypothermiaor
hyperthermia
AdjunctsTraumatripleradiographs,laboratorystudies,urinaryorgastriccatheters,temperature,ECGand
oxygensaturationmonitoring,considerbloodtransfusion
ConsidertransferForhigherlevelofcareifnecessary

ShockInThePolytraumatizedPatient
Hemorrhagicshock

Inthetraumapatient,shockisassumedtobecausedbyhemorrhageuntilprovenotherwise.Hemorrhagicshockis
aclinicaldiagnosisbasedonvitalsignsandphysicalexaminationfindings.Thehematocritvaluedropsbutdoesnot
equilibratefullyinthefaceofacutebleedinguntilseveralhourshavepassedtoallowinterstitialfluidtoflowintothe
intravascularspace.Also,rememberthatfluidresuscitationdilutesthebloodandlowersthehematocritvalue.

TreathemorrhagicshockinitiallywithwarmedisotoniccrystalloidfluidsandpackedRBCsifnecessary.Theuseof
albuminiscontroversialandhasnotbeenprovenbeneficial.Surgicalcontrolofthesourceofbleedingisanintegral
partofresuscitationandmustnotbedelayedbyfullreestablishmentofintravascularvolume. [6]Treatmentisaimed
towardsnormalizationofphysiologicparameters:pulserate(60100beatsperminute),bloodpressure(mean
arterialpressure90100mmHg),pH(7.357.45),urineoutput(>0.5mL/kg/hforadults,1mL/kg/hforchildren,2
mL/kg/hforneonates),mentalstatus,serumlactatelevel,andnobasedeficit.Forpatientswithinvasivemonitoring
devicesinplace,normalizationofthecentralvenousormixedvenousoxygenextractionratio(6570%)shouldbe
considered.

Neurogenicshock

Neurogenicshockisinsufficienttissueperfusionsecondarytoahighspinalcordinjurythatcausesdisruptionofthe
sympatheticoutflowtotheheartandbloodvessels.Donotconfusethiswith"spinalshock,"whichisaneurologic
conditionreferringtothetransientareflexiaandflaccidityobservedintheinitialstageofaspinalcordinjury(which
constitutesalowermotorneuronlesionassociatedlaterwithhyperreflexiaandspasticity).Considerneurogenic
shockinanypatientwithaslowpulse,warmanddryextremities,andhypotension,especiallythosewithdirect
traumatotheupperspine,acuteparaplegia,orquadriplegia.Resuscitatewithfluidsandvasopressorsifneeded,
andimmediatelyconsultaneurosurgeon.

Hypoxicshock

Remembertofrequentlyreassesstheairway,breathing,andcirculationforairwaycompromise,mucousplug,
equipmentfailure,apnea,pneumothorax,hemothorax,orflailchest.Providesufficientoxygenandpositivepressure
ventilationifnecessary.

Alsoconsidercomorbidconditionssuchassepsis,dehydration,congestiveheartfailure,andanaphylaxisthatmay
causeshock.Headtraumaisrarelyacauseofhypotensioninadults.Anypatientwithhypotensionandheadinjuries
isusuallybleedingfromanothersource,oftentheabdomen.

Table.ClassesofHemorrhagicShock(OpenTableinanewwindow)

Blood Pulse, Capillary

Loss, Refill,

Mental
Class Beatsper BloodPressure InitialTreatment
Status
%Volume Minute Seconds

ClassI <15 <100 Normal <2 Anxious Intravenousfluids

Class 1530 <120 Redpulsepressure >2 Very Intravenousfluids
II anxious
Class 3140 <140 Redsystolicblood >2 Combative Intravenousfluidsplus
III pressure blood

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Class 41+ >140 Redsystolicblood >2 Obtunded Intravenousfluidsplus
IV pressure blood

Bloodtransfusions

ConsidertransfusionofbloodorpackedRBCsforanypatientwhosustainedtraumaandhasseverebloodlossesor
unstablevitalsignsthatdonotrespondtoinitialfluidresuscitation.Fullycrossmatchedbloodisbest,butmost
laboratoriesneed1hourofpreparationtime.Typespecificbloodisusuallyavailablein10minutes.TypeOblood
shouldbereservedfortrueemergencies.Rhnegativebloodshouldbeusedinwomenofchildbearingage
otherwise,Rhpositivebloodisacceptable.

Remembertoaskthepatientaboutprevioustransfusionsandtransfusionreactions.Ifthepatientdevelopsa
hemolyticreaction,characterizedbychestorflankpain,nauseaandvomiting,fever,anddarkurine,stopthe
transfusionimmediatelyandprovidefluids,urinealkalinizationwithbicarbonate,andmannitol.Minorallergicor
febrilereactionscanbetreatedwithantipyreticsandantihistamines,withouttheneedtostopthetransfusion.

Ifposttraumaticcoagulopathyissuspected,emergentlyconsultahematologist. [7]

SecondarySurvey
SpecializedTests

Thesecondarysurveyisperformedonlyaftertheprimarysurveyhasbeenfinishedandallimmediatethreatstolife
havebeenaddressed.Thesecondarysurveyisaheadtotoeexaminationdesignedtoidentifyanyinjuriesthat
mighthavebeenmissed.

Specializeddiagnostictestsareperformedtoconfirmpotentiallylifethreateninginjuryonlyaftertheprimarysurvey
hasbeencompleted,allimmediatethreatstolifearetreatedorstabilized,andhemodynamicandventilationstatus
arenormalized.ThesetestsincludeCTscanning,extremityradiography,endoscopy,andformalultrasonography. [8,
9]

Recentreportsontheuseofultrasonographytomeasureopticnervesheathdiameterforthedetectionofraised
intracranialpressuresuggestagoodcorrelation,withasensitivityof90%andaspecificityof85%.Thisbedside
diagnostictoolisoperatordependentbutcanprovideadditionalclinicaldatapointstohelpdecideonthenext
appropriatediagnosticortherapeuticapproach,includingearlytransfertoahigherlevelofcareforsuspectedraised
intracranialpressure. [10]

Thetraumapatientmustbereevaluatedconstantlytoidentifytrendsinphysicalexaminationandlaboratory
findings.Administerintravenousopiatesoranxiolyticsinsmalldosestominimizepainandanxietywithoutobscuring
subtleinjuriesorcausingrespiratorydepression.

FocusedPatientHistory

Thehistoryinthesecondaryexaminationisfocusedonthetraumaandpertinentinformationifthepatientistobe
senttosurgery.ThemnemonicSAMPLEcoversthebasics.

SymptomsPain,shortnessofbreath,othersymptoms
Allergiestomedications
Medicationstaken
Pastmedical/surgicalhistory
LastmealImportanttodetermineriskofaspiration
Eventsleadinguptotrauma

HeadandSkullExamination

Headtraumaisresponsiblefor50%oftraumadeathsandthereforeshouldbeofthehighestpriorityduringthe
secondarysurvey.Intracranialbleeding,includingsubarachnoidhemorrhage,intracranialhemorrhage,subdural
hematoma,andepiduralhematomaallcanbeidentifiedbyaneurologicexaminationandnoncontrastheadCT
scanning.Suspectintracranialinjuryinanypatientwithfocalneurologicsigns,alteredmentalstatus,lossof
consciousness,persistentnauseaandvomiting,orheadache,evenifthosesymptomsmaybeexplainedeasilyby
otherintoxicationsorinjuries.AnypatientwithsuspectedintracranialinjuriesshouldundergoheadCTscanningas
soonasheorsheishemodynamicallystable.

Examinationoftheheadinvolvesassessingthelevelofconsciousness,eyes,andskull.Thelevelofconsciousness
canbequicklyquantifiedusingtheGCS.Theeyesareinspectedforvisualacuity,pupillarysize,andextraocular
movements.Funduscopyisusedtoevaluatepreretinalhemorrhage.Theskullisexaminedandpalpatedfor
lacerations,tenderness,orfractures.Lookforsignsofbasilarskullfracture,suchastheBattlesign(ie,bruisingat
themastoidarea),raccooneyes(ie,periorbitalecchymoses),orcerebrospinalfluidrhinorrheaorotorrhea.

Headinjurymanagementinvolvesaggressivetreatmentofhypoxiaandhypotensiontopreventsecondarybrain
injuryandanimmediateconsultationwithaneurosurgeon.Maintainthemeanarterialbloodpressureat90mmHg
oraboveinpatientswithsuspectedintracranialinjuryinordertomaintaincerebralperfusionpressure. [11]Methods
totreatintracranialhypertension,suchasraisingtheheadofthebed,hyperventilation,furosemide(Lasix),and
mannitol,maybeconsideredunderthesupervisionofaneurosurgeon.TheTBIscaleisasfollows:

MildTBIGCSratingof1415
ModerateTBIGCSratingof913requirescarefulmonitoringtoavoidhypotensionorhypoxia
SevereTBIGCSratingof8orlessrequirescarefulmonitoringtoavoidhypotensionorhypoxia,butalso
requiresintubationandadmissiontoanintensivecaresetting

MaxillofacialExamination

Injuriestothefacearerarelylifethreateningunlesstheyinvolvetheairway.Lookinsidethemouthandnosefor
bleedingorhematomas.ExaminethemaxillaandmandibleforinstabilityassociatedwithLeFortfractures.
Considerearlyintubationtoprotecttheairway,whichmaybecomecompromisedlaterbecauseoftrachealswelling
orexcessivesecretions.

NeckExamination

Theneckcontains3veryimportantstructuresanteriorly(ie,trachea,pharynx/esophagus,greatvessels)andholds
thespineposteriorly.Allthesestructuresmustbeevaluatedinpatientswithpenetratingtraumatotheneck.Any
patientwithpenetratingtraumatotheneckinwhichthesuperficialfasciaandmusclesarepenetratedshould
receiveimmediateconsultationwithanotolaryngologistorgeneraltraumasurgeon.

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ChestExamination

Thoracicinjuriesaccountfor25%ofthetraumarelatedmortalityrate.Ofthoracicinjuries,10%arefatal.Only10%
ofbluntinjuriesand1530%ofpenetratingtraumainjuriesrequirethoracotomyand/orspecializedsurgical
proceduresthus,mostcasesofthoracictraumacanbemanagedbyanyATLStrainedphysician.

Inspectthechestforbruising,deformity,andmotionofthechestwallduringrespiration.Auscultatetheheartfor
muffledheartsoundsormurmursassociatedwithtraumaticvalvulardamage.Auscultatethelungsforbreath
sounds.Palpatethechestforsubcutaneousemphysemaorbonycrepitus,whichmayindicatetracheobronchial
disruptionorribfractures,respectively.

InjuriesthatMustBeConsideredintheSecondaryExamination

Traumaticruptureoftheaorta
Diagnosis:Usechestradiographytoscreenforawidenedmediastinumorothersignsofrupture.
Aortographyiscumbersomeandisusedinfrequently.ThedefinitivediagnosisismadewithCT
angiographyofthechest,ortransesophagealechocardiography. [12]
Treatment:Useaninterpositionalgraftorrepairtherupture.
Tracheobronchialdisruption
Diagnosis:Considerthisdiagnosisifacollapsedlungdoesnotexpandafterchesttubeinsertion,a
massiveairleakpersists,orprogressivesubcutaneousemphysemaisnoted.
Treatment:Performbronchoscopyandsurgicalrepair.
Diaphragmaticdisruption
Diagnosis:Stomach(gastricbubble)and/orbowelcanbeseeninthethoraxonchestradiographs,CT
scans,orlaparotomyfindings.
Treatment:Insertanasogastrictubetodecompressthestomachthen,performsurgery.
Bluntcardiacinjury
Significance:Thismaycausecontusion,chamberrupture,orvalvulardisruption.
Diagnosis:ECGandcardiacechoaidindiagnosis.
Treatment:Consultwithacardiothoracicspecialistforrupture,valvedisruption,orcontusionmonitor
thepatientfor624hoursforarrhythmias.
Pulmonarycontusion
Diagnosis:Pulmonaryopacitiescanbeseenonchestradiographs.
Treatment:Avoidfluidoverloadifthepatientisfluidresuscitated.Administeroxygenandanalgesia,
andconsiderintubation.
"Blastlung":Blastlungisseenwithhighenergyexplosiveinjuries,suchasterroristbombings.Asreported
fromIsrael,thestrengthofexplosivesstrappedtoanindividuallimitstheoccurrenceoffatalblastlungto
within6metersofthedetonation.AccordingtotheUSCentersforDiseaseControlandPreventionInjury
Center,blastlungisthemostcommonfatalprimaryblastinjuryamonginitialsurvivors.Signsmaybe
immediateormaybedelayedupto48hours.Thetriadofapnea,bradycardia,andhypotensionis
characteristic.Blastlungshouldbesuspectedinvictimsofexplosiveinjurywhohavedyspnea,cough,
hemoptysis,orchestpain.
Simplepneumothorax
Significance:Thiscandevelopintotensionpneumothorax,especiallyifintubationandpositive
pressureventilationareused.
Treatment:Chesttubeplacementisindicated.
Hemothorax
Significance:Thismaybecomeamassivehemothorax,mayclot,andmaycauselungentrapmentor
becomeanempyema.
Treatment:Chesttubeplacementisindicated.
Mediastinaltraversingwounds
Significance:Thismaycausedamagetotheheart,greatvessels,tracheobronchialtree,or
esophagus.
Treatment:Patientswithsymptomatic,hemodynamicallyunstable,andmediastinaltraversingwounds
areimmediatelytakentotheoperatingroom.Patientswithstablemediastinaltraversingwounds
undergoanextensiveworkupwithCTangiography,esophagraphy,andbronchoscopy/endoscopyin
consultationwithasurgeon.

AbdominalExamination

Abdominaltraumaisseparatedintobluntandpenetratinginjuries.Patientsareimmediatelysenttotheoperating
roomforlaparotomyifanyofthefollowingarepresent:eviscerationpenetratinginjuriescausedbyfirearmsor
objectsand/oranyinjuryaccompaniedbyshock,freeairunderthediaphragmonchestradiographs,and/or
peritonealsigns.Bluntabdominalinjuriescanbesubtle.Solidorgandamagethatiscausingoccultbleedingintothe
abdomencanbeoverlookedinpatientswithotherinjuriesthatdistractattention.Mostpatientswithbluntabdominal
traumawhoarehemodynamicallystableandhavenoevidenceofintraabdominalbleedingcanundergoCT
scanning,andmanyaretreatedwithconservativemeasures.

Examinetheabdomenforsurgicalscars,contusions(seatbeltsign),orlacerations.Listenforbowelsounds.Feel
gentlyfortenderness,andthenconsiderFASTorDPLtoruleoutintraabdominalbleeding.

FASTisaquick,sensitivewaytodetectfluidintheabdominalcavity.FASTcandetectaslittleas300500mLof
freefluid.FASTcanbeaccuratelyperformedbyproperlytrainedphysiciansorsurgeons.ThelimitationsofFAST
areoperatordependanceaninabilitytodetectretroperitonealblood(eg,frompelvicfractures)andaninabilityto
differentiatebloodfromurine,ascites,orotherabdominalfluid.

DPLisasensitivetechniquefordetectingintraabdominalblood.TheadvantagesoverFASTincludeincreased
sensitivityandtheabilitytoanalyzethetypeofintraperitonealfluid(eg,blood,ascitesincirrhoticpatients,bowel
contents).ThedisadvantageisthatDPLtakeslongerthanFASTandisinvasive.WiththeadventoffastspiralCT
scanners,DPLisinfrequentlyresortedto.

Inthepresenceofhypotension,apositiveFASTorDPLresultisanindicationforimmediatelaparotomy.

SpinalCord/VertebralColumn

Palpatespinousprocessestoassessforpointtenderness.Anypointtenderness,bonystepoffs,orabnormalities
shouldpromptimmediatespinalradiographytoevaluatethedamage.Managementofspinalfracturesincludestotal
immobilizationofthespineandconsultationwithaspinalsurgicalspecialist.Theuseofhighdose
methylprednisoloneisnolongerrecommended.Anypatientwithhypotensionandaslowpulseshouldbeassessed
forneurogenicshockandahighspinalcordinjury.

Afterwards,completetheneurologicexamination,includingmotorandsensoryexaminationsandreflexes.

Cervicalspineclearance

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Allpatientswithanypossibilityofcervicalspinefracturebasedonhistory,physicalexaminationfindings,or
mechanismofinjurymustbeimmobilizedwithahardcollaruntilaproperexaminationcanbeperformed. [13]
Patientswhocanbeconsideredforclinicalcervicalspineclearancemustmeetthefollowingcriteria:

Nofocalneurologicdeficits
Nodistractinginjuries,eg,gunshotwound,pelvicfracture,longbonefracture
Nointoxications(eg,alcohol,opiates)
Fullorientationandawareness
Nomidlinenecktenderness

Instructthepatienttoslowlyrotatetheheadfromsidetoside.Ifthisisperformedwithoutpainortingling
sensationsornumbnessoftheextremities,thatpatientalmostcertainlydoesnothaveacervicalspinefracture
(99.8%negativepredictivevalue).Otherpatientsmusthaveaminimumof3cervicalspineradiographs(ie,lateral,
anteroposterior,andopenmouthodontoidviews)andpotentiallyotherimagingstudiestoruleoutcervicalspine
involvement.

Donotleavepatientsonthelongboardwithahardcollarinplacelongerthannecessary.Thelimitationof
movementcausesbothanxietyandmusculoskeletalpain,whichdistressthepatientandcanobscurefollowup
examinations.Continuouspressurefromthebackboardmaycausedecubitusulcerstotheposteriorskullandother
posteriorbonyprominences.

GenitourinaryExamination

Performarectalexamination,examinetheperineum,andperformagenital/vaginalexamination.Rectaltoneisan
indicatorofspinalcordfunction,andapatientwithpoorrectaltoneshouldbeconsideredtohaveaspinalcordinjury
untilprovenotherwise.Thestoolisassessedforfreshbloodthatmightindicateanopenpelvicfractureorother
injurythathaslaceratedtherectum.Avaginalorgenitalexaminationisperformed.AFoleycatheterisplaced
unlesscontraindicatedbysignsofurethrainjury,suchasahighridingprostate,bloodatthemeatus,or
scrotal/perinealhematoma.

SummaryoftheSecondarySurvey

FocusedpatienthistorySymptoms,allergies,medications,pastmedical/surgicalhistory,lastmeal,events
leadinguptotrauma
Head/skullEyes,skull,tympanicmembrane,andpupilsevaluation
MaxillofacialPalpationforinstabilityinspectionforintraoralbleedingornasalseptalhematoma
NeckMidlinepositionofthetrachea
ChestChestinspection,palpation,andauscultation
AbdomenInspection,auscultation,palpation,andpercussion(ConsiderFASTand/orDPL.)
Spine/vertebraePalpationofthespinalcolumn,neurologicexamination,clearingthecervicalspine
GenitourinaryPerinealexamination,rectalexamination,genital/vaginalexamination
MusculoskeletalPalpationofthepelvis,extremities,andsplintfractures(Considerimmediatereductionof
dislocations.)

ImmediateManagementOfMusculoskeletalInjuries
Thesecondarysurveyendswiththeassessmentofthemusculoskeletalsystem,andthisiswhentheorthopedist's
skillsarerequired. [14,15,16]Palpatealljointsandlongbones,andassesspulses,capillaryrefill,sensation,and
motorstrength.Alsodeterminewhetherdifferentlimblengthsmayindicatehipfractureordislocationorpelvic
fracture.Splintallfracturesaboveandbelowthejointafterrealignmentofthelimb.Performimmediatereductionof
dislocations,especiallyifneurovascularcompromiseispresent.

SurgicalprioritiesDamagecontrolversusearlytotalcare

Splintingisalwaysindicatedinthepolytraumapatient.Betterhealingisobservedincasesinwhichearlysurgical
immobilizationoffracturesisperformed,butthisinterventioncanactuallybeharmfulifperformedtooearlyon
unstabletraumapatients.Patientswhoareunderresuscitated,asevidencedbyincreasedserumlactatelevelsor
basedeficit,shouldhaveearlysplintingorskeletaltractionuntiladequatelyresuscitated.Ifthepatientisinthe
operatingroomforlifesavingsurgery,temporaryexternalfixationalsomaybeused,especiallyforthepatient's
lowerextremitylongbonefractures.Definitivesurgicalrepairisdelayeduntilthepatientisstableandadequately
resuscitated. [17,18]

Earlydefinitivestabilizationcanbeusedafterensuringoptimalresuscitationandtheabsenceofimpendinglife
threateningconditions.Aretrospectivestudyof750femoralfracturestreatedfrom19992006inCleveland,Ohio
found656definitivestabilizationsweresafelyusedwithin24hoursofinjury. [19]

Pelvicfractures

Pelvicfracturemustbesuspectedinanypatientwithanappropriatemechanismofinjury,paininthepelvicregion,
orleglengthdiscrepancies.OthersignsaretheDestotsign(ie,hematomaofscrotumoringuinalligament),the
Earlesign(ie,hematomaortendernessalongbonesonrectalexamination),andtheRouxsign(ie,asymmetryin
thedistancesbetweenthegreatertrochanterandthepubicspineoneachside). [20,21]

Testforpelvicstability(bypushingposteriorlyandthenmediallyontheiliaccrestsanddownwardonthesymphysis
pubis)onlyiftheclinicianbelievesthatthepelvisisintact.Ifapelvicfractureissuspectedonclinicalgrounds,this
examisdiscouragedasitcanexacerbatepainandhemorrhage.Instead,orderanteroposteriorpelvicradiographsas
soonastheprimarysurveyiscompleted.Paycarefulattentiontotherectalexaminationfindings,whichmaybethe
onlyindicationofadangerousopenpelvicfractureimpingingontherectum.

Pelvicfracturesresultfromhighenergytraumasuchasmotorcycleaccidents,accidentsinvolvingvehicleshitting
pedestrians,orfallsfromhigherthan12feet.Pelvicfracturescancauseconsiderablemorbidityandmortalityfrom
bleeding,damagetonerves,anddamagetogenitourinarystructuresandtherectum.

Pelvicfracturescanbleedfromthepelvicvenousplexusor,occasionally,theinternaliliacarteriesanditsbranches.
Shockandhypotensionmaybetheonlyindicatorsofpelvichemorrhageinpolytraumapatients.

Themechanismofinjurycanprovidecluesastothetypeofpelvicinjury.Anteroposteriortraumaopensthepelvic
ringandincreasesthevolumeofbloodthatcanbeheldinthecavity.Initialtreatmentmustincludestabilizationof
thepelvistoreducethisvolume.Lateraltraumatendstoclosethepelvisandcausebladderand/orurethralinjury.

Treatmentistemporarystabilizationbynoninvasivemethods,suchasasheetorpelvicbinder.Thesetemporary
methodsmaycausepressureulcerationsoftheskinoverthebonyprominencesofthepelvis.Consequently,
externalfixationshouldbeappliedearlyintheacutecarephasetoavoidthiscomplication.Thiswillusuallyrequire
orthopedicsurgicalexpertiseandanoperatingroomwithgeneralanesthesia.

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Openfractures

Anyopenwoundreachingafractureisanopenfracture.Openfracturesmustbetreatedaggressivelytoprevent
infection,whichcaneasilyspreadtosofttissuesortobone.Allopenfracturesaretreatedinitiallywith
immobilization,irrigationofthewound,debridementofdevitalizedtissue,andprophylacticantibiotics(oftenafirst
generationcephalosporin).Surgicaldebridementmaybedelayeddependingonthepatient'sphysiologicresponseto
theinjuryandresuscitation.Ifunstable,irrigationandasterilewounddressing,alongwithsplintingortraction,are
requireduntilthepatientisabletoproceedtotheoperatingroomfordefinitivedebridementandfracture
stabilization.Dependingontheseverityoftheinjury,externalorinternalfixation,flapconstruction,orvascularrepair
mayberequiredafterwards.

TheGustiloandAndersonclassificationoflongboneopenfracturesisasfollows:

ClassILessthan1cm,lowenergy,oftensimplefractures
ClassIIGreaterthan1cm,oftencomminutedfractureswithsomecrushingcomponent
ClassIIIGreaterthan1cmwoundorsignificantsofttissueinjuryorfracturecomminution,highenergy(eg,
gunshotwounds,motorvehicleaccidents,fallsfromheight),subdividedbasedonmanagementrequired
ClassIIIAExtensivesofttissuedamagebuthasadequateperiostealbonecoverageandusually
doesnotrequiremajorreconstructivesurgery
ClassIIIBExtensivesofttissuedamagewithperiostealstrippingthatleavesboneexposed,requires
flapplacementforsofttissuecoverage
ClassIIICVascularinjurytoanamedarteryrequiringrepair

Softtissueandjointinjuries

Allsofttissueinjuriesshouldbetreatedwithcopiousirrigation.Debridementisnecessaryifanydevitalizedtissue
remains,inordertopreventdeadtissuefrombecominganidusofinfection.Coveropenwoundswithsterile
dressingssoakedinsaline.

Serioussofttissuedestruction(includingGustilo/AndersonclassIIIB/IIIC)mayrequireflapconstruction.Immediate
freeflapconstructionmaybeperformedwithin48hoursofthetraumaifthepatientisstable.Radicaldebridement
isperformedatthesiteofinjury,andafreeflapisinserted.Ifdebridementisnotperformed,reconstructionshould
bedelayeduntilthetissueshavehealedatthemarginsandnoevidenceofinfectionisnoted.Flapsaremost
commonlyharvestedfromthelatissimusdorsi,gracilis,serratusanterior,orrectusabdominusmusclesformedium
tolargesizedwounds.

Injuriesthatmaycompromisethejointspaceshouldbethoroughlyevaluated.Arthroscopicirrigationandwound
debridementshouldbeperformedtoensurehealingandlessenthechanceforinfection.

Crushsyndrome(traumaticrhabdomyolysis)
Crushinjuryofanextremitymayreleaselargeamountofmyoglobinandpotassiumorothertoxicbyproductsof
musclebreakdown.Thiscanleadtorenalfailureandelectrolyteabnormalities,lethaldysrhythmias,and
disseminatedintravascularcoagulopathy.Intravascularfluidisshiftedbyosmoticpressureintothemuscle
compartments,whichcausescompartmentsyndromelocallyandhypovolemicshockwithanaddedcontributionto
renalinsufficiencysystemically. [22]

Anylimbthathasbeencompressedorcrushedshouldnotbereperfuseduntilvigorousfluidresuscitationisinitiated
toprotectthekidneysandheart.Sodiumbicarbonatetherapymaybeconsideredtoalkalinizetheurineandprevent
precipitationofmyoglobinintherenaltubules.Mannitol,12mg/kgofa20%solutionadministeredover4hours,
mayalsobeconsidered,buthardevidencesupportingitsuseislacking.

Evaluationofgunshotwounds

Avoidunderestimatingthedamagecausedbygunshotwoundsbecausetheinjuriesoccurbeneaththeskin.Splint
extremitiesuntilunderlyingfractureshavebeenruledoutwithappropriateradiographs.Withlowvelocitygunshot
woundsfromcivilianarms,thedamageisusuallylimitedtothepathofthebullet.Highvelocityweaponssuchas
assaultrifleroundscauseshockwavedamageasthebulletentersthefleshand,therefore,aremorecomplicated
becauseadjacenttissuesarepotentiallyinjured.Surgicalinterventionisbasedontheclinicalassessmentofthe
wound.Remembertoreportallgunshotwoundstothepolice.

SpecialPatientPopulations
Geriatricpolytrauma

Patientsolderthan65yearsaccountfor36%ofambulancetransportsand25%oftotaltraumacosts.Elderly
patientsarelesslikelytobeinvolvedintraumabutaremorelikelytodiefromtrauma.Fallsarethemostcommon
accidentinpeopleaged75yearsorolderandarethesecondmostcommonaccidentinpeopleaged6574years.
Mostfallonalevelsurface,andmostsustainanisolatedorthopedicinjury.Motorvehicleaccidentsaretheleading
mechanismthatbringselderlypatientstoatraumacenter.

Vitalsignsmaybedifficulttoassessinelderlypatients.Elderlypatientsmaynotbeabletomountatachycardic
responsetoshockbecauseofmedicationsorreducedsensitivitytosympatheticoutflow.Aseeminglynormalblood
pressuremightactuallybedangerouslylowinapatientwithbaselinehypertension.Considerinvasivemonitoring,
suchasacentralvenouslineorSwanGanzcatheter,becausefluidoverloadcanbejustasdangerousas
hypovolemiainthesepatients.

Elderlypatientsarepredisposedtohipfracturesbecauseofosteopenicandosteoporoticchanges.Longbone
fracturescancausesignificantmorbiditywithlossofmobility.Considerearlyplacementofintramedullaryrodsin
thesepatientstofacilitatemobilitylater.Theyalsohaveanincreasedprevalenceofribfracturesandincreased
respiratorycomplicationsfromtraumaandrecovery,suchaspulmonarycontusionorpneumonia.

Polytraumainchildren

Traumaistheleadingcauseofdeathinchildhood.Eachyear,22millionchildrenareinjured,whichis1in3
children.Fallsandmotorvehicleaccidentscause90%ofcasesofpediatricmultisystemtrauma,butmotorvehicle
accidentsaretheleadingcauseofdeath.Childrenarenotsimplysmalladultstheyrequirespecialcare.

Immediatelyassessthechild'sweight,eitherbyascaleortheBroselowpediatricmeasuringtape.Accuratedosing
ofmedicationsandfluidsisessential.Childrenhavelargersurfaceareatomassratios,sokeepingthechildwarm
topreventhypothermiaisevenmoreimportant.

Childrenhaveincreasedbloodlossassociatedwithlongboneandpelvicfracturescomparedwithadultstherefore,
earlysplintingandstabilizationareevenmoreimportant.Theclinicalexaminationisoftheutmostimportance
becauseradiographsaredifficulttointerpretasaresultofincompleteossification.

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Childrenhavetremendousreservestocompensateforhypovolemia,sowhentheystarttoshowsignsofshock,it
mayalreadybeatanadvancedstage.Childreninitiallyrespondtohypovolemiawithtachycardiaandmaynotdrop
theirbloodpressureuntiltheyhavelost45%oftheircirculatingvolume.Considerearlytransfertoapediatrictrauma
center.

Polytraumainpregnantpatients

Traumaisthelargestcauseofnonobstetricmorbidityandmortalityinpregnantwomen.Significanttrauma
complicates67%ofpregnancies. [23]

Pregnantwomentoleratebloodlossbecauseofalargecirculatingbloodvolumeandmaynotinitiallyshowsignsof
shock.Pregnantpatientsareathighriskforaspirationduringanesthesia.Thisisbecauseofthereductionofgastric
motilitybyprogesteroneandincreasedintragastricpressurefromtheenlargeduterus.Considerearlynasogastric
tubeplacementandsuction.

Thefetusmustalsobeconsideredapatient.Thebonypelvistendstoprotectthefetusupto12weeks'gestation,
butafterward,itisvulnerabletoabdominaltraumaincurredbythemother.Estimationoffetalageandviability
becomespartoftheprimarysurveyinpregnantpatients.Ifthegestationisgreaterthan22weeks,fetalviability
mustbedeterminedwithfetalhearttonesandanultrasonicbiophysicalprofile.Earlyconsultationwithan
obstetriciangynecologistisrecommended.

Child,domestic,andelderabusevictims

Beawareofthepossibilityofchild,elder,andspouseabuseintraumatizedpatients.Besuspiciousofany
inconsistentstoriesbetweendifferentparties,signsofpartiallyhealedtrauma,andtraumainconsistentwiththe
mechanismdescribedbythepatientandrelatives.Ifnecessary,separatethechild,spouse,orelderlypatientfrom
thefamily.Donotbehesitanttoinvolvesocialservicesorthepolice.Physiciansarerequiredtonotifytheproper
authoritiesinanycaseofsuspectedchildabuse,aswellaswithdomesticandelderabuseinmanystates.

RiskManagement:MissedInjuries
Bornetalreported39missedfracturesin26of1006consecutiveblunttraumapatientsseenatalevelItrauma
centeroveran18monthperiod. [24]Noseriousadverseoutcomeswerereportedinthisstudy,butmissedinjuries
havebeencalledthetraumasurgeon'snemesisbyEndersonandMaull. [25]

TertiarySurvey

Atertiarytraumasurvey,includingadetailedhistoryandphysicalexamination,andareviewofwrittenradiology
reportsonallstudiesorderedhasbeenrecommended.Evaluateforpotentialabdominalcompartmentsyndrome
duetobowelandmesenteryswellingandresultinghighintraabdominalpressure.Thetertiarysurveyisperformed
24hoursafterthepolytraumapatienthasbeenadmittedtothewardorICUor24hoursaftertheinitialsurgery,
exceptifitwasconsidereda"damagecontrol"operation. [26,27]

ContributorInformationandDisclosures
Author
ChatVDang,MDClinicalProfessorofEmergencyMedicine,CharlesDrewUniversityofMedicineandScience
ClinicalProfessor,DepartmentofMedicine,UniversityofCalifornia,LosAngeles,DavidGeffenSchoolof
Medicine

Disclosure:Nothingtodisclose.

Coauthor(s)
EricMichaelSchultzMD,MA

EricMichaelSchultzisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andEmergencyMedicineResidentsAssociation

Disclosure:Nothingtodisclose.

SpecialtyEditorBoard
JamesFKellam,MDViceChair,DepartmentofOrthopedicSurgery,DirectorofOrthopedicTraumaand
Education,CarolinasMedicalCenter

JamesFKellam,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOrthopaedic
Surgeons,OrthopaedicTraumaAssociation,andRoyalCollegeofPhysiciansandSurgeonsofCanada

Disclosure:Nothingtodisclose.

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:MedscapeSalaryEmployment

SamuelAgnew,MD,FACSAssociateProfessor,DepartmentsofOrthopedicSurgeryandSurgery,Chiefof
OrthopedicTrauma,UniversityofFloridaatJacksonvilleCollegeofMedicineConsultingSurgeon,Departmentof
OrthopedicSurgery,McLeodRegionalMedicalCenter

SamuelAgnew,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAssociationforthe
SurgeryofTrauma,AmericanCollegeofSurgeons,OrthopaedicTraumaAssociation,andSouthernOrthopaedic
Association

Disclosure:Nothingtodisclose.

DineshPatel,MD,FACSAssociateClinicalProfessorofOrthopedicSurgery,HarvardMedicalSchoolChiefof
ArthroscopicSurgery,DepartmentofOrthopedicSurgery,MassachusettsGeneralHospital

DineshPatel,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAcademyofOrthopaedic
Surgeons

Disclosure:Nothingtodisclose.

ChiefEditor
MaryAnnEKeenan,MDProfessor,ViceChairforGraduateMedicalEducation,DepartmentofOrthopedic
Surgery,UniversityofPennsylvaniaSchoolofMedicineChiefofNeuroOrthopedicsProgram,Departmentof

http://emedicine.medscape.com/article/1270888overview#a30 10/11
1/29/2015 ThePolytraumatizedPatient
OrthopedicSurgery,HospitaloftheUniversityofPennsylvania

MaryAnnEKeenan,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofOrthopaedicSurgeons,AmericanOrthopaedicAssociation,AmericanOrthopaedicFootandAnkle
Society,AmericanSocietyforSurgeryoftheHand,andOrthopaedicRehabilitationAssociation

Disclosure:Nothingtodisclose.

AdditionalContributors
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofpreviouscoauthor
ClarenceWoods,MD,tothedevelopmentandwritingofthisarticle.

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