David E. Manthey, MD
Traumatic injuries
to look for evidence of penetrating injuries, subcutaneous emphysema, or an expanding hematoma of the anterior neck. Determine if the trachea is midline. Deviation of the trachea may be associated with a local hematoma or tension pneumothorax.
Open the patient’s mouth carefully to identify abnormalities such as bleeding or swelling. The gentle use of a tongue blade may facilitate this task. Can the patient swallow and handle secre- tions?
Some trauma patients arrive at the ED after intubation in the field. Do not assume that the airway is secure. Correct endotracheal (ET) tube placement may be confirmed by the direct visual- ization of the ET tube passing through the vocal cords, the presence of a normal oxygen saturation, and the detection of end-tidal carbon dioxide (CO2). Other measures to assess ET tube place- ment include auscultation of symmetric breath sounds over the chest, the absence of breath sounds over the epigastrium, fogging within the ET tube, symmetric chest rise with ventilation, and the esophageal bulb detection device.
However, these methods are not as reassuring as direct visualization and the detection of end- tidal CO2.
Assume injury to the cervical spine in any patient with the following findings:
• multi-system or major trauma;
• altered level of consciousness;
• blunt injury above the clavicles;
• appropriate mechanism of injury;
• neck pain, ecchymosis or deformity;
• neurologic deficits.
Treatment
All trauma patients should receive supplemental oxygen regardless of their oxygen saturation.
Oxygenation may be monitored with a pulse oximeter if an appropriate waveform can be identified.
The tongue remains the most common reason for airway obstruction. When a patient is supine or unconscious, the tongue can be raised by maneu- vers such as the chin lift or jaw thrust, or with devices such as the nasopharyngeal or oropharyn- geal airway. The neck should neither be flexed nor extended if a cervical spine injury is suspected or the patient is unconscious (Figure 6.1). The air- way should remain clear of debris and vomit by a manual sweep or a suction device.
A trauma patient should be intubated for any of the following reasons:
• apnea or inadequate ventilation;
• protection from aspiration;
• impending or suspected airway compromise;
• hypoxia despite supplemental oxygen;
• closed head injury with Glasgow Coma Scale (GCS)9.
A complete approach to controlling a patient’s airway is described in Chapter 2. An organized approach in a stepwise pattern should utilize one or more of the following methods:
(a) Chin lift/jaw thrust/nasopharyngeal airway/oropharyngeal airway:The use of adjunctive airways and simple maneuvers to lift the tongue out of the pharynx often allows ventilation of the patient until a definitive airway can be established.
(a) (b)
Figure 6.1
(a) A patient with an extension teardrop fracture of the vertebral body of C2. (b) Inadvertent hyperextension of the patient’s neck could lead to subluxation of the vertebral bodies and injury to the spinal cord.Courtesy: Michael Zucker, MD.
Traumatic injuries (b) Bag-valve mask (BVM):Every clinician
should be skilled at ventilating a patient using a BVM, which allows ventilation of an apneic patient or patient with respiratory distress until a definitive airway can be established. Providing a good mask seal and ensuring that the tongue does not obstruct the pharynx are essential for effective BVM ventilation.
(c) Intubation:ET intubation can be
performed by direct laryngoscopy, over an endoscope or guidewire, or through a laryngeal mask airway (LMA). Direct laryngoscopy is safe in the trauma patient when performed with in-line immobilization to protect the cervical spine. Rapid sequence intubation (RSI) may facilitate intubation of a patient without requiring bag-valve mask ventilation.
However, prior to paralyzing the patient, it is important to assess for a difficult airway and ensure that the patient can be effectively BVM-ventilated should the intubation prove difficult or impossible.
(d) Transtracheal jet ventilation: When intubation fails, ventilation using a needle placed through the cricothyroid membrane will temporarily allow oxygenation of the patient.
(e) Surgical cricothyroidotomy: This
surgical airway may be necessary when ET intubation either fails or is not feasible.
It involves incising the cricothyroid membrane to allow placement of an ET or tracheostomy tube directly into the trachea (Figure 6.2).
Breathing Assessment
Evaluation of the patient’s breathing determines how well the patient is oxygenating and ventila- ting. Employ a pulse oximeter to assess oxygena- tion and, if available, a quantitative end-tidal CO2 monitor to assess ventilation. An arterial blood gas will assess both oxygenation and ventilation, and provides the patient’s acid–base status, which is often related to the adequacy of resuscitation efforts.
Auscultate the lungs for bilateral symmetric breath sounds. The lack of breath sounds on one side may indicate a pneumothorax or hemothorax.
The clinician should search for signs of a tension pneumothorax, such as a deviated trachea away from the affected side, distended neck veins, decreased breath sounds on the affected side, and hypotension (Figure 6.3).
Percussion of the chest may help differentiate a pneumothorax from a hemothorax. However, this technique may be of limited utility during a noisy trauma resuscitation.
Observe the chest wall for symmetric rise as well as for any paradoxical movement suggestive of a flail chest (Figure 6.4). Flail chest is caused by the fracture of two or more ribs at two or more segments, causing a free-floating segment that moves inward with inspiration due to negative pressure generated.
Palpate the entire thorax (anterior and poste- rior) for crepitus and rib tenderness. Crepitus suggests an underlying pneumothorax, while rib tenderness alerts the physician to a possible rib fracture and underlying pulmonary contusion.
Look for an open (sucking) chest wound.
If the chest wound is two-thirds the size of the patient’s trachea or larger, air can preferen- tially enter the thoracic cavity through this chest wall injury, resulting in a tension or open pneumo- thorax.
Treatment
When evaluating a trauma patient’s respiratory status, one must keep in mind life-threatening conditions that must be addressed. These include hypoxia, tension pneumothorax, open pneumo- thorax, massive hemothorax, tracheo-bronchial tree disruption, and flail segment.
Hypoxia should be treated with supplemental oxygen. Intubation should be performed if neces- sary. A diligent search for reversible causes of impaired ventilation should occur.
Figure 6.2
Surgical cricothyroidotomy.Courtesy: Mel Herbert, MD.
Traumatic injuries
Apprehension, agitation;
increasing cyanosis, air hunger (ventilation severely impaired)
Possible subcutaneous emphysema
Shock; skin cold, clammy
Tracheal displacement toward uninjured side Distended neck veins
Hyperresonant percussion note;
breath sounds or absent
Figure 6.3
Tension pneumothorax. Campbell, John E., Basic Trauma Life Support for Advanced Providers, 5th ed., Copyright 2004. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.
(a) (b)
Figure 6.4
(a) Illustration of flail chest. (b) Chest X-ray showing flail chest with an underlying lung contusion. Reproduced from D. Mandavia et al, Color Atlas of Emergency Trauma, Cambridge, Cambridge University Press, 2003.
Emergent treatment of a tension pneumo- thorax converts it to a simple pneumothorax. This can be accomplished by needle decompression (needle thoracostomy) using a 14-G catheter over needle (Figure 6.5). Insertion of the needle over the third rib (second intercostal space) in the mid- clavicular line results in a release of intrapleural air and the subsequent reversal of adverse hemo- dynamic effects. The catheter is left in place until
a 36-French chest tube is promptly placed at the 4th intercostal space in the mid-axillary line (chest tube thoracostomy).
An open pneumothorax allows air to preferen- tially enter the thoracic cavity through the defect rather than the trachea. This results in significant hypoxia, increased work of breathing, and hyper- carbia. This wound should be treated with an air occlusive dressing (such as a defibrillator pad or
Vaseline gauze) taped on three sides to produce a flutter valve (Figure 6.6). This type of dressing will prevent the entrance of air into the pleural space during inhalation but allow the escape of intrapleural air during exhalation.
A massive hemothorax (Figure 6.7) is identi- fied by more than 1500 ml of blood within the thoracic cavity. It is initially treated and diag- nosed with a tube thoracostomy. The use of an auto-transfuser with the pleuravac will allow this blood to be infused back to the patient. Continued
bleeding (the drainage of 200 ml of blood per hour for 2–4 hours), blood transfusions, or the patient’s hemodynamic status dictate the need for operative intervention (thoracotomy).
A flail segment occurs when two or more con- tiguous ribs are broken in two or more places.
The paradoxical movement of this segment, the restricted chest wall movement due to pain, and the underlying pulmonary contusion lead to hypoxia and ineffective ventilation. Prevention of over hydration in this clinical situation may
Traumatic injuries
Figure 6.5
Needle thoracostomy for tension pneumothorax. Reproduced from D. Mandavia et al, Color Atlas of Emergency Trauma, Cambridge, Cambridge University Press, 2003.
On inspiration, dressing seals wound, preventing air entry
Dressing allows trapped air to escape through untaped section of dressing on expiration
Collapsed lung
Figure 6.6
Treatment of an open pneumothorax. Campbell, John E., Basic Trauma Life Support for Advanced Providers, 5th ed., Copyright 2004. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.
Traumatic injuries
avert fluid overload of the injured lung. Intubation with positive pressure ventilation is often required to treat this injury.
Circulation Assessment
Shock is defined by inadequate organ perfusion and tissue oxygenation, not by a specific blood pressure measurement. A patient with a low blood pressure may continue to perfuse well, as evi- denced by normal mentation, skin temperature, and color. Alternatively, a “normal” measured blood pressure may be found in a patient who is not adequately perfusing his or her vital organs.
Hypovolemia, typically from hemorrhage, is the most common cause of shock in trauma patients. Most preventable trauma deaths result from the failure to recognize and adequately treat hemorrhagic shock. Always assume that hypo- volemic shock is present, and treat it until proven otherwise. Familiarity with the classes of hypo- volemic shock is important, as they correlate with blood loss and help guide therapy (Table 6.1).
Other causes of shock in the trauma patient include neurogenic shock (from spinal cord injury), obstructive shock (from cardiac tamponade), and
distributive shock (from sepsis). Cardiogenic shock may be the initial cause of a traumatic injury, but is rarely the result of one.
Evaluation of a patient’s circulatory status can be difficult. Use all available options when assess- ing a trauma patient for the presence of shock.
Assess the patient’s mental status. Confusion, restlessness, combativeness or unconsciousness may all result from shock. Other causes of altered mental status in the trauma patient include head injury or intoxication.
Check and re-check the patient’s vital signs.
The presence of hypotension suggests a signifi- cant shock state. However, children and healthy adults can maintain their blood pressure in the face of severe blood loss, although other signs of shock will usually be apparent.
Calculate the pulse pressure, which is the dif- ference between the systolic and diastolic blood pressure. A narrowed pulse pressure may reflect peripheral vasoconstriction occuring in order to maintain cardiac output.
The patient’s pulse may be elevated due to hypovolemia, or secondary to pain and stress.
The earliest manifestations of shock include tachycardia and cutaneous vasoconstriction. The pulse may also be misleadingly normal due to the inability to develop tachycardia secondary to age,
Cyanosis
Neck veins flat
Breath sounds absent; dull to percussion
Shock Respiratory difficulty
as a late symptom
Figure 6.7
Massive hemothorax. Campbell, John E., Basic Trauma Life Support for Advanced Providers, 5th ed., Copyright 2004. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.
medications (such as beta- or calcium channel blockers), or a vagotonic response to hemoperi- toneum.
Examine the patient’s extremities. Delayed capillary refill time (2 seconds) may reflect decreased peripheral perfusion. Cool, moist, or pale extremities suggest shock.
Always compare peripheral and central pulses.
If the central pulses are markedly stronger than the peripheral pulses, this may be a sign of periph- eral vasoconstriction in order to preserve preload and maintain cardiac output.
Evaluate the patient’s jugular veins. Flat jugu- lar veins suggest hypovolemia. Full neck veins are normal in the recumbent patient. Distended jugular veins suggest an obstructive process.
When combined with impending shock, this finding suggests cardiac tamponade (Figure 6.8), tension pneumothorax, or cardiogenic shock in the trauma patient.
Assess the patient’s urinary output. It should be at least 0.5 ml/kg/hour in the adult patient, 1 ml/kg/hour in the pediatric patient and 2 ml/
kg/hour in children 1 year of age. Decreased urine output may reflect poor renal perfusion
secondary to continued hypovolemia and under- resuscitation.
The assessment of a patient’s circulatory sta- tus is an ongoing process. When resuscitating the patient with the crystalloid, it is important to determine how the patient responds to each fluid challenge.
Treatment
During the assessment of the patient’s circulation, one must stop all obvious external bleeding. Direct pressure or a compression bandage accomplishes this in most instances. In some cases, placing a hemostatic figure-of-eight stitch over the bleeding area may be required. Blind probing or clamping deep within a wound should be avoided.
Venous access is required in all trauma patients for the administration of isotonic fluids and blood (if necessary). Two large-bore intra- venous (IV) catheters (16 G or larger) are pre- ferred. Short, large-caliber peripheral IVs allow the rapid infusion of large volumes of fluid. If the patient’s condition prevents placement of periph- eral IVs, a central venous catheter may be placed
Traumatic injuries
Table 6.1 Estimated blood loss, signs and treatment for classes of shock
Class of shock Blood loss Signs Treatment
Class I 0–750 ml (up to 15% of Tachycardia PO fluids (if not NPO),
blood volume) IV crystalloid fluids
Class II 750–1500 ml (15–30% Tachycardia IV crystalloid fluids
of blood volume) Tachypnea
Pulse pressure narrows
Class III 1500–2000 ml (30–40% Tachycardia (120) IV crystalloid fluids,
of blood volume) Tachypnea (30–40) packed RBCs
Narrowed pulse pressure Decreased systolic blood pressure Decreased urinary output Decreased mental status Decreased capillary refill
Class IV 2000 ml (40% Tachycardia (140) IV crystalloid fluids
blood volume) Tachypnea (35) with packed RBCs
Absent pulse pressure Markedly decreased systolic
blood pressure No urinary output Confused to lethargic Markedly decreased
capillary refill
NPO: nil per os; RBCs: red blood cells.Source: Committee on Trauma, American College of Surgeons.Advanced Trauma Life Support Instructor Manual, 5th ed., Chicago: American College of Surgeons, 1997.
in the subclavian, internal jugular, or femoral vein.
A peripheral venous cutdown may be performed on the saphenous vein. In children8 years of age, intraosseous placement of a needle may provide rapid vascular access as the primary approach or if peripheral IV access fails.
Fluid resuscitation should be given rapidly, up to a predetermined amount. The patient’s hemo- dynamic response should be evaluated after this initial bolus. Patients who respond quickly may not need further fluids or blood, as they may have limited blood loss. Patients who respond only transiently are likely to have ongoing blood loss, requiring further resuscitation with fluids and likely blood products. These patients require a rapid search for the cause of their blood loss.
Patients who do not respond to the initial bolus require additional resuscitation with blood and fluids. An emergent trip to the operating room (OR) may be required to diagnose the source of bleeding, as well as control it. Finally, consider other causes for hemodynamic compromise, such as neurogenic or cardiogenic shock, which require alternate therapeutic approaches.
Blood products should be used for patients who remain hemodynamically unstable or who have ongoing blood loss requiring replacement.
When there is no time to type and screen a patient, type O blood should be utilized. Administer
Rh-negative blood to women of childbearing age.
When it is available, administer ABO type-specific and Rh-compatible blood. This blood can be ready approximately 15 minutes after the blood bank receives the type and screen specimen. Type and crossmatched blood is the best source to avoid incompatibility reactions, but requires over an hour to obtain.
Depending on the etiology of the shock state, the physician may utilize other procedures such as:
1. needle decompression followed by tube thoracostomy for tension pneumothorax;
2. needle pericardiocentesis or pericardial window for cardiac tamponade;
3. circumferential pelvic binding, external fixation, or pelvic angiography with embolization of bleeding vessels for the treatment of displaced pelvic fractures.
An ED thoracotomy is indicated for a pene- trating chest trauma patient who loses vital signs within a few minutes of arriving at or within the ED. This procedure should only be performed if the hospital has the facilities and staff to address the injury. A thoracotomy allows for definitive treatment of pericardial tamponade, repair of a cardiac laceration, cross-clamping the aorta to prevent ongoing blood loss, and clamping the pulmonary arteries.
Traumatic injuries
Trachea midline This results in a low cardiac output and high central venous pressure
Normal breath sounds Distended neck veins
Blood in the pericardial sac compresses the heart and impairs ventricular filling Reflex tachycardia attempts to (but cannot) compensate for a low output
Tamponade is diagnosed by distention of neck veins, hypotension and narrowed pulse pressure
Figure 6.8
Cardiac tamponade. Campbell, John E., Basic Trauma Life Support for Advanced Providers, 5th ed., Copyright 2004. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.
Often the patient may leave the ED for the OR during the circulation assessment portion of the primary resuscitation. This may be necessary to obtain control of active bleeding within the chest or abdominal cavity.
Disability Assessment
Assessment of the patient’s disability during the primary survey should be brief and directed to the following three areas: level of consciousness, pupillary examination, and movement of extrem- ities. It is always important to assess neurologic function prior to paralysis of the patient as part of rapid sequence intubation (RSI).
Assess the level of consciousness with the AVPU approach or the Glasgow Coma Scale (GCS). AVPU relates to the patient’s level of response: the patient may be Alert, respond to Voice or Pain, or remain Unresponsive.
The GCS (Table 6.2) is used to follow the patient’s status, guide therapy, and communicate with consultants. Scores range from a minimum of 3 to a maximum of 12, with a score of 8 or less indicating coma. A GCS drop of two is consid- ered deterioration, while a drop of three is con- sidered a catastrophic change.
The pupil examination should look for pupil symmetry and reactivity to light. A dilated,
unreactive (“blown”) pupil in a comatose patient suggests transtentorial intracranial herniation leading to unilateral compression of the third cra- nial nerve. Disconjugate gaze may be associated with various etiologies of coma.
Assessment of movement in all extremities is a gross evaluation of spinal cord function, not peripheral nerve function. It is more important to judge symmetry and strength in all extremities than isolated peripheral nerve function.
Treatment
The two most dangerous insults to the trauma- tized brain, hypoxia and hypotension, should be addressed during the initial evaluation and resuscitation. ET intubation is indicated in any patient with a GCS9.
In cases of neurologic deterioration or lateral- izing neurologic signs, mannitol and controlled hyperventilation to a partial pressure of carbon dioxide (PCO2) between 30 and 35 mmHg may be employed as temporizing measures to reduce intracranial pressure. Other therapies to consider in the severely brain injured patient include anti- convulsants, deep sedation, and elevating the head of the bed to 30°. Neurosurgical procedures such as operative craniotomy, skull trephination with burr hole placement (Figures 6.9a and b), or intraventricular pressure monitor placement are often required.
Traumatic injuries
Table 6.2 Glasgow Coma Scale Eye opening
Spontaneous 4 Reticular activating system intact (though patient may not be aware) To verbal command 3 Opens eyes when told to do so
To pain 2 Opens eyes in response to pain
None 1 Does not open eyes to any stimuli
Verbal response
Oriented – converses 5 Aware of self and environment; oriented to person, place and time Disoriented – converses 4 Organized and well articulated, but disoriented to person, place or time Inappropriate words 3 Random exclamatory recognizable words
Incomprehensible 2 Moaning, no recognizable words
No response 1 No response or intubated
Motor response
Obeys verbal commands 6 Readily moves limbs when told to do so
Localizes to painful stimuli 5 Moves limb in an effort to remove painful stimulus Flexion withdrawal 4 Pulls away from pain in flexion
Abnormal flexion 3 Decorticate rigidity
Extension 2 Decerebrate rigidity
No response 1 Hypotonic, flaccid; suggests loss of medullary function or concomitant spinal cord injury
Adapted from Marx JA (ed.).Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed., St. Louis:
Mosby, 2002.