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Initial Assessment of the Trauma Patient
Airway
Basic life support: Effective basic life support prevents hypoxia and hypercapnia from contributing to the patient’s decreased level of consciousness. All trauma patients should be considered to have full stomachs and are therefore at high risk for pulmonary aspiration. When assisting ventilation, one should only provide tidal volumes enough to provide chest rise, and cricoid pressure can be applied, although the efficacy is controversial.
Cervical spine injury: Assume the presence of cervical spine injury if the patient is complaining of neck pain or has significant head injuries, neurologic signs or symptoms suggestive of cervical spine injury, or intoxication or loss of consciousness. The cervical collar (C-collar) can make airway management difficult because it limits the degree of cervical extension. Therefore, alternative devices such as video laryngoscopes and fiberoptic bronchoscopes should be available. The front part of the C-collar can be removed during intubation as long as the head and neck remain neutral by applying in-line stabilization.
Tracheostomy: When a trauma has occurred that distorts the facial or upper airway anatomy such that the ability to mask ventilate is hindered or if hemorrhage into the airway prevents a patient from lying supine, consider elective tracheostomy or cricothyroidotomy before anesthetizing the patient.
Breathing: Initiate ventilation immediately after securing the airway. If a patient had multiple injuries, one should be concerned for possibility of a pulmonary injury, which could develop into a tension pneumothorax with the initiation of mechanical ventilation. This may manifest as hemodynamic instability after mechanical ventilation. If this occurs, stop mechanical ventilation and perform bilateral needle thoracostomy and then chest tube insertion.
Circulation: Determine if the patient has a pulse and a blood pressure. Usually this information has been previously communicated by prehospital personnel. Emergency thoracotomy is no longer performed in patients without blood pressure or palpable pulse (even if organized cardiac activity is present) after blunt trauma because there is a lack of evidence that this improves survival. Resuscitative thoracotomy is currently only done in patients with penetrating trauma with preserved, organized cardiac rhythms or other signs of life.
Neurologic function: Perform a rapid neurologic assessment, including level of consciousness, pupillary size and reactivity, lateralizing signs that suggest intra- or extracranial injuries, and spinal cord assessment. Hypercarbia is often a cause of depressed level of neurologic responsiveness but also consider alcohol intoxication, drug effects, hypoglycemia, and hypoperfusion.
Injury assessment: Fully expose the patient and use caution because this increases the risk of hypothermia. All fluids must be warmed, and forced air warmers can be used.
Hemorrhage and Trauma-Induced Coagulopathy
Blood volume: The blood volumes for adults, children, and infants are 70 mL/kg, 80 mL/kg, and 90 mL/kg, respectively.
Classes of Hemorrhage
• Class I: Volume that can be lost without hemodynamic consequence; represents less than 15% of the circulating blood volume
• Class II: Loss of volume that prompts a sympathetic response to maintain perfusion; represents 15% to 30% of the circulating blood volume. The diastolic blood pressure will increase because of vasoconstriction, and the heart rate will increase to maintain cardiac output. Intravenous (IV) fluids are usually indicated, and transfusions may be needed if the bleeding continues.
• Class III: Consistently results in decreased blood pressure; represents 30% to 40% of the circulating blood volume. Vasoconstriction and tachycardia are not enough to maintain perfusion. A metabolic acidosis develops, and hypovolemic/hemorrhagic shock develops. Blood transfusions are necessary to maintain oxygenation and tissue perfusion.
• Class IV: Life-threatening hemorrhage; more than 40% of the circulating blood volume is lost. The patient will be unresponsive and severely hypotensive. Rapid control of bleeding and blood-based resuscitation will be required to prevent death. It is common that these patients will develop a coagulopathy after their injury, require massive blood transfusion, and have a high likelihood of dying.
Trauma-induced coagulopathy: Common after major trauma; it is thought that global tissue hypoperfusion plays an important role. During hypoperfusion, the endothelium releases thrombomodulin and activated protein C to prevent microcirculation thrombosis. Thrombomodulin binds thrombin, thereby preventing thrombin from cleaving fibrinogen to fibrin. The thrombomodulin–thrombin complex activates protein C, which then inhibits the extrinsic coagulation pathway through effects on cofactors V and VIII. Activated protein C also inhibits plasminogen activator inhibitor-1 proteins, increasing tissue plasminogen activator, resulting in hyper-fibrinolysis.
Tranexamic acid: Trauma-induced coagulopathy is not solely related to impaired clot function. Fibrinolysis is an equally important component as a result of plasmin activity on existing clot. Tranexamic acid administration has been associated with decreased bleeding during cardiac and orthopedic surgeries, presumably because of its antifibrinolytic properties. Studies suggest that there is a significantly reduced risk of death from hemorrhage when it is initiated.
Hemostatic Resuscitation
1:1:1 ratio: Giving blood products in a 1:1:1 ratio (red blood cells [RBCs]: fresh-frozen plasma [FFP]: platelet) early in resuscitation is the accepted approach to trauma resuscitation and is termed damage control resuscitation. RBCs improve oxygen delivery to tissues, and FFP provides clotting factors V and VIII along with fibrinogen. Platelets and cryoprecipitate are likely not necessary in the initial phase of resuscitation because platelet and fibrinogen levels are normal in early coagulopathy. Platelets may be beneficial if the resuscitation is prolonged or if a recalcitrant coagulopathy is noted.
Emergency transfusions: Type O-negative blood is available for immediate transfusion at most trauma centers. Administration of blood products usually progresses from O-negative to type-specific to crossmatched units as the acute need decreases. When the amount of uncrossmatched blood given reaches 8 or more units, one should not begin transfusing type specific blood; type O blood should be continued until the patient has stabilized.
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