Chapter 35 Assessment and Stabilization of the Trauma Patient
Trauma has far-reaching effects on society. Unintentional injury ranks as the fifth leading cause of death in the United States, claiming 41 of every 100,000 people.1 When intentional injuries such as assaults and suicide attempts are added, the rate increases to 60.5 deaths per 100,000 people.2 Yet death rates account for only a small portion of the effects of trauma. In 2004, 1.9 million hospitalizations were trauma related and trauma accounted for 6% of all hospital discharges.3 Trauma also directly affects the health care system. For example, 42.2 million people visit emergency departments every year for treatment of unintentional injuries.2 Annually, $33.7 billion is spent on inpatient trauma care, $31.8 billion dollars is spent on emergency department costs, and another $13.6 billion is spent on outpatient visits.3
The Trauma System
Death from trauma has a trimodal pattern of distribution.
• The first morbidity peak occurs within seconds or minutes of injury. These deaths result from lacerations of the heart, large vessels, brain, or spinal cord. Because of the severity of such injuries, few patients are salvageable.
• The second morbidity peak takes place minutes or hours after the traumatic event. Deaths in this period generally result from intracranial hematomas or uncontrolled hemorrhage from pelvic fractures, solid organ lacerations, or multiple wounds. Care received during the first hour after injury (the so-called “golden hour”) is crucial to trauma patient survival.
• The third morbidity peak occurs days to weeks following trauma. Death during this period results from sepsis, multiorgan failure, or respiratory or other complications.
To maximize patient care, trauma systems have been developed to minimize the impact that this trimodal distribution of death has on traumatically injured patients. A trauma system is “an organized, coordinated effort in a defined geographic area that delivers the full range of care to all injured patients and is integrated with the local public health system.”4 Trauma systems begin with inclusive 9-1-1 emergency systems that activate trained prehospital providers. If patients are to survive the first morbidity peak, help must arrive in a timely fashion.
Minimizing death in the second trimodal peak requires a responsive prehospital system that can transport patients rapidly, providing stabilizing care in transit and delivering patients to the most appropriate facility that is capable of providing the needed care, preferably within that “golden hour.” The American College of Surgeons as well as many state trauma systems have developed a trauma designation classification that assists prehospital personnel in determining which facility would be most prepared to receive a traumatically injured patient. Table 35-1 gives an overview of what resources exist at a facility based on the trauma designation it is given.
TABLE 35-1 TRAUMA VERIFICATION LEVELS
a American College of Surgeons. (2010, April 22). Level I requirements by chapter. Retrieved from http://www.facs.org/trauma/vrc1.pdf
b American College of Surgeons. (2010, April 22). Level II requirements by chapter. Retrieved from http://www.facs.org/trauma/vrc2.pdf
c American College of Surgeons. (2010, April 22). Level III requirements by chapter. Retrieved from http://www.facs.org/trauma/vrc3.pdf
d American College of Surgeons. (2010, April 22). Level I pediatric requirements by chapter. Retrieved from http://www.facs.org/trauma/vrcped1.pdf
e American College of Surgeons. (2010, April 22). Level II pediatric requirements by chapter. Retrieved from http://www.facs.org/trauma/vrcped2.pdf
Approach to Care of the Trauma Patient
The Primary Assessment
Airway
An adequate airway is required for breathing and circulation; therefore assessment and protection of the airway is always paramount in care of the trauma patient. Patients at particular risk of a compromised airway are those with altered levels of consciousness (Glasgow Coma Scale score of 8 or less) and those with maxillofacial and neck injuries. See Chapter 8, Airway Management, for further discussion of airway management techniques.
Most traumatic incidents place a patient at risk for spinal cord injury. In fact, it is estimated that there are 12,000 new cases of spinal cord injury every year associated with trauma.5 It is also estimated that as many as 25% of spinal cord injuries occur after the initial insult as part of patient transport and initial management.6 Therefore assessment and protection of the spinal cord should begin with the initial stages of trauma assessment and care, that is, with airway management. See Chapter 37, Spinal Cord and Neck Trauma, for further discussion of spinal cord injuries.
Table 35-2 summarizes assessment findings of concern and potential interventions associated with the airway and cervical spine.
TABLE 35-2 AIRWAY AND CERVICAL SPINE ASSESSMENT AND INTERVENTIONS
| COMPONENT OF ASSESSMENT | FINDINGS OF CONCERN | POTENTIAL INTERVENTIONS |
|---|---|---|
| Airway | • Allow position that maximizes airway • Perform jaw thrust or chin lift • Remove or suction out loose objects • Insert a nasopharyngeal or oropharyngeal airway (Never insert a nasopharyngeal airway into patients with facial trauma. Consider the nasopharyngeal airway for conscious patients who require assistance to maintain their airway.) | |
| Cervical spine |
Breathing
Even with an open airway, a patient must be able to exchange gases through the airway for effective breathing. Therefore assessment and interventions for breathing should always follow those for the airway. See Chapter 18, Respiratory Emergencies, for further discussion of respiratory assessments. Table 35-3 summarizes assessment findings of concern and potential interventions associated with breathing.
TABLE 35-3 BREATHING ASSESSMENT AND INTERVENTIONS
