Assessment and Stabilization of the Trauma Patient

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


Stabilization of the trauma patient is best implemented with a standardized approach that ideally involves a team of uniquely trained individuals. Emergency department staff need to be prepared to care for patients who are traumatically injured.



The Trauma System


Death from trauma has a trimodal pattern of distribution.



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





















LEVEL CRITERIA
Level I trauma center
Level II trauma center
Level III trauma center
Level IV trauma center
Pediatric trauma center The American College of Surgeons designates pediatric facilities as Level I and Level II pediatric trauma centers using similar criteria with an emphasis on being able to provide trauma care to pediatric patientsd,e

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


Regardless of the type of emergency department to which a trauma patient is taken, initial assessment and care of the trauma patient should be delivered in a standardized fashion by a coordinated team of health care providers trained in the delivery of trauma care. The team leader (or captain) oversees the course of patient resuscitation. Team composition varies from facility to facility but usually consists of at least one physician, one nurse, and ancillary care personnel.




The Primary Assessment


The first five letters in the mnemonic (A-B-C-D-E) represent the first part of trauma resuscitation: airway, breathing, circulation, disability, and exposure and environmental control. These first five steps include assessment of potentially life-threatening injuries and appropriate interventions. Potentially lethal conditions such as pneumothorax, hemothorax, pericardial tamponade, flail chest, and hemorrhage can be detected during the primary assessment. As each major problem is identified, appropriate interventions are initiated.



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

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









FINDINGS OF CONCERN POTENTIAL INTERVENTIONS


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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Assessment and Stabilization of the Trauma Patient

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