A – Airway (Key Question: Do We Need to Take Control of the Airway Right Now?)

In many patients, a thorough assessment of the airway can be completed by asking one question: “what is your name?” A speaking patient, answering a question directly, typically has a patent and self-maintained airway. Changes in voice, gurgling, stridor, or the inability to speak in full sentences should be noted as clues to impending airway problems. Ultimately the decision must be made if it is necessary to immediately take control of the airway. Box 1.3 lists the most important things to consider when deciding to intubate a trauma patient.^{10, 11}

If the patient must be intubated, it is critical to mentally and physically prepare for an anatomically and physiologically difficult airway. Anatomy may be severely distorted by the trauma or simply difficult to visualize due to a cervical collar in place, swelling, or bleeding. The need for a backup plan should always be anticipated; before intubating, have a gum elastic bougie, supraglottic airway, video laryngoscope, and/or scalpel for cricothyrotomy available. As with any other anticipated difficult airway, a verbalized plan for front-of-the-neck access should be in place should a cricothyrotomy be required.

The already-physiologically-stressed trauma patient may respond profoundly to induction and paralytic agents – as many are already reliant on a sympathetic surge to maintain their cardiac output. Consider medication selection in the context of the patient’s physiology. For example, ketamine^12–18 or etomidate^19–23 are better choices for induction in the context of hypotension, as they are less likely to cause a drop in blood pressure. Relative contraindications for paralytic agents should also be considered.^24–26 Likewise, consider adjusting the dosages of medications for hypotension; lower doses of sedatives and higher doses of paralytics may be required.²⁷ Attention should be given to beginning pre-oxygenation and optimization of the patient’s physiology (mean arterial pressure, oxygen saturations, etc.). If the mental status allows, insert a supraglottic airway, place a nasal cannula, apply a bag valve mask, and/or utilize noninvasive ventilation to pre-oxygenate as would be expected with any non-trauma patient.

B – Breathing (Key Questions: Are Chest Tubes Required? Is There Bleeding in the Chest?)

Assessment of breathing is a look (ensure equal chest rise, quantify the respiratory rate, check for wounds), listen (auscultate bilaterally), and feel (press on the chest wall to assess for crepitus or flail rib segments) process. Glance at the monitor and note the oxygen saturation. Pneumothorax can be more subtle than anticipated. Careful attention to asymmetric breath sounds (as referred sounds from one side of the chest could be heard on the collapsed-lung side), neck veins, and tracheal deviation could be crucial to picking up a pneumothorax or hemothorax before it develops tension physiology.

If there is concern for pneumothorax or hemothorax in a hemodynamically unstable patient, needle decompression of the chest or placement of a chest tube should be completed immediately. This is both a diagnostic and therapeutic procedure in critically ill trauma patients, especially those with penetrating trauma to the chest.

C – Circulation (Key Question: Where Are They Bleeding and Do They Need Blood?)

Coagulopathy, acidosis, and hypothermia – the trauma triad of death –all primarily stem from shock in trauma. Finding and promptly methodically stopping major hemorrhage is paramount. The trauma adage is that blood can be found in six major places: the chest, the abdomen, the pelvis, the retroperitoneum, the thighs (or areas around other long bones), and the street.

External hemorrhage may be obvious or discovered when exposing the patient. Internal hemorrhage may be more subtle and requires considering the patient’s heart rate, blood pressure, and appearance. Obtain a complete set of vital signs and assess peripheral circulation. Weak pulses and cool extremities imply a shock state, as does a more objective rise in the shock index (heart rate divided by systolic blood pressure). While cutoffs for tachycardia and blood pressure are more poorly defined in the literature, a shock index <0.7 or >1.3 is correlated with poorer outcomes,²⁸ and a shock index >0.95 is correlated with the need for massive transfusion.²⁹

Ensure that good intravenous access has been obtained – at least two large-bore (i.e., at least 18-gauge) IVs in most trauma patients. While short, 18-gauge peripheral IVs are excellent methods for volume resuscitation, consideration should be given to placement of an intraosseous or central venous line if peripheral access is limited or difficult. While obtaining IV access, lab work should be sent, including a typical trauma panel of labs: complete blood count, venous blood gas (serum lactate), basic chemistry, coagulation studies, and type-and-screen for potential transfusion. Additional labs may be obtained, but they usually do not guide initial management. Initial hemoglobin and hematocrit levels may be falsely reassuring, as it takes time for blood concentrations of heme to equilibrate to rapid blood loss. Patients known to be on anticoagulants, or with elevated coagulation times, ought to be reversed in the context of active hemorrhage.

Hypotension/Shock

Classically taught “classes of shock” based on various vital sign cutoffs is important to appreciate; however, the literature demonstrates that they are not entirely reliable and often insensitive predictors of shock.^{30, 31} Normotensive elderly patients might be in shock. Children and healthy adults might compensate very well, leading to deceptively normal vital signs. The trajectory in tachycardia, mean arterial pressure, and mental status must be considered in any trauma patient with the potential for active bleeding.

If the patient is hypotensive, blood loss must be at the top of the differential for the cause, but also consider non-bleeding causes of hypotension in trauma; namely, tension pneumothorax, cardiac tamponade, spinal cord injury, myocardial dysfunction (from contusion, underlying heart disease, arrhythmia, or infarction), and toxic ingestions. Box 1.4 discusses causes of hypotension in trauma.

External bleeding should be stopped with direct pressure. Consider that holes in the skin are not always lined up with where blood originates. Attempts to apply pressure at potentially retracted vascular structures, or over proximal pressure points, may be reasonable additional measures. If blood loss from an extremity cannot be stopped with direct pressure, consider placing hemostatic stitches (e.g., a figure-of-eight or whip stitch) or staples if the wound is small enough. If bleeding cannot be controlled from a larger wound, such as an amputation, utilize a tourniquet (preferably a commercially available product or manual blood pressure cuff).

Blood loss from the pelvis is often associated with pelvic fractures, which may be stabilized with binding (either with a commercially available device or properly placed and secured bedsheet). While there are various types of pelvic fractures – some of which do not benefit from binding – a hypotensive patient with suspected active bleeding in the pelvis might benefit from empiric binding as a temporary measure.

Whether suffering from internal or external bleeding, a hemodynamically unstable patient needs to have replaced what has been lost: whole blood. Transfusion with packed red blood cells alone may not be adequate. Consider initiating a massive transfusion protocol. Protocols vary by institution but should include a mix of products containing packed fresh frozen plasma (FFP), platelets, and red blood cells (PRBC). The PROPPR and PROMMTT trials have demonstrated that overall transfusion in a ratio of 1:1:1 of FFP:Platelets:PRBCs is optimal.^{32, 33} Prothrombin Complex Concentrate (PCC) can be considered as an alternative to FFP, as it does not require thawing and is often more readily available. Consider supplemental calcium, as citrate in blood products can chelate body stores of calcium, potentiating hypotension. The CRASH-2 trial also demonstrated the efficacy of tranexamic acid (TXA), if given within the first three hours, to improve mortality in patients in hemorrhagic shock from trauma.³⁴ While IV fluids can temporarily elevate the circulating blood volume, they dilute clotting factors and perhaps unnecessarily increase the mean arterial pressure affecting hemostasis. They should be used sparingly and only as a bridge to blood products. Vasopressors have no role in hemorrhagic shock from trauma. Target resuscitation to a MAP of 65 mm Hg typically – and increase this goal to 80 mm Hg in any patient suspected of head injury or spinal cord injury.^35–37 This strategy of allowing penetrating trauma patients to remain slightly hypotensive is sometimes referred to as “permissive hypotension,” and, although it has been demonstrated to be effective in one randomized trial, subsequent human trials have not been able to validate the benefit; therefore, the strategy remains controversial.³⁸

Lastly, consideration may be given to more invasive hemostasis options such as a resuscitative thoracotomy^39–41 or placement of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA),^42–44 in select patients nearing death.

D – Disability (Key Question: Is There a Major Neurologic Deficit?)

During the primary survey the neurological assessment should include Glasgow Coma Scale (GCS),⁴⁵ pupillary exam, and gross motor/sensory assessment of all four extremities. Mental status is a key assessment in the overall status of the trauma patient. GCS can help assess the trajectory of the patient over time. Studies have indicated that simply assessing the motor component of the GCS can be a simplified, binary assessment (can the patient follow simple commands?) and is equally predictive of the need for airway management and mortality, discussed in Table 1.4.⁴⁶ Localized neurologic (or vascular) deficits in the context of a mangled or deformed extremity may prompt a rapid bone or joint reduction and improve the likelihood of limb salvage.

All trauma patients with a significant mechanism of injury should be placed in a cervical collar until it is demonstrated they do not have an injury to the cervical spine, whether by clinical decision rules (in highly assessable patients, such as NEXUS or the Canadian C-Spine Rule) or by imaging and exam.^{47, 48}

If using induction or paralytic agents for intubation, the next possible neurologic exam will likely be significantly delayed. Consider performing a thorough baseline exam, if possible, prior to intubation.

If there is clinical evidence of brain herniation from head trauma, hyperosmolar therapy should be started to partially abate rises in intracerebral pressure (and subsequent losses in cerebral perfusion pressure).^49–56 Any intubation performed in this context should be completed by an experienced provider, as first-pass success minimizes hypotension and hypoxia.^{55, 57, 58} Definitive therapy will require neurosurgical intervention.

E – Expose (Key Question: What Injuries Haven’t Been Found Yet?)

Norman McSwain, a trauma surgeon and developer of the initial Advanced Trauma Life Support (ATLS) program, noted that “paranoia prevents disasters: the most severe injury is under the unremoved clothes.” Every trauma patient should be exposed from head-to-toe in order to be examined thoroughly for injuries. Careful attention must be paid to areas that hide injuries, such as the axilla, skin folds, and the perineum. All patients must be rolled to examine the back. Key questions to consider in the primary survey are listed in Table 1.5.

Trauma Bay Imaging

A chest x-ray has long been the tradition for the trauma bay imaging of choice to evaluate for pneumothorax. In reality, a chest x-ray is poor at identifying this pathology, with sensitivity of 28–75%, especially if performed supine. The alternative is the eFAST (Extended Focused Assessment with Sonography in Trauma). This ultrasound exam is more sensitive (86–98%) than chest x-ray, and equally specific. It can be performed faster (no pun intended), and synergize better with the next steps.⁵⁹ If the patient is unstable with traumatic mechanism and there is clinical evidence to suggest pneumothorax (especially tension pneumothorax), a chest tube should be placed empirically without waiting for imaging.

The eFAST is a six-part study that assesses for abdominal free fluid, pericardial effusion, and pneumothorax. The prominent role for this procedure was largely designed to replace the need for diagnostic peritoneal lavage (DPL) to rule-out or rule-in abdominal sources of bleeding in blunt trauma patients with unstable vital signs, primarily as a means to guide operative therapy. In practice, the eFAST exam is also performed routinely on stable trauma patients, looking to identify the same abdominal and pericardial pathology early, and to identify pneumothoraces without the need for a chest x-ray. Positioning of the patient is key to enhancing the sensitivity of the exam. Brief periods in Trendelenburg (for the right and left upper quadrant views), reverse-Trendelenburg (for the suprapubic view), and supine (for the subxiphoid and lung views) will help position organ tissue, fluid, and air to improve diagnostics. Serial eFAST exams are not unreasonable in a stable patient, or one in whom the clinical picture has changed (sudden hypoxia or hypotension). Ultrasound has been noted to be as high as 100% sensitive for identifying the need for laparotomy in unstable patients, though only 75% sensitive (and 98% specific) for identifying free fluid in stable and unstable trauma patients cohorted together.^60–65 Figure 1.2 describes ultrasound views.

Figure 1.2 The eFAST assesses six locations, looking for intraperitoneal fluid, pericardial fluid, and pneumothorax. Extended Focused Assessment with Sonography in Trauma (eFAST) views: (1) Right upper quadrant view; (2) Left upper quadrant view; (3) Suprapubic view (two axes); (4) Subxiphoid view; and (5) Lung views (bilaterally)

If the mechanism or primary and secondary survey suggest a possible pelvic fracture, a portable film of the pelvis should be completed as well. As mentioned above, any unstable patient where a pelvic source of bleeding is suspected should empirically have the pelvis placed in a binding device. Suspected pelvic fracture is an indication for portable pelvis x-ray in the trauma bay, but this may be omitted to pursue more expedient definitive CT imaging in the hemodynamically stable patient.

CT Scans

Given the limitations of chest x-ray, pelvic x-ray, and the eFAST exam, more advanced imaging is often required to completely assess injuries. CT scans should be completed for areas where potentially clinically relevant injury has occurred. Priority should be given to scans identifying immediate life threats (such as intracranial hemorrhage in an obtunded fall victim with clinical evidence of herniation) over operative planning scans (such as three-dimensional reconstruction images of a trimalleolar ankle fracture) that do not immediately impact the next steps in management or disposition of the patient.

Some decision rules may aid in ruling-out clinically relevant injury, such as the NEXUS,⁴⁷ Canadian Head CT,⁶⁶ and C-spine⁴⁸ rules, though clinical judgment will dictate when most CT imaging is ordered. Some strategies involve major trauma patients routinely receiving whole-body or “pan-scan” CT imaging; others advocate for more selective imaging based on mechanism and exam. Whole Body CT (WBCT) typically includes non-contrast studies of the head and c-spine, as well as IV contrast enhanced studies of the chest, abdomen, and pelvis. In the era of multi-detector CT scanners, a trauma “pan-scan” typically delivers approximately 20 mSv of radiation (a 0.35% increased risk of cancer in one’s lifetime, compared to the population’s lifetime inherent risk of death from cancer of approximately 25%).⁶⁷ Proponents of whole-body scans argue that diagnoses are less likely to be missed and are identified faster. Advocates for the selective scanning highlight the unnecessary radiation exposure and increased incidental, clinically irrelevant findings that lead to further unnecessary – or at worst potentially harmful – testing and treatment. Little prospective evidence exists on the matter. Most recently, the REACT-2 trial, a prospective, multicenter study with intention-to-treat analysis of major trauma patients, found no difference in mortality (24-hour, 30-day, or overall) for WBCT vs. selective imaging. While the evidence is scant, WBCT may be a better option in patients who are not easily assessed (intoxicated, severely injured, altered mental status with unreliable exam, etc.).⁶⁸