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  Assess all trauma patients with a rapid primary survey followed by a more comprehensive secondary evaluation.

  
  
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  Address all emergent life threats in a stepwise manner during the primary survey before progressing to the next stage.

  
  
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  Treat hemodynamically unstable patients as hemorrhagic shock until proven otherwise.

  
  
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  Initiate aggressive volume resuscitation in all unstable patients while concurrently searching for active sources of hemorrhage.

Trauma is currently the fourth leading cause of death in the United States across all age groups and the leading cause of death in patients under the age of 44 years. It is responsible for more deaths in patients under the age of 19 years than all other causes combined. Approximately 40% of all emergency department (ED) visits are for trauma-related complaints, and the annual costs exceed $400 billion. Adding to these costs, permanent disability is actually 3 times more likely than death in this cohort.

Trauma is broadly classified by mechanism into blunt and penetrating varieties, with the former more than twice as common as the latter. Regardless of mechanism, victims of significant trauma present with a wide range of complex problems, and their proper care necessitates a multidisciplinary approach, including emergency physicians, trauma surgeons, and the appropriate subspecialties. Most trauma care delivery systems follow the Advanced Trauma Life Support guidelines developed and maintained by the American College of Surgeons.

The mortality rates for traumatic injuries typically follow a trimodal distribution. Certain injury patterns including major vascular injuries and high cervical cord disruption with secondary apnea result in near immediate death. The second cohort of injuries, including conditions such as pneumothorax and pericardial tamponade, typically evolve over a duration of minutes to hours and are generally responsive to aggressive emergent intervention. Septicemia and multisystem organ failure account for the third peak of fatalities and typically occur weeks to months after injury.

History

Attempt to identify the severity of mechanism, as this will predict the patterns of injury. For example, determine the approximate speed of a motor vehicle collision (MVC) and whether or not the patient was restrained. Emergency medical service personnel can be an invaluable resource, especially in amnestic and nonverbal patients. In assault patients, inquire if they can recall exactly what they were struck with and the number of times. Ask if there was any loss of consciousness, as this may portend to a significant head injury. For penetrating trauma, ask about the number of shots heard and how many times the patient felt himself or herself get shot.

Obtain a brief medical history using the AMPLE mnemonic. Ask about any known drug allergies, current medication use, past medical history, last oral intake, and the immediate events leading up to the injury. Keep in mind that regardless of past history, elderly patients have less physiologic reserve and are prone to higher rates of morbidity and mortality. In females of childbearing age, always ask about the last menstrual period and assume that they are pregnant until proven otherwise. Pregnant patients are at higher risk for domestic violence and warrant unique considerations such as placental abruption, uterine rupture, the supine hypotensive syndrome, and fetal distress or demise. Even apparently minor injuries including falls and low-speed motor vehicle accidents can induce preterm labor or placental abruption.

Always ask about any evolving symptoms and identify the exact locations of pain, as this will guide your physical exam. Patients with altered mental status should be treated as having a traumatic brain injury until proven otherwise. Shortness of breath may indicate an underlying pneumothorax (PTX), pulmonary contusion, or pericardial tamponade. Chest pain may indicate an underlying fracture of the ribs or sternum, hemothorax (HTX), or traumatic aortic injury (TAI). Assume that patients with abdominal pain, hematemesis, or rectal bleeding have an intra-abdominal visceral injury until proven otherwise. Patients complaining of hematuria should be considered at a high risk for injury to the genitourinary (GU) tract. Neurologic complaints including weakness and paresthesias may indicate an underlying spinal cord injury or vascular dissection.

Physical Examination

The physical exam in major trauma patients is very systematic and can be divided into primary and secondary surveys.

Primary Survey

The primary survey is a very brief and focused exam meant to identify and address emergent life threats. It should proceed in a stepwise approach outlined by the ABCDE mnemonic. Always treat any encountered abnormalities before proceeding to the next step in the survey. If a patient decompensates at any point during his or her clinical course, return to the beginning of the primary survey and reassess. Assume an unstable cervical spine injury in all major trauma victims until proven otherwise and immediately immobilize on presentation.

Assess the airway for patency. Signs of potential airway compromise include pooling pharyngeal secretions, intraoral foreign bodies, stridulous or gurgling respirations, obvious oropharyngeal burns, significant midface, mandibular, and laryngeal fractures, and expanding neck hematomas.

Evaluate the patient’s breathing and ventilation. Expose the chest and look for any signs of asymmetrical or paradoxical chest wall movement, obvious deformities or open wounds, tracheal deviation, and jugular venous distention. Auscultate the chest to confirm strong symmetric bilateral breath sounds. The goal is to identify the presence of emergent life threats including tension PTX, massive HTX, open PTX (sucking chest wound), and flail chest.

Rapidly assess the patient’s circulation by evaluating for signs of altered mental status. A depressed level of consciousness should be considered hypovolemic shock until proven otherwise. Other findings concerning for hemorrhagic shock include pale, cool, and mottled extremities and thready peripheral pulses. Auscultate the heart to detect distant heart tones suggestive of an underlying pericardial effusion. Identify all sources of active bleeding and control with the application of direct pressure.

Perform a rapid neurologic exam, noting any evidence of disability or deficits. Document the patient’s level of consciousness; note the size, symmetry, and reactivity of the pupils; and assess for any focal numbness or weakness. Perform a rectal exam to ensure adequate rectal tone and determine the patient’s Glasgow Coma Scale (GCS).