Trauma Assessment

The initial assessment and management of seriously injured patients is a challenging task and requires a rapid and systematic approach.
This systematic approach can be practised¹ to increase speed and accuracy of the process but good clinical judgement is also required. Although described in sequence some of the steps will be taken simultaneously.

The aim of good trauma care is to prevent early trauma mortality. Early trauma deaths occur because of failure of oxygenation of vital organs or central nervous system injury or both.
Injuries causing this mortality occur in predictable patterns and recognition of these patterns led to the development of advanced trauma life support (ATLS) by the American College of Surgeons. A standardised protocol for trauma patient evaluation has been developed.^2,3,4 The protocol celebrated its 25th anniversary in 2005.⁵ Good teaching and application of this protocol is held to be an important factor in improving the survival of trauma victims worldwide.⁶

Different systems of trauma scoring have been developed.

• Stabilise the patient
• Identify life threatening conditions in order of risk and initiate supportive treatment
• Organise definitive treatments or organise transfer for definitive treatments

Assessment and management will begin out of hospital at the scene of injury and good communication with the receiving hospital is important. The preparatory measures are outlined below to 'set the scene':

The prehospital phase

• Coordination and communication with the receiving hospital so that the trauma team can be alerted and mobilised
• Airway maintenance
• Control of external bleeding shock
• Keeping the patient immobilised
• Information gathering: time of injury; related events; patient history. Key elements are the mechanism of injury to alert the trauma team to degree and type of injury.
• Keeping time at the scene to a minimum

The hospital phase

• Preparation of a resuscitation area
• Airway equipment (laryngoscopes etc accessible, tested)
• Intravenous fluids (warming equipment etc)
• Immediately available monitoring equipment
• Methods of summoning extra medical help
• Prompt laboratory and radiology backup
• Transfer arrangements with trauma centre.

Guidelines on protection when dealing with body fluid should be followed throughout this and subsequent procedures.

This is the sorting of patients according to their need for treatment and the resources available. It starts at the scene (see above) and and continues at the receiving hospital.^7,8 Priority is given to patients most likely to deteriorate clinically and triage takes account of vital signs, prehospital clinical course, mechanism of injury, age and other medical conditions. In trauma centres team work should ensure critically injured patients are evaluated as diagnostic procedures are performed simultaneously thus reducing the time to treatment. A team approach is demanding of personnel and resources and in smaller institutions, nonhospital settings or with mass casualties available personnel and resources can rapidly be overwhelmed:

• Triage is done according to the ABC principles below (Airway with cervical spine protection, Breathing, Circulation and haemorrhage control).
• Selection of hospital according to available services, so that trauma patients should be taken to trauma centres.
• Multiple casualties. Where the number of patients and severity of injury does not exceed the capacity of the treatment centre, life threatening injuries and multiple system injuries are treated first.
• Mass casualties. When the the number of patients and severity of injury does exceed capacity of the treatment centre,patients are selected for treatment according to best chance of survival with least expenditure of resources (time, personnel, equipment, supplies).

This comprises:

• Primary survey
• Resuscitation
• Secondary survey
• Definitive treatment or transfer for definitive care

Primary survey

For speed and efficacy a logical sequence of assessment to establish treatment priorities must be gone through sequentially, although with good team work some things will be done simultaneously (Resuscitation procedures will begin rapidly or even simultaneously with the assessment involved in the primary survey i.e. lifesaving measures are initiated when the problem is identified). Special account should be taken of children, pregnant women⁹ and the elderly¹⁰ as their response to injury is modified. The primary survey is according to:

• A= Airway maintenance cervical spine protection:¹¹
  • Are there signs of airway obstruction, foreign bodies, facial, mandibular or laryngeal fractures?
  • Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all times. If the patient can talk the airway is likely to be safe but remain vigilant and recheck. Glasgow Coma Scale less than 8 requires definitive airway.
  • Cervical spine protection is paramount throughout airway management process. Avoid excessive movement of cervical spine(no hyperextension, flexion or rotation). History of the trauma will indicate likelihood of cervical spine instability. Immobilisation and protection of spine should be achieved and maintained. Assume cervical spine injury in any multisystem trauma especially with altered level of consciousness. X-rays can be taken once immediately life threatening conditions dealt with.
  Possible treatments: May be just secretion control, intubation or airways as above or surgical airway (eg cricothyroidotomy, emergency tracheostomy).
• B= Breathing and ventilation:¹²
  Evaluate breathing: lungs, chest wall, diaphragm. Chest examination with adequate exposure: watch chest movement, auscultate, percuss to detect lesions acutely impairing ventilation:
  • Tension pneumothorax
  • Flail chest
  • Haemothorax
  • Pneumothorax.
  Note: it can be difficult to tell whether the problem is an airway or ventilation problem. What appears to be an airway problem leading to intubation and ventilation, may turn out to be a pneumothorax or tension pneumothorax which will be exacerbated by intubation and ventilation.
  Possible treatments: pneumothorax, haemothorax, tension pneumothorax and sucking chest wounds with tube thoracostomy. Initial treatment for flail chest is mechanical ventilation.
• C= Circulation with haemorrhage control:
  Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly observe:
  • Level of consciousness
  • Skin colour
  • Pulse.
  Bleeding should be assessed and controlled:
  • Direct manual pressure should be used (not tourniquets except for traumatic amputation as these cause distal ischaemia).
  • Transparent pneumatic splinting devices may control bleeding and allow visual monitoring.
  • Occult bleeding into the abdominal cavity and around long bone or pelvic fractures is problematic.
  Note:response to blood loss differs in
  • Elderly - limited ability to increase heart rate, poor correlation between blood loss and blood pressure.
  • Children - tolerate proportionately large volume loss but then rapidly deteriorate.
  • Athletes do not show same heart rate response to blood loss.
  • Chronic conditions and medication may affect response and early on in trauma management will not be known about.
  Possible treatments: Cardiac tamponade by pericardiocentesis, direct pressure or surgery to control bleeding
• D= Disability: Neurological status:
  After A,B and C above rapid neurological assessment is made to establish:
  • Level of consciousness, using Glasgow Coma Scale
  • Pupils:size, symmetry and reaction
  • Any lateralising signs
  • Level of any spinal cord injury (limb movements, spontaneous respiratory effort)
  Note: remember oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all also affect level of consciousness.
  
  Note: re-evaluation is important as deterioration can occur from all these causes. Remember with head injury the lucid interval that occurs with acute epidural haematoma.
  
  Possible treatment: Pupil asymmetry or dilation, impaired or absent light reflexes, hemiplegia/weakness suggest expanding intracranial mass or diffuse oedema. IV mannitol, ventilation and urgent neurosurgical opinion is mandatory.
  
  
• E= Exposure/ environmental control= undress patient, but prevent hypothermia. Clothes may need to be cut off, but after examination attention to prevention of heat loss with warming devices, warmed blankets etc is important, Intravenous fluids should be warmed before infusion.

Resuscitation

Prompt resuscitation is critical to patient survival:

• A=Airway:
  • Protect and maintain
  • Jaw lift and chin lift technique may be employed
  • Nasopharyngeal airway in conscious patient or
  • Oropharyngeal in unconscious with no gag reflex as temporary measure
  • Definitive airway should be established if patient unable to maintain integrity of airway.
• B=Breathing/ventilation/oxygenation:
  • Definitive airway control may require endotracheal intubation (mechanical factors compromising airway, ventilatory problems, or unconscious).
  • Cervical spine should be protected throughout.
  • Surgical airway may required if nasal or oral intubation are contraindicated or fail.
  • Tension pneumothorax may require decompression immediately.
  • All patients should be given oxygen (either by mask or endotracheal tube).
  • Pulse oximeters are useful to monitor saturation of haemoglobin (see below).
• C=Circulation:
  • Bleeding control is of paramount importance and is achieved by direct pressure or surgical intervention.
  • Intravenous access should be achieved with 2 large cannulae (size and length of cannula is determinant of flow not vein size) in an upper limb. Access by cut down or central venous catheterisation may be done according to skills available.
  • At cannula insertion blood should be taken for crossmatch and baseline investigations.
  • IV fluids will need to be given rapidly (often of the order of 2-3 litres as a bolus) and should be warmed. Ringer's lactate is the preferred initial crystalloid solution.
  • If there is no response to bolus IV therapy blood should be given. (O-negative if typed blood not available).
  • Attention to prevention of hypothermia again is essential:warm room, warm blankets, warmed fluids.

Additional considerations to primary survey and resuscitation

ECG monitoring

Can guide resuscitation by diagnosing dysrhythmias, ischaemia, cardiac injury, pulseless electrical activity (PEA which may indicate cardiac tamponade, hypovolaemia,tension pneumothorax, extreme hypovolaemia). Hypoxia or hypoperfusion should be suspected if bradycardia, aberrant conduction , premature beats. Hypothermia produces dysrhythmias.

Urinary/gastric catheters

• Output of urine can guide fluid replacement (reflects renal perfusion). Adequate output is 0.5-1 cc/kg/hour. Prior to catheter insertion urethral injury should be excluded-suspect if blood at meatus, pelvic fracture, scrotal blood, perineal bruising. PR and genital examination mandatory prior to catheter insertion.
• Gastric catheters are inserted to reduce aspiration risk. Suction should be applied. Care should be taken not to provoke aspiration by triggering gagging.

Other monitoring

Monitoring of resuscitation by measuring various important parameters measures adequacy of resuscitation efforts. Values for various parameters should be obtained soon after the primary survey and reviewed regularly. Important parameters are:

• Pulse rate,¹³ blood pressure, ventilatory rate, arterial blood gases, body temperature and urinary output.
• Carbon dioxide detectors may identify dislodged ET tubes
• Pulse oximetry measures oxygenation of haemoglobin colorimetrically (sensor on finger, ear lobe etc)

Diagnostic procedures

Care should be taken that these do not hamper resuscitation. They may be best deferred to the secondary survey. Modifications to the ATLS guidelines have been suggested.^14,15 X-rays most likely to guide resuscitation early on, especially in blunt trauma, include:

• Chest Xray
• Pelvic Xray (It has been suggested that CT scans may be used in some stable patients¹⁴)
• Lateral cervical spine Xray.

This begins after the ABCDE of the primary survey, once resuscitation is underway and the patient is responding with normalisation of vital signs. The secondary survey is essentially a head to toe examination with completion of the history and reassessment of progress, vital signs etc. It requires repeat physical examinations and may require further Xray and lab tests. It comprises:

• History:
  • A=Allergies
  • M=Medication currently used
  • P=Past illnesses/Pregnancy
  • L=Last meal
  • E=Events/Environment related to injury
• Physical examination This will repeat some examinations already undertaken in the primary survey and will be further informed by the progress of the resuscitation. It aims to identify serious injuries, occult bleeding etc. A review of neurological status including GCS score is also undertaken. Back and spinal injuries are commonly missed and pelvic fractures cause large blood loss which is often under estimated.

Additional considerations to secondary survey

A range of further diagnostic tests and procedures may be required after the secondary survey. These include CT scans , Ultrasound investigations, contrast Xrays, angiography, bronchoscopy, oesophageal ultrasound etc.

Definitive care

Choosing where care should continue most appropriately will depend on results of the primary and secondary surveys and knowledge of the facilities available to receive the patient. The closest appropriate facility should be chosen.

Records and legal considerations

Remember:

• Records. Keep meticulous records (times for all entries etc). Team work with time keeping and recording of clinical measurements, and observations can be helpful. Some units have a member of the nursing staff whose sole role is to accurately record and collate patient care information.
• Consent for treatment. Not always possible with life saving immediately necessary treatment and consent may have to be given later.
• Forensic evidence may be required in injuries caused by criminal activity.

Regular training in resuscitation by the whole practice team is recommended. Attention to a team approach is essential. Involvement in medical cover at schools, sports events, car accidents (BASICS) requires higher level training and regular refresher courses.