Thissiteisintendedforhealthcareprofessionals

InitialEvaluationoftheTraumaPatient
Updated:Jan31,2014
Author:DavidJDries,MDChiefEditor:JohnGeibel,MD,DSc,MSc,AGAFmore...

OVERVIEW

Overview
Theinitialevaluationofapersonwhoisinjuredcriticallyfrommultipletraumaisachallengingtask,
andeveryminutecanmakethedifferencebetweenlifeanddeath.
Overthepast50years,assessmentoftraumapatientshasevolvedbecauseofanimproved
understandingofthedistributionofmortalityandthemechanismsthatcontributetomorbidityand
mortalityintrauma.
Mortalitycanbegroupedintoimmediate,early,andlatedeaths.Immediatedeathsarecausedbya
fatalinjuryofthegreatvessels,heart,orneurologicsystem.[1]Immediatemortalityoccursatthe
sceneofinjury,asshownintheimagebelow.

Immediatemortalityintraumaoccursatthesceneoftheinjury.Preventionofthesedeathsrequiresa
multidisciplinarypublichealthsystemsapproach.CourtesyofKevinKilgore,MDCarsonHarris,MDandDavid
Hale,MD,RegionsHospital,StPaul,Minn.

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Earlydeathsmayoccurfromminutestohoursaftertheinjury.Thesepatientsfrequentlyarriveata
hospitalbeforedeath,whichusuallyoccursbecauseofhemorrhageandcardiovascularcollapse.Late
traumamortalitypeaksfromdaystoweeksaftertheinjuryandisprimarilyduetosepsisandmultiple
organfailure.Organizedsystemsfortraumacarearefocusedonthesalvageofapatientfromearly
traumamortality,whereascriticalcareisdesignedtoavertlatetraumamortality.[2,3]
Earlytraumadeathsresultfromfailedoxygenationofthevitalorgans,massivecentralnervous
systeminjury,orboth.Themechanismsoffailedtissueoxygenationincludeinadequateventilation,
impairedoxygenation,circulatorycollapse,andinsufficientendorganperfusion.Massivecentral

nervoussystemtraumaleadstoinadequateventilationand/ordisruptionofbrainstemregulatory
centers.Injuriesthatcauseearlytraumamortalityoccurinpredictablepatternsbasedonthe
mechanismofinjurythepatient'sage,sex,andbodyhabitusorenvironmentalconditions.
RecognitionofthesepatternsledtothedevelopmentoftheAdvancedTraumaLifeSupport(ATLS)
approachbytheAmericanCollegeofSurgeons.[4]ATLSisthestandardofcarefortraumapatients,
anditisbuiltaroundaconsistentapproachtopatientevaluation.Thisprotocolensuresthatthemost
immediatelifethreateningconditionsarequicklyidentifiedandaddressedintheorderoftheirrisk
potential.
Theobjectivesoftheinitialevaluationofthetraumapatientareasfollows:(1)torapidlyidentifylife
threateninginjuries,(2)toinitiateadequatesupportivetherapy,and(3)toefficientlyorganizeeither
definitivetherapyortransfertoafacilitythatprovidesdefinitivetherapy.

TriageandOrganizationofCare
Theobjectiveoftriageistoprioritizepatientswithahighlikelihoodofearlyclinicaldeterioration.
Triageoftraumapatientsconsidersvitalsignsandprehospitalclinicalcourse,mechanismofinjury,
patientage,andknownorsuspectedcomorbidconditions.Findingsthatleadtoanaccelerated
workupincludemultipleinjuries,extremesofage,evidenceofsevereneurologicinjury,unstablevital
signs,andpreexistingcardiacorpulmonarydisease.[5]
Whenperformingatriagewithpatientswhohavedifferenttypesofinjuries,theprioritiesoftheprimary
survey(seeInitialAssessment)helptodetermineprecedence(eg,apatientwithanobstructedairway
receivesgreaterpriorityforinitialattentionthanarelativelystablepatientwithatraumaticamputation).
Intraumacenters,ateamofprovidersevaluatespatientswhoarecriticallyinjuredandsimultaneously
performsdiagnosticprocedures(seetheimagebelow).Thisparallelprocessingapproachcan
dramaticallyreducethetimerequiredtoassessandstabilizeapatientwithmultipleinjuries.[6]

Traumaresuscitationsinvolvingsimultaneousdiagnosisandtreatmentbymultipleprovidersdemandleadership
andorganizationtofunctioneffectively.CourtesyofKevinKilgore,MDCarsonHarris,MDandDavidHale,MD,
RegionsHospital,StPaul,Minn.

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Theteamapproachtotraumaisresourceintensive[7]however,theavailablepersonneland
resourcescanbecomeoverwhelmedquicklyinnonhospitalsettings,insmallerinstitutions,andin
masscasualtysituations.Undertheseconditions,additionalfactorsaffectthetriageprocess,including
thenumberandskilllevelsofavailableproviders,theavailableequipment,andtheprovider'sestimate
oftheclinicalprobabilityofeachpatient'ssurvival.Thetriageobjectivebecomeshowtomaximizethe

numberofpatientswhoaresalvagedundertheprevailingconditions.Thisprocesscanresultin
bypassingseriouslyinjuredpatientsuntillesscriticalpatientshavebeenstabilized.Triageunder
conditionsoflimitedresourcesisdifficult.[8]
Regardlessoftheclinicalsetting,thecareteamshouldbeorganizedbeforepatientarrival.
Leadershipandunityofcommandareessentialfordirectingarapidandefficientworkup.Inlarger
institutionswithdedicatedtraumaservices,generalsurgeonsformthecoreofthetraumateamin
closecooperationwiththeemergencydepartmentstaff.Aphysicianfromeitherservicewhois
experiencedinthecareoftraumapatientsservesastheteamleaderanddirectsevaluationand
resuscitation.
Additionalphysiciansormidlevelprovidersareresponsibleformanagingtheairway,conductingthe
primaryandsecondarysurveys,andperformingotherproceduresasneeded.Nursesandtechnicians
monitorvitalsigns,gainintravenous(IV)access,andobtainbloodsamples.Respiratorytherapists
andradiologytechnologistsshouldalsobepresent.Asconsultants,neurosurgeonsandorthopedic
surgeonsmustbeavailableimmediatelytothetraumateam.Earlyconsultationwithaneurosurgeon
ismandatorywhensignificantcentralnervoussysteminjuryispresent.Specificproceduresperformed
bybothneurosurgeonsandorthopedistscanbelifesaving.

InitialAssessment
[#target9]Theinitialevaluationfollowsaprotocolofprimarysurvey,resuscitation,secondarysurvey,
andeitherdefinitivetreatmentortransfertoanappropriatetraumacenterfordefinitivecare.[4]This
approachistheheartoftheATLSsystem,whichisdesignedtoidentifylifethreateninginjuriesandto
initiatestabilizingtreatmentinarapidlyefficientmanner.Absolutediagnosticcertaintyisnotrequired
totreatcriticalclinicalconditionsidentifiedearlyintheprocess.Whenresourcesarelimited(eg,one
clinician),donotperformsubsequentstepsintheprimarysurveyuntilafteraddressinglifethreatening
conditionsintheearliersteps.

Primarysurvey
ThestepsoftheprimarysurveyareencapsulatedbythemnemonicABCDE(airway,breathing,
circulation/hemorrhage,disability,andexposure/environment).
Theairwayisthefirstpriority.Assessitbydeterminingtheabilityofairtopassunobstructedintothe
lungs.Criticalfindingsincludeobstructionoftheairwayduetodirectinjury,edema,orforeignbodies
andtheinabilitytoprotecttheairwaybecauseofadepressedlevelofconsciousness(seetheimage
below).Treatmentsimplymaybesecretioncontrolwithsuctioningormayrequireendotracheal
intubationorplacementofasurgicalairway(eg,cricothyroidotomy(seethevideobelow),emergent
tracheostomy).[9,10]

Establishmentofadefinitiveairwaymayrequireemergencyplacementofasurgicalairwaywhenfacialtrauma
precludesorotrachealintubation.CourtesyofKevinKilgore,MDCarsonHarris,MDandDavidHale,MD,
RegionsHospital,StPaul,Minn.

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0:00 /2:18

SurgicalcricothyroidotomySeldinger.VideocourtesyofThereseCanares,MD,andJonathanValente,MD,Rhode
IslandHospital,BrownUniversity.

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Next,evaluatethebreathingtodeterminepatientabilitytoventilateandoxygenate.Criticalfindings
includetheabsenceofspontaneousventilation,absentorasymmetricbreathsounds(consistentwith

eitherpneumothoraxorendotrachealtubemalposition),dyspnea,hyperresonanceordullnessto
chestpercussion(suggestingtensionpneumothoraxorhemothorax),andgrosschestwallinstability
ordefectsthatcompromiseventilation(eg,flailchest,suckingchestwound).Treatpneumothorax,
hemothorax,tensionpneumothorax,andsuckingchestwoundswithatubethoracostomy.Initial
treatmentforaflailchestismechanicalventilation,whichfrequentlyisrequiredforotherinjuries
associatedwithventilationandoxygenationdeficits.
Evaluatethecirculationbyidentifyinghypovolemia,cardiactamponade,andexternalsourcesof
hemorrhage.Inspectneckveinsfordistensionorcollapse,determinewhetherthehearttonesare
auscultated,anddeterminewhethertheexternalhemorrhageisidentifiedandcontrolled.Initiate
treatmentofhypovolemiabyrapidlyinfusingalactatedRingersolutionvia2largebore,peripheral,IV
catheters.Placethempreferentiallyintheupperextremities.Treatcardiactamponadeby
pericardiocentesis,orplaceasubxiphoidpericardialwindow,followedimmediatelybysurgeryto
exploreandrepairthesourceofbleeding.[11]Controlanyexternalbleedingwithdirectpressureor
surgery.
Determinethedisabilityofthepatientbyperforminggrossmentalstatusandmotorexaminations.
Determinewhetheraseriousheadorspinalcordinjuryexists.Assessthegrossmentalstatususing
theGlasgowComaScale(seetheGlasgowComaScalecalculator).Examinethepupilsforsize,
symmetry,andreactivenesstolight.Obtainanearlyassessmentofspinalcordinjurybyobserving
spontaneousmovementoftheextremitiesandspontaneousrespiratoryeffort.
Pupillaryasymmetryordilation,impairedorabsentlightreflexes,andhemiplegiaorweakness
suggestimpendingherniationofthecerebrumthroughthetentorialincisuraduetoanexpanding
intracranialmassordiffusecerebraledema.[12]Thesefindingsindicatetheneedforemergency
treatmentofintracranialhypertension,includingadministrationofIVmannitol,hypertonicsaline,
sedatives,andmusclerelaxants,afterobtainingadefinitiveairway.Urgentneurosurgicalconsultation
ismandatory.
Intheabsenceofadepressedlevelofconsciousness,paraplegiaorquadriplegiaindicatesspinal
cordinjury.Possibilityofaspinalcordinjuryrequiresfullspinalimmobilization.Ifinspiratoryeffortsare
weakorwhenahighcervicalcordlesionissuspected,performanendotrachealintubation.[13,14]
Thefinalstepintheprimarysurveyincludespatientexposureandcontroloftheimmediate
environment.Completelyremovepatientclothesforathoroughphysicalexamination.Simultaneously,
initiatetreatmenttopreventhypothermia,aconditionthatisfrequentlyiatrogenicintheexposed
patientinanairconditionedemergencydepartment.Treatprophylacticallywiththeadministrationof
warmedIVfluids,blankets,heatlamps,andwarmedaircirculatingblanketsasneeded.

Otherprocedures
Performseveralmonitoringanddiagnosticadjunctsinconcertwiththeprimarysurvey.[4]PlaceECG
andventilatorymonitoringleads,andstartcontinuouspulseoximetryassoonaspossible.Monitors
providedatathatarecriticaltoguidingresuscitation.Ifthepatientrequiresanartificialairway,perform
agastricintubationtodecompressthestomachandtolessenthelikelihoodofaspirationofgastric
contents.Duringtheresuscitationphase,insertaurinarycathetertofacilitatemeasuringtheresponse
tofluidresuscitation.PlacementofaFoleycatheteriscontraindicatedifurethralinjuryisevident.
Signsofurethralinjuryincludebloodatthemeatus,ecchymosisinthescrotumorlabiummajora,ora
highridingprostate,whichcanbeidentifiedduringarectalexamination.Anyofthesefindings
mandatearetrogradeurethrogramtoexcludeurethralinjurypriortobladdercatheterization.

ResuscitationandComprehensiveAssessment

ResuscitationPhase
Duringtheprimarysurvey,whenmakingdiagnosesandperforminginterventions,continueuntilthe
patientconditionisstabilized,thediagnosticworkupiscomplete,andresuscitativeproceduresand
surgeriesarecomplete.Thisongoingeffortinvolvesmonitoringpatientvitalsigns,protectingthe
airwaywithassistedventilationandoxygenationasrequired,andprovidingresuscitationwithIVfluids
andbloodproducts.
Patientswithmultipleinjuriesmayrequireseverallitersofcrystalloidoverthefirst24hourstosustain
intravascularvolume,tissueandvitalorganperfusion,andurineoutput.Administerbloodfor
hypovolemia,whichisunresponsivetocrystalloidbolus.[15]Ifongoingbloodlossisnotcontrolledby
directpressureandtransfusionwithbloodorbloodproducts,surgeryorimagingbasedprocedures
mayberequiredtoattainhemostasis.Theendpointsofresuscitationarenormalvitalsigns,absence
ofbloodloss,adequateurineoutput(0.51cc/kg/h),andnoevidenceofendorgandysfunction.
Parameters,suchasbloodlactatelevelsandbasedeficitonanarterialbloodgas,maybehelpfulwith
patientswhoareseverelyinjured.[16]
Anabundanceofstandardvitalsigndataguidesevaluationandresuscitationoftheinjuredpatient.
TheCommitteeonTraumafortheAmericanCollegeofSurgeonshaslongpublishedcategoriesof
shockthatallowthecliniciantopredictthelikelihoodofsignificantbloodlossandtoanticipatethe
typeandamountoffluidrequirements.[4]
Theshockclassification,asshownintheTablebelow,allowsthecliniciantocharacterizethepatients
responsetoinjury,asbloodlossassociatedwithinjuryprogresses,mentalstatusdeteriorates,heart
rateincreases,bloodpressurefalls,andoliguriaisapparent.[4]Thepatientwithpersistentvitalsign
evaluationsuggestinghypotensionisatsignificantriskforlossof3040%ofbloodvolumeon
presentation.
Table.EstimatedFluidandBloodLossesBasedonPatientsInitialPresentation[4](OpenTableina
newwindow)

ClassI

ClassII

ClassIII

ClassIV

BloodLoss(mL)

Upto750

7501500

15002000

>2000

BloodLoss(%blood
volume)

Upto15%

1530%

3040%

>40%

PulseRate

<100

>100

>120

>140

BloodPressure

Normal

Normal

Decreased

Decreased

PulsePressure(mm
Hg)

Normalor
increased

Decreased

Decreased

Decreased

RespiratoryRate

1420

2030

3040

>35

UrineOutput(mL/h)

>30

2030

515

Negligible

CNS/MentalStatus

Slightlyanxious

Mildly
anxious

Anxious,
confused

Confused,
lethargic

FluidReplacement(3:1
rule)

Crystalloid

Crystalloid

Crystalloidand
blood

Crystalloidand
blood

SecondarySurvey
Formallybeginthissurveyaftercompletingtheprimarysurveyandafterstartingtheresuscitation
phase.Atthistime,identifyallinjuriesbyconductingathoroughheadtotoeexamination.
Reviewthepatient'svitalsigns,andperformaquickrepeatoftheprimarysurveytoassesspatient
responsetotheresuscitationeffortandtoidentifyanydeterioration.
Then,reviewthepatient'shistory,includingreportsfromprehospitalpersonnelandfromfamily
membersorothervictims.
Ifthepatientisableorotherinformationsourcesareavailable,collectcriticaldata,including
preexistingmedicalproblems,currentmedicationsandallergies,tetanusimmunizationstatus,timeof
lastmeal,andeventssurroundingtheinjury.Thesedataassistwithfocusingthesecondarysurveyby
identifyingthemechanismofinjury,thelikelihoodofcoldorheatinjury,andthepatient'sgeneral
physiologicstatus.

SubsequentPhysicalExamination
Thedictum"fingersortubesineveryorifice"guidesthisexamination.
Examineeachregionofthebodyforsignsofinjury,bonyinstability,andtendernesstopalpation.
Evaluatetheheadandfaceformaxillofacialfractures,ocularinjury,andanopenorclosedhead
injury,includingabasilarskullfracture.

Periorbitalecchymosis,or"raccooneyes,"isaclassicdiagnosticsignofbasilarskullfracture.CourtesyofKevin
Kilgore,MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

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Performadetailedcranialnerveexaminationaspartofathoroughneurologicevaluation.
Inspecttheneckanteriorlyforevidenceofairwayorgreatvesselinjury,andpalpateposteriorlyfor
bonyabnormalityortendernesssuggestiveofcervicalspineinjury.

Inpatientswithblunttraumaandpatientswithanunknownmechanismofinjury(eg,"founddown"),
observefullspineprecautionsuntilinjurytothespinalcolumnisexcluded.

Chestexamination
Palpatethechestwallfortenderness,instability,orcrepitation,followedbyauscultationofthelungs
andheart.
Inthepatientwithpenetratingtrauma,performathoroughsearchforadditionalentryorexitwounds,
includingexaminingtheaxillaeandback.
Assesschesttubesforoutputandairleaks,andusetheportablechestxraytoevaluateforbony
abnormalities,persistentpneumothorax,evidenceofmediastinalinjury,andplacementoftubesand
lines.

Abdomenandpelvisexamination
Inspecttheabdomenfordistensionorotherevidencesuggestinggrossintraabdominalbleedingor
injury.
Inpatientswithpenetratingtrauma,locallyexplorelowvelocitywoundstodetermineifthemuscular
fasciaispenetrated.
Urgentlyexplorehighvelocitypenetratinginjuriesintheoperatingroom.
Palpatetheiliaccrestsonceforinstabilitytodetectsignificantpelvicfractures.Useaportable
anteroposterior(AP)radiographtoaidindetectingthesefractures.Ifafractureisdiagnosed,avoid
additionalmanipulationofthepelvistopreventexacerbationofpelvicbleeding,whichisnotoriously
difficulttocontrol.[17]
Inspectforevidenceofbleeding(ecchymosis)ontheperineum,grossbloodonthevaginalandrectal
examinations,andurethralinjury,followedbyplacementofaFoleycatheter.
Inpatientswithasuspectedspinalcordinjury,recordtheanalsphinctermotortone.

Extremityevaluation
Inthisevaluation,identifylongbonefracturesthatrequirestabilization,maycausevascular
compromise,andshowevidenceofamajornerveinjury.
Performplainxrayfilmstoidentifydeformity,tenderness,orinstability.
Conducttemporarysplintstabilizationpriortomovingthepatientfromtheemergencydepartment.
Immediatelyactonanyevidenceofvascularcompromise,sinceischemicinjurytoanextremitycan
becomeirreversibleinhours.

Neurologicexamination
Theelementsoftheneurologicexaminationfrequentlyarecompletedduringtheregionalportionsof
thesecondarysurveyhowever,includeaformalassessmentofthespinetocompletetheneurologic
assessment.
Logrollthepatientwithinlinestabilizationoftheheadandneck.

Inspecttheentirespinefromtheocciputtothesacrumforbonyabnormalities,deformities,and
tenderness.Atthesametime,performadetailedsurveyofthebacktoidentifypenetratinginjuries,
ecchymoses,orotherinjuries.Backinjuriesfrequentlyaremissed.

ImagingandLaboratoryStudies
Radiographicimagingstudiesprovidecrucialdiagnosticdatathatguidetheinitialevaluation.The
sequenceandtimingofthesestudiesareimportant.Stagetheimagingstudiessothatlifesaving
interventionsidentifiedintheprimarysurveyandresuscitationphasesarenotimpeded.Also,ensure
thatthepatientishemodynamicallystableenoughfortransfertotheradiologysuite.

Anteroposteriorradiographs
TheAPchestradiographisthemostcommonimagingstudyperformedontraumapatients.Itcanbe
easilyobtainedduringtheresuscitationphase,anditprovidesinformationonthepresenceofa
hemothorax,pneumothorax,orpulmonarycontusion.TheAPchestradiographalsoaidsinthe
placementofchestandendotrachealtubes,whicharecriticaltotheresuscitationeffortandthe
primarysurvey.[18]

Thischestradiographdemonstratesbilateralpulmonarycontusionsinatraumapatient.CourtesyofKevinKilgore,
MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

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Forpatientswithblunttrauma,aportableAPpelvisfilmcaneasilybeobtainedduringthe
resuscitationphase.Thisfilmcanhelpconfirmthepresenceofsignificantpelvicfractures(asdepicted
intheimagebelow),whichareoftenthesitesofhemorrhagethatrequireexternalfixationand/or
angiographicembolizationforcontrol.

Theanteroposteriorpelvisradiographquicklyhelpsidentifymajorpelvicfracturesandjointdisruptions.Courtesy
ofKevinKilgore,MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

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Focusedabdominalsonogram
Thefocusedabdominalsonogramfortrauma(FAST)complementstheportablechestandpelvis
films.[19]Atraumaclinicianwhohasbeenformallytrainedinthetechniquequicklyandeasily
performsthisportableultrasoundexaminationinthetraumaresuscitationroom.Itisusedtoidentify
freefluidintheperitonealcavity,pericardialeffusion,hemothorax,andpneumothorax.[19]Becauseof
itsspeed,sensitivity,andnoninvasivecharacter,FASTlargelyhassupplantedothertechniquesfor
rapidassessmentofunstabletraumapatients.Thistechniquerequiresamajorcommitmenttoattain
proficiencytherefore,itisnotfrequentlyusedoutsideofmajortraumacenters.[20,21]
Generally,donotperformdiagnosticstudiesifthecapabilitytoactontheinformationgainedisnot
immediatelypresent.Forexample,patientswithblunttraumainitiallytransportedtosmallrural
emergencydepartmentsfrequentlyhaveindicationsforadvancedimaging.Ifanappropriatelytrained
surgeonisnotpresentintheinstitution,thenthesestudiesareofquestionablevalue,sincetheymay
delaythetransferofthepatienttoatraumacenter.Consequently,stageimagingstudiesandprioritize
thembasedonpatientstability,thepracticalutilityofthedatatobeobtained,andtheimperativeneed
forearlytransfertoobtaindefinitivecare.

CTscan
TheCTscanisthedefinitiveradiographicstudyinmostpatientswithtrauma.CTimagingofthe
abdomen,pelvis,chest,cervicalspine,andheadisthemostsensitiveandaccuratenoninvasive
diagnostictoolforidentifyingmajorinjury.Bedsideassessmentofblunttraumaticinjurywasrecently
evaluatedtoassesstheimpactofCTscans.[22]Bedsideevaluationwaseffectiveinrulingoutserious
injuriesinpatientswithlowriskofseriousinjury.Overalldiagnosticaccuracyofbedsideassessment
waslow,however,suggestingthatCTbeutilizedinhighacuitypatientstoavoidmissinginjuries.[22,
23]

OverrelianceonCTimagingcanbedetrimentalifemergentoperationsaredelayed.Onereviewof
patientspresentingwithhypotension(systolicBP<90mmHg)andsignificantabdominalinjury

demonstratedgreatermortalityifsurgerywasdelayedbyaCTscan.[24]Excessiveradiationexposure
isalsoaconcern.[25]

CTscanoftheabdomenidentifiessignificantsofttissueinjurywithhighsensitivityandspecificity.Atraumaticliver
lacerationduetoblunttraumawithribfragmentpenetrationintotheliverparenchymaisshown.CourtesyofKevin
Kilgore,MDCarsonHarris,MDandDavidHale,MD,RegionsHospital,StPaul,Minn.

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ObtainaCTscanoftheheadtoidentifyintracranialbleeding(asseenintheimagebelow)andto
guideneurosurgicalintervention.[26]ObtainaheadCTscanfortraumawithoutIVcontrast,and
performitfirstwhenindicated,priortotheinjectionofanIVcontrastforabdominalandpelvicscans.
ManycentersscanthecervicalspineatthesamesettinginpatientsreceivingCTevaluationofthe
head.

TheheadCTscanfortraumaidentifiesspaceoccupyinglesionsanddirectsoperativeevacuation.Thelenticular
shapeofthislesionidentifiesitasanepiduralhematoma.CourtesyofKevinKilgore,MDCarsonHarris,MDand
DavidHale,MD,RegionsHospital,StPaul,Minn.

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ObtainaCTscanofthechesttoevaluatemediastinalinjuries.[27]CTscanningisreplacing
aortographyasthestateoftheartstudyforimagingmediastinalvascularstructures,particularlythe
aorta.[28]CTscanningisalsomoresensitivethanAPchestradiographyinthedetectionof
pneumothorax,ribfractures,pulmonarycontusion,andhydrothorax.Formostpatientswithtrauma,
CTscansofthehead,chest,abdomen,andpelvisaresufficienttoguideoperativeandnonoperative
managementofinjuriesintheirrespectiveregionsofthebody.[29]
CTscansoftheabdomenandpelvisusuallyareperformedtogether,usingbothIVandoralcontrast.
[30] Usethisstudytoidentifyinjuriestoabdominalandpelvicorgansandtoidentifybleedinginthe
retroperitoneumandpelvis.
AsthequalityofCTscanscontinuestoincrease,theroleofangiographycontinuestofocustoa
greaterdegreeoninterventionsratherthanondiagnosis.[31]
AgrowingvolumeofdatasupportstheaggressiveuseofCTscanningintheevaluationofblunt
trauma.[32,33]Forexample,abdominalinjurybecomesmorelikelywithvelocitychangesofgreater
than20km/h.Extremesofageorextremity,head,orspineinjuriesarepredictiveofabdominaltrauma
aswell.Theabsenceofcoincidentinjurydecreasestheriskofabdominalinjury.[34]Onereviewof
aorticinjuriesrevealsanincreasedriskwithlateralimpactsandlackofseatbeltuse.Associated
injurieswerepoorpredictors.[35]
SeveralreportsfrommajortraumacentersemphasizethevalueofCTscanningtoevaluate
penetratingtorsoinjuries.Patientsrequiringhospitalizationorextendedperiodsofobservationinthe
emergencydepartmentmaynowbesenthomewithalategenerationCTscanthatdemonstratesthe
benigntrackofabulletwoundorstabbinginjury.[36,37,38,39]Withincreasingresolution,evensmall
bowelandmesentericinjuriesarenowreadilyidentified.Theseinjurieswerepreviouslydifficultto
detectandcanbeasourceoflatemorbidityforpatients.[40]
ApracticeofearlycomprehensivemultisliceCTisrapidlyevolvinginurbantraumacenters.Thisuse
ofadvancedCTtechnologyleadstoamoreaccurateandfasterdiagnosiswithareductionin
resourceutilization.WhetherincreasingradiationexposurewiththeuseofadvancedCTtechnology
willbecomeaclinicalandsocialissueisunclear.

Spineevaluation
CTscanningisreplacingplainradiographsinmanypatientsbeingevaluatedforspinetrauma.[41,42]
Currentscannersofferthecapabilitytoreconstructspineimagesatthesametimethatscansare
obtainedofthechest,abdomen,andpelvis.[43]Manyclinicianswillscanthecervicalspineinpatients
withotherindicationsforscansoftheheadortheheadandtorso.Orthopedicandneurosurgical
consultantsaremakingincreaseduseofCTinevaluationofthespine.
Obtainplainxrayfilmsofthespineinpatientswithhighenergyblunttraumaandinothertrauma
patientswithknownorsuspectedneurologicdeficitsifCTscanningisunavailableorifa
complimentaryimageisdesired.[44]

Forpatientswithalowlikelihoodofspinalinjury,defermostorallofthespinalradiographseriesuntil
theresuscitationphaseiswellunderwayand,ifnecessary,afterperformingalifesavingemergent
laparotomy,craniotomy,orotheroperations.
Ifagreaterthanroutineneedtoexcludecervicalspineinjuryexists,performaportablelateralcervical
spine(Cspine)filmduringtheresuscitationphase.AnadequatelateralCspinexray(eg,visualizing
fromtheskullbasetoT1)helpsidentifymostCspinefracturesandsubluxations.Ultimately,afullC
spineseries(ie,AP,lateral,andodontoidviews)mustbeperformedtoexcludeinjury,andvirtuallyall
traumaclinicianswillrequestCTifanydoubtexists.
TheAdvancedTraumaLifeSupportcurriculumpointsoutthat,withidentificationofacervicalspine
fracture,thelikelihoodofanotherbreakinthespinalcolumnis10%.Controversyexistswhether
completeCTimagingissufficienttoruleoutcervicalspineinjury.Ifthepatientcannotcooperatewith
aphysicalexaminationtoallowanassessmentofligamentousstability,manycenterswillperformMRI
toruleoutligamentousinjuryofthecervicalspine,evenifhighquality,multislice,multidetectorCT
imagesfailtoidentifythisinjury.
ForpatientswithaneurologicdeficitbutnegativeplainfilmsandCTscans(formerlycalledspinalcord
injurywithoutradiographicabnormality),conductanMRIofthespinalcolumnandnerveroots.An
MRIisthemostsensitivemethodfordetectingthistypeofsofttissueinjury,althoughCTscanninghas
becomethestandardforacuteevaluationofthevastmajorityofspinalcolumninjuries.[14,21,45]

Angiography
Angiographycanbebothadiagnosticprocedureandatherapeuticprocedure,anditisvaluablein
selectedtraumapatients.Themostcommonindicationforemergentangiographyintraumaisto
identifyandcontrolarterialbleedingfrompelvicfracturesorintheretroperitoneum.Contemplate
emergentthoracicaorticangiographywhenplainxrayfilmsoraCTscanofthechestreveals
evidenceofatypicalmediastinalbleeding.CTisnowthediagnosticmodalityandstentgraftingthe
treatmentforbluntaorticinjury.[46,47,48]Inaorticinjury,angiographyisthehistoricalstandardfor
diagnosisandoperativeplanning.[48]Withsuspectedbleedingintheretroperitoneumandpelvis,an
angiographicembolizationoftenisquickerandsaferthansurgicalapproachesinthesedifficult
difficulttoaccessareashowever,thisisonlytruewitharterialbleeding,whilethemorecommoncase
ofvenousbleedingremainsadifficultmanagementproblem.[46]
Angiographyalsofacilitatesnonoperativemanagementofinjurytotheliver,spleen,andkidney
followingblunttrauma.Specificcriteriaforangiographyandembolizationhavenotbeenagreedupon.
[49] ACTscanoftheabdomenwithintravenouscontrastfrequentlydemonstratesareasofactive
bleeding,whichmaybetargetedbytheinterventionalradiologistinthepatientwhoissufficiently
stabletotoleratethetimedelayrequiredtoobtainangiographyandorganspecificembolizationof
bleedingpoints.

Labstudiesduringtheinitialevaluation
Themostimportantlabstudyisthetypeandcrossmatch,whichoftencanbecompletedwithin20
minutesofreceiptofthebloodsample.
Arterialbloodgasesarealsousefulintheinitialassessmentperiod,althoughtheiruseforserial
monitoringhasdeclinedsincetheintroductionofcontinuouspulseoximetry.
Abaselinehemoglobinorhematocritdeterminationisusefulonarrival,withtheunderstandingthatin
acutehemorrhage,afallinhematocritmaynotbeapparentuntilautogenousmobilizationof
extravascularfluidoradministrationofIVresuscitationfluidscommences.

Urinescreensfordrugsofabusecommonlyareorderedintraumacenters.Forsimilarreasons,check
bloodalcoholandglucoselevelstoidentifycorrectablecausesofadecreasedlevelofconsciousness.
ArecentreviewfromthedataoftheNationalTraumaDataBankoftheUnitedStatesrevealsa
disturbingdeclineinsubstanceusescreening,despitetheimportanceofsubstanceuseasa
contributiontoinjury.[50]Earlyhyperglycemiahasbeenlinkedtoanincreasedriskofinfectious
complicationsandmortalityafterinjury.[51]
Formosttraumapatients,serumelectrolytes,coagulationparameters,cellbloodcounts,andother
commonlaboratorystudiesarelessusefulduringthefirst12hoursthantheyareafterstabilization
andresuscitation.

SpecialInjuries
Theforegoingdiscussionisapplicabletomosttraumapatientswitheitherblunttraumaorpenetrating
traumahowever,patientswithburns,coldinjuries,andelectricalinjurieshavespecialconsiderations
thatmustbeaddressedduringtheinitialassessmentandresuscitation.

Burns
Anearlyimperativeistostoptheburningprocess,especiallyinthecaseofchemicalburns,inwhich
thecontinuedcontactoftheagentwiththepatient'sskinmaynotbereadilyapparent.Thisprocess
mayrequirerepeatedtestingofthepatient'sskin,specificchemicalneutralization,andextensive
lavageoftheaffectedareas.Iffullthicknessburnsofanextremityorthethoraxaresuspected,
escharotomiesmayberequiredtopreventcompartmentsyndromeandimpairedventilation,
respectively.[52]
Iftheclinicalhistoryorthephysicalexaminationsuggeststhatupperairwayburnsorinhalationinjury
maybepresent,thenearlyintubationandmechanicalventilationareindicated.
Finally,patientswithlargeburnsrequirelargevolumesofIVcrystalloidresuscitationfluids.Whilethis
resuscitationcanbedelayedbrieflywhileperforminglifesavinginterventions,earlycommencementis
beneficial.

Coldinjuries
Thedominantimperativeisrewarming,particularlyinthecaseofsystemichypothermia,butitis
equallyapplicabletocoldinjuriestotheextremities(eg,frostbite).[53]Whilemildhypothermiais
managedasdescribedabovefortheprimarysurvey(seePrimarysurveyinInitialAssessment),treat
severecoldinjurieswithimmersioninwaterwarmedto40C.AdministerIVfluidsonlyasindicated,
basedonthepatient'sphysiologicstatus(notonthewoundsize).Inthecaseofseverehypothermia
withcardiacarrestand/orapnea,donotstopresuscitationeffortsuntilthepatientisrewarmed
thoroughly.[54]

Highvoltageelectricalinjuries
Althoughsometimesconsideredasburninjuries,highvoltageelectricalinjuries(eg,lightningstrikes,
powerlines)presentadifferentsetofproblems.[52]First,muchofthetissueinjuryfromelectrical
injuriesmaynotbeapparentonphysicalexamination.Massivemyonecrosisanddamagetobothsoft
tissueandbonemaybeconcealedbeneathnormalappearingskinbetweentheentranceandexit
woundstherefore,maintainalowthresholdformeasurementofcompartmentpressuresand
performanceofdecompressivefasciotomies.Carefullyandcontinuouslymonitortheurineoutputfor

evidenceofmyoglobinuria,whichcanleadtoacuterenalfailureifuntreated.Likewise,provide
continualcardiacmonitoringtothepatientbecauseoftherisksofdirectmyocardialinjuryand
hyperkalemiaarisingfrommyonecrosis.

Perils,Pitfalls,andControversies
Asudden,expecteddeteriorationofaninitiallystablepatientisacommonproblemencountered
duringthecareofmultipletraumapatients.Thissituationisespeciallyproblematicafterperforming
thoroughprimaryandsecondarysurveysandinstitutingaresuscitationplan.Thesolutiontothese
crisesliesintheABCs(airway,breathing,andcirculation)oftheprimarysurvey.[55]
Injuriescanevolvefromsubclinicaltoclinicallyapparentoverthecourseofarapidtraumaworkup,
andeventhebestdiagnosticworkupisnotperfecttherefore,itisnecessarytoensurethattheairway
isclear,thatventilationisadequate,andthatthebloodpressureandendorganperfusionare
sufficient.Byrapidlyrecheckingtheelementsoftheprimarysurveyfirst,easilycorrectedproblems
(eg,malpositionedendotrachealtubes,tensionpneumothorax,unsuspectedhemorrhage)canbe
rapidlyidentifiedandaddressed.
Nevertheless,thesurveymaymissinjuries,especiallyinseriouslyinjuredpatientswhorequire
intensiveresuscitativeand/orsurgicalprocedurestostabilize.Thistendencyisexacerbatedbythe
focusedprioritiesoftheprimarysurveyandresuscitationphase.Asimpleremedyforthisproblemis
frequentandthoroughreassessment.Performaformaltertiarysurveywithin1836hoursafter
admission.Itconsistsofathoroughheadtotoeexaminationinconjunctionwithareviewofall
laboratorydataandimagingstudiesobtainedsinceadmission.Whilethetertiarysurveydoesnot
reducetheincidenceofinjuriesmissedduringtheprimaryandsecondarysurveys,itdecreasestheir
morbidityandmortalitybyearlieridentificationandtreatment.
Adifficultaspectoftreatingmultipletraumapatientsisprioritizingbetweencompetinginjuriesinthe
samepatient.The3examplesthatfollowillustrateclinicaldilemmasindecisionmakingfacedby
surgeonscaringfortraumavictims.

Patient1
Arelativelystraightforwardexampleisanindividualwithaposteriordislocationofthekneejointand
concomitantvascularcompromisebelowtheknee.Inthiscase,thecompetinginterestsarethe
orthopedicrepairofthekneejointversustherepairofdamagedvessels,presumablyincludingthe
poplitealartery.Althoughadisruptedkneejointisclearlyanurgentproblem,especiallyifthejoint
spaceisopen,theshortviabilityofadevascularizedlimb(34h)andtheincreasingriskof
compartmentsyndromewithincreasingtimeofischemiaaretheparamountissues.Therefore,
vascularrepairusuallyisperformedfirst,followedbytheorthopedicrepair.

Patient2
Amoredifficultdilemmaoccursintheunstablehypotensivepatientwithabdominalandheadinjuries.
Theneedforoperativeexplorationandcontrolofabdominalhemorrhagemustbebalancedagainst
theneedforaheadCTscantoidentifyandlocalizepotentiallyfatalintracranialmasslesionsfor
neurosurgicaldrainage.Aruleofthumbinsituationssuchastheseisthatbluntheadtraumaalone
usuallydoesnotcausehypotension,andhypovolemiaistheprobableculprit.Preservingtheblood
pressureandcerebralperfusionisessentialtopreventsecondarybraininjurythus,measuresto
controlhypotensionandintraabdominalbleedingoftenareprioritizedearlierthanheadinjuries,which
areprognosticallymoreserious.

Patient3
Afinalexampleliesinthetimingofoperativeversusangiographictreatmentofbluntpelvictrauma
withknownorsuspectedhemorrhagefrompelvicfractures.Thesafetyandefficacyofangiographic
embolizationmustbebalancedagainsttheknowledgethatmostcausesofpelvichemorrhageare
venousinoriginand,therefore,arenotamenabletoangiographicembolization.Furthermore,the
resuscitationoftheunstablepatientismuchmoredifficultintheangiographysuitethanintheICU.No
simplerulesapply,andonlythegoodjudgmentoftheseniorclinicianresponsibleforthepatientcan
identifythebestapproachineachcase.
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