Approach to trauma: Clinical sciences

Trauma is one of the major causes of mortality and morbidity worldwide. A standardized approach to trauma, known as the “trauma protocol” allows providers to systematically assess and quickly identify potentially life-threatening injuries, while simultaneously initiating resuscitation. The trauma protocol is composed of primary, secondary, and tertiary surveys, performed one after another. The goal is to first identify life-threatening injuries and stabilize the patient; then, perform a more thorough head-to-toe assessment to catch the not-so-obvious injuries; and finally, follow up 24 hours later to make sure no other injuries were missed. This protocol is performed on every trauma patient regardless of the mechanism of injury.

So, when a patient presents with trauma, start with a primary survey, which can be summarized as A, B, C, D, and E.

A stands for Airway. Ensure your patient has an open airway and the ability to maintain a patent airway. Start by asking them their name and what happened. If they can speak, they have an open airway. However, if they show any signs of airway compromise, such as altered mental status, gurgling noises, inability to speak clearly, or evidence of an expanding neck hematoma, secure the airway as soon as possible. In this case, intubate or consider obtaining a surgical airway via cricothyroidotomy. Also, stabilize the C-spine to maintain cervical spine restriction by placing a cervical collar and keeping it in place until a traumatic injury to this area has been ruled out.

The next step in the primary survey is B for Breathing. This part focuses on identifying any injuries that affect ventilation and oxygenation. Key assessments include checking for tracheal deviation; evaluating for symmetrical chest rise; auscultating for lung sounds; and palpating the chest wall for evidence of trauma. Any injuries that can impair ventilation such as pneumothorax or hemothorax should be addressed immediately with bedside procedures such as rapid needle decompression with subsequent chest tube placement, needle thoracocentesis, or tube thoracostomy. Also remember to place supplemental oxygen on all adult trauma patients, and monitor oxygen saturation with pulse oximetry.

Okay, let’s move on to C for Circulation. Hypotension in an adult trauma patient is assumed to be from bleeding until proven otherwise, so look for any signs of external or internal bleeding. Additionally, place two large-bore intravenous or intraosseous catheters for fluid resuscitation and transfusion of blood products. Be sure to place them away from the area of the trauma in case there’s a major vascular injury. Finally monitor their hemodynamic status by observing their level of consciousness, skin perfusion, and vital signs.

Now, here’s a clinical pearl! The chest, abdomen, retroperitoneum, and long bones like the femur, are areas that can accommodate large amounts of blood if an internal hemorrhage is present. If you suspect injuries to these areas, keep a close eye on your patient's blood pressure and heart rate, since hemorrhagic shock can occur very quickly.

Next up is D for Disability, focusing on neurological status assessment. Assess your patient’s level of consciousness by calculating the Glasgow Coma Scale, or GCS. Also check pupillary size and reaction to light, and look for signs of spinal cord injury by assessing motor function and sensation in all four extremities.

Here's another clinical pearl! The GCS is a scoring tool used to assess a patient's neurological condition. It evaluates eye opening, verbal response, and motor response. Eye opening can be assessed as spontaneous, 4 points; to verbal stimuli, 3 points; only to pain stimuli, 2 points; or no response, 1 point. You can remember this by SEES: 4 letters for 4 eye points! Similarly, verbal response is evaluated as oriented and coherent, 5 points; confused or inappropriate words, 4 points; incomprehensible sounds, 3 points; verbal response to pain, 2 points; no verbal response, 1 point. Remember this by TALKS: 5 letters for 5 verbal points! Lastly, motor response has 6 categories: obeys commands, 6 points; localizing to pain, 5 points; withdraws to pain, 4 points; flexion to pain, also known as decorticate posturing, 3 points; extension response to pain, or decerebrate posturing, 2 points; and no response, 1 point. Remember this by MOVING: 6 letters for 6 points! Now, the score can range from 15, indicative of a normal functioning patient, to 3, which is indicative of a comatose patient. Any patient with a GCS of 8 or less needs to be intubated. Remember, GCS of 8, intubate!

Lastly, let’s discuss E for Exposure and Environmental control. Remove all of your patient’s clothing for a thorough assessment and to eliminate any potential contamination. Remember to place warm blankets on your patient to prevent hypothermia.

Alright, now that the primary survey is completed and your patient has been stabilized, let’s discuss the secondary survey. This involves a thorough history and physical examination and additional work-up to identify any underlying traumatic injuries that were not obvious during the primary survey.

Now, essential components of your patient’s history include known allergies, current medications, past illness, pregnancy status, timing of their most recent oral intake, and events related to the injury. The physical exam should follow a head-to-toe sequence, and includes obtaining labs and imaging to assist in identifying underlying traumatic injuries. Keep in mind that primary and secondary surveys are not like your typical ABCDE and H&P. They need to be done fast, as there is no time to waste in trauma. Primary survey typically takes 1-2 minutes, and H&P portion of the secondary survey usually takes about 5 minutes. Typical labs include a type and cross, CBC, and CMP.

Additional tests to consider are ABGs; coagulation studies including a rotational thermoelectrometry, also known as ROTEM; lipase, and serum alcohol level. Also, order urine studies like urinalysis; urine pregnancy test for biological female patients; and urine toxicology screen.