Management of the severely injured patient is fast moving, dynamic, and complex. No two cases are quite the same, and a flexible approach to each clinical scenario is vital. At the same time, the general approach to acute trauma care can be distilled down to a series of predictable and reproducible actions (Algorithm I), which should unfold independently of the known or suspected injuries:
- Manage the airway.
- Manage traumatic shock.
- Manage severe traumatic brain injury (TBI).
- Manage potentially life-threatening torso injuries.
- Manage potentially limb-threatening injuries.
- Manage noncritical injuries.
Manage the Airway
Effective airway management is the first and most critical step in the trauma resuscitation. The literature reminds us that delayed or ineffective airway management is one of the most common causes of preventable death in trauma. (J Trauma 2003;55:162.)
The decision to intubate is a complex one, influenced by several factors. (Table 1.) Because the clinical picture often evolves rapidly in the setting of acute injury, the general dictum “intubate early” applies much more often than not. This is particularly true for injuries that are likely to cause abrupt airway obstruction, or that are likely to threaten overall cardiopulmonary reserve. This proactive philosophy allows the emergency physician to approach the intervention when the patient's physiology is at its best, not at its worst.
Once the decision to secure the airway has been made, the clinician should address two critical questions: Will airway management be difficult, and how will the patient's injuries affect the airway management plan? To answer the first question, applying the LEMON mnemonic (which is endorsed in the most recent edition of ATLS) reliably predicts difficult intubation. (Manual of Emergency Airway Management, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008:81.) The LEMON Law is described in more detail on www.EM-News.com. (http://bit.ly/LEMON.) When considering the second question, a simple mnemonic, the “trauma airway ABCS,” can be useful to anticipate changes in physiology that may occur during airway management. (Manual of Emergency Airway Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:251.)
Manage Traumatic Shock
Once airway management is accomplished, the pinnacle priority is to control immediate threats to central perfusion. When shock is obvious, the clinician must immediately identify the most likely cause or causes, and execute a well thought out plan for stabilization and definitive management. (Table 2.) In the patient with blunt trauma ora gunshot wound to the torso, it is safest to assume that shock could come from any source or a combination of sources. In the patient suffering stab wounds, the approach will be somewhat different, based on the likely trajectory of the wound.
In the patient with a “normal” blood pressure (SBP≥90 mm Hg), it is vital to recognize the early signs of “compensated shock” before frank hypotension becomes manifest. These signs include altered mental status, tachycardia, cool extremities, decreased urinary output less than 2 cc/kg/hr, and weak peripheral pulses. It is also important to understand that even transient hypotension can be a marker of significant injury. A recent trauma center study revealed that a single systolic blood pressure reading of under 105 mm Hg was associated with a significantly higher need for therapeutic intervention and intensive care monitoring. (J Trauma 2010; 68:1289.)
Manage Brain Injury
Once hemodynamic resuscitation is under way, the next critical step is to assess the likelihood of an intracranial lesion requiring neurosurgical intervention. (Table 3.) Physical examination and assessment of the Glasgow Coma Scale (GCS) score are the primary bedside assessment tools. Patients with a GCS score less than 8, especially in the presence of lateralizing signs, must be presumed to have a surgical lesion until proven otherwise. In this setting, computed tomography (CT) of the head must be prioritized, even above interventions targeted at ongoing but manageable hemorrhage, a presumed intra-abdominal injury, or compromise of an extremity. Because patients with a GCS score greater than 13 have a very small probability of neurosurgical lesions, urgent neuroimaging is seldom required. Patients with a midrange GCS score should be prioritized based on individual circumstances.
Manage Torso Injuries
The next step in the management algorithm involves more definitive characterization of other potentially life-threatening injuries. (Table 4.) This is the primary phase for more sophisticated diagnostic imaging techniques, and CT scanning has become the diagnostic gold standard in this setting.
Manage Limb Injuries
Once potentially life-threatening injuries have been identified with stabilization under way, injuries threatening limb function can be addressed. (Table 5.) Top on the problem list include injuries where peripheral circulation is potentially compromised, such as peripheral vascular injuries, severe closed or open extremity fractures, massive soft tissue injuries, and compartment syndrome. The diagnostic approach combines a sophisticated bedside examination and targeted imaging studies.
Manage Noncritical Injuries
When this step is reached, the patient is stable by definition. Despite this, it is important to remain vigilant because important function-threatening injuries can be missed, especially in severe, multisystem trauma. The solution is to perform a complete head-to-toe examination at the appropriate time. This may be feasible early in the resuscitation during the secondary survey, or may have to wait until after other life-threatening injuries are dealt with as part of a tertiary survey. (Table 6.)
New Column! Critical Points
Critical Points is a new column in EMN's enewsletter, EMNow, focusing on emergency department critical care. Each article will provide concise assessment and management recommendations for common clinical scenarios, that is, the “critical points” of effective care.
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