Trauma

Trauma is a leading cause of mortality in the U.S. and globally. About half of the patients who die from trauma do so nearly immediately from causes such as massive head injury, high-cervical-spine injury, aortic rupture, and airway complications. One-third of trauma patients die within hours from causes including tension pneumothorax, massive hemothorax, cardiac tamponade, subdural and epidural hematoma, and massive hemorrhage (liver, spleen, pelvic fracture, aortic rupture). Trauma management is focused on systematic identification and intervention to address life-threatening injuries.

The following topics relate to management of trauma in patients:

• Advanced Trauma Life Support (ATLS)

• Clinical Decision Rules for Imaging

• Massive Transfusion Protocol

Advanced Trauma Life Support (ATLS)

ATLS principles provide a framework for the rapid assessment and care of patients with trauma .

Preparation

• Everyone on the team should know their role prior to the patient’s arrival. Specifically, establish who will be leading the trauma evaluation and resuscitation, who will perform specific assessments, and the priorities for evaluation based on prehospital notification.

• Wear protective garments (gown, shield, gloves, shoe covers, N95 masks if anticipated intubation).

• Prepare equipment for intubation, including adjunct airway support devices such as nasopharyngeal or oropharyngeal airways and surgical airway supplies, chest tube, and thoracotomy supplies.

• Ask for the trauma cooler if massive transfusion is anticipated and notify trauma personnel, as required by the case and your institution policy.

• As the patient arrives, designated team members obtain vitals and intravenous (IV) access and place monitoring equipment.

• The leader should stand at the patient’s feet and take emergency medical service (EMS) report; all other team members should also pay attention.

Primary Survey

The primary survey involves a quick assessment for severe bleeding and application of pressure if indicated. The ABCDEs (Airway, Breathing, Circulation, Disability, Exposure) is a systematic approach to the immediate assessment and treatment of patients with trauma.

Secondary Survey

The secondary survey is a detailed evaluation from head to toe that includes the AMPLE history:

A - Allergies

M - Medications

P - Past medical history

L - Last meal

E - Events (what happened)

During the physical exam, document skin exam for all areas (burns, abrasions, hematomas, puncture wounds, and/or lacerations), as well as the following:

Adjuncts and interventions to the secondary survey (if indicated): Foley catheter, anticoagulation reversal, other indicated imaging, splint application, analgesia, antibiotics, and tetanus-diphtheria-acellular pertussis vaccine (Tdap)

Workup

Blood has likely been drawn after the primary and secondary survey. Crossmatch blood if significant bleeding. Also consider complete blood count (CBC), venous blood gas (VBG), urinalysis (UA), basic metabolic panel (BMP), human chorionic gonadotropin (HCG), toxicologic testing, liver function tests (LFTs), lipase, troponin, prothrombin time/international normalized ratio (PT/INR), and thromboelastogram (TEG).

Clinical Decision Rules for Imaging

Imaging is based on clinical evaluation. The following clinical decision rules are used to minimize the need for imaging:

Massive Transfusion Protocol

If your hospital is a trauma center, it has a massive transfusion protocol (MTP) in place. Massive transfusion is variably defined as replacement of >50% of blood volume in 4 hours (blood volume is ~70 mL/kg in adults) and is predicated based on the concept of balanced transfusion (typically in a ratio of packed red blood cells [pRBC] to fresh frozen plasma [FFP] to platelets of 1:1:1) to avoid dilutional coagulopathy and address potential hypothermia and hypocalcemia.

The criteria for MTP activation and its component benefits and policies are typically institution specific. Decisions to activate MTP typically consider the following:

• hemodynamic instability

• rate and expected trajectory of blood loss

• clinical context (traumatic, gastrointestinal, obstetric, or surgical)

Assessment of Blood Consumption (ABC) Score: Different MTP trigger systems have been studied in civilian and military populations; the ABC Score is often used because it is easily calculated and does not require laboratory studies.

Other MTP scoring systems consider additional variables such as base deficit, INR, hemoglobin, long-bone fracture or complex pelvic fracture, and gender.

Protocols are designed to rapidly allocate blood products to critically ill patients and to prevent, identify, and treat any acute complications of massive transfusion. These include:

• acute hemolytic transfusion reactions

• febrile nonhemolytic transfusion reactions

• transfusion-associated circulatory overload

• transfusion-related acute lung injury

• allergic reactions

• bacterial sepsis

• hypocalcemia (presenting with tingling, classically perioral or in the extremities, progressing to tetany and, in severe cases, hypotension, cardiac dysfunction, and seizures)

• hypokalemia, hyperkalemia

• acidosis

• hypothermia

• dilutional coagulopathy

• dilutional thrombocytopenia

Adjunct treatments for patients with hemorrhagic shock or life-threatening hemorrhage might also include tranexamic acid, fibrinogen supplementation, and/or reversal of anticoagulation or platelet dysfunction after conversation with consultant specialists.

(Source: Patient Blood Management Guidelines: Module 1 — Critical Bleeding/Massive Transfusion, 2011 Commonwealth of Australia. This work is based on/includes The National Blood Authority’s Patient Blood Management Guideline: Module 1 — Massive Transfusion/Critical Bleeding, which is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Australia license.)