Initial Evaluation and Management

Patient and scene-specific information, including mechanism and time of injury, events related to the injury, patient history, and pre-hospital interventions will help the anesthesiologist and other team members prepare for triage and initial treatment.

 

The following is taken from:

Varon, Albert J. (2012-06-01). Essentials of Trauma Anesthesia (Kindle Locations 713-725). Cambridge University Press. Kindle Edition.

Trauma Area Setup:

Airway/ventilation
• laryngoscope (check bulb brightness and integrity)
• appropriate blade selection and sizes
• appropriately sized endotracheal tubes (check cuff integrity) with stylet and 10 cc syringe attached
• oropharyngeal and nasopharyngeal airways, tracheal tube introducer (“gum elastic bougie”), and other airway adjuncts immediately available
• bag-valve-mask attached to high-flow oxygen with capnogram adapter attached (preferred if available) or colorimetric end-tidal carbon dioxide (CO2) device
• wall suction on and functioning, with rigid suction tip (Yankauer) attached
• drug kit with rapid sequence intubation agents readily available
• alternative airway devices present and readily available (laryngeal mask airway or other supraglottic airway device, video laryngoscope, cricothyroidotomy

Vascular Access
• intravenous access supplies including large-bore peripheral intravenous catheters
• warmed intravenous crystalloid solutions
• central venous catheter kits (introducer or large-flow double lumen catheter kit)
• intraosseous needles and device for placement
• arterial line kits and transducer cables available

Monitors
• electrocardiogram
• pulse oximeter
• non-invasive blood pressure
• temperature
• continuous waveform capnogram
• invasive arterial pressure monitoring should be readily available

Equipment:
• ultrasound machine readily available for FAST exam and insertion of intravascular catheters
• surgical trays for chest tube placement, cricothyroidotomy, and vascular access •

Universal (standard) precautions:
• face mask
• eye protection
• water-impervious apron
• gloves

During the initial evaluation, the presence of the anesthesiologist is paramount since he or she can contribute significantly to these objectives. For example, a significant percentage of critically injured patients require early airway intervention because of a low or decreasing Glasgow Coma Scale (GCS) score, hypoxemia, shock, or other elements of airway or respiratory failure. Management of the trauma airway necessitates advanced training and experience due to the possibility of blood in the airway and anatomical distortion secondary to soft tissue swelling or injury. In this patient population, there is often inadequate time for preoxygenation, which contributes to more rapid oxygen desaturation and limits the time available to secure a definitive airway. Because the incidence of mild to moderate hypoxia is common, the presence of a skilled anesthesiologist can benefit the patient. Many
anesthesiologists have experience with resuscitation, rapid establishment of vascular access, and familiarity with the concepts espoused by crisis resource management (CRM) principles. As a member of a “team of experts,” the anesthesiologist is ideally suited for a role in the initial evaluation and management of the trauma patient.

The initial focus is on recognizing life-threatening problems following trauma, during which survival rates may be improved with rapid interventions like airway management and control of arterial hemorrhage. Prioritizing care during the first 60 minutes post-injury, often referred to as the “golden hour,” is the most important lesson of ATLS.

ATLS emphasizes the ABCDE of the trauma mnemonic:

  • Airway

Determine airway patency by asking the patient to speak.
If unable to speak, is the patient able to make any sounds at all demonstrating any degree of airway patency?
Perform a quick inspection of the mouth, nose, and neck. Is there upper or lower airway obstruction? Are teeth intact? Is there blood or gastric contents in the oropharynx?
Suction the mouth and begin assisting ventilations with a bag-valve-mask as needed. Consider transient use of airway adjuncts (oral or nasopharyngeal airways) to facilitate ventilation. If the patient is unable to maintain his or her airway, prepare to intubate.

  • Breathing

Perform a rapid chest exam and listen for presence of breath sounds – are they equal bilaterally?
How well is the patient ventilating?
Are there signs of chest injury (flail chest, contusions, wounds of any type)?
Place a pulse oximeter and provide supplemental oxygen as needed.
If tension pneumothorax is suspected, treat immediately with needle decompression or chest tube placement. For needle decompression, a large caliber intravenous catheter is inserted in the second intercostal space in the mid-clavicular line, avoiding the inferior aspect of the rib.
A chest tube will be required after needle decompression. This is usually placed in the fifth intercostal space just anterior to the mid-axillary line.
Prepare to intubate the trachea if the patient has signs of respiratory distress, hypoventilation, extreme hyperventilation, profound hypoxemia, massive chest injury, or signs of abnormal breathing secondary to central nervous system injury, alcohol, or drugs.

  • Circulation with hemorrhage control

STOP any external bleeding!
Shock indicates loss of blood volume until proven otherwise.
The brain is very susceptible to a lack of oxygen supply, level of consciousness is one of the best indicators of the adequacy of oxygenation and perfusion.
Examine skin color, including mucous membranes, capillary refill, and peripheral and central pulses.
Assess pulse rate, quality, and regularity. Not all patients in hemorrhagic shock have tachycardia – bradycardia may be observed when profound shock is present.
Initiate resuscitation immediately if the patient presents with signs of shock (altered level of consciousness, weak pulses, delayed capillary refill, pale skin color, low blood pressure).
In patients with shock or hypothermia, non-invasive blood pressure and pulse-oximetry may not be functional. Therefore, one should be prepared to insert an arterial catheter for direct blood pressure monitoring and blood gas analysis.

In my opinion, attempting to insert an arterial line in a patient in profound shock is silly and a waste of time and resources. It is very difficult and usually impossible to insert a radial artery a-line in the patient with profound shock. A femoral a-line is more likely to be successful but that will only delay the surgery. If a blood gas is needed, obtain a venous gas taken from the neck. Instead, continue using the non-invasive blood pressure and resuscitate the patient with crystalloid, blood, and plasma until the non invasive pressure monitor begins to detect a blood pressure. After fluid resuscitation and return of a non-invasive pressure attempts at inserting a radial a-line will be more likely.

  • Disability

Is the patient alert on arrival?
Can they speak or communicate in any way?
Are they appropriate?
Do they appear altered by alcohol or drugs?
If not previously performed, the GCS score should be obtained.
An abnormal level of consciousness should prompt a re-evaluation of the patient’s oxygenation, ventilation, and perfusion.
The presence of intoxication (drugs or alcohol) or hypoglycemia may also alter the GCS score and prompt the early use of diagnostic tests such as CT scans of the head and spine.
In addition to the GCS score, pupil size and reactivity, as well as extremity movements should be checked. The presence of lateralizing or focal signs suggestive of central nervous system injury should prompt early head CT.

  • Exposure

The patient must be completely exposed to examine for any signs of injury.
Trauma patients are at risk for hypothermia and care must be taken to quickly place warm blankets over patients after exposure and examination, and to maintain a warm environment.

Resolution of urgent needs during the primary survey is followed by a meticulous secondary survey and further diagnostic studies designed to reduce the occurrence of missed injuries.

  • Resuscitation phase

During the secondary survey, the anesthesiologist has a role in supporting ongoing resuscitation of the unstable trauma patient.

All monitors are placed and functional, including the establishment of invasive arterial monitoring as indicated.
Placing adequate IV access, including central access if peripheral access is deemed to be inadequate or if central access is needed for surgical procedures.
Ensuring blood is drawn for type and cross-match and baseline hematologic tests including pregnancy test (when applicable).
Establishing a definitive airway (intubation) when indicated.
Selecting and initiating an appropriate level of ventilatory support to maintain adequate oxygenation and normocapnia.
Administering warmed isotonic crystalloids as boluses if no radial pulse is present or the patient has an altered level of consciousness consistent with hypoperfusion.
Preparing to transfuse warmed uncross-matched type O packed red blood cells to patients demonstrating signs of progressive shock and continued blood loss.

  • Secondary survey

A systematic detailed head-to-toe physical exam should follow the primary survey and initial resuscitation phase to uncover injuries missed during the primary evaluation.
An “AMPLE” history should be obtained at this time – Allergies, Medications, Past medical history/pregnancy, Last meal, Events related to the injury.
Surgical conditions such as facial fractures, orthopedic injuries, and spinal fractures are discovered and consultations are initiated to facilitate subsequent repair.

  • A more thorough neurological exam (including a GCS score if not already done) should be performed to include motor and sensory responses in all extremities.
  • Examination of the head should be performed looking for wounds, lacerations, contusions, and fractures. Identify signs of basilar skull fracture including cerebrospinal fluid, or blood from nose or ears. Eyes should be examined again for pupil symmetry and reactivity to light. The face should be examined for fractures, lacerations, or contusions, and the mouth and oropharynx for bleeding.
  • Examination of the neck should be performed while maintaining a neutral alignment; examine the anterior and posterior aspects for wounds, lacerations, contusions, and bony abnormalities. Carefully replace the cervical collar after neck inspection. Determine if the trachea is midline and evaluate for crepitus, which may indicate an airway injury.
  • Palpate the chest for deformity and examine for contusions and wounds. Note any asymmetrical chest movements that may be indicative of a flail chest. Breath sounds should be re-evaluated for equality, especially if the trachea has been intubated. • Abdomen: Examine for bruising (i.e., seatbelt sign), lacerations, tenderness to palpation, and distension.
  • The pelvis should be palpated for discomfort or instability, but not excessively manipulated.
  • Palpate all four extremities for lacerations, wounds, and fractures or deformities. If any fractures are diagnosed, distal pulses must be examined by palpation or Doppler ultrasound.
  • Roll the patient to examine the back for contusions, lacerations, and any bony abnormalities along the spine. The entire length of the spine should be carefully examined for step-offs and palpated for tenderness in any region. A rectal exam should be performed to determine rectal tone and presence of blood.
  • Identify any trauma to the external genitalia and examine for blood at the urethral opening prior to insertion of a bladder catheter.
  • Chest and pelvic radiographs and a FAST exam (to determine the presence of intra-abdominal free fluid suggestive of hemorrhage).
  • If the patient is hemodynamically stable, CT imaging may be undertaken. The head, neck, chest, abdomen, and pelvis should be scanned as deemed necessary by the trauma team. CT scanning has replaced cervical spine X-rays at many trauma centers.

Additional Considerations:

  1. FAST exam: In patients with major trauma, the FAST exam is frequently the initial imaging examination since it is readily available, requires minimal preparation time, and may be performed with portable equipment that allows greater flexibility in patient positioning. Four views are evaluated to determine the presence of abnormally large intraperitoneal collections of free fluid or the presence of a pericardial effusion. Typical sites of fluid accumulation in the presence of a solid organ injury are Morison’s pouch (liver laceration), the pouch of Douglas (intraperitoneal rupture of the urinary bladder), and the splenorenal fossa (splenic and renal injuries). FAST is also used to exclude injuries to the heart and pericardium but is not reliable in the detection of bowel, mesenteric, and bladder injuries. CT is better suited for the evaluation of these possible injury sites. If there is time after the initial FAST survey, ultrasound examination may be extended to rule out pneumothorax or for vascular access or other interventional procedures. When the anesthesiologist is alerted that a positive FAST has been identified, it is important to know what view was positive and how much free fluid was noted. A stable patient may still be a candidate for a rapid CT scan to better differentiate the nature of the injuries as well as to evaluate for significant intracranial pathology prior to surgery.
  2. CT imaging: Since the FAST exam has poor sensitivity for the detection of most solid organ injuries, the initial survey is followed by a more thorough examination with multi-detector CT unless the patient is hemodynamically unstable. With improvements in CT accessibility, speed, and image quality over the last decade, many surgeons will send the hemodynamically stable, blunt injury patient directly to CT imaging and forego the FAST exam. In such instances, the time to definitive diagnosis and final management decisions can be reduced significantly although this practice varies greatly. In the hemodynamically unstable patient with a negative FAST exam, and no clear diagnosis, CT scanning may provide additional information. In this setting, the anesthesia provider may need to accompany the patient to the scanner to provide ongoing resuscitation and ventilatory management. If the trachea has not been intubated, definitive airway control may be warranted prior to patient transfer to the imaging suite. The ability of multi-detector CT angiography (CTA) to identify vascular injury (e.g., carotid dissection, sites of active hemorrhage, aortic dissection, damage to peripheral vessels) has also improved over the last decade and is frequently included as part of the initial CT protocol. In most trauma centers, CTA is the first-line assessment tool for vascular injury. CTA affords a rapid, accurate, non-invasive method of detecting vascular injury and appropriately triaging patients for further evaluation or immediate intervention.
  3. Angiography: Although now more frequently used as follow-up to initial CTA, angiography still plays an important role in the early management of the trauma patient. Interventional radiology procedures such as embolization and the placement of endovascular grafts and stents have altered the need for operative interventions in many conditions. Selective arterial embolization that does not cause ischemia or infarction to uninvolved vascular distributions allows surgery to be avoided or provides hemodynamic stability prior to open operation. For example, many splenic injuries with active hemorrhage can be controlled through angiography with embolization without need for an emergent laparotomy. Similarly, aortic injuries can frequently be managed non-operatively with endovascular stent placement. Because the actively bleeding patient may be unstable during an interventional radiology procedure, involvement of the anesthesia team to provide ongoing resuscitation is invaluable. This requires the availability of portable anesthesia equipment and familiarity with this out-of-the-OR location.

Prioritization of surgical management:

  • At any point during the initial evaluation and management of the trauma patient, the need for surgical intervention may arise. Table 2.4 provides an algorithm for prioritizing surgical management in the trauma patient with the understanding that individual situations will vary according to available resources and the patient’s response to therapy. The trauma patient will often present to the OR with the need for more than one surgical procedure, by more than one surgical service. Frequently, there are a combination of injuries requiring emergency surgery and injuries that can be repaired at a later date in a more elective fashion. The anesthesiologist plays an important role in determining which procedures to perform, in which order, and which procedures should be postponed until the patient is more stable.
  • Emergent cases must reach the OR as soon as possible. While surgical airway access and resuscitative thoracotomy usually occur in the resuscitation or trauma unit, immediate follow-up in the OR will be necessary should the patient survive. Also considered emergent are any exploratory surgeries (laparotomy or thoracotomy) in a hemodynamically unstable patient, and craniotomy in a patient with a depressed or deteriorating mental status. Limb-threatening orthopedic and vascular injuries should undergo surgical exploration as soon as necessary diagnostic studies have been performed.
  • Urgent cases are not immediately life-threatening, but require surgery as soon as possible to reduce the incidence of subsequent complications. Examples include exploratory laparotomy in stable patients with free abdominal fluid; irrigation, debridement, and initial stabilization of open fractures; and repair of contained rupture of the thoracic aorta not amenable to endovascular repair. Early fixation of closed fractures, especially spine and long-bone fractures, has been shown to benefit trauma patients by reducing the incidence of subsequent pulmonary complications. Definitive repair within 24 hours is recommended in otherwise stable, non-brain-injured patients.
  • Non-urgent cases are those that can be safely delayed until a scheduled OR time is available. Face, wrist, and ankle fracture fixation are not time-dependent although early surgery will shorten the patient’s length of stay. These surgeries are commonly postponed, and may be undertaken days to weeks following injury, when tissue edema has resolved and the patient is otherwise stable.
  • A key element requiring attention by the anesthesiologist and surgeon is the extent of surgery to be performed in a patient with multiple injuries. The concept of “damage control” has revolutionized surgical thinking in the past decade. With damage control surgery, the focus is on limiting initial therapeutic procedures to those required for hemostasis while delaying reconstructive procedures until adequate resuscitation has been achieved. In a typical example, the surgeon treating an unstable blunt trauma patient might perform an exploratory laparotomy, rapid splenectomy, staple resection of injured bowel (without attempt at re-anastomosis), ligation of bleeding large vessels, and packing of all four abdominal quadrants. The abdomen would be left open under a sterile watertight dressing and the patient taken to the intensive care unit (ICU) for continued resuscitation and stabilization. Angiographic embolization might be used to facilitate liver and retroperitoneal hemostasis during this time. Following resolution of shock; warming; and normalization of laboratory values, the patient would return to the OR in 24–48 hours for debridement of non-viable tissue, reconstruction of the bowel, placement of enteral feeding access, and abdominal closure. The concept of damage control may also be applied to orthopedic injuries where initial external fixation of the pelvis and long bones is adequate for temporary stabilization of fractures without imposing the additional physiologic burdens of intramedullary nailing or open fixation. While objective indicators of the need for damage control have not been established, this approach should be considered in any patient with persistent hypotension, elevated lactate, or transfusion requirement in excess of one blood volume.

Teamwork and crisis resource management (CRM):

  • The trauma team is ideally suited for the application of teamwork and CRM principles as espoused by a number of experts in the field of team training. The trauma team typically comprises a multi-disciplinary group of individuals from the fields of surgery, anesthesiology, emergency medicine, radiology, nursing and support staff, each of whom provide simultaneous inputs into the assessment and management, with their actions coordinated by a team leader. The goals of the team are to rapidly resuscitate and stabilize the patient, identify and treat life-threatening problems, prioritize and determine the nature and extent of the injuries, and prepare the patient for transfer to the next phase of care, which may be the OR, ICU, or another facility. A well-structured team aims to provide rapid input to the management of the critically injured patient without the need to contact and request the presence of individual team members. The leader of the trauma team must be experienced in the diagnosis and management of trauma patients and the likely pitfalls associated with dealing with severely injured patients. They must also be comfortable directing and responding to other team members, all the while demonstrating good communication and leadership skills. Most commonly, the leader is a surgeon or an emergency medicine physician depending on local availability or ACS trauma center status. As a component of the trauma service, the trauma team has been independently shown to reduce time in the resuscitation or trauma department, reduce missed injuries, and speed the evaluation and treatment process, all of which contribute to mortality reduction. Beyond the structure of the trauma team, training and auditing are critical to optimizing performance. Extrapolation from the realm of CRM training in anesthesiology suggests that these same principles can be effective in the training and improvement of trauma team responses.

Key points:

  • Trauma is a disease that touches all ages and classes of patients, from young and vigorous to elderly and frail.
  • The anesthesiologist, as perioperative physician, is in the ideal position to understand and apply new techniques and processes in the resuscitation of the traumatically injured patient throughout the course of their care.
  • As a member of the trauma team, the anesthesiologist can bring together an understanding of the physiology of trauma, principles of airway management and resuscitation, and CRM.
  • Care of the trauma patient requires the anesthesiologist to be comfortable working outside of the traditional OR to include the emergency department, radiology suite, and ICU.
  • The proper application of damage control principles requires input from all members of the trauma team, particularly the anesthesiologist.Varon, Albert J. (2012-06-01). Essentials of Trauma Anesthesia (Kindle Locations 973-981). Cambridge University Press. Kindle Edition.