glucose, electrolytes, AED levels, ABG, tox screen
fied and the patient has returned to normal mental status.
Antiepileptic drugs are not indicated initially, as only one
third of these patients will have a second seizure over their
lifetimes. The patient should have an outpatient work-up
with a neurologist including an EEG and MRI. I nstruct the
patient to avoid driving vehicles, swimming, or participating
in any other activity that may put themselves or anyone else
in danger if a second seizure occurs. Patients with a known
seizure disorder may be discharged if there are no compli
eating factors after their antiepileptic drug levels are r epleted.
Duvivier E, Pollack C. Seizures. In: Marx J A. Rosen's Emergency
Medicine. 7th ed. Philadelphia, PA: Elsevier, 2009. Chapter 100,
Lung D, Catlett C, Tintinalli J. Seizures and status epilepticus in
adults. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ,
Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A
Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 1 1 53-1 1 59.
Tarabar A, Ulrich A, D'Onofrio G. Chapter 99 Seizures. In Adams
J, Barton E, Collings J, DeBlieux P, Gisondi M, Nadal E.
Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia,
PA Saunders, 2013, pp. 857-69.
• Assess all trauma patients with a rapid primary
survey followed by a more comprehensive secondary
• Address all emergent life threats in a stepwise manner
during the primary survey before progressing to the
Trauma is currently the fourth leading cause of death in
the United States across all age groups and the leading
cause of death in patients under the age of 44 years. It is
responsible for more deaths in patients under the age of
19 years than all other causes combined. Approximately
40% of all emergency department (ED) visits are for
trauma-related complaints, and the annual costs exceed
$400 billion. Adding to these costs, permanent disability is
actually 3 times more likely than death in this cohort.
Trauma is broadly classified by mechanism into blunt
and penetrating varieties, with the former more than
twice as common as the latter. Regardless of mechanism,
victims of significant trauma present with a wide range
of complex problems, and their proper care necessitates
a multidisciplinary approach, including emergency physicians,
trawna surgeons, and the appropriate subspecialties. Most
trawna care delivery systems follow the Advanced Trawna
Life Support guidelines developed and maintained by the
The mortality rates for trawnatic injuries typically
follow a trimodal distribution. Certain injury patterns
including major vascular injuries and high cervical cord
disruption with secondary apnea result in near immediate
death. The second cohort of injuries, including conditions
• Treat hemodynamically unsta ble patients as hemorrhagic shock until proven otherwise.
• Initiate aggressive volume resuscitation in all unstable
patients while concurrently searching for active sources
such as pnewnothorax and pericardia! tamponade, typically
evolve over a duration of minutes to hours and are generally
responsive to aggressive emergent intervention. Septicemia and
multisystem organ failure account for the third peak of fatalities
and typically occur weeks to months after injury.
Attempt to identify the severity of mechanism, as this will
predict the patterns of injury. For example, determine the
approximate speed of a motor vehicle collision (MVC) and
whether or not the patient was restrained. Emergency
medical service personnel can be an invaluable resource,
especially in amnestic and nonverbal patients. In assault
patients, inquire if they can recall exactly what they were
struck with and the nwnber of times. Ask if there was any
loss of consciousness, as this may portend to a significant
head injury. For penetrating trawna, ask about the number
of shots heard and how many times the patient felt himself
Obtain a brief medical history using the AMPLE
mnemonic. Ask about any known drug allergies, current
medication use, past medical history, last oral intake, and
the immediate events leading up to the injury. Keep in
mind that regardless of past history, elderly patients have
less physiologic reserve and are prone to higher rates of
morbidity and mortality. In females of childbearing age,
always ask about the last menstrual period and assume that
they are pregnant until proven otherwise. Pregnant patients
are at higher risk for domestic violence and warrant
unique considerations such as placental abruption,
uterine rupture, the supine hypotensive syndrome, and
fetal distress or demise. Even apparently minor injuries
including falls and low-speed motor vehicle accidents can
induce preterm labor or placental abruption.
Always ask about any evolving symptoms and identify
the exact locations of pain, as this will guide your physical
exam. Patients with altered mental status should be
treated as having a traumatic brain injury until proven
otherwise. Shortness of breath may indicate an underlying
pneumothorax (PTX), pulmonary contusion, or pericardia!
tamponade. Chest pain may indicate an underlying fracture
of the ribs or sternum, hemothorax (HTX), or traumatic
aortic injury (TAl). Assume that patients with abdominal
pain, hematemesis, or rectal bleeding have an intra-abdominal
an underlying spinal cord injury or vascular dissection.
The physical exam in major trauma patients is very systematic
and can be divided into primary and secondary surveys.
The primary survey is a very brief and focused exam meant
to the beginning of the primary survey and reassess. Assume
an unstable cervical spine injury in all major t rauma victims
until proven otherwise and immediately immobilize on
Assess the airway for patency. Signs of potential airway
compromise include pooling pharyngeal secretions, intraoral
foreign bodies, stridulous or gurgling respirations, obvious
oropharyngeal burns, significant midface, mandibular, and
laryngeal fractures, and expanding neck hematomas.
Evaluate the patient's breathing and ventilation. Expose
the chest and look for any signs of asymmetrical or
paradoxical chest wall movement, obvious deformities or
open wounds, tracheal deviation, and jugular venous
distention. Auscultate the chest to confirm strong symmetric
bilateral breath sounds. The goal is to identify the presence
of emergent life threats including tension PTX, massive
HTX, open PTX (sucking chest wound), and flail c hest.
Rapidly assess the patient's circulation by evaluating for
signs of altered mental status. A depressed level of
consciousness should be considered hypovolemic shock
and thready peripheral pulses. Auscultate the heart to detect
distant heart tones suggestive of an underlying pericardia!
effusion. Identify all sources of active bleeding and control
with the application of direct pressure.
Perform a rapid neurologic exam, noting any evidence
of disability or deficits. Document the patient's level of
consciousness; note the size, symmetry, and reactivity of
the pupils; and assess for any focal numbness or weakness.
Perform a rectal exam to ensure adequate rectal tone and
determine the patient's Glasgow Coma Scale (GCS).
Completely expose the patient to ensure that all
potential life threats have been accounted for. Carefully
log-roll the patient to examine the back and rule out any
occult penetrating injuries. Once complete, immediately
cover the patient with warm blankets to prevent the
The secondary survey is a complete head-to-toe examination
globe for penetrating injuries, lacerations, or proptosis.
Examine the mid-face, looking for evidence of fracture,
lacerations, epistaxis, or septal hematomas. Look for signs
bedside "halo-test." Check for dental injuries or evidence of
mandibular fracture, including point tenderness, malocclusion, and sublingual hematomas.
Inspect the neck, noting any signs of obvious tracheal
deviation, laryngeal fracture, subcutaneous emphysema, or
expanding hematoma. Carefully palpate the cervical spine
to detect any point tenderness or bony step-offs. Re-inspect
the chest, noting any signs of contusions, asymmetry,
paradoxical movement, or penetrating injury. Palpate the
ribs and sternum, checking for point tenderness, soft tissue
crepitus, and bony deformity. Repeat auscultation of the
lungs and heart and document any abnormalities. Inspect
the abdomen for any signs of distention, contusions, or
penetrating injury. Palpate all 4 quadrants to elicit any
tenderness, guarding, or rebound. Carefully assess the pelvis
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