Inspect the perineum for lacerations, contusions, and
hematomas. Perform vaginal and rectal examinations to
assess for gross blood or mucosal trauma. Note the rectal tone
and check the prostate for signs of displacement. Findings
consistent with urethral injury include scrotal hematomas,
blood at the urethral meatus, and a high-riding prostate.
Look for any signs of blunt or penetrating trauma to the
extremities. Document any open wounds, point tenderness,
or obvious deformities. Range all joints, looking for abnormal
movement. Palpate all muscle compartments to detect any
signs of developing tension. Roll the patient and palpate the
entire spine, noting any point tenderness or bony step-offs.
Assess the pulses in all 4 extremities. In penetrating
trauma, the "hard" signs of arterial injury include absent
distal pulses, pulsatile bleeding, expanding hematomas,
and the presence of bruits or thrills. The "soft" signs of
arterial injury include diminished distal pulses, visible
hematomas, corresponding peripheral nerve deficits, or
delayed capillary refill. Patients with soft signs for arterial
injury require the measurement of the arterial pressure
index (API). The API can be calculated by dividing the
systolic pressure of the affected extremity by the systolic
pressure of the contralateral unaffected limb. An API <0.9
is considered abnormal and suggestive of arterial injury.
Finally, perform a comprehensive motor and sensory
examination, reevaluate the pupils and mental status, and
Check a STAT bedside capillary blood glucose level in all
patients with an abnormal mental status as hypoglycemia
can mimic a traumatic brain injury. Check a complete
blood count to assess an initial hematocrit and follow
serially to assess for occult hemorrhage and responsiveness
to therapy. If available, obtain a bedside serum base deficit
and lactate level and follow serially to gauge responsiveness
to therapy. Send a type and screen on all trauma patients
and crossmatch blood as necessary for patients likely to
require transfusions or operative intervention. Obtain a
urinalysis to rule out gross hematuria, a bedside urine
pregnancy test in all female patients of childbearing age,
and a urine toxicology screen in patients with an abnormal
level of consciousness. Check coagulation studies in all
patients with a clotting disorder (eg, patients on warfarin).
Portable plain radiography is readily available at most
institutions for the rapid bedside evaluation of trauma
patients. Plain films are useful for diagnosing bony
fractures including unstable pelvic and spinal injuries;
determining the trajectory of penetrating projectiles;
identifying HTX, PTX, or an abnormal mediastinum; and
detecting the presence of intraperitoneal free air.
Bedside ultrasonography provides a quick, highly sensitive,
noninvasive, and readily repeatable modality to detect occult
(see Chapter 88 for further details).
Computed tomography ( CT) imaging has revolutionized
the care of trauma patients. That said, this modality does
expose the patient to increased health care costs, potential
contrast reactions, and harmful ionizing radiation, so every
pursued only in patients who are stable enough to safely
leave the resuscitation area for an extended period of time.
CT imaging of the head has become invaluable for the
evaluation and treatment of patients with traumatic brain
emergencies ( eg, TAl) and evolving pulmonary contusions.
CT of the abdomen and pelvis can simultaneously detect
solid viscus injury (eg, liver and spleen) and intraperitoneal
hemorrhage and determine the severity of pelvic injuries.
Finally, CT angiography has rapidly become the preferred
patients with "soft signs" for arterial injury).
Magnetic resonance imaging is useful for the evaluation
of patients with potential spinal cord injury and to further
delineate the severity of traumatic brain injury. That said, its
use should be limited only to stable patients who can afford
prolonged excursions outside of a resuscitation arena.
The coordinated resuscitation of a critically ill trauma patient
may require a multitude of simultaneous interventions. The
resuscitation (Chapter 3), needle thoracostomy and
(Chapter 8 7), and diagnostic peritoneal lavage (Chapter 88).
Perform a retrograde urethrogram and cystogram in
all patients with suspected urethral and bladder injuries.
Indications include straddle injuries, pelvic fractures,
scrotal hematomas, high-riding prostates, and blood at the
urethral meatus. A urethrogram is performed by injecting
intravenous (IV) dye into the urethral meatus while
simultaneously capturing a pelvic radiograph to detect any
signs of urethral disruption (ie, contrast extravasation).
Avoid the insertion of a Foley catheter into any patient with
a demonstrated urethral injury without GU consultation.
For patients with an intact urethra, insert a catheter and
(cystogram) to detect any evidence of bladder rupture.
Obtain a complete set of vital signs and note any
abnormalities. Hemodynamic instability in the setting of
trauma is hemorrhagic shock until proven otherwise.
Initiate aggressive volume resuscitation in said patients.
Discharge home Admit for observation and
serial testing Operative intervention
Figure 84-1. Trauma principles diagnostic a lgorithm. OR, operating room.
Perform an immediate primary survey and address any
emergent life threats including airway obstruction,
tension or open PTX, massive HTX, and pericardia!
tamponade. Use your laboratory and imaging studies as
necessary to determine the presence and severity of
injury. Following patient stabilization, perform a
comprehensive secondary survey and treat all encountered
Evaluation and treatment should coincide during the
primary survey. All life-threatening conditions must be
stabilized before further evaluation. Secure the airway in
any patient with signs of impending compromise.
Patients with a GCS �8 require endotracheal intubation
to guard against obstruction and/or aspiration. Examine
the thoracic wall to identify any open PTX and cover
to my in all patients with signs of tension PTX, and place
a chest tube in all patients with evidence of traumatic
Patients with evidence of impaired circulation require
large-bore IV access and aggressive volume resuscitation
(Lactated Ringer's or normal saline) . Attempt to
determine the class of hypovolemic shock to guide fluid
resuscitation and identify the need for packed red blood
cell transfusion (Table 84- 1). Concurrently attempt to
identify the source of hemorrhage to determine the need
for surgical intervention. Unstable patients with either
clinical evidence (hypotension, distant heart sounds,
jugular venous distention) or ultrasonographic
confirmation of pericardia! tamponade require emergent
Provide sufficient analgesia to ensure patient comfort
and facilitate further evaluation. Small boluses of IV
fentanyl are ideal because of its short duration of activity
and minimal hemodynamic side effects. Ketarnine can be
used both as an analgesic and sedative agent in lower than
normal "subdissociative" doses without concern for
respiratory or cardiovascular depression. Ondansetron can
Table 84-1. Cl asses of hypovolemic shock .
Class I Class II Class Ill Class IV
Blood loss Up to 750 750-1,500 1 ,SOD--2,000 >2,000
Blood loss Up to 15% 1 5-30% 30-40% >40%
Pulse rate <100 >100 >120 >140
BP Normal Normal Decreased Decreased
Pulse pres· Normal or Decreased Decreased Decreased
RR (breaths/ 1 4-20 20-30 30-40 >35
Urine output >30 20-30 5-15 Negligible
CNS/mental Slightly Mildly Anxious, Confused,
status anxious anxious confused lethargic
Fluid repla£e· Crystalloid Crystalloid Crystalloid Crystalloid
,.,Fluid replacement should be 3x the estimated blood loss.
be given to reduce nausea and vomiting, and haloperidol
may be necessary to sedate agitated patients.
The majority of blunt trauma victims require admission for
observation to rule out occult injuries not detected on
either the primary and secondary surveys or CT imaging.
Hemodynamically unstable patients with positive focused
assessment with sonography for trauma (FAST) or CT
imaging typically require operative intervention. Victims of
penetrating trauma generally require admission and
operative intervention when the implements clearly violate
significant body cavities or injure vital anatomical
Blunt trauma patients with minor injuries who remain
hemodynamically stable on serial assessments can be
safely discharged. Penetrating trauma patients may be
discharged provided that the path of the implement
clearly does not violate any significant body cavities nor
approach any vital anatomical structures. Always ensure
that the patient is able to ambulate and tolerate oral intake
Bailitz J, et al. Emergent Management of Trauma. 3rd ed.
Chapter 3. Patient Evaluation. New York, NY: McGraw Hill,
Bonatti H, Calland J. Trauma. Emerg Med Clin North Am.
Brunett PH, Cameron PA. Trauma in adults. In: Tintinalli JE,
Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.
Tintinalli's Emergency Medicine: A Comprehensive Study Guide.
7th ed. New York, NY: McGraw-Hill, 20 11.
Initial assessment and management. ATLS Student Course
Manual. 9th ed. Chapter 1. Chicago, IL: American College of
• Traumatic brain injury can be classified by severity into
mild (Glasgow coma Sca le [GCS] <::1 4), moderate (GCS
9-1 3), and severe (GCS ::::: 8) categories.
• An emergent noninfused head computed tomography is
the imaging modal ity of choice in patients with cranial
Between 1.2 and 2 million patients sustain some form of
traumatic brain injury (TBI) in the United States every
year. Fortunately the majority of cases ( -80%) are mild,
as moderate and severe TBI is associated with significant
long-term disability and death. In fact, head injuries are
the leading cause of traumatic death in all patients
younger than 25 years. Currently more than 50,000
deaths and 370,000 hospitalizations are attributable to
TBI on an annual basis. The associated costs of caring for
patients with acute and chronic TBI are astronomical,
exceeding $4 billion per year. TBI occurs as the normal
physiologic function of the brain is disrupted by either
secondary (develop over time owing to neurochemical
and inflammatory responses). Patients with TBI can be
further stratified by their Glasgow Coma Scores (GCS)
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