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Trauma I – ABCs of Trauma

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Triage and Transport Trauma patients are initially evaluated in the field by pre-hospital personnel. They are stabilized and transported to a suitable facility based on clinical status and the capabilities of the center. The method of transport is based on the severity of injury and the distance to the receiving facility. On arrival, patients are triaged based on the mechanism of injury, severity of injury, hemodynamic stability and resources available. In situations involving multiple victims, those with the most severe or life-threatening injuries are generally treated first. In situations where casualties overwhelm resources, however, patients that are unlikely to survive may receive expectant management in order to devote resources to patients with survivable injuries. Once appropriately triaged, trauma patients undergo an assessment of vital signs, primary survey, secondary survey, resuscitation and definitive care. Primary Survey The first component of the systematic approach to the trauma patient is called the primary survey. The purpose of the primary survey is to identify life-threatening injuries and initiate appropriate resuscitation. A simple mnemonic, ABCDE, is used to guide the steps of the primary survey. Evaluation of the severely injured patient must occur quickly and methodically to decrease the risk of missed injuries. Any decline in a patient’s status warrants repeating the primary survey as clinical conditions in trauma can shift rapidly (1). A- Airway Maintenance with Cervical Spine Protection The airway must be rapidly assessed for patency in all trauma patients. This can be done simply in awake patients by asking them to state their name and what occurred during the incident. If the patient has difficulty or is unable to speak, maneuvers include suctioning the oropharynx, searching for and removing foreign bodies, and identification of significant facial trauma or evidence of burn injury. Definitive airway management is required in the following scenarios: • Patients with depressed mental status or unable to protect their airway, such as patients with Glasgow Coma Scale (GCS) of 8 or lower. • Patients with significant maxillofacial trauma at high risk for airway obstruction, • Patients with severe hemodynamic instability. In preparation for endotracheal intubation, simple maneuvers for opening the airway can be performed to improve oxygenation and ventilation. A jaw-thrust (chin-lifts are not used in blunt trauma patients given the need to protect the cervical spine) may be the most important initial procedure for an obtunded patient. An oral airway or nasal trumpet can be inserted. Finally, supplemental oxygen must be administered, usually by bag valve mask. In general, for obtunded or severely injured patients it is preferable to establish a definitive airway with a cuffed endotracheal tube. Such tubes allow for oxygenation and ventilation in addition to preventing gastric contents or blood from entering the lower airways.

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