Triage

the cardiovascular system, and arranging for definitive therapy (which usually involves rapid transfer to a trauma center).

The main objective of triage is to put patients in categories according to their chance of survival. The vital signs are assessed along with the patient’s mechanism of injury, age, and suspected underlying medical conditions. Evidence that a faster workup is necessary include having multiple injuries, being extremely young or quite elderly, having severe neurological trauma, having an instability of the vital signs, having preexisting cardiac disease or having lung disease.

The primary survey is performed first to identify those things that are life-threatening. Obstructed airway takes precedence over impaired circulation and things like the necessity of amputation or other organ injury. If possible, caregivers need to assess all body systems at the same time, while simultaneously correcting those things that are correctable. By evaluating and treating at the same time, patients with multiple traumatic injuries can be treated and stabilized faster.

The need for a resuscitation team is labor intensive but is necessary in the trauma setting and in cases where there are mass casualties. When many victims are in need of care, the triage process allows for the maximal amount of care to be given to those patients who are expected to survive their injuries but that need intervention. In some cases, the most severely injured patients are not treated because they are not expected to survive even with maximal resuscitation.

The resuscitation team needs to be organized as soon as it is deemed necessary to treat one or more traumatized patients. Leadership roles need to be established early and equipment needs to be operable. In larger hospitals, surgeons need to be notified and available to correct any surgicallycorrectable traumatic injuries. The team leader should be a physician skilled in the management of trauma patients.

Other doctors or providers are designated to be responsible for the airway management, blood pressure control, and the secondary survey of the patient. If procedures need to be done, a healthcare provider skilled in that area needs to be available to provide the service. Nurses must be available for the continual monitoring of the vital signs, intravenous access, and the attainment of blood samples. If possible, respiratory therapists need to be on hand for airway management and x-ray services need to be available for radiologic studies.

Neurosurgeons and orthopedic surgeons need to be contacted immediately as soon as it becomes evident they are needed. If there is severe CNS trauma, a neurosurgeon must be readily available to provide emergency neurosurgical intervention for patients with CNS trauma.

The first step in trauma care is the performance of a primary survey. It involves an evaluation of the airway, breathing, circulation, disability, and environmental exposure. The first priority is airway. This is assessed by determining the ability of environmental air to enter lungs that are unobstructed. Obstruction of the airway can be due to direct injury to the pharynx or larynx, foreign bodies inside the airway, edema, or an inability of the individual to protect their airway because of a decreased level of consciousness. Treatment of airway disturbances can be done by removing excretions using suction or by intubating the patient. If facial trauma is present, the patient can have a surgical airway placed.

The next step is to evaluate the patient’s ability to spontaneously ventilate and oxygenate for themselves. Findings of impaired ventilation include the absence of spontaneous breathing, absent or asymmetric breath sounds, shortness of breath, or dullness of the chest wall during chest percussion. There can be disturbances of the chest wall suggestive of chest wall injury, a sucking chest wound, or flail chest. These can be managed by treating the hemothorax, pneumothorax, tension pneumothorax, or sucking chest wound with an emergency thoracostomy and chest tube placement.

If the patient has a flail chest, they need mechanical ventilation, which is often necessary for other injuries that are causing the ventilation difficulty. The circulation is next assessed by looking for evidence of low blood volume, cardiac tamponade, and external sources of bleeding. The neck veins need to be evaluated for collapse or distention and there needs to be an assessment of the heart tones. The hypovolemia needs to be treated by placing two large-bore peripheral intravenous catheters containing Ringer’s lactate and giving a large fluid bolus. Upper extremity catheters are preferred over lower extremity catheters. If there is cardiac tamponade, pericardiocentesis is warranted. This needs to be followed by immediate surgery to find and repair the cause of bleeding. External bleeding can be controlled by direct pressure or emergent surgery.

The patient’s estimated level of disability can be assessed by doing an initial gross mental status examination and a motor examination. Find out if there has been a serious head injury or spinal cord injury. Use the Glasgow Coma Scale to assess the patient’s level of consciousness. The pupils need to be looked at for size, reactivity to light, and symmetry. Spinal cord injury needs to be assessed by observing motor movement.

Pupillary findings or hemiplegia suggests possible upcoming herniation of the cerebrum through the tentoria incisura because of an expanding mass in the brain or because of cerebral edema. If these findings are seen, the patient needs emergency management for increased intracranial pressure. Treatment includes intravenous mannitol, hypertonic saline, sedatives, and muscle relaxants. This needs to be done after an adequate airway is established. Emergency neurosurgical intervention is necessary.

If there is no decreased level of consciousness and the presence of paraplegia or quadriplegia, there is probably a spinal cord injury. The possibility of a spinal cord injury necessitates full spinal immobilization. If respiratory efforts are weak because of a high cervical spinal cord injury, endotracheal intubation is necessary.

The last step in the primary survey includes evaluating the patient’s exposure to a harmful environment, and control of the environment. The patient’s clothes need to be removed and a thorough physical examination needs to be undertaken. Treatment for hypothermia needs to be undertaken as removing their clothing can worsen this problem. Warm blankets can be provided along with warming of the intravenous fluids. Heat lamps may be used and, if available, warmed air-circulating blankets.

There can be diagnostic intervention and monitoring along with the primary survey. The electrocardiogram leads can be placed and pulse oximetry can be implemented. Monitors can provide information crucial to the resuscitation process. If the patient needs an artificial airway, they need gastric intubation to remove excess stomach gas and fluids. If possible, a urinary catheter can be placed, which can allow for evaluation of the patient’s fluid status. This can’t be done in situations of a urethral injury. A retrograde pyelogram should be done if a urethral injury is suspected before a catheter can be placed.

While the primary survey is going on, the provider is simultaneously making diagnoses and doing interventional procedures until the patient’s condition is more stable. During this time, the patient has ongoing monitoring of the vital signs, protection of the airway, oxygenation, intravenous fluid resuscitation, and the administration of blood products.

Patients who have multiple injuries may need several liters of crystalloid fluids over the first twenty-four hours to maintain an adequate blood pressure, tissue perfusion, and end-organ perfusion. The urine output needs to be adequate during this time. Blood is given for low blood volume that isn’t responsive to intravenous crystalloids. If blood loss isn’t controlled by direct pressure and transfusion, surgery or diagnostic imagery needs to be done to evaluate and treat the source of the bleeding.

The endpoint of the resuscitative process includes normal vital signs, lack of ongoing blood loss, normal urine output, and lack of evidence of end organ damage. Things like base deficits found in arterial blood gases and blood lactate levels may aid in the treatment of severely injured patients. The patient with abnormal vital signs suggesting low blood pressure is at a high risk for blood loss of at least thirty to forty percent.

After the primary survey is finished and after resuscitation, a head-to-toe evaluation of the patient’s body is performed. The vital signs are continually reviewed, and the provider needs to repeat the primary survey to assess the patient’s response to the resuscitative process. The patient’s history is looked at as well as any reports from prehospital personnel. If family members or witnesses are available, they can enhance the patient’s history.

Find out if the patient has any preexisting medical conditions and if they are on any medications. Find out their allergies, tetanus status, time of last meal, and any events related to the injury. The secondary survey is done while paying attention to the mechanism of injury, the likelihood of a coexisting cold or heat injury, and the patient’s overall physical status. Each body area needs to be evaluated for evidence of injury, including the abdominal organs and bones. A full neurological assessment needs to be undertaken as part of this survey. This should include a complete cranial nerve evaluation.

The neck should be evaluated for evidence of airway injury or damage to the great vessels. The posterior aspect of the spine should be evaluated for cervical injury, or tenderness, to the cervical spine. Full spinal precautions need to be undertaken if there is blunt trauma and an unknown mechanism of injury.

The chest should be palpated for injury to the chest wall. Crepitation, tenderness, or instability of the chest wall suggests a chest injury. The patient’s heart and lungs need to be listened to. There should be an evaluation for penetrating trauma to the chest. Chest tubes need to be evaluated to make sure they are working and a portable chest x-ray is necessary to assess for continued pneumothorax, mediastinal trauma, bony injuries, and to assess the placement of endotracheal tubes, gastric tubes, and chest tubes.

The abdomen needs to be assessed for distension or other evidence suggestive of an intra-abdominal injury or intra-abdominal bleeding. If there is penetrating trauma, a local evaluation should be undertaken to see if the abdominal muscles were penetrated. High velocity penetrating trauma needs surgical evaluation and intervention. The pelvis needs to be assessed for pelvic fractures. An AP pelvis film can be done to look for fracture. If a pelvic fracture is suspected, the pelvis should not be manipulated as this can worsen the bleeding.

Perineal evaluation needs to be undertaken, looking for bleeding, gross blood in the vaginal canal, blood in the rectum, or urethral blood. If there is no suspicion of urethral trauma, a Foley catheter can be placed. If there is a suspicion of spinal cord injury, the anal sphincter tone should be assessed during this part of the evaluation.

An extremity evaluation should happen next. If long bones are fractured, these require stabilization. Plain films of the bones should be done to identify deformities, tenderness, or bone instability. Temporary splints need to be placed before discharging the patient from the emergency room to another part of the hospital. If there is extremity evidence of vascular compromise, this should be treated as ischemic injury to the extremities can result in irreversible damage to these areas.

The neurological examination is usually done during the secondary survey but now is the time to formally assess the patient’s spine for injuries. The entire spine needs to be palpated for bony abnormalities, tenderness, or deformity. A detailed evaluation of the back should be undertaken to evaluate for bruising or penetrating injuries.

X-ray imaging can provide critical data that are used to guide the initial evaluation. X-rays should be done in a particular order so that life-threatening injuries are identified and treated first, with lesser injuries identified and treated last. The patient needs to be fully resuscitated before being transferred radiology for secondary x-rays.

The most important x-ray in trauma patients is the AP chest x-ray. It can be performed in the resuscitation phase and can help identify lung contusions, pneumothorax, or hemothorax. This x-ray can also identify positioning of the endotracheal tube, chest tubes, and gastric tubes. An AP portable pelvis film can be taken in the resuscitative phase, which can help identify life-threating sources of bleeding. If the pelvis is bleeding, angiographic embolization or external fixation needs to be undertaken.

After x-rays, a focused abdominal sonogram for trauma or FAST needs to be undertaken. This should be done by a trauma clinician who is skilled in this technique. The ultrasound does not take very much time and can identify multiple things, including pneumothorax, hemothorax, pericardial effusion, and free fluid in the peritoneal cavity. This is the fastest and most effective way of evaluating the trauma patient for chest and abdominal injuries. It is usually done in major trauma centers as it takes a lot of skill to do this examination.

The CT scan can provide definitive evidence of injuries. It can evaluate the patient for abdominal, pelvic, chest, cervical spine, and cranial injuries. Overuse of the CT scan can be harmful if the patient needs emergency surgery as this can delay the surgery and may not be helpful in treating the patient. If the patient is hypotensive and has a major abdominal injury, they need to have emergency surgery before undertaking a CT scan.

When time provides, a CT scan of the head should be done to identify any intracranial injuries that need assessment by the neurosurgeon. The CT scan should be done without intravenous contrast and should be done prior to doing a contrast CT study of the pelvis and abdomen. Scanning of the cervical spine can be done at the same time as the head CT.

A CT scan of the chest can be done to evaluate the patient for any mediastinal injuries. CT scanning can evaluate the patient for aortic or other great vessel trauma and is superior to doing angiographic studies of these organs. It is also a more sensitive test for evaluation of rib fractures, pneumothorax, rib