PRIORITIZING TRAUMA CARE

The advanced trauma life support (ATLS) course of the American College of Surgeons is the most popular training program for trauma physicians of all disciplines.^[8] Though not comprehensive in subspecialty areas—such as airway management or interpretation of radiographs—the ATLS curriculum nonetheless provides an organizational framework and a common language for assessing injured patients. ATLS is based on a primary survey that includes simultaneous diagnostic and therapeutic activities intended to identify and treat life- and limb-threatening injuries, beginning with the most immediate. This focus on urgent problems is first captured by the "golden hour" catch phrase and is one of the most important lessons of ATLS. Resolution of urgent needs is followed by a meticulous secondary survey and further diagnostic studies designed to reduce the incidence of missed injuries. Knowing the basics of ATLS is essential for any physician who interacts with trauma patients in the first hours after admission. Figure 63-1 is a simplified representation of the ATLS protocol.

ATLS begins with the ABCDE acronym: airway, breathing, circulation, disability, and exposure. Verification of an adequate open airway and acceptable respiratory mechanics is of primary importance because hypoxia is the most immediate threat to life. An inability to oxygenate the patient will lead to permanent brain injury and then death within 5 to 10 minutes. Trauma patients are at risk for airway obstruction and inadequate respiration for the reasons listed in Table 63-1 . Endotracheal intubation, whether performed in the prehospital environment or the ED, must be immediately confirmed by capnometry for patients who have vital signs; esophageal intubation or endotracheal tube dislodgement is common and devastating if not promptly corrected. Patients in cardiac arrest may have very low end-tidal CO₂ values; direct laryngoscopy should be performed if there is any question about the location of the endotracheal tube.

If establishment of a secure airway and adequate ventilation requires a surgical procedure such as tracheostomy, tube thoracostomy, or open thoracotomy, this procedure must precede all others. Indeed, these procedures are commonly performed in the ED, with or without the

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Figure 63-1 Simplified assessment and management of a trauma patient. CBC, complete blood count; CT, computed tomography; ECG, electrocardiogram; ED, emergency department; FAST, focused assessment by sonography for trauma; GCS, Glasgow Coma Scale. (Redrawn and adapted from the Advanced Trauma Life Support curriculum of the American College of Surgeons.)

Hemorrhage is the next most pressing concern because ongoing loss of blood will be fatal in minutes to hours. The symptoms of shock are presented in Table 63-2 . Shock is presumed to be a consequence of hemorrhage until proved otherwise. Assessment of the circulation consists of an early phase, during active hemorrhage, and a late

TABLE 63-1 -- Causes of obstructed airway or inadequate ventilation in trauma patients

Airway Obstruction

Direct injury to the face, mandible, or neck

Hemorrhage in the nasopharynx, sinuses, mouth, or upper airway

Diminished consciousness secondary to traumatic brain injury, intoxication, or analgesic medications

Aspiration of gastric contents or a foreign body (e.g., dentures)

Misapplication of oral airway or endotracheal tube (esophageal intubation)

Inadequate Ventilation

Diminished respiratory drive secondary to traumatic brain injury, shock, intoxication, hypothermia, or oversedation

Direct injury to the trachea or bronchi

Pneumothorax or hemothorax

Chest wall injury

Aspiration

Pulmonary contusion

Cervical spine injury

Bronchospasm secondary to smoke or toxic gas inhalation

phase, which begins when hemostasis is achieved and continues until normal physiology is restored. In the early phase, diagnostic efforts will focus on the five sites of bleeding detailed in Table 63-3 because they are the only areas in which exsanguinating hemorrhage can occur. Any surgical procedure to diagnose or control active hemorrhage is considered to be an emergency that must be brought to the OR as soon as possible. Included are operative procedures for penetrating trauma such as pericardial window and neck exploration, which are performed to rule out hemorrhage in sensitive compartments. The anesthesiologist will be responsible for fluid volume management and appropriate resuscitation in the perioperative period; the goals for early and late resuscitation from hemorrhagic shock are discussed in more detail later (also see Chapter 47 and Chapter 78 ).

Next in the primary survey is an assessment of the patient's neurologic status by measurement of the Glasgow Coma Scale (GCS) score ( Table 63-4 )^[9] ; examination of the pupils for size, reactivity, and symmetry; and determination of preserved sensation and motor function in each of the extremities. Significant abnormalities on the neurologic examination are an indication for immediate cranial CT. Most trauma patients with a diminished GCS score will

TABLE 63-2 -- Symptoms of shock

Pallor

Diaphoresis

Agitation or obtundation

Hypotension

Tachycardia

Prolonged capillary refill

Diminished urine output

Narrowed pulse pressure

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After the primary survey a more deliberate secondary survey is undertaken that includes a thorough history and

TABLE 63-4 -- Glasgow Coma score *

Eye-Opening Response

4 = Spontaneous

3 = To speech

2 = To pain

1 = None

Verbal Response

5 = Oriented to name

4 = Confused

3 = Inappropriate speech

2 = Incomprehensible sounds

1 = None

Motor Response

6 = Follows commands

5 = Localizes to painful stimuli

4 = Withdraws from painful stimuli

3 = Abnormal flexion (decorticate posturing)

2 = Abnormal extension (decerebrate posturing)

1 = None

*The Glasgow Coma score is the sum of the best scores in each of three categories.

Another category of urgency arises in patients with a time-dependent potential for systemic infection. Because sepsis is a leading cause of complications and death in trauma patients, open injuries should be thoroughly débrided—and closed if appropriate—at the earliest opportunity. Other urgent indications for surgery include perforation of the bowel, open fracture, and extensive soft tissue wounds. The frequency of infectious complications of open fractures increases in linear fashion with time from the moment of injury until operative débridement ^[10] ; the anesthesiologist must balance the need for early surgery against the need for diagnostic studies and adequate preoperative resuscitation and may be required to determine the priority of this procedure relative to other management issues.

Figure 63-2 is an algorithm for prioritizing surgical management in a trauma patient; it is presented with the understanding that individual situations will vary according to available resources and the patient's response to therapy. Trauma patients will often arrive at the OR with a need for more than one surgical procedure by more than one surgical service. Trauma patients may have injuries requiring emergency surgery coexisting with injuries that can be repaired at any time. 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.