Initial Evaluation of the Patient Presenting with Trauma

Educational Objectives

The goal of this program is to improve initial management of airway, breathing and circulation in patients with traumatic injuries. After hearing and assimilating this program, the clinician will be better able to:

1. Implement recommended strategies for managing the airway.
2. Choose appropriate treatment for different types of trau�matic chest injuries.
3. Evaluate the literature on various methods of hemorrhage control.

Summary

Airway injuries: consider examination of patients with breathing problems as these may be caused by airway swelling; diagnosing airway injury may be difficult in some cases; may include neck trauma, dyspnea, dysphonia or aphonia, wheezing, hemoptysis, subcutaneous emphysema, air leak from the wound, and pneumomediastinum; can be anywhere in the chest region; one pitfall is exacerbation of the issue because of intubation; the patient should be intubated with bronchoscopy, placing the balloon below the injury site; in the breathing category, there are many reasons why a patient might not be oxygenating or ventilating well; tension pneumothorax (PTX) is frequently managed with needle decompression

Common treatment methods: literature on advanced trauma life support now includes lateral placement of decompression needles (to second intercostal space on the midclavicular line) as an option; computed tomography (CT) has shown that chest wall thickness is ≈1 cm less in lateral position; needle thoracostomy (TC) — the needle is generally not placed well; a review by Neeki et al (2021) showed proper placement in only ≈25% of patients, and ≈20% of patients had no medical indication; in another systematic review, decompression failure rate was 76%, with 39% of decompressions performed in patients who did not have a PTX; there was a significant complication rate but no significant difference in anterior vs lateral placement; a study reported higher complication rate with needle TC vs finger TC

Open PTX vs sucking chest wound: the primary treatment is a temporary dressing with tape on 3 sides and chest tube placement (CTP); occult PTX is seen on CT but not on chest x-ray; ≤2% of trauma admissions and ≤30% of PTXs are occult PTX; in asymptomatic patients do not require treatment; discussion may be needed if the patient requires positive pressure ventilation (PPV); a study by Moore et al (2011) showed that 6% of patients required CTP for progressive PTX, and observation failed in ≈14% of patients on PPV, none of whom developed tension PTX; another study showed that 40% of patients on a ventilator for ≥5 days required CTP

Respiratory compromise: pulmonary contusions — may be caused by rib fractures; can be a ventilatory problem from lung swelling (edema) and require supportive care; rib blocks may help in pulmonary mechanics; massive hemothorax (HTX) — may lead to inadequate gaseous exchange; defined as loss of 1.5 L of blood; diagnosed by shock, absent breath sounds on the affected side, and percussion dullness; criteria for thoracotomy include ongoing bleeding from the chest; blunt trauma — may be exacerbated by thoracotomy; focus on coagulopathy and angioembolization of intercostal arteries

Size and positioning of chest tube: in the HTX setting, the chest tube is placed and blood begins to drain but may stop because of a clot; in this case, another chest x-ray is needed as thoracotomy may be required; not all HTXs required drainage; according to current guidelines from the Eastern Association for the Surgery of Trauma, HTX with <300 mL of blood does not require drainage; a study compared small (28-32 Fr) vs large (36-40 Fr) chest tube sizes but had limitations; the speaker does not prefer using 14-Fr chest tubes for HTX and prefers to use sizes 20 or 24 Fr; 14 Fr and 16 Fr may be used for PTX but not for HTX; a study (Benns et al; 2015) looking at positioning of CTP (eg, anterior, posterior, superior, inferior, avoiding fissure) showed no difference in success rates, and severity and mechanism of injury were the most important factors influencing outcomes

Risks of inadequate drainage: if blood is not effectively drained, risk for empyema increases; risk for empyema is 33% in patients with residual HTX; a meta-analysis suggested that antibiotics should be used in HTX; empyema and pneumonia after CTP favor antibiotics; prolonged course of antibiotics can be harmful; 2011 guidelines from the European Society of Cardiology recommended that persistent, retained HTX after CTP should be treated with early video-assisted thoracoscopic surgery (VATS), not with a second chest tube; this should be done within the first 3 to 7 days of hospitalization to reduce risk for infection; a study showed that VATS was associated with decreased duration of chest tube drainage, and 40% of patients with second CTP went on to require surgery; thrombolytics may be needed if surgery is not performed; thrombolytics are shown to be effective in eliminating the need for surgery; adjunct therapies include thoracic irrigation and suction evacuation

Autotransfusion from chest tube: may result in accelerated coagulation and increase proinflammatory and anti-inflammatory cytokine mediators; not needed if a good blood bank is available

Circulation and hemorrhage control: definitive control of hemorrhage and restoration of adequate circulating volume are the goals of treating hemorrhagic shock; prehospital control of bleeding involves tourniquets if direct pressure is not effective; complications may occur if the tourniquet is not correctly applied; in the United States, mortality rate is ≈30% in patients with major pelvic fracture who are hypotensive; it is important to close the pelvic volume in these patients as 85% of bleeding originates from the veins and soft tissues; wrapping with a sheet or use of pelvic binders may be effective; it is also important to stabilize the pelvis

Transfusion: acidosis, hypothermia, and coagulopathy occur in a vicious cycle; empiric products and ratios — a trial compared 1:1:2 vs 1:1:1 ratios and found that, among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio vs a 1:1:2 ratio does not result in significant differences in mortality at 24 hr or 30 days; more patients receiving the 1:1:1 ratio achieved hemostasis, and fewer died from exsanguination; use of whole blood — superior; however, whole blood is not associated with significant survival benefit or reduced blood product utilization, however, it seems to be safe; there is no demonstrable benefit in using fresh whole blood vs stored blood, and adverse events may occur; a study demonstrated that the goal of massive transfusion protocol directed by thromboelastography (TEG) resulted in survival benefit (less hemorrhagic and early deaths), and fewer blood products were used; another study showed significant reduction in bleeding, transfusion requirements, complications rate, and hospital costs when rotational thromboelastometry was added to the algorithm for bleeding management; patients receiving >4 units of blood in the first hour have deficits in TEG that indicate a need for platelets and cryogenic processing

Damage control resuscitation: there are several components; promoted components include permissive hypotension and limiting crystalloid; fluid resuscitation and avoidance of hypotension are important principles in the management of blunt trauma; in penetrating trauma, delaying aggressive fluid resuscitation until hemorrhage is controlled may prevent additional bleeding; a study found that organ hypoperfusion is associated with oxygen debt, which is unfavorable for the patient and may result in kidney failure; blood pressure target of 85 mm Hg is too low; hypotension is associated with mortality and trauma; in traumatic brain injury, hypotension is associated with higher death rates, and there is a time limit for organ perfusion; more research is needed for permissive hypotension

Prehospital plasma: can be considered during longer transport time; blood is available in helicopters, but plasma is not; 44% of injuries seen in trauma centers occur from falls and 25% from motor vehicle accidents; >30% of these patients are aged >65 yr; patients may also be on anticoagulants (requires reversal); resuscitative endovascular balloon occlusion of the aorta is not a replacement of resuscitative thoracotomy

Readings

Benns MV, Egger ME, Harbrecht BG, et al. Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions. J Trauma Acute Care Surg. 2015;78(2):386-390. doi:10.1097/TA.0000000000000479; Bozzay JD, Bradley MJ. Management of post-traumatic retained hemothorax. Trauma. 2019;21(1):14-20; Görlinger K, Pérez-Ferrer A, Dirkmann D, et al. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol. 2019;72(4):297-322. doi:10.4097/kja.19169; Hannon L, St Clair T, Smith K, et al. Finger thoracostomy in patients with chest trauma performed by paramedics on a helicopter emergency medical service. Emerg Med Australas. 2020;32(4):650-656. doi:10.1111/1742-6723.13549; Moore FO, Goslar PW, Coimbra R, et al. Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study. J Trauma. 2011;70(5):1019-1025. doi:10.1097/TA.0b013e318213f727; Neeki MM, Cheung C, Dong F, et al. Emergent needle thoracostomy in prehospital trauma patients: a review of procedural execution through computed tomography scans. Trauma Surg Acute Care Open. 2021;6(1):e000752. Published 2021 Aug 27. doi:10.1136/tsaco-2021-000752; Rossaint R, Bouillon B, Cerny V, et al. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14(2):R52. doi:10.1186/cc8943.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Biffl was recorded at the 42nd Annual Current Concepts in Emergency Care, held December 5-10, 2021, at Maui, HI, and presented by Emergencies in Medicine. For information on future CME activities from this presenter, please visit https://emergenciesinmedicine.com/. Audio Digest thanks the speakers and Emergencies in Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

EM400102

Qualifies for:

Trauma

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.