Emergency medical services (EMS) calls into the community hospital where you are working to alert the staff that they are bringing in by ambulance a 34-year-old male driver who survived a head-on automobile collision. Initial details over the radio inform you that he was found conscious in the car. An IV was started while he was placed in a cervical collar and on a trauma board for transport. He is currently lucid and conversant with EMS staff. His vital signs are BP 100/70 mm Hg, pulse 100 bpm, respiratory rate 18 breaths per minute, and pulse oximetry 99% on nasal cannula. He denies pain, but the EMS staff can smell alcohol. Initial field physical examination revealed head lacerations with some bleeding, but he is moving all extremities, and he has no gross deformities.
What other information would you seek to elicit from the EMS staff? What instructions would you convey?
Initial reports from the field tend to be brief and consist of bare essentials to alert the receiving facility. The field staff focus on major presenting signs and symptoms that can be managed or temporized while preparing for and implementing transport to the hospital. Interventions such as splinting, intubation, IV placement, and, in some communities, drug administration are performed. Review and advice from the receiving physician or facility is often sought. The current paradigm emphasizes “scoop and run” or rapid transport to a definitive facility rather than aggressive and prolonged management in the field.1 Some would even advocate against placement of IVs prior to beginning transport in urban areas, since the time to place IVs may be equivalent to the time of transport. Location and time of transport probably have a major effect on level and outcomes of care. Advanced life support (ALS) providers are more prevalent in the urban than the rural setting, which is probably the opposite of what is required. Interestingly, however, ALS has not been shown to provide benefit in the EMS setting, and the use of EMS causes delays in time of transport owing to advanced interventions for severe trauma. More concerning, ALS measures, particularly endotracheal intubation, worsened outcomes for patients with initial Glasgow Coma Scale (GCS) scores < 9.2,3
Estimated time of arrival (ETA) and information about the nature of the injury and patient help the receiving facility prepare personnel and resources appropriately. Further exchange of information might consist of requests for guidance from the receiving physician; otherwise, the EMS staff will focus on transport and patient stability. Transport, IV placement, and directly applied pressure to the head wounds along with vital signs and basic patient observation are the key at this time, which is known as the prehospital phase.
The patient is en route to your facility, which is a 50-bed rural hospital with a surgeon on home beeper call. ETA is 15 minutes. You are the only physician covering the emergency department (ED). What preparations would you make?
This patient may arrive in stable condition with minor injuries that you can easily manage or could decompensate at any point from overt or occult causes. A room or area should be set aside for this patient, with space for equipment and personnel. Nursing and support staff, including radiology, should be on standby. Endotracheal intubation equipment (laryngoscopes and endotracheal tubes of different sizes, a bag-mask device, end-tidal CO2 confirmation device, oral or nasal airways, and suction at a minimum) should be prepared and checked. Warm IV fluid sets should be prepared. Standard monitors including noninvasive blood pressure, pulse oximetry, and continuous electrocardiography (ECG) must be present. The blood bank should be informed and asked to have un–cross-matched type O blood available if needed. Universal precautions must be observed; therefore, gowns, gloves, and eye/face protection should be donned. The surgeon should be called in. Arrangements for possible transfer to a higher level care facility should be initiated.
The patient arrives at your facility. EMS informs you that he remained stable during transport. He is moved to a hospital stretcher, still in the c-collar and on the trauma board. The bandages on his head are soaked with blood, and he is looking around and following commands. What do you do next?
You can begin a simple initial assessment as the patient rolls in. Is the patient conscious? Is he in distress? Does he have any gross injuries? Is your team assembled and prepared? EMS will give you a brief but fuller summary than performed over the radio. Details such as mechanism of injury, restrained vs unrestrained, time of extraction, and events during transport provide insight into likely sites and severity of injuries.
A simple and systematic approach is emphasized by the advanced trauma life support (ATLS) guidelines. Many of the steps can be performed in parallel by the team. Coordination by a team leader is essential, along with communication among team members.
A rapid primary survey is followed by treatment of abnormal vital functions. A secondary survey follows, and then definitive care.
ATLS guidelines reduce initial trauma management to ABCDE:
Airway maintenance with cervical spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: neurologic status
Exposure/environmental control: completely undress the patient but prevent hypothermia4
EMS confirms that he was an unrestrained driver who hit a roadside tree. There were skid marks leading up to the tree. He was found conscious, and extraction time was minimal. There was major impact damage to the front of the car, with “starring” of the windshield. The steering wheel was cracked. No air bag was deployed. EMS placed a 16-gauge IV en route. He denied significant medical history or allergies. EMS held pressure on bleeding anterior head lacerations. You begin your initial assessment. He is breathing comfortably with good chest rise and appears awake. The ED tech places a pulse oximeter probe and noninvasive blood pressure monitor along with ECG leads on the patient. BP is 90/65 mm Hg with a pulse of 120 bpm and Spo2 of 99%. No significant ECG abnormalities are apparent on the monitor in leads II and V5 other than the sinus tachycardia. Head-to-toe primary survey shows 2 approximately 8-cm lacerations on top of the head with some minor degloving. There is ongoing dark, venous-appearing blood loss here. No other head injury is apparent, and the ear canals are clear. He is already moving his eyes and head to follow movement around him in the ED and appears to do so comfortably. In fact, he is asking you, “Am I going to be OK, Doc?” You can smell alcohol on his breath. You do not see any blood or injured teeth on mouth inspection, and his airway is Mallampati 3. The face is uninjured. You take off the c-collar and have an assistant hold his head. There is no apparent neck injury, and he has good carotid pulses. You replace the collar. Your team has already warmed the room, removed his clothing, and placed him under warm blankets. You inspect the chest, abdomen, pelvis, and lower extremities visually and by palpation. He has some bruising of the lower chest, consistent with steering wheel impact. Otherwise you see nothing remarkable. The lungs are clear. His abdomen is flat but mildly tender in the upper region; there are no masses. Your team performs a logroll with neck stabilization, and you inspect the back, which has no abnormalities. The perineal region and rectal examination are unremarkable. He has good strength and sensation in all his extremities to a brief examination.
You should be concerned about this patient. He suffered a high-energy impact without restraint and has a head injury along with signs of chest or abdominal injury. Table 30-1 outlines typical patterns of injury based on injury mechanism. The lack of severe abdominal pain and relative lack of physical findings can be masked by altered mental status. Furthermore, patients, particularly the young, can compensate for initial injury for some time before abruptly deteriorating. Significant injuries can remain relatively occult, dictating continued patient reassessment. The relative blood pressure stability provides no reassurance; hypotension is a late sign of decompensation.5 The tachycardia is nonspecific but may portend ongoing blood loss or impending hemodynamic compromise.
| Mechanism of Injury | Suspected Injury Patterns |
|---|---|
Frontal impact automobile collision Bent steering wheel Knee imprint on dashboard Bull’s-eye fracture of the windshield | Cervical spine fracture Anterior flail chest Myocardial contusion Pneumothorax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation of hip or knee |
| Side impact automobile collision | Contralateral neck sprain Cervical spine fracture Lateral flail chest Pneumothorax Traumatic aortic disruption Diaphragmatic rupture Fractured spleen/liver/kidney Fractured pelvis or acetabulum |
| Rear impact automobile collision | Cervical spine injury Soft tissue injury to neck |
| Ejection from vehicle | Precludes meaningful prediction of injury patterns, but increases risk of all injuries |
| Pedestrian struck by motor vehicle | Head injury Traumatic aortic disruption Abdominal visceral injuries Fractured lower extremities/pelvis |
You have performed a rapid primary survey and should now address vital functions while beginning a secondary survey. Fluid administration is indicated. The tachycardia could be due to pain, anxiety, or more likely ongoing blood loss. There is little or no disadvantage to a fluid bolus at this point. Normal saline or Ringer’s lactate, 1 to 2 L, warmed, should be given rapidly. A nasogastric (NG) tube (because there is no facial or skull base injury, the nasal route is appropriate) for lavage and a urinary catheter are important. You should also address the most obvious injury and source of blood loss; that is, the scalp lacerations. Scalp wounds can cause significant blood loss. The wound should be inspected gently but not probed. Depressed skull fracture or foreign material should be identified if possible. Leakage of clear fluid indicates cerebrospinal fluid leak. Staples or sutures can quickly stop blood loss; because the scalp is highly vascular, infection is unlikely.
The patient’s pulse reduces to 95 bpm after the fluid administration. His blood pressure remains the same. You perform another abdominal examination with similar results. A plain film of the chest is unremarkable, and laboratory studies are pending. It has been 25 minutes since his arrival. Nasogastric lavage and the urine are clear of blood. The nurse asks if you want to perform a FAST examination. What is the FAST examination? How is it performed? Who can perform it?
Current practice has incorporated the FAST (Focused Assessment with Sonography in Trauma) examination into trauma care worldwide. The basic premise of FAST is to identify fluid in the pericardium or peritoneum. An extended FAST (eFAST) examination is used at some centers; this protocol uses ultrasound to look for pathologic fluid or air in the thorax.
The FAST examination has four views (Figure 30-1); eFAST adds thoracic views.6 The examination is usually performed initially with the patient supine. The patient can be moved, if clinically appropriate, to improve sonographic windows; for example, to the right lateral position to demonstrate fluid in the right upper quadrant. There is no established, widely accepted certification in FAST; however, United States surgical and emergency medicine residencies now promote training in this technique.
Figure 30-1.
Focused assessment with sonography for trauma (FAST). Views are clockwise starting from top: pericardial, left upper quadrant, pouch of Douglas/retrovesicular space, right upper quadrant. (Reproduced with permission from Sisley AC, Rozycki GS, Ballard RB, Namias N, Salomne JP, Feliciano DV. Rapid detection of traumatic effusion using surgeon-performed ultrasonography. J Trauma. 1998;44:291-296.)
What are the FAST examination’s test characteristics? What other diagnostic tools are at your disposal to evaluate this patient’s abdominal trauma?
Evidence supports the widespread adoption of FAST. Ultrasound in abdominal trauma has been shown to improve patient outcomes, reduce the use of diagnostic peritoneal lavage (DPL) and computed tomography (CT), and shorten time to the operating room (OR).7 Cost savings are significant—more than enough to pay for the cost of the ultrasound machine.8 Scoring based on fluid depth in the abdomen correlates with need for laparotomy.9 FAST can detect as little as 250 mL of free fluid in the abdomen, with an average positive FAST at 619 mL.10
Classic diagnostic tools for abdominal trauma are the DPL and the CT scan. DPL is sensitive for blood in the abdomen but is somewhat time consuming; requires operator experience; has reduced effectiveness or application in the pregnant, obese, or postsurgical patient; and is invasive. Use of the DPL has decreased with the advent of FAST. CT scan is sensitive not only for free fluid but also for solid organ injury and free air and is now widely available. However, it is costly and time consuming, as well as requiring transport of a potentially unstable patient out of a highly monitored setting (Table 30-2).11
| FAST | DPL | CT | |
|---|---|---|---|
| Advantages | Rapid Good sensitivity and specificity for intraabdominal fluid Noninvasive Low cost Available bedside | Rapid 98% sensitive for intraperitoneal bleeding | Highly specific and sensitive for particular organ injury and intraperitoneal blood. Can be extended to include head, thorax, pelvis, extremities Noninvasive |
| Disadvantages | Operator experience–dependent Limited by obesity, subcutaneous air, previous surgeries | Invasive Requires training Complicated by obesity, pregnancy, cirrhosis, coagulopathy, or preexisting surgery | Time consuming/transport delay Costly Requires cooperative patient |
| Contraindications | Lack of operator experience | Existing indication for laparotomy | Hemodynamic instability Allergy to contrast |
| Notes | Scan should be repeated to assess for slow bleeding Can be used to assess pericardial fluid and cardiac function | Open or Seldinger infraumbilical approach preferred Positive test is by gross aspiration, or > 100 000 RBC/mm3, 500 WBC/mm3, positive Gram stain | Gastrointestinal, diaphragmatic, and pancreatic injuries can be missed Patient must be monitored during transport and scan |
FAST equipment is small and portable. It can be performed at the bedside by a member of the trauma team while initial review and resuscitation efforts are under way. ATLS guidelines recommend a repeat FAST examination 30 minutes after the first scan to demonstrate developing hemoperitoneum in slowly bleeding patients or patients close to the time of injury.4
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