Initial management of trauma in adults

INTRODUCTION — Traumatic injuries can range from minor isolated wounds to complex injuries involving multiple organ systems. All trauma patients require a systematic evaluation to maximize outcomes and reduce the risk of undiscovered injuries.

The initial management of adult trauma patients is reviewed here. The initial evaluation and management of specific injuries and the management of pediatric trauma are discussed separately.

●Emergency trauma management (see "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Approach to shock in the adult trauma patient" and "Emergency ultrasound in adults with abdominal and thoracic trauma")

●Head, neck, and spine trauma (see "Management of acute moderate and severe traumatic brain injury" and "Acute traumatic spinal cord injury" and "Suspected cervical spine injury in adults: Choice of imaging" and "Cervical spinal column injuries in adults: Evaluation and initial management" and "Penetrating neck injuries: Initial evaluation and management" and "Thoracic and lumbar spinal column injury in adults: Evaluation")

●Chest trauma (see "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Initial evaluation and management of chest wall trauma in adults" and "Initial evaluation and management of rib fractures" and "Initial evaluation and management of blunt cardiac injury")

●Abdominal and pelvic trauma (see "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults" and "Pelvic trauma: Initial evaluation and management" and "Minor pelvic fractures (pelvic fragility fractures) in the older adult" and "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management")

●Extremity trauma (see "Severe upper extremity injury in the adult patient" and "Severe lower extremity injury in the adult patient")

●Children, older adults, pregnancy & other special populations (see "Trauma management: Approach to the unstable child" and "Trauma management: Overview of unique pediatric considerations" and "Geriatric trauma: Initial evaluation and management" and "Initial evaluation and management of major trauma in pregnancy")

EPIDEMIOLOGY — Trauma is a leading cause of mortality globally [1]. Worldwide, road traffic injuries are the leading cause of death between the ages of 18 and 29, while in the United States, trauma is the leading cause of death in young adults and accounts for 10 percent of all deaths among men and women [2]. Over 45 million people globally sustain moderate to severe disability each year due to trauma [1]. In the United States alone, more than 50 million patients receive some form of trauma-related medical care annually, and trauma accounts for approximately 30 percent of all intensive care unit (ICU) admissions [3,4].

According to the World Health Organization (WHO), road traffic injuries accounted for 1.25 million deaths in 2014, and trauma is expected to rise to the third leading cause of disability worldwide by 2030 [1,5]. Outside areas of armed conflict, penetrating injuries are responsible for fewer than 15 percent of traumatic deaths worldwide [6], but these rates vary by country. As examples, while homicide accounts for as many as 45 percent of deaths in Los Angeles, penetrating injuries account for only 13 percent of deaths in Norway [7]. Approximately half of traumatic deaths result from central nervous system (CNS) injury, while a third result from exsanguination [8].

Patients with serious traumatic injuries have a significantly lower likelihood of mortality or morbidity (10.4 versus 13.8 percent; relative risk [RR] 0.75, 95% CI 0.60-0.95) when treated at a designated trauma center [9]. Older age, obesity, and major comorbidities are associated with worse outcomes following trauma [10-18]. In trauma patients with significant hemorrhage, a lower score on the Glasgow Coma Scale (GCS) and older age are each independently associated with increased mortality [19]. In a large retrospective study from the United States National Trauma Data Bank, warfarin use was associated with an approximately 70 percent increased risk of mortality following trauma, after adjusting for other important risk factors (odds ratio [OR] 1.72; 95% CI 1.63-1.81) [20].

While the most common causes of mortality from trauma are hemorrhage, multiple organ dysfunction syndrome, and cardiopulmonary arrest [21], the most common preventable causes of morbidity are unintended extubation, technical surgical failures, missed injuries, and intravascular catheter-related complications [22].

Relatively few patients die after the first 24 hours following injury. Rather, the majority of deaths occur either at the scene or within the first four hours after the patient reaches a trauma center [23,24].

The "golden hour" concept, which emphasized the increased risk of death and the need for rapid intervention during the first hour of care following major trauma, was described in early trauma studies and has been promulgated in textbooks and instructional courses [25]. Undoubtedly, there are instances when rapid intervention improves the outcome of injured patients (eg, obstructed airway, tension pneumothorax, severe hemorrhage), especially in battlefield injuries [26]. However, the relationship between timing and mortality may be more complex than once thought. A large study using registries from multiple trauma centers across North America found no association between emergency medical services (EMS) intervals (eg, on scene and transport times) and trauma patient mortality [27,28].

MECHANISM — Particular mechanisms predispose patients to specific injuries. Common blunt trauma mechanisms and their most frequently associated injuries are described in the accompanying table (table 1). In addition, certain high-risk blunt mechanisms, including pedestrians struck by automobiles, motorcycle accidents, severe motor vehicle accidents (eg, extensive damage leading to prolonged extrication time), and falls greater than 20 feet, have been associated with greater morbidity and mortality [29-32].

PREPARATION

Pre-arrival preparation — Whenever possible, emergency medical services (EMS) should notify the receiving hospital that a trauma patient is en route. This provides the receiving hospital with information and time that can be crucial to the management of the severely injured patient.

Ideally, the information provided by EMS includes:

●Patient age and sex

●Mechanism of injury

●Vital signs (some clinicians ask for the lowest blood pressure and highest pulse)

●Apparent injuries

Early notification enables emergency department (ED) staff to do the following:

●Notify additional personnel (eg, ED staff, trauma surgery, obstetrics, orthopedics, radiology, interpreter services)

●Assure resources are available (eg, ultrasound, CT, operating room space)

●Prepare for anticipated procedures (eg, tracheal intubation, chest tube)

●Prepare for blood transfusion

In addition, information provided by EMS prior to arrival can help hospital-based clinicians focus on more likely injuries (table 1). As an example, a description of a feet-first fall from great height raises suspicion for fractures of the calcaneus, lower extremity, and lumbar spine; similarly, report of a prolonged motor vehicle extrication due to collapse of the driver's side compartment raises concern for injuries such as rib fractures, pulmonary contusion, and lacerations of the spleen and kidney.

Universal precautions against blood and fluid borne diseases should be part of the trauma team's preparation. These include gloves, gowns, masks, and eye protection for all members of the team involved in the resuscitation. Lead shields for staff should be available if portable x-rays are to be performed during resuscitation efforts.

Trauma team — In rural hospitals, the trauma team may be limited to one physician and a nurse. In such settings, the team might enlist help from EMS personnel or other clinicians to manage critically ill or multiple patients. Teams at major trauma centers may include emergency physicians, trauma surgeons, subspecialist surgeons, emergency nurses, respiratory therapists, technicians, and social workers. Regardless of the setting, all teams must have a clearly designated leader who determines the overall management plan and assigns specific tasks. While leaders of smaller teams might find themselves having to perform procedures in order to care effectively for their patients, leaders of larger teams should avoid performing procedures. This allows the leader to remain focused on their supervisory responsibilities and on the patient and possible changes in their condition.

Regardless of setting or team composition, optimal care of a trauma patient requires effective and efficient communication and teamwork among all members [33,34]. Good care begins with a pre-arrival briefing and the assignment of general roles and specific tasks, and continues throughout the resuscitation as the team uses closed-loop communication and maintains a common vision of the plan of care. Notably, it is important to include the alert patient (or health care proxy) in this communication, keeping them informed of the plan of care and any changes [35].

Breakdowns in the care plan and medical mismanagement typically occur due to one or more of four potential problems [34]:

●Communication breakdowns (eg, changes in the patient's physiologic state or critical test results are not effectively communicated, overall management plan or priority of tasks is not conveyed clearly by the team leader)

●Failures in situational awareness (eg, failure to recognize shock, failure to anticipate blood transfusion needs, failure to modify standard management for higher risk patients)

●Staffing or workload distribution problems (eg, insufficiently trained staff conducting a procedure, inadequate staff for patient volume)

●Unresolved conflicts (eg, unresolved hostility about other team members perceived to be performing inadequately, disagreement about overall management plan, disagreement among senior clinicians vying for team leadership)

PRIMARY EVALUATION AND MANAGEMENT

Overview — A clear, simple, and organized approach is needed when managing a severely injured patient. The primary survey promulgated in Advanced Trauma Life Support (ATLS) provides such an approach [25]. The primary survey is organized according to the injuries that pose the most immediate threats to life and is performed in the order described below. In settings with limited resources, the primary survey simplifies priorities and any problems identified should be managed immediately before moving on to the next step of the survey. However, at major trauma centers, many capable clinicians may be present, allowing the team to address multiple problems simultaneously.

The primary survey consists of the following steps:

●Airway assessment and protection (maintain cervical spine stabilization when appropriate)

●Breathing and ventilation assessment (maintain adequate oxygenation)

●Circulation assessment (control hemorrhage and maintain adequate end-organ perfusion)

●Disability assessment (perform basic neurologic evaluation)

●Exposure, with environmental control (undress patient and search everywhere for possible injury, while preventing hypothermia)

Keep the following points in mind while performing the primary survey:

●Airway obstruction is a major cause of death immediately following trauma [27,33]. The airway may be obstructed by the tongue, a foreign body, aspirated material, tissue edema, or expanding hematoma.

●Definitive guidelines for tracheal intubation in trauma do not exist. It is generally best to intubate early if the patient has sustained significant injuries to the face or neck that may lead to swelling and distortion of the airway. In cases of hemodynamic instability, it may be best to delay intubation until adequate physiologic optimization has been achieved, as the medications used for rapid sequence intubation can exacerbate hypotension. (See "Approach to shock in the adult trauma patient" and "Rapid sequence intubation in adults for emergency medicine and critical care".)

●Once an airway has been established, it is important to secure it well and to ensure it is not dislodged any time the patient is moved. Unintended extubation is the most common preventable cause of morbidity in trauma patients [22].

●Unconscious patients with small pneumothoraces that are not visible or are missed on the initial chest radiograph may develop tension physiology after tracheal intubation from positive pressure ventilation. It is important to re-auscultate the lungs of trauma patients who develop hemodynamic instability after being intubated and to be attentive to ventilator pressure alarms.

●Hemorrhage is the most common preventable cause of mortality in patients with trauma [21]. Be alert for subtle signs of hemorrhagic shock, particularly in the elderly, who may be on cardiovascular medications that blunt such signs, and in young, healthy adults who may not present with obvious manifestations. Hypotension generally does not manifest until at least 30 percent of the patient's blood volume has been lost [36]. Such patients are at high risk of death. Elderly patients may be hypotensive relative to their baseline blood pressure but still have blood pressure measurements in the "normal" range. A single episode of hypotension substantially increases the likelihood that a serious injury has occurred [37,38]. (See "Approach to shock in the adult trauma patient" and "Geriatric trauma: Initial evaluation and management".)

●Brain injuries are common in patients who have sustained severe blunt trauma and even a single episode of hypotension increases their risk of death [36,39].

Airway — Severely injured patients can develop airway obstruction or inadequate ventilation leading to hypoxia and death within minutes. Observational studies suggest that airway obstruction is a major cause of preventable death among trauma patients [40,41]. Therefore, airway evaluation and management remain the critical first steps in the treatment of any severely injured patient [25].

Several studies suggest that checklists improve the efficiency and reduce the complications associated with airway management of trauma patients [42-45]. In a prospective study of 141 intubated trauma patients, implementing pre-arrival and pre-induction preparation checklists reduced intubation-related complication rates by 7.7 percent (95% CI 0.5-14.8) [42]. A sample checklist is provided in the accompanying table (table 2).

Maintaining the patient’s stretcher at a slight angle with the head slightly elevated (reverse Trendelenburg position), or elevating just the head to about 30 degrees if cervical spine precautions are not required, can help to decrease the risk of aspiration and improve lung capacity by reducing abdominal pressure on the chest.

Assessment — In a conscious patient, initial airway assessment can be performed as follows [46]:

●Begin by asking the patient a simple question (eg, "What is your name?"). A clear accurate response verifies the patient's ability to mentate, phonate, and to protect their airway, at least temporarily.

●Observe the face, neck, chest, and abdomen for signs of respiratory difficulty, including tachypnea, accessory or asymmetric muscle use, abnormal patterns of respiration, and stridor.

●Inspect the oropharyngeal cavity for disruption; injuries to the teeth or tongue; blood, vomitus, or pooling secretions. Note if there are obstacles to the placement of a laryngoscope and endotracheal tube.

●Inspect and palpate the anterior neck for lacerations, hemorrhage, crepitus, swelling, or other signs of injury. Palpation of the neck also enables identification of the landmarks for cricothyrotomy.

In the unconscious patient, the airway must be protected immediately once any obstructions (eg, foreign body, vomitus, displaced tongue) are removed. Management of the airway generally and in a patient with direct airway trauma is discussed separately. (See "Airway management in the adult with direct airway trauma for emergency medicine and critical care" and "Penetrating neck injuries: Initial evaluation and management" and "Rapid sequence intubation in adults for emergency medicine and critical care".)

Airway management in a trauma patient unable to protect his or her airway is completed in an expedient yet controlled fashion. When possible, perform a brief preintubation assessment to gauge the potential difficulty of intubation and determine basic baseline neurologic function (eg, pupillary light reflex, movement of extremities). Methods and mnemonics to assess airway difficulty are reviewed separately, but the application of the LEMON mnemonic to trauma patients is described here. (See "Approach to the difficult airway in adults for emergency medicine and critical care".)

●L: LOOK: Facial and neck injuries can distort external and internal structures making it difficult to visualize the glottis or insert an endotracheal tube.

●E: EVALUATE 3-3-2: This refers to the intraoral, mandibular, and hyoid-to-thyroid notch distances (picture 1). The cervical collar must be opened to make these assessments. The distances referred to can be narrowed by fracture, hematoma, or other anatomic distortions (eg, soft tissue swelling).

●M: MALLAMPATI: A standard calculation of the Mallampati score cannot be performed in many trauma patients; injured patients requiring emergency intubation often cannot open their mouths spontaneously (figure 1). Nevertheless, an effort should be made to determine how much of the retropharynx can be seen and whether injuries of the oropharynx or pooled blood, vomitus, or secretions are present.

●O: OBSTRUCTION/OBESITY: Either factor can interfere with visualization and management of the traumatized airway. Any number of injuries can obstruct the airway including internal or external hematomas or soft tissue edema from smoke inhalation. Obesity complicates performance of cricothyrotomy.

●N: NECK MOBILITY: In-line stabilization is necessary in most trauma patients. Once the cervical collar is removed by a second skilled provider, that provider should stabilize the spine while orotracheal intubation is performed. It is important to note that the risk of neurologic injury from hypoxemia is much greater than the risk of spinal injury due to neck extension during intubation. Judicious relaxation of immobilization may be necessary in some cases [46].

Difficult airway devices — Devices for difficult airway management are discussed separately. (See "Devices for difficult airway management in adults for emergency medicine and critical care" and "Video laryngoscopes and optical stylets for airway management for anesthesia in adults".)

A number of airway tools and rescue airways can be helpful when managing a trauma patient. Devices that should be available at the bedside include:

●Suction (ie, multiple pumps and tips)

●Bag-valve mask attached to high flow oxygen

●Oral and nasal airways

●Rescue airways (eg, Combitube, Laryngeal mask airway)

●Endotracheal tube introducer (ie, gum elastic bougie)

●Video laryngoscope, if available

●Cricothyrotomy kit

●Endotracheal tubes in a range of sizes

●Laryngoscopes, including a range of different sized blades and handles

●Preferred adjunct intubating devices (eg, lightwand)

Direct laryngoscopy relies on direct visualization of the glottis, which is often difficult in the severely injured patient whose airway may be obstructed and whose neck cannot be manipulated. In contrast, video laryngoscopes provide an excellent view of the glottis with minimal movement of the cervical spine and appear to be well suited for airway management in the trauma patient [47-49]. According to a review of over 4000 trauma intubations performed at 23 emergency departments between 2016 and 2018, video laryngoscopy was associated with significantly higher first-pass success (90 versus 79 percent, difference 11 percent, 95% CI 8-13) and lower esophageal intubation rates (1.5 versus 0.4 percent, difference 1.1 percent, 95% CI 0.4-2) than direct laryngoscopy [50].

The endotracheal tube introducer (or gum elastic bougie) is another invaluable tool for airway management in the trauma patient, particularly when the glottic view is limited. Its use is discussed separately. (See "Endotracheal tube introducers (gum elastic bougie) for emergency intubation".)

Intubation — Tracheal intubation of the injured patient is often complicated by the need to maintain cervical immobilization, the presence of obstructions such as blood, vomitus, and debris, and possibly by direct trauma to the airway [51]. Nevertheless, many trauma patients require intubation for immediate airway protection or because of the projected disease course. Intubation improves oxygenation, thereby helping to meet increased physiologic demands, and allows for testing and procedures to be performed more easily and with less patient discomfort. (See "The decision to intubate".)

Ideally, airway managers should have a predetermined back-up plan with all necessary tools at the bedside, including rescue airways and a cricothyrotomy kit, before proceeding with intubation. In crash scenarios, this may not be possible. A sample checklist to assist with airway management of the adult trauma patient is provided in the accompanying table (table 2).

Clinicians should consider the expected course of disease and need for interventions when deciding to secure an airway. Patients often warrant early intubation to ensure airway protection or to allow for deeper sedation and pain control. Examples of this include: a patient who is hemodynamically stable for the moment but at risk of deterioration and who requires a complex diagnostic study that must be performed in a remote radiology suite; and a patient with significant injury in imminent need of an orthopedic or other painful procedure. Critically ill trauma patients at risk for hypotension following sedation and paralysis for intubation should be treated aggressively prior to intubation. Post-intubation hypotension should be anticipated and mitigated as much as possible. In a retrospective review of 444 patients, in-hospital mortality was nearly doubled for those who had a single episode of post-intubation hypotension compared with those who did not (29.8 versus 15.9 percent) [52].

Airway management techniques used in trauma, including rapid sequence intubation, rescue airways, video laryngoscopy, and direct laryngoscopy, are discussed in greater detail separately. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and "Extraglottic devices for emergency airway management in adults" and "Video laryngoscopes and optical stylets for airway management for anesthesia in adults" and "Direct laryngoscopy and endotracheal intubation in adults".)

Cricothyrotomy — Clinicians who manage trauma must be prepared to perform a cricothyrotomy when orotracheal intubation cannot be accomplished. The performance of cricothyrotomy and the approach to the failed airway are discussed separately. (See "Approach to the failed airway in adults for emergency medicine and critical care" and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

In trauma patients with a potentially difficult airway, a double set-up, in which simultaneous preparation is made to perform orotracheal intubation and cricothyrotomy, may be the best approach. This enables the clinician to transition immediately to a cricothyrotomy if attempts at oral intubation are unsuccessful.

Trauma patients may have sustained injuries to the neck that make cricothyrotomy difficult to perform, and therefore, it is important to optimize any attempt at orotracheal intubation.

Cervical spine immobilization — Assume that an injury to the cervical spine has occurred in all blunt trauma patients until proven otherwise. Conversely, patients with isolated penetrating trauma, no secondary blunt injury, and an intact neurologic examination typically do not have an unstable spinal column injury [46]. Routine spinal immobilization is not recommended following penetrating injury, and has been demonstrated to be associated with increased mortality. In addition, it is unnecessary when managing their airway in patients with penetrating neck trauma [53-57]. (See "Cervical spinal column injuries in adults: Evaluation and initial management".)

The anterior portion of the cervical collar should be temporarily removed and manual in-line stabilization maintained for all patients with blunt traumatic injuries receiving airway interventions, including bag-mask ventilation [58,59]. Preintubation airway interventions are associated with as much spinal column subluxation as intubation [58,59].

Tracheal intubation should not be attempted with the anterior portion of the cervical collar in place. Intubations performed with the complete cervical collar in place are associated with greater spinal subluxation than those performed with the anterior portion removed and manual in-line stabilization maintained [60].

The safety of manual in-line stabilization for patients with blunt traumatic injuries needing intubation is well established. Few case reports describe spinal injury during intubation, and in all cases, the spine was not manually stabilized [61-63].

Breathing and ventilation — Once airway patency is ensured, assess the adequacy of oxygenation and ventilation [25]. Chest trauma accounts for up to 25 percent of trauma-related deaths, largely due to its harmful effects on oxygenation and ventilation [24]. The management of blunt and penetrating chest trauma is discussed in detail separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults".)

Inspect the chest wall looking for signs of injury, including asymmetric or paradoxical movement (eg, flail chest), auscultate breath sounds at the apices and axillae, and palpate for crepitus and deformity. In unstable patients, obtain a portable chest radiograph. Tension pneumothorax, massive hemothorax, and cardiac tamponade are immediate threats to life that should be identified at this stage of the primary survey. Ultrasound can provide important information about all these diagnoses during this portion of the assessment. (See 'Ultrasound (FAST exam)' below and "Emergency ultrasound in adults with abdominal and thoracic trauma".)

Presumptively treat patients exhibiting signs of tension pneumothorax, including hypotension, dyspnea, and ipsilateral decreased breath sounds, with needle decompression before obtaining imaging. Delays to obtain a portable chest radiograph can cause significant morbidity. If confirmation is needed prior to treatment, ultrasound can be performed rapidly at the bedside; it is more sensitive than plain radiograph for detecting pneumothorax. Needle decompression is performed with a large bore (14 gauge or larger) angiocatheter, either in the second intercostal space in the midclavicular line or in the fifth intercostal space in the midaxillary line. If resources are immediately available, it is appropriate to proceed directly to chest tube insertion without intervening needle decompression. The assessment and management of traumatic pneumothorax in adults are reviewed in greater detail separately. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Pulmonary injury'.)

A standard 14-gauge angiocatheter cannot penetrate the chest wall and reach the pleural space in up to one-third of adult trauma patients. A 7.5 cm (3 inch) armored angiocatheter can reach the pleural space in most instances. Needle decompression is followed immediately by tube thoracostomy.

Tube thoracostomy in an unstable trauma patient is performed in anticipation of both hemothorax and pneumothorax using a size 24 to 28 French chest tube. Performance of tube thoracostomy is reviewed separately. (See "Thoracostomy tubes and catheters: Placement techniques and complications".)

Circulation

Recognition and management of hemorrhage — Once the airway and breathing are stabilized, perform an initial evaluation of the patient's circulatory status by palpating central pulses. If a carotid or femoral pulse is verified and no obvious exsanguinating external injury is noted, circulation may momentarily be assumed to be intact; completion of the primary survey should not be delayed by the determination of an exact blood pressure.

While circulation is assessed, two large-bore (16 gauge or larger) intravenous (IV) catheters are placed, most often in the antecubital fossa of each arm, and blood is drawn for testing, particularly for blood typing and crossmatch. Intraosseous cannulation or central venous catheter placement (ideally under ultrasound guidance) can be performed if there is difficulty establishing peripheral IV access. (See "Intraosseous infusion".)

Life-threatening hemorrhage must be controlled. A combination of manual pressure, proximal compression with either a tourniquet or a manual blood pressure cuff, and elevation is typically sufficient to control external arterial hemorrhage. When these are unsuccessful, hemostatic agents may be used, if available. Venous bleeding is controlled with direct pressure. Bleeding from severe pelvic injuries may require the application of a pelvic binder. (See "Pelvic trauma: Initial evaluation and management", section on 'Management' and "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Hemostatic agents'.)

Emergency thoracotomy may be needed for trauma patients without femoral or carotid pulses. The procedure is most effective for victims of stab wounds to the chest who have pulses or other witnessed signs of life (eg, voluntary movement) initially. It is rarely beneficial in patients with blunt trauma or when performed in facilities without ready access to appropriate surgical care. Of note, trauma patients who require cardiopulmonary resuscitation (CPR) within one hour of hospital arrival have a low rate of survival to hospital discharge (only 13 percent in one study [64]), so maintaining perfusion and avoiding the need for CPR is exceptionally important. Emergency thoracotomy is discussed in greater detail separately. (See "Resuscitative thoracotomy: Technique" and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)

In patients in extremis with impending arrest, placement of a resuscitative balloon for occlusion of the aorta (REBOA) by those trained in this technique may be life-saving [65,66]. Use of this device is most effective to temporize patients with intra-abdominal or retroperitoneal sources of hemorrhage until more definitive therapy with surgery or angioembolization is possible, and so rapid transport to the operating room and/or angiographic suite is essential. REBOA is not appropriate for use in those with suspected thoracic sources of exsanguination or in patients in cardiac arrest, in whom EDT should be performed instead. (See "Endovascular methods for aortic control in trauma", section on 'REBOA technique'.)

Most trauma patients with hypotension or signs of shock (eg, pale, cool, moist skin) are bleeding, and patients with severe hemorrhage have significantly higher mortality (table 3) [67]. Initial fluid resuscitation for these patients may consist of a bolus of intravenous crystalloid (eg, 20 mL/kg isotonic saline). However, patients with obvious severe or ongoing blood loss should be transfused immediately with type O blood (women of childbearing age should be transfused with O negative blood). While mildly unstable patients may be treated with isotonic crystalloid in lieu of blood, unnecessary infusion of crystalloid should be avoided [68]. Fluid resuscitation, including the appropriate use of delayed fluid resuscitation and transfusion of the trauma patient in shock are discussed separately. (See "Approach to shock in the adult trauma patient".)

Patients with persistent hemodynamic instability despite an initial fluid bolus generally require blood transfusion and definitive control of the bleeding source. Significant hemorrhage occurs in any of five sites:

●External

●Intrathoracic

●Intraperitoneal

●Retroperitoneal

●Pelvic or long bone fractures

If transfusion is required, give whole blood or blood products in a 1:1:1 ratio of plasma, platelets, and red cells [69]. Patients requiring transfusion may benefit from treatment with tranexamic acid if it is given within three hours of injury. Transfusion of the trauma patient and the use of antifibrinolytic agents such as tranexamic acid are discussed in detail separately. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Resuscitation and transfusion' and "Etiology and diagnosis of coagulopathy in trauma patients" and "Ongoing assessment, monitoring, and resuscitation of the severely injured patient", section on 'Management of acute traumatic coagulopathy'.)

It is important to obtain manual blood pressure measurements in trauma patients with systolic blood pressures below 90 mmHg, as automated blood pressure cuffs often overestimate values significantly in these patients [70]. Furthermore, data suggest that the traditional threshold of a systolic blood pressure below 90 mmHg to define shock is inaccurate [71-74]. The appropriate systolic or mean arterial blood pressure threshold for defining shock varies by age. A significant proportion of trauma patients with hemorrhagic shock have a systolic blood pressure above 90 mmHg; using a cut-off of 110 mmHg is likely to be more appropriate in the elderly. (See "Geriatric trauma: Initial evaluation and management".)

Reversal of anticoagulation — Some trauma patients, particularly elders with comorbidities, may be taking anticoagulants. Provided below are several tables outlining methods for reversing particular anticoagulants in cases of life-threatening bleeding, as well as links to more detailed discussions of how to manage bleeding associated with these medications:

●Warfarin (see "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Serious/life-threatening bleeding'). Initial emergency treatment to reverse anticoagulation due to warfarin in patients with severe hemorrhage is outlined in the following table (table 4).

●Direct thrombin inhibitors (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban) (see "Management of bleeding in patients receiving direct oral anticoagulants"). Initial emergency treatment to reverse anticoagulation due to direct oral anticoagulants in patients with severe hemorrhage is outlined in the following table (table 5).

●Heparin (see "Heparin and LMW heparin: Dosing and adverse effects", section on 'Bleeding').

●Low molecular weight heparin (see "Heparin and LMW heparin: Dosing and adverse effects", section on 'Bleeding').

Nonhemorrhagic causes of shock — In adult trauma patients, nonhemorrhagic causes of shock include tension pneumothorax and cardiac tamponade. These injuries are best detected by physical examination or ultrasound assessment (ie, FAST). Particularly in older patients, the clinician may need to consider medical causes of hypotension that preceded and possibly caused the trauma, such as myocardial infarction, arrhythmia, malfunctioning pacemaker or left ventricular assist device (LVAD), or gastrointestinal bleeding. (See 'Ultrasound (FAST exam)' below and "Emergency ultrasound in adults with abdominal and thoracic trauma" and "Approach to shock in the adult trauma patient" and "Geriatric trauma: Initial evaluation and management".)

Disability and neurologic evaluation — Once problems related to the airway, breathing, and circulation are addressed, perform a focused neurologic examination. This should include a description of the patient's level of consciousness using the Glasgow Coma Scale (GCS) score, and assessments of pupillary size and reactivity, gross motor function, and sensation (table 6). Also note any lateralizing signs and the level of sensation if a spinal cord injury is present. Acute neurologic injury, including imaging recommendations and medical and surgical management, is discussed in detail separately. (See "Management of acute moderate and severe traumatic brain injury" and "Acute traumatic spinal cord injury".)

The GCS score is widely used and can be employed to follow the patient's neurologic status. Unfortunately, a number of studies suggest that the initial GCS score is not predictive of outcome in patients with severe brain injury, and intubation, sedatives, and alcohol or other drug intoxication may interfere with its application [75-77].

Maintain spinal immobilization for all patients with the potential for spinal cord injury. The presence of a motor deficit or a spinal cord sensory level indicates the need for imaging of the brain, spinal cord, and their vascular supply.

Exposure and environmental control — Be certain that the trauma patient is completely undressed and that his or her entire body is examined for signs of injury during the primary survey. Missed injuries pose a grave threat [78]. Regions often neglected include the scalp, axillary folds, perineum, and in obese patients, abdominal folds. Penetrating wounds may be present anywhere. While maintaining cervical spine precautions, examine the patient's back; do not neglect examination of the gluteal fold and posterior scalp.

Hypothermia should be prevented if possible and treated immediately once identified. Hypothermia contributes to both coagulopathy [79] and the development of multiple organ dysfunction syndrome [80]. During winter months and whenever a hypothermic trauma patient is being treated, the resuscitation room should be heated; the United States Military Joint Theater Trauma System Clinical Practice Guideline on hypothermia prevention recommends emergency department (ED) and operating room (OR) temperatures of at least 29.4°C (85°F) during the treatment of these patients [81]. Rapidly remove wet clothing, make liberal use of warm blankets and active external warming devices, and warm IV fluids and blood. Treatments for hypothermia are discussed separately. (See "Accidental hypothermia in adults".)

Diagnostic studies

Portable radiographs — Plain radiographs play an important role in the primary evaluation of the unstable trauma patient. Screening radiographs should be obtained, either in the emergency department (ED) or the operating room (OR), even in hemodynamically compromised patients who are sent directly to the OR during or after their primary survey. Prompt imaging of the lateral cervical spine, chest, and pelvis can detect life threatening injuries that might otherwise be missed. However, the sensitivity of the lateral cervical spine radiograph is only 70 to 80 percent [82-84], and some sacral and iliac fractures can be missed on plain pelvic radiographs.

Clinical decision rules (eg, NEXUS) can be used to determine the need for cervical spine imaging in hemodynamically stable trauma patients. Assessment of the spinal column injuries in trauma, including the selection of imaging studies, is discussed separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management" and "Suspected cervical spine injury in adults: Choice of imaging".)

Plain radiography of the chest and pelvis is often obtained for trauma patients not thought to require CT imaging. The decision to obtain these images should be made based upon the injury mechanism and clinical findings. The evaluation of patients with penetrating trauma often includes images of the region of penetration; even in stable patients, these radiographs can detect retained foreign bodies or fragments. However, patients with blunt trauma should undergo imaging with plain radiographs only if clinical findings suggest the presence of injury [85-87]. Plain radiographs can be omitted altogether if there is no clinical suspicion of injury and the studies are unlikely to alter emergency management. (See "Pelvic trauma: Initial evaluation and management", section on 'Plain radiograph'.)

A plain radiograph of the chest should be obtained in patients with penetrating injuries of the chest, back, or abdomen regardless of the need for CT. Plain films may reveal subdiaphragmatic free air, a foreign body, or a pneumothorax or hemothorax.

If the clinician determines that CT imaging is needed based upon the mechanism or clinical suspicion, there is no role for either a plain radiograph of the chest or pelvis in hemodynamically stable patients with blunt trauma [85,88-91].

Ultrasound (FAST exam) — Focused Assessment with Sonography for Trauma (FAST) is an essential part of the primary circulation survey for unstable patients, in whom it often determines management [92-98]. FAST is used primarily to detect pericardial and intraperitoneal blood, and it is more accurate than any physical examination finding for detecting signs of intra-abdominal injury. In hemodynamically stable patients, FAST can be delayed until the secondary survey and is ideally performed by a second operator while the remainder of the secondary survey is completed. The performance of the FAST examination and evidence supporting its use are discussed separately. (See "Emergency ultrasound in adults with abdominal and thoracic trauma".)

The accuracy and role of FAST may be more limited in patients with significant pelvic fractures because it is less sensitive for detecting pelvic bleeding and cannot differentiate between blood and urine. Retroperitoneal bleeding is also not reliably visualized with ultrasound. The management of such patients is discussed separately. (See "Pelvic trauma: Initial evaluation and management", section on 'Initial management'.)

FAST is less sensitive for injury in penetrating trauma than blunt trauma, and the results of ultrasound examinations in penetrating trauma patients, particularly negative results, must be interpreted with caution. (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Clinical studies'.)

The Extended FAST (E-FAST) includes examinations of the thoracic cavity looking for pneumothoraces. Preliminary studies suggest the sensitivity of E-FAST is better than plain radiograph for this injury [99].

Emergency computed tomography (CT) — Trauma patients found to be hemodynamically unstable during the primary survey are aggressively resuscitated while clinicians attempt to determine the most likely causes of their instability. If the source of hemorrhage in an unstable trauma patient cannot be determined using diagnostic imaging studies immediately available at the bedside, or if additional information is needed to direct operative care, in most cases the treating emergency physician and surgeon must decide whether to perform emergency CT imaging first or to take the patient directly to the operating room. This decision is based upon the patient's response to initial resuscitation measures, their probable injuries and anticipated operative intervention, and the proximity of the CT scanner to the resuscitation bay. The issue of total body CT is discussed separately. (See 'Computed tomography, including total body CT' below.)

Imaging must not delay transfer in situations when patients require higher levels of care than can be provided at the initial facility. If transfer will be needed, the process should be initiated as early as possible (in some cases, immediately upon patient arrival and assessment). If CT imaging is needed and can safely and reasonably be done without delaying transfer, it may be obtained. (See 'Patient transfer' below.)

In rare instances, patients may have known and potentially life-threatening allergies to IV contrast [100]. In such cases, assessment options include: non-contrast CT, ultrasound, exploratory surgery, and (when patient stability and resources allow) MRI or radionuclide red cell scan [101].

Diagnostic peritoneal tap or lavage — Diagnostic peritoneal tap (DPT) or lavage (DPL) has a role similar to FAST in the unstable patient in whom a source of bleeding has not been found [102]. It can be performed to detect intraperitoneal blood when FAST is unavailable or indeterminate in hemodynamically unstable patients, to determine the type of intraperitoneal fluid when it is important to do so (eg, blood versus urine in the setting of a pelvic fracture), or at physician discretion. (See "Diagnostic peritoneal lavage (DPL) or aspiration (DPA)".)

Electrocardiogram — An electrocardiogram (ECG) should be obtained for all patients injured by mechanisms with the potential to cause cardiac injury. Signs of blunt cardiac injury can include arrhythmias, significant conduction delays, or ST segment changes. Findings consistent with pericardial tamponade include tachycardia, low voltage, and electrical alternans. If ECG findings consistent with cardiac injury are present, formal echocardiography (in addition to the FAST examination) should be performed. In addition, cardiac monitoring should continue throughout the trauma evaluation and resuscitation, including during diagnostic testing, as changes in heart rate and blood pressure may herald rapid clinical deterioration. (See "Initial evaluation and management of blunt cardiac injury" and "Cardiac tamponade".)

Laboratory tests — The practice of obtaining routine "screening" laboratory tests on trauma patients is neither useful nor cost-effective [103,104]. Testing should be performed based upon clinical suspicion and should be limited to those tests that may alter management. As examples, a pregnancy test (eg, urine hCG) should always be performed on women of child-bearing age, and a blood type and screen or crossmatch should be obtained for patients with significant trauma who may reasonably be expected to require transfusion.

Clinical circumstances determine the need for further testing. As examples, patients taking warfarin likely need coagulation studies (eg, prothrombin time) and patients found on the ground for an undetermined time need studies (eg, creatine kinase) to determine if rhabdomyolysis is present. (See "Clinical features and diagnosis of heme pigment-induced acute kidney injury".)

At initial presentation, the need for transfusion of blood products in the severely injured trauma patient is determined on clinical grounds, and may involve massive transfusion protocols. Thereafter, routine coagulation studies do not predict coagulopathy accurately in the acute trauma patient; where available, thromboelastography provides a faster and more accurate means for detecting imbalances in the hemostatic system and assessing ongoing needs for treatment. (See "Etiology and diagnosis of coagulopathy in trauma patients".)

Commonly obtained but rarely helpful tests include the metabolic panel (a fingerstick blood sugar will often suffice, provided the patient is not exhibiting signs of electrolyte abnormality or acidosis), alcohol level in a patient who is clearly intoxicated, toxicologic screen when it is not relevant to clinical care, and cardiac biomarkers, unless cardiac contusion or ischemia is suspected [105]. (See "Initial evaluation and management of blunt cardiac injury", section on 'Diagnostic tests'.)

Elevation of both the serum lactate concentration and base deficit correlates with increased mortality in trauma patients [106-109]. However, the base deficit is essentially a surrogate for lactate and an elevated base deficit in the absence of an elevated lactate is not predictive of increased mortality [110]. Furthermore, while elevated levels should heighten suspicion for severe injury, a normal lactate and base deficit do not ensure the absence of significant injury, especially in geriatric trauma patients. In addition, laboratory values lag behind clinical improvement after aggressive resuscitation. Thus, the patient may no longer be in shock despite an elevated lactate suggesting otherwise [111,112]. (See "Geriatric trauma: Initial evaluation and management".)

The white blood cell (WBC) count is nonspecific and of little value during the initial evaluation of the trauma patient [104]. The positive and negative predictive value of, respectively, an elevated or normal WBC is poor. Epinephrine release from trauma can cause demargination and may elevate the WBC to 12,000 to 20,000/mm³ with a moderate left shift. Solid or hollow viscus injury can cause comparable elevations [113].

PATIENT TRANSFER — Clinicians at hospitals with limited resources to manage trauma should consult the nearest trauma center as soon as it becomes apparent that a patient has sustained injuries beyond the management capacity of their hospital. Many patients needing to be transferred for trauma evaluation are not sent. In a review of National Trauma Data Bank, only 20 percent of patients initially taken to non-tertiary centers and meeting trauma guideline criteria for transfer were subsequently transferred [114]. The risk adjusted odds for mortality was higher for non-transferred patients compared with those who were treated at level I or II trauma centers. Geriatric trauma patients are an important example of this phenomenon. They are frequently are under-triaged, resulting in increased morbidity and mortality. (See "Geriatric trauma: Initial evaluation and management", section on 'Problem of under-triage'.)

Patients should be stabilized as well as possible without delaying transfer; delays are associated with increased mortality [115,116]. Criteria for transfer are based upon the patient's demographics, mechanism of injury, and clinical findings. It cannot be overemphasized that a complete workup is not a requirement for transfer; postponing transfer to obtain laboratory results or imaging studies only delays definitive treatment. Often such studies must be repeated at the receiving facility.

Computed tomography (CT) imaging should only be obtained in patients who might otherwise be appropriately treated at the initial facility. If a negative CT would allow the patient to be discharged, it should be performed, but if that patient requires transfer regardless of the results, then transfer should not be delayed. Likewise, procedures and other interventions should only be performed to treat emergency conditions or prevent possible patient deterioration during transport. Endotracheal intubation, tube thoracostomy, and pelvis fracture stabilization are common examples of necessary interventions; laceration repair, unless it is performed to prevent exsanguination, is not. For hemodynamically unstable patients, blood – if available – should be transfused. Transfusion can begin at the initial facility or be performed during transport by sending units of blood with the emergency transport team.

The decision of when to transfer an unstable patient should ideally be made by the transferring and receiving physicians in collaboration. Clear communication is critical: the transmission of vital information allows receiving clinicians to mobilize needed resources while the inadvertent omission of such information can delay definitive care. Information should be conveyed in both verbal and written (via the patient record) form and should include the patient's identifying information, relevant medical history, prehospital course, and ED evaluation and treatment (including procedures performed and imaging obtained) [25]. The use of a transfer checklist can help to ensure that important information is not omitted.

SECONDARY EVALUATION AND MANAGEMENT — Definitive management of a hemodynamically unstable trauma patient must not be delayed to perform a more detailed secondary evaluation. Such patients are taken directly to the operating room (OR) or angiography suite, or transferred to a major trauma center.

A careful, head-to-toe secondary assessment (ie, secondary survey) is performed in all trauma patients determined to be stable upon completion of the primary survey. The secondary survey includes a detailed history, a thorough but efficient physical examination, and targeted diagnostic studies, and plays a crucial role in avoiding missed injuries. Commonly missed injuries include [117-119]:

●Blunt abdominal trauma: Hollow viscus injury, pancreatoduodenal injuries, diaphragmatic rupture

●Penetrating abdominal trauma: Rectal and ureteral injuries

●Thoracic trauma: Aortic injuries, pericardial tamponade, esophageal perforation

●Extremity trauma: Fractures (especially in distal extremities), vascular disruption, compartment syndrome

Delayed reevaluation of the trauma patient (ie, tertiary survey) is also useful for preventing missed injuries and for detecting injuries that present late [117]. It is most helpful if the patient is reevaluated when fully alert. Any member of the trauma team with advanced assessment skills can perform the tertiary survey; however, it is best if the same clinician performs all serial examinations for a given patient in order to detect subtle changes.

History — The mechanism of injury can increase suspicion for certain injuries. Prehospital personnel often know important information and should be queried regarding the mechanism and history of the injury. If this cannot be done immediately upon arrival because of the patient's status, ask the prehospital providers to remain in the emergency department (ED) until this can be accomplished. Often the history is conveyed while medics and hospital clinicians transfer the patient and important information may be forgotten or missed.

While listening to the history, keep in mind that the scenes of accidents can be chaotic and not all information will be reliable. As an example, a patient described as "found down" may have been assaulted or struck by a car.

Mechanism-related information to be obtained from prehospital personnel includes [120]:

●Blunt trauma

•Seat belt use

•Steering wheel deformation

•Airbag deployment

•Direction of impact

•Damage to the automobile (especially intrusion into the passenger compartment)

•Distance ejected from the vehicle

•Height of fall

•Body part landed upon

●Penetrating trauma

•Type of firearm

•Distance from firearm

•Number of gunshots heard

•Type of blade

•Length of blade

Inquire also about the patient's medications, allergies, and medical and surgical history. If this information is unknown, it can be helpful to assign someone the task of contacting family members to obtain it. The use of anticoagulant and antiplatelet medications is steadily rising and increases the risk of internal bleeding in trauma patients, and therefore these agents should specifically be discussed [121-123].

As an example of the risks associated with anticoagulants, a retrospective study of 11,374 adult trauma patients reported that the use of antiplatelet drugs was associated with an increased risk of death (propensity adjusted outcome 9.4 versus 8 percent mortality) and major morbidity among the 1327 (11.7 percent) patients taking them at the time of their injury [121]. Patients taking multiple antiplatelet medications were at greater risk than those taking a single drug.

While such questions do not typically affect the immediate treatment of traumatic injuries, it is important to ask trauma patients about possible domestic violence. The reported prevalence of domestic violence continues to increase among both children and adults, and can lead to a pattern of repeated traumatic injury [124]. (See "Intimate partner violence: Diagnosis and screening" and "Intimate partner violence: Childhood exposure" and "Elder abuse, self-neglect, and related phenomena" and "Peer violence and violence prevention".)

A history of mental illness, including thoughts or attempts at suicide, may be significant, particularly in the setting of single car accidents or falls from a height, which may be initially unrecognized suicide attempts. Knowledge of alcohol or drug abuse may help to detect or prevent withdrawal during hospital admission.

Physical examination — The goal of the secondary survey is to identify injuries. This includes the performance of a thorough but efficient physical examination. Use standard precautions against blood or fluid-borne infection.

Head and face — Inspect and palpate the entire bony structure of the head and face for tenderness, deformity (eg, step off), and bleeding. Scalp lacerations are easily missed visually but often found by palpation. Be attentive for foreign bodies, such as glass in the scalp after a car accident.

Note any signs suggesting basilar skull fracture (eg, hemotympanum). Retroauricular (Battle's sign) and periorbital ecchymosis (raccoon's eyes) are also indicative of basilar skull fracture but generally do not appear until at least 24 hours after an injury. Look for nasal septal hematomas. (See "Skull fractures in adults" and "Initial evaluation and management of facial trauma in adults".)

Perform an ocular examination including an evaluation of pupillary size, shape, reactivity, and extraocular movement. Look for signs of globe rupture and intraocular hemorrhage (see "Open globe injuries: Emergency evaluation and initial management" and "Orbital fractures" and "Approach to the adult with acute persistent visual loss", section on 'Retinal problems' and "Traumatic hyphema: Clinical features and diagnosis"). Point-of-care ultrasound can be used to rule in retinal detachment and other traumatic ocular injuries but should not be used to rule out injuries in those patients in whom a high clinical suspicion of injury exists. These patients should still receive emergency ophthalmologic consultation [125].

Patients with mild traumatic brain injury may not have external signs of trauma. Validated decision tools, including the New Orleans Criteria [126] and the Canadian CT Head Rule [127], can be used to determine the need for neuroimaging [128] with computed tomography (CT). (See "Acute mild traumatic brain injury (concussion) in adults".)

Neck — Assume that all patients with blunt trauma have sustained an injury to the cervical spine. This assumption can be disproved by appropriate application of clinical decision rules, such as NEXUS or the Canadian C-Spine Rule, or by radiologic evaluation using plain radiographs or CT. Assessment of the cervical spine following trauma is discussed separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management" and "Suspected cervical spine injury in adults: Choice of imaging".)

Inspect and palpate the entire neck for signs of injury. The management of penetrating neck trauma is discussed separately. (See "Penetrating neck injuries: Initial evaluation and management".)

Chest — Inspect and palpate the entire chest wall. Pay particular attention to the sternum and clavicles. Injuries at these sites are often missed, and fractures of these bones suggest the presence of further injury, including of intrathoracic structures. Careful auscultation can detect a previously missed small hemothorax, pneumothorax, or pericardial effusion not yet causing tamponade. The NEXUS-Chest criteria may be used to determine whether chest imaging is necessary in an adult following blunt trauma [129]. (See "Initial evaluation and management of blunt thoracic trauma in adults".)

Abdomen — Inspect the abdomen and flanks for lacerations, contusions (eg, seat belt sign), and ecchymosis; palpate for tenderness and rigidity. The presence of a seat belt sign, rebound tenderness, abdominal distension, or guarding all suggest intra-abdominal injury. Note that the absence of abdominal tenderness does not rule out such injury.

Keep in mind that the abdominal examination is often unreliable, particularly in the elderly, patients with distracting injuries or altered mental status, and patients late in pregnancy, and can change dramatically over time. (See "Geriatric trauma: Initial evaluation and management" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of major trauma in pregnancy".)

Rectum and genitourinary — Inspect the perineum of all patients for signs of injury. (See "Straddle injuries in children: Evaluation and management".)

Traditionally, the digital rectal examination (DRE) was considered an essential part of the physical examination for all trauma patients. However, the sensitivity of the DRE for injuries of the spinal cord, pelvis, and bowel is poor, and false positive and negative results are common [120,130-132]. Thus, routine performance is unnecessary and generally unhelpful. The examination is warranted in cases where urethral injury or penetrating rectal injury is suspected. If the examination is performed, check for the presence of gross blood (sign of bowel injury), a high-riding prostate (sign of urethral injury), abnormal sphincter tone (sign of spinal cord injury), and bone fragments (sign of pelvic fracture). (See "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management" and "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Secondary trauma survey' and "Pelvic trauma: Initial evaluation and management".)

Perform a vaginal examination on all patients at risk for vaginal injury (eg, those with lower abdominal pain, pelvic fracture, or perineal laceration) [25]. Take care to avoid injury from bone fragments if a pelvic fracture is known or suspected.

Musculoskeletal — Inspect and palpate the entire length of all four extremities looking for areas of tenderness, deformity, or decreased range of motion. Also assess and document the neurovascular status of each extremity. Manipulate all joints thought to be uninjured both passively and actively to verify their integrity; immobilize and obtain radiographs of any area with a suspected fracture.

Note all penetrating wounds, especially those overlying suspected fractures, suggesting an open injury. The treatment of open fractures includes irrigation and debridement, application of a clean dressing, and prophylactic antibiotics. Preliminary low-pressure wound irrigation can be performed in the trauma bay, but definitive irrigation and debridement is performed in the operating room (OR). (See "Osteomyelitis associated with open fractures in adults".)

Post traumatic compartment syndrome is an important source of patient morbidity. Increasing pain, tense compartments, and pain with passive stretching of the muscles contained within the compartment should prompt immediate measurement of intracompartmental pressures. (See "Acute compartment syndrome of the extremities".)

Inspect and palpate the pelvis. Ecchymosis over the pelvis or tenderness along the pelvic ring warrants diagnostic imaging. Examination findings (eg, instability) or imaging studies consistent with pelvic ring disruption indicate the need for pelvic immobilization and immediate orthopedic evaluation. Repeat examinations to assess pelvic stability are unnecessary and likely to exacerbate bleeding. (See "Pelvic trauma: Initial evaluation and management".)

Neurologic — The trauma patient's neurologic status can change dramatically over time (eg, from the effects of an expanding subdural hematoma). Serial examinations should be performed and carefully documented. During the secondary survey, perform a detailed assessment of the sensorimotor function of the extremities and repeat an assessment of the patient's Glasgow Coma Scale (GCS) score (table 6). (See "The detailed neurologic examination in adults".)

Skin — Examination of the skin may reveal lacerations, abrasions, ecchymosis, hematoma, or seroma formation. Look closely at areas where lesions may be missed, such as the scalp, axillary folds, perineum, and, particularly in obese patients, abdominal folds. Do not neglect examination of the back, gluteal fold, and posterior scalp. Penetrating wounds may be present anywhere. The management of skin wounds is discussed separately. (See "Clinical assessment of chronic wounds" and "Basic principles of wound management".)

Appropriate tetanus prophylaxis should be given as appropriate to patients with breaks in their skin (table 7). (See "Infectious complications of puncture wounds", section on 'Tetanus immunization'.)

Additional imaging

Plain radiographs — Plain radiographs are used during the secondary survey primarily to evaluate the spine, pelvis, and extremities for fractures, dislocations, and foreign bodies.

Computed tomography, including total body CT — Multidetector computed tomography (MDCT) has become the modality of choice for imaging trauma patients because of its speed and accuracy. However, most studies of comprehensive whole body CT scanning ("pan scan") for all patients with significant trauma are methodologically limited, and have reached contradictory conclusions [133-142]. Pending further research, we do not advocate comprehensive CT scanning in patients without significant alterations in mental status and believe imaging studies should be performed selectively based upon clinical assessment and the mechanism of injury. While whole body CT scanning may improve outcomes following certain high-risk trauma, such as explosions, high speed motor vehicle collisions, and falls from great heights [96,143], we believe it should not be used indiscriminately given the short-term risk of contrast-related renal injury, long-term risk of radiation-induced cancer, effectiveness of more conservative approaches, and the substantial costs [98,144]. (See "Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis, and management" and "Radiation-related risks of imaging".)

In an international, multi-center trial, adult trauma patients with evidence of severe injury were randomly assigned to either whole body CT (n = 541) or selective CT imaging (n = 542) [145]. In-hospital mortality did not differ between groups (whole body CT 86 [16 percent] versus selective CT 85 [16 percent]), nor did it differ significantly among patients with polytrauma or brain injury.

Some authors advocate whole body CT for severely injured patients with alterations in mental status. In a retrospective database analysis of 5208 patients in Japan with scores on the Glasgow Coma Scale (GCS) ranging from 3 to 12, decreased mortality was noted in patients who received whole body CT scans [146]. Although further study of the outcomes and cost effectiveness of whole body CT is needed, the approach may be beneficial in such patients, in whom examination findings are often limited or unclear.

It should be noted that while CT may be useful in the evaluation of patients with blunt trauma [147], it has limited utility for evaluating the trajectory and effects of low velocity penetrating injury (eg, stab wounds) because of the lack of tissue disruption and gas dispersion (seen with high velocity injuries) [148], and because injuries to luminal structures are often difficult to detect [149]. Diagnostic laparoscopy may be useful in patients with penetrating injury and signs of peritoneal penetration despite negative CT imaging. Although improving, the accuracy of CT for detecting diaphragm injuries is also limited, and depending on the nature of the patient’s injuries, additional diagnostic studies may be needed. The use of CT for specific injuries is discussed in detail separately, including topics devoted to particular injuries. (See "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults" and "Pelvic trauma: Initial evaluation and management" and "Recognition and management of diaphragmatic injury in adults".)

Most patients should be hemodynamically stable before CT imaging is performed, and resuscitation should be sufficient to minimize the risk of decompensation while the patient is in the CT scanner. If the patient is unstable, CT imaging is usually deferred. (See 'Emergency computed tomography (CT)' above.)

Analgesia and sedation — Injured patients are in pain. Do not neglect to provide them with appropriate analgesia and sedation if needed. Short-acting agents, such as fentanyl and midazolam, are generally preferred to avoid adverse hemodynamic effects, but these require more frequent monitoring and administration. The results of a few randomized trials suggest that inhaled methoxyflurane provides effective analgesia for trauma patients, but it may not be available in many emergency departments [150,151]. (See "Pain control in the critically ill adult patient" and "Approach to the management of acute pain in adults".)

Victims of crime — Clinical evaluation and treatment of injuries is the foremost responsibility of the clinician caring for a trauma patient. When possible, caretakers should consider and act on the need to preserve potential evidence if the trauma may be connected to a crime. As examples, placing removed clothing into paper bags, avoiding cutting through holes in clothing created by penetrating injuries, and careful documentation of injuries may all be significant. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department" and "Intimate partner violence: Intervention and patient management".)

COMMON PITFALLS — The systematic evaluation of the trauma patient outlined above is designed to help clinicians focus on life-threatening problems and minimize the risk of missed injuries. Nevertheless, one systematic review noted that up to 39 percent of trauma patients have injuries that are initially missed and up to 22 percent of these missed injuries are clinically significant (defined as injuries associated with increased mortality, requiring additional procedures or alterations in treatment, or resulting in significant pain, complications, or residual disability) [78].

Potential pitfalls in trauma management and ways to avoid them are discussed below:

Esophageal intubations — Between 0.5 and 6 percent of prehospital intubations are esophageal due to airway difficulty or displacement during transport. Verify the position of all endotracheal tubes either by direct visualization or use of an end-tidal carbon dioxide (ETCO₂) detector.

Hemorrhagic shock — Approximately 30 percent of the circulating blood volume may be lost before the onset of hypotension [25]. A transient response to one or more fluid boluses means the patient likely has ongoing hemorrhage and is in a persistent state of shock. A high index of suspicion should be maintained and an aggressive search for the source of ongoing hemorrhage is warranted. (See "Approach to shock in the adult trauma patient" and "Initial management of moderate to severe hemorrhage in the adult trauma patient".)

Cardiac tamponade — Assume that elevated jugular venous pressure (JVP) in a trauma patient is caused by pericardial tamponade. However, hypovolemic patients with tamponade may not have elevated JVP. Perform the FAST exam early in the circulation evaluation of the unstable patient and begin by looking at the heart. (See "Cardiac tamponade".)

Thoracoabdominal injury — Assume that any penetrating wound of the thorax or abdomen involves both compartments until proven otherwise.

Penetrating bowel injury — During the initial resuscitation, injuries caused by low velocity penetrating wounds (typically stab wounds) are easily missed by ultrasound, because there is too little intraperitoneal blood to be detected, and by CT, because there is inadequate tissue destruction. For stab wounds, high clinical suspicion may warrant further evaluation by laparoscopy, laparotomy, or diagnostic peritoneal tap despite initially negative imaging studies. Alternatively, a trauma surgeon may opt to perform serial observations of patients with abdominal stab wounds (and some extraperitoneal gunshot wounds) over a 12- to 24-hour period.

Gunshot wounds typically require therapeutic laparotomy and should be distinguished from the aforementioned stab wounds – these high velocity injuries are associated with a much greater morbidity and mortality than their low velocity counterparts. (See "Initial evaluation and management of abdominal gunshot wounds in adults" and "Initial evaluation and management of abdominal stab wounds in adults".)

Open book pelvic fractures — The unstable pelvis should not be manipulated multiple times; additional manipulation exacerbates hemorrhage. Once suspected, open or unstable pelvic fractures should be stabilized using a pelvic binder, or a sheet if no binder is available. If the patient is hemodynamically stable, computed tomography (CT) imaging is obtained. The unstable patient requires either surgery or angiography. (See "Pelvic trauma: Initial evaluation and management".)

Ocular injuries — Periorbital swelling and ecchymosis does not preclude performing an ocular examination. Patients with such findings are at higher risk of ocular injury. In addition, injuries such as a globe rupture or retro-orbital hematoma must be diagnosed quickly in order to maximize the opportunity to salvage vision. (See "Overview of eye injuries in the emergency department" and "Approach to diagnosis and initial treatment of eye injuries in the emergency department" and "Open globe injuries: Emergency evaluation and initial management" and "Orbital fractures" and "Approach to the adult with acute persistent visual loss", section on 'Retinal problems' and "Traumatic hyphema: Clinical features and diagnosis".)

Elder patients — Assume that older patients involved in trauma have sustained a significant injury, even if they appear well. The paradox of elder trauma patients is that their physiology and medical interventions can both mask and exacerbate the severity of injuries. Medications are but one example: beta blockers may mask the effects of shock by suppressing tachycardia, while warfarin and other anticoagulants increase the risk of severe hemorrhage. A table summarizing important considerations in the elder trauma patient is provided (table 8). (See "Geriatric trauma: Initial evaluation and management".)

Common cognitive errors — Several cognitive errors appear to be relatively common during the initial management of injured patients, particularly those who do not look sick initially. Among these are [34]:

●Premature diagnosis – The hemodynamic status of trauma patients is often dynamic and the results of their initial diagnostic studies preliminary. Avoid making premature assumptions about patients' injuries and stability.

●Overreliance upon early negative results – No study is perfect and initial studies may not reveal the full extent of a patient's injuries or indeed any injury. Reassess the patient. Reevaluation may include serial eFAST examinations if the patient’s status has changed.

●Attributing abnormal findings to benign causes – Trauma patients, particularly young healthy adults, may not immediately manifest signs of severe injury. When abnormal findings arise, assume they reflect injury.

●Distractions – Dramatic or obvious injuries, performance of critical procedures, and other aspects of trauma care can distract clinicians, causing them to neglect serious but less apparent injuries or changes in patient status.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Cervical spine injury" and "Society guideline links: Thoracic and lumbar spine injury in adults".)

SUMMARY AND RECOMMENDATIONS

●Epidemiology and trauma team performance – Trauma is a leading cause of mortality globally. All trauma patients require a systematic approach to management in order to maximize outcomes and reduce the risk of undiscovered injuries. Optimal care requires effective and efficient communication and teamwork among clinicians. Common breakdowns in team management are described in the text. (See 'Epidemiology' above and 'Trauma team' above.)

●Mechanism and associated injuries – Particular mechanisms predispose patients to specific injuries. Common blunt trauma mechanisms and their most frequently associated injuries are described in the accompanying table (table 1).

●Primary survey for life-threatening injury – The primary survey used in Advanced Trauma Life Support is organized according to the injuries that pose the most immediate threats to life. Problems are managed immediately in the order they are detected. The individual steps (including assessments of the airway, breathing, circulation, and neurologic injury) and important principles of the primary survey are described in the text. (See 'Primary evaluation and management' above.)

●Airway management – Observational studies suggest that airway obstruction is a major cause of preventable death among trauma patients. Therefore, airway evaluation and management remain the critical first steps in the treatment of any severely injured patient (table 2). (See 'Airway' above and 'Breathing and ventilation' above.)

●Bleeding – Hemorrhage is the most common preventable cause of mortality in trauma. Most trauma patients with signs of shock (eg, pale, cool, moist skin) are bleeding. Be alert for subtle signs of hemorrhagic shock, particularly in the elderly and young, healthy adults who may not present with obvious manifestations. Hypotension generally does not manifest until at least 30 percent of the patient's blood volume has been lost. (See 'Circulation' above.)

●Diagnostic testing – Diagnostic testing plays an important role in trauma management. The appropriate use of studies is described in the text. (See 'Diagnostic studies' above.)

●Resource-limited settings – Clinicians at hospitals with limited resources for trauma management should consult the nearest trauma center as soon as it becomes apparent that a patient has sustained injuries beyond the management capacity of their hospital. It cannot be overemphasized that a complete workup is not a requirement for transfer. (See 'Patient transfer' above.)

●Secondary survey – A secondary survey is performed in all trauma patients determined to be stable upon completion of the primary survey. The secondary survey includes a detailed history, a thorough but efficient physical examination, and targeted diagnostic studies, and plays a crucial role in avoiding missed injuries. The secondary survey is described in detail above. (See 'Secondary evaluation and management' above.)

●Common pitfalls – Up to 39 percent of trauma patients have injuries that are initially missed, and up to 22 percent of these are clinically significant. Common pitfalls and guidance for avoiding missed injuries are provided in the text. (See 'Common pitfalls' above.)