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38

Initial Evaluation of the Trauma Patient


William P. Schecter

Introduction
The modern approach to the trauma patient is based on the
Advanced Trauma Life Support (ATLS) program of the American
College of Surgeons. The ATLS program was designed for highincome countries (HICs) and establishes both a protocol of care
and a common language for all providers. The goal of care is
transport of the right patient to the right place at the right time.
In other words, the patient should be transported as rapidly as
possible to a hospital with clinical capabilities suitable to care
for the patients particular injuries. Unfortunately, most trauma
patients in the developing world do not have access to hospitals
with advanced trauma care capability, if they have access to a
hospital at all. Transport may take hours to days. The relevance
of ATLS to low- and middle-income countries (LMICs) has
therefore recently been questioned.1 Nevertheless, mastery of the
principles of ATLS provides the individual with an organized
approach, which can be modified based on the clinicians specific
training, experience, and available resources.
Efficient care of the injured patient requires a fundamental
change in mind-set. Two parallel processes, one therapeutic and
one diagnostic, replace the traditional history and physical examination. We initiate treatment of physiologic abnormalities while
pursuing the precise diagnosis. The goal is diagnosis and treatment of life-threatening conditions within 60 minutes of injury,
the so-called golden hour. The ATLS program has four phases:
the primary survey, the stage of resuscitation, the secondary survey, and definitive care.2

The Primary Survey


The primary survey has five components: airway, breathing,
circulation, disability, and exposure (see Table 38.1). Although
airway control is traditionally considered the first treatment priority, in an LMIC with limited or no access to blood, immediate
control of active external bleeding is also of high priority.
External hemorrhage should be controlled by direct pressure.
Bleeding from the extremities can be temporarily controlled
by application of a tourniquet proximal to the injury. A blood
pressure cuff elevated to 250 mmHg secured with tape and
placed over cast padding (if available) is a convenient tourniquet.
Definitive control of massive hemorrhage requires urgent access
to an operating room (OR).

Airway
There are three basic maneuvers in airway management: open
the airway, give oxygen, and maintain cervical spine stability. If
the patient is able to speak, the airway is intact. Oxygen, if available, should be given.
Cervical spine stabilization is unnecessary if the patient has an
isolated penetrating injury. A neurologic injury caused by penetrating neck trauma is immediate. The cervical spine should be
stabilized in all cases of blunt trauma. Stabilization is particularly important after blunt head or maxillofacial injury. The goal
is prevention of delayed neurologic injury caused by instability.
Although the utility of a cervical collar has recently been questioned,3 cervical spine stabilization remains a sound principle
following blunt injury.
If the patient is apneic, unconscious, or has signs of airway
obstruction, the first step is a chin lift or jaw thrust. A chin lift is
performed by placing the thumb underneath the chin and lifting
forward, and a jaw thrust is performed by placing the long fingers behind the angle of the mandible and pushing anteriorly and
superiorly (Figure38.1). This maneuver lifts the tongue from the
hypopharynx. If suction is available, it should be used to clear the
airway. If not, clear the airway manually if necessary.
An oral airway, if tolerated, may keep the airway open, permitting spontaneous ventilation. If it is not tolerated, a nasopharyngeal airway may help (Figure38.2).
The signs of upper airway obstruction are listed in Table38.2. In
general, an adult does not develop signs of upper airway obstruction unless the airway is 3 mm or less in diameter. Sweating is
a sign of sympathetic discharge, an indication of hypercarbia.
Patients with signs of upper airway obstruction unresponsive to a
jaw thrust and oral airway require a definitive airway. The other
indications for a definitive artificial airway are listed in Table38.3.
There are two choices for establishing a definitive airway:
endotracheal intubation and a surgical airway. A laryngeal mask
is a good choice for temporarily controlling the airway if intubation is difficult or impossible. If the patient has satisfactory
spontaneous ventilation, the surgical airway can be established
under controlled conditions. If not, a rapid cricothyroidotomy is
necessary. Endotracheal intubation is discussed in Chapter 6.

Cricothyroidotomy
The cricothyroid membrane is located between the thyroid and
cricoid cartilage. I prefer a 23 cm transverse incision centered
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TABLE38.1
Primary survey
Airway
Open airway
Oxygen
Stabilize cervical spine
Breathing
Jugular venous distension
Tracheal midline
Symmetric chest wall expansion
Chest wall pain and crepitus
Bilateral breath sounds
Circulation
External hemorrhage
Pulse, peripheral perfusion
Blood pressure
2 large-bore IVs
Blood for hematocrit, type and cross match
2 L of warm crystalloid (in an adult)
Disability
Glascow Coma Scale
Pupils
Movement of extremities
Exposure
Remove clothing
Log roll the patient
Keep the patient warm

FIGURE 38.2 Nasopharyngeal airway. Image by Janet Fong, 2010


[updated 2013 Dec; cited 2014 Jan 27]. Available from: http://www.aic.cuhk
.edu.hk/web8/Hi%20res/nasopharyngeal_CMYK.jpg

TABLE38.2
Signs of upper airway obstruction
General signs of respiratory distress
Tachypnea
Tachycardia
Flaring of the alae nasi
Specific signs of upper airway obstruction
Inspiratory stridor
Supraclavicular and intercostal retractions
Inspiratory sternal retractions

TABLE38.3
Indications for an artificial airway
1. Hypoventilation
2. Hypoxia
3. Airway protection (unconscious patient)
4. Pulmonary toilet

FIGURE 38.1 Jaw thrust. Image by Janet Fong, 2012 [updated 2013 Dec;
cited 2014 Jan 27]. Available from: http://www.aic.cuhk.edu.hk/web8/
Hires/Modifiedjawthrustdhs2.jpg

over the membrane. Expect a lot of bleeding in the emergency


situation. The patient is often struggling and the anterior jugular
veins distended. Some surgeons use a vertical incision. If exposure is difficult, I make a vertical incision teeing off the transverse incision inferiorly in the midline. An assistant providing
exposure with retractors is very helpful. The inferior portion of
the thyroid cartilage is grasped with a tracheal hook stabilizing
the airway and lifting it into the wound. Open the cricothyroid
membrane with a knife, spread the incision with a clamp, and
insert a small number 6 endotracheal tube or tracheostomy tube.

Once ventilation and oxygenation are restored, a formal tracheostomy can be performed in an OR if one is available. If not, the
cricothyroidotomy tube can be left in place (Figure38.3).
Commercial percutaneous cricothyroidotomy kits using the
Seldinger technique are available. A needle is inserted into the
trachea via the cricothyroid membrane and a wire passed through
the needle. Make a small skin and subcutaneous incision. Pass
the wire through the dilator over which sits a #6 cuffed tube.
Then insert the dilator/tracheostomy tube unit into the trachea
using the wire as a guide. Remove the wire and dilator, leaving
the tube in place. Clinicians familiar with the technique, which
requires some force, can place these tubes rapidly. However, in
an emergency, use the most familiar technique. In any case, it is
unlikely that you will have access to these kits in remote areas.

Breathing
There are five parts of the breathing assessment (see Table38.1).
The presence of jugular venous distension suggests a tension
pneumothorax or cardiac tamponade. If symmetric breath
sounds are present, jugular venous distension is most likely due
to cardiac tamponade. A tracheal shift is a rare physical finding

Initial Evaluation of the Trauma Patient

457

FIGURE 38.3 Cricothyroidotomy. Image by Janet Fong. 2010 [updated 2013 Dec; cited 2014 Jan 27]. Available from: http://www.aic.cuhk.edu.hk/web8/
cricothyroidotomy.htm

associated with a contralateral pneumothorax. A tension pneumothorax more often is associated with asymmetric chest wall
expansion and ipsilateral decreased breath sounds.
There are two life-threatening problems that must be immediately identified and treated in the breathing component of the
primary survey: tension pneumothorax and hemothorax. Both
of these problems are treated by tube thoracostomy and may
occur simultaneously. A tension pneumothorax can be distinguished clinically from a simple pneumothorax by hypotension.
Decreased breath sounds and hypotension require immediate
pleural decompression without waiting for a chest X-ray.

Needle thoracostomy (Figure38.4) will immediately decompress a tension pneumothorax. Insert the needle in the second or
third intercostal space in the midclavicular line. Hit the rib with
the needle and walk off the superior edge of the rib to avoid the
possibility of injuring the intercostal artery which passes along
the inferior portion of the rib. The needle thoracostomy will
equalize the pressure between the pleural space and the atmosphere, resulting in a simple pneumothorax. Placement of a chest
tube is therefore mandatory.
A chest tube should be placed under sterile conditions with
sufficient local anesthesia. Use 30 cc of 1% Xylocaine in an adult

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FIGURE 38.4 Needle thoacostomy. Image by Janet Fong, 2010 [updated


2013 Dec; cited 2014 Jan 27]. Available from: http://www.aic.cuhk.edu.hk
/web8/Hi%20res/needle%20thoracostomy%20(janet).jpg

infiltrating the periosteum of the rib above and below the fifth
intercostal space. Make the skin incision large enough to admit
your index finger. A large clamp should be used to dissect the
intercostal muscles. Then enter the pleural space. Insert your
index finger into the pleural space to ensure that the lung is not
stuck up to the chest wall. Then insert a #36 chest tube superomedially, making sure that all the holes in the tube are in the
pleural space. Connect the tube to underwater seal and suture
it in place. If you dont have commercial chest tubes, any sterile
tube connected to underwater seal will serve the purpose.

Circulation
There are seven maneuvers included in the circulation component of the primary survey (see Table38.1). Control of external
hemorrhage is the first priority. In addition to extremity bleeding (previously discussed), bleeding from the scalp is a frequent
problem. Dressing the scalp covers the wound but does not stop
the bleeding. A running locking stitch will achieve a watertight
closure allowing a clot to tamponade the bleeding. Skin staples
are an alternative rapid closure if available. The patient can be
taken to the OR for suture removal, wound toilet, and definitive
hemostasis after stabilization.
A palpable radial pulse generally indicates a systolic pressure above 90 Torr. A weak, rapid pulse after trauma is a sign
of hypovolemia. A blood pressure measurement will confirm
hypotension. Two large-bore IVs (at least 16-gauge) are recommended for adults. Blood should be sent for type and crossmatch
if you are fortunate enough to have a blood bank. Hypovolemia
should be treated with a 2 L infusion of warm crystalloid solution. If the patient fails to respond, blood should be administered
if available.
If there is a penetrating injury to the anterior chest and upper
abdomen, consider the diagnosis of cardiac tamponade. Becks
triad (jugular venous distension, muffled heart sounds, and hypotension) is associated with cardiac tamponade. Pulses paradoxicus (a fall in systolic blood pressure > 10 mmHg on inspiration) is

associated with cardiac tamponade, tension pneumothorax, pulmonary hypertension, and obstructive lung disease. If an ultrasound machine is available, it will demonstrate the presence of
pericardial fluid. It can also be used to guide pericardiocentesis.
Cardiac tamponade requires immediate treatment. If this
diagnosis is suspected and you have access to an OR, transport the patient immediately. Maintain verbal contact with the
patient. Mental status is an excellent sign of cerebral perfusion.
Patients with tamponade frequently arrest on induction of anesthesia. The patient should be prepped and draped and the surgical team scrubbed before induction of anesthesia if possible. If
the patient is stable and the diagnosis is in doubt, start with a
pericardial window. This procedure involves making an upper
midline abdominal incision through the fascia, elevating the
xyphoid, grasping the pericardium with a hook to pull it inferiorly, and making a small incision in the pericardium. If there
is clear fluid, hemopericardium is excluded. If blood is present,
a left anterior thoracotomy or median sternotomy is required to
expose and repair the heart injury.
If you dont have access to an OR, your only option is pericardiocentesis. This treatment is usually not effective unless the
hole in the heart is small. I use an 18 spinal needle attached to a
12 cc syringe. If you have an intravenous (IV) extension tubing
and a three-way stopcock, the operator can stabilize the needle
while an assistant aspirates the blood. If ultrasound is available,
it should be used to guide placement of the needle. If not, you
will be unsure whether the blood you are aspirating is coming
from the ventricle or the pericardium. If you have an electrocardiogram (EKG) machine and alligator clips, you can run a V-1
EKG strip and connect the V-1 lead to the needle as you insert it.
Insert the needle in the subxiphoid position and aim toward the
left shoulder. If you encounter an elevated ST segment (current
of injury) during needle insertion, it means that the needle is in
the wall of the ventricle. If you aspirate blood without a current
of injury, the needle is most likely in the pericardium. There are
commercial pericardiocentesis kits containing catheters which
can be placed in the pericardium with the Seldinger technique.
These catheters can be used for repeated aspiration but are most
useful for serous collections.

Disability
The disability component of the primary survey is really a minineurologic exam. The word disability was used because it begins
with the letter D (ABCDE). It has three components: examination
of the pupils, mental status, and extremity motion (see Table38.1).
Symmetric pupils that respond to light indicate an intact reflex arc
from the optic nerve to the third cranial nerve (carrying parasympathetic fibers from the Edinger-Westphal nucleus in the midbrain to the pupillary constrictor muscles). A unilateral dilated
pupil after trauma is most often due to herniation of the uncus of
the cerebellum over the tentorium cerebelli causing pressure on
the ipsilateral 3rd cranial nerve. Direct ocular trauma or homatropine ophthalmic drops can also cause papillary dilation. Bilateral
dilated pupils unresponsive to light with absent corneal reflexes
are a poor prognostic sign associated with brain death.
Mental status should be assessed in all patients. A convenient
universally accepted method is the Glascow coma scale (see
Table38.4)4. Scores of 1315 indicate mild disability. Scores of

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Initial Evaluation of the Trauma Patient


TABLE38.4

TABLE38.5

Glascow coma scale

Life-threatening injuries requiring diagnosis and treatment during


the primary survey

Eye opening

Verbal response

Motor response

Spontaneously
To speech
To pain
None
Orientated
Confused
Inappropriate
Incomprehensible
None
Obeys commands
Localizes to pain
Withdraws from pain
Flexion to pain
Extension to pain
None

Maximum score

4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
15

813 indicate moderate disability. Severe disability, a Glascow


coma score 8, is an indication for intubation to prevent pulmonary aspiration of gastric contents.
If the patient moves all four extremities to command, paraplegia is excluded. If the patient is obtunded or unconscious,
administer a noxious stimulus. Pinch the skin under the axilla.
If the patient moves only the ipsilateral side, pinch the skin in
the contralateral axilla. If the legs do not move, pinch the legs. If
neither the upper nor lower extremities move, apply supraorbital
pressure. A grimace or movement above the shoulders suggests
quadriplegia. Be sure to record the findings. If the patient is later
discovered to be paraplegic, the question always arises: Was he
paraplegic on arrival?

Exposure/Environment
There are three parts of the exposure/environment section
of ATLS: undress the patient, log roll the patient to examine
the back, and then cover the patient to maintain warmth (see
Table38.1).
Complete exposure of the patient is important to exclude penetrating injuries. However, be aware of your surroundings. In
an austere environment, you can affect outcome only by stopping external hemorrhage, opening the airway, decompressing a
tension pneumothorax, and maintaining body heat. Exposing a
patient in a cold environment without the possibility of treatment
will adversely affect outcome.
Correct log rolling is a four-person job. One person maintains
in-line traction on the head and one on the feet. Two people control the trunk. The patient is rotated 90 degrees. Look for signs
of injury. Palpate the thoracic and lumbosacral spine looking for
step-offs associated with a fractured spine.
Now is a good time to do a rectal exam when the patient is in
the lateral position. Check for a high riding prostate, a sign of
transection of the membranous urethra (almost always associated with a pelvic fracture), or gross blood (which could signify
a bowel injury).

1. Airway obstruction
2. Tension pneumothorax
3. Massive hemothorax
4. Sucking chest wound
5. Cardiac tamponade
6. Shock

TABLE38.6
Resuscitation stage
1. Review ABCD
2. Monitors (EKG, pulse oximetry, blood pressure, capnometer)
3. Gastric tube
4. Urinary catheter
5. AP chest X-ray
6. AP pelvic X-ray

The life-threatening conditions which must be diagnosed and


treated during the primary survey are listed in Table38.5. It is
important to carefully consider and either treat or exclude each
of these diagnoses based on the clinical findings.

Stage of Resuscitation
After completion of the primary survey, proceed immediately to
the stage of resuscitation (see Table38.6). The first step is a review
of A, B, C, and D. Is the airway still intact? If the patient was intubated in the primary survey, is the tube in the correct position?
Does the patient have bilateral breath sounds? If a chest tube was
inserted during the primary survey, is it still in the correct position? What is the chest tube output? Has there been a change in
the hemodynamic status of the patient? If the patient was initially
hypotensive during the primary survey, has he responded to the
fluid challenge? If not, does the patient need blood? Has there
been any change in the patients mental status? The patient should
be connected to a pulse oximeter, continuous blood pressure monitor, EKG, and capnometer, if available. If appropriate, arterial
blood gases should be measured. In many hospitals in developing nations, these monitors are unavailable. If this is the case,
the patient will have to be monitored by checking vital signs and
mental status. The ATLS program prioritizes patient management. If there is a team of people available to manage the patient,
monitors are usually connected to the patient during the primary
survey. Nevertheless, they are listed in the stage of resuscitation
because of their position in the hierarchy of priorities.
At this point, a urinary catheter and gastric tube should be
inserted if indicated. All moderately and severely injured patients
require a urinary catheter to monitor urine output. Inspect the
perineum prior to insertion of the catheter. Perineal swelling and
blood at the urethral meatus in addition to a high riding prostate
are physical findings associated with urethral transaction. If an
attempt to place a urinary catheter is unsuccessful, a suprapubic

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urinary catheter is usually required. In hospitals with specialist


capability, a catheter can sometimes be passed with cystoscopic
guidance after studying the injury with a retrograde urethrogram. Gastric intubation is indicated to treat gastric distension
and prevent aspiration pneumonia. Pass the tube through the
mouth instead of the nose in the presence of facial fractures to
avoid inadvertent intubation of the cranial vault through a fractured cribriform plate.
The last component of the stage of resuscitation involves radiology. The most important film is the anteroposterior (AP) chest
X-ray. Two liters of blood can hide in each pleural space in a
supine injured patient with minimal physical findings on chest
examination. Delay in obtaining a chest X-ray is a common cause
of underestimation of severity of injury.
The next most important X-ray is an AP view of the pelvis. A
major pelvic fracture can be an important cause of extraperitoneal pelvic hemorrhage. Early diagnosis is important to stabilize
the fracture with a pelvic binder and arrange urgent angiographic
embolization of the source of bleeding in the unlikely event that
this technology is available.
Computerized tomographic (CT) scans of the neck have
replaced crosstable lateral cervical spine films to exclude cervical spine injuries because of increased accuracy. If CT scans
are unavailable, assume that the blunt trauma victim, particularly
one with a head injury, has a cervical spine injury and maintain
spine immobilization until the injury can be excluded clinically
or radiographically.

The Secondary Survey


The secondary survey as envisioned by ATLS is a head-to-toe
physical examination. As a concept, it has much broader application. In a real sense, images obtained in the CT scanner or
angiography suite are part of the secondary survey since
they identify injuries hidden to the clinicians natural senses.
Similarly, an exploratory laparotomy or thoracotomy performed
in an unstable patient facilitates precise diagnosis and treatment.
The important point is initiation of effective treatment of all lifethreatening injuries as soon as possible.
The head-to-toe physical examination should be a repetitive
process. Each examination should be more detailed, focusing on
subtle findings that may have been overlooked during the primary
survey and initial examination. Life-threatening injuries should
be treated immediately rather than delaying treatment until the
end of the exam. In practice, treatment and examination proceed
simultaneously. An abbreviated medical history is important. The
mnemonic AMPLE is useful to emphasize the key points: allergy,
medications, previous hospitalization and operations, last meal,
events surrounding the injury (i.e., mechanism of injury). If the
patient is responsive but requires intubation, take an AMPLE
history if possible as preparations are being made for intubation.
Now is a good time to get the name and phone number of a relative. Once the tube goes in, the opportunity is lost.

Head
Palpate the skull looking for scalp lacerations and depressed
skull fractures. Actively bleeding scalp lacerations should be

rapidly closed to control bleeding if this step was omitted in the


primary survey. Examine the mastoid processes looking for a
hematoma (Battles sign), a finding associated with basal skull
fracture.

Face
Palpate the supra and infraorbital rims, the zygomas, the nose,
the maxilla, and the mandible. Examine the teeth. Do not put
your fingers in the patients mouthyou may be bitten! Search
for periorbital hematomas (raccoon eyes) and cerebrospinal fluid
(CSF) otorrhea and rhinorrhea. These signs are also associated
with basal skull fractures.

Neck
Open the anterior portion of the cervical spine collar if the patient
is wearing one. Reexamine the jugular veins and the trachea. Slip
your hand behind the neck and feel for swelling or step-offs that
may be a sign of cervical spine fracture. Reattach the anterior
portion of the cervical spine collar.

Chest
Now take a moment and step back to observe the patients respiratory pattern. It is easy to miss a subtle flail chest during the
rush of the primary survey. Flail chest is a condition which
occurs when there are two or more contiguous ribs fractured in
multiple places in a segment of the chest wall. The injured segment is free-floating. On inspiration, this segment will be paradoxically sucked into the chest while the rest of the chest wall
expands. Fractures of the costochondral junctions on either side
of the sternum can also result in a flail sternum. Some cases of
flail chest can be treated by chest wall analgesia and pulmonary
physiotherapy. However, if the work of breathing is too great or
gas exchange deteriorates due to an underlying pulmonary contusion, intubation and positive pressure ventilation are essential.

Abdomen
Inspect the abdomen looking for bruises or evidence of penetrating injury. A seat-belt sign, a bruise across the chest and abdomen caused by impact of the seat belt, is sometimes an indication
of underlying small bowel and pancreatic injury. Look to see if
the abdomen is scaphoid or distended. A distended abdomen
may indicate free air from a ruptured viscus or intra-abdominal
hemorrhage. If the patient is conscious, look for signs of peritoneal irritation. Your goal is to move the peritoneum with as
little stimulus as possible. Ask the patient to cough. Abdominal
tenderness after coughing is an important sign of peritoneal irritation. If the patient has an umbilical hernia, the peritoneum is
just underneath the skin. Gently tap on the skin to elicit pain.
Next, gently palpate the four abdominal quadrants looking for
tenderness. Then percuss the four abdominal quadrants to give a
graded stimulus to the abdomen. If no pain is elicited, deeply palpate the four abdominal quadrants. After deep palpation, release
the pressure suddenly to search for rebound tenderness.
Abdominal auscultation, while recommended by the ATLS,
does not provide much useful information unless the patient has

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Initial Evaluation of the Trauma Patient


high pitched bowel sounds associated with a bowel obstruction (an
unlikely presentation immediately after injury). Unfortunately,
bowel sounds can be present after severe injury or absent in a
perfectly normal patient. If a patient is unconscious or paralyzed,
the abdominal physical examination is unreliable.

Pelvis
Although ATLS recommends gentle palpation of the pelvis
to assess stability, I consider pelvic fracture to be a radiologic
diagnosis. Vigorous movement of a fractured pelvis increases
bleeding. If the patient has an open book pelvic fracture (i.e.,
a fracture of the pubic symphysis widening at the pelvic ring),
reducing the fracture reduces the volume of the pelvis and probably limits bleeding due to the tamponade effect of the retroperitoneal hematoma. Immediate external fixation is unnecessary
in the immediate postinjury period. Effective reduction can
be temporarily achieved with a commercially available pelvic
binder. Alternatively, a folded sheet placed under the patient
and tightly secured anteriorly over the pelvis serves the same
function.

Extremities
Inspect and palpate all four extremities looking for external rotation, malalignment, swelling, crepitus, or localized pain. Palpate
and record the carotid, brachial radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Pay particular attention
to pulses distal to a suspected fracture. Carefully examine and
record sensory and motor function distal to a suspected fracture.
Long bone fractures with a distal pulse deficit should be reduced
by inline traction. All fractures should be immobilized and
splinted. Avoid circumferential dressings or casts until you are
sure that the patient has stabilized. Be alert to the development
of a compartment syndrome (elevated pressure due to swelling
in the subfascial compartments of the extremities), which may
cause muscle and nerve death ultimately leading to loss of function and/or amputation. Pain and decreased sensation distal to
the affected area are the first signs to appear. Swelling and firmness of the compartment and pain on passive motion are also
associated findings. A pulse deficit is the last finding to appear. If
you wait for a pulse deficit prior to fasciotomy, you have waited
too long.

Neurological Examination
Now is the time to perform a more detailed neurological examination. Re-examine the patients mental status. Examine cranial
nerves IIXII. Do a detailed examination of the motor and sensory status of all four extremities. Examine the reflexes of the
upper and lower extremities. A more detailed examination of the
unconscious patient is beyond the scope of this chapter.
Potential injuries that should be diagnosed during the secondary survey are listed in Table38.7. These injuries threaten
the patient in a delayed fashion. The diagnosis and treatment of
some of them may not be possible depending on the available
resources.

TABLE38.7
Potentially life-threatening injuries requiring diagnosis during the
Secondary Survey
1.
2.
3.
4.
5.
6.
7.

Simple pneumothorax
Pulmonary contusion
Flail chest
Blunt aortic injury
Esophageal perforation
Diaphragmatic injury
Intra-abdominal injury
a. Intra-abdominal hemorrhage
b. Hollow viscus injury
c. Pelvic fracture

BOX38.1

LMIC-SPECIFIC CONSIDERATIONS

Delayed transport means that many patients die before


reaching hospital.
Inadequate or absent blood bank means that many patients
will bleed to death after arrival to hospital.
Limited imaging capability means that many injuries will be
missed.
Limited or absent surgical capability means that some
patients with surgically correctable injuries will die.
Limited or absent ICU capability means that postoperative
care will be rudimentary.

BOX38.2

KEY POTENTIALPITFALLS
TOAVOID

Do not focus on the obvious injury. Focus on the primary


survey.
Stop external hemorrhage!
Secure the airway early if required.
Dont miss a tension pneumothorax causing hypotension.

Synthesis
If you are in a facility lacking surgical or intensive care unit
(ICU) resources, patients with life-threatening intrathoracic or
intra-abdominal hemorrhage by this time will be dead due to
uncontrolled hemorrhage. Patients with bowel injury and peritonitis will be dead in 2472 hours of severe sepsis without surgical intervention.
Make a list of all known, suspected, and possible injuries. Do
your best to exclude suspected and possible injuries given the
available resources and the (im)possibility of transfer to another
facility for definitive care.
If you have surgical capability, remember that hemostasis
is the key factor in survival. Do not leave bleeding patients in
the casualty ward expecting fluid resuscitation to improve the
situation. Immediate transfer to the OR for control of hemorrhage, continuing resuscitation and completion of the diagnostic
workup, is the key to success.

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COMMENTARY
Sebastian O. Ekenze, Nigeria
Trauma is a major cause of preventable morbidity and mortality in LMICs. This is a growing health concern due mostly
to the following factors: increasing sophistication and rapid
growth of motorized transport without adequate safety precautions, increasing regional conflicts, and terrorism.
Significant challenges exist in the care of trauma patients
in LMICs. These challenges are related to delayed presentation of trauma patients (due to lack of education, financial
resources, and emergency vehicle services), capacity (lack of
infrastructure and shortage of physical and human resources),
and lack of proper emergency medical services. As a result,
there is inadequate evaluation and management of trauma
patients.
In the initial evaluation of trauma patients, it is important to
emphasize that, while ATLS is the gold standard, its application in LMICs may need to be tailored to the capacity in this
setting. Most health facilities in LMICs lack facilities for airway, breathing management, and vascular access. Facilities
for focused resuscitation and investigations are also limited.

Understanding the principles of ATLS is thus indispensable in this setting to achieve an organized approach to the
care of the injured patient. For the few patients who may present within the golden hour and those who present after a
few hours with life-threatening conditions, the phases of
ATLS (primary survey, resuscitation, secondary survey, and
definitive care) may be applied as the facilities permit in order
to achieve resuscitation, diagnosis, and treatment of the conditions. However, the cases that present late in poor clinical
state (probably from inadequate or inappropriate treatment
before presentation) may require a more thorough initial history and physical examination to determine the extent of the
problem and the contributory factors.
In LMICs, the decision to operate during the initial evaluation of trauma patients with deteriorating clinical condition
is critical especially in the event of inconclusive diagnosis
due to lack of requisite diagnostic facilities. In such cases, it
may be life-saving to undertake operative treatment based on
clinical findings.