Approach to the trauma patient – ABCDE of trauma care

Approach to the trauma patient – ABCDE of trauma care

Case

Jane Doe, 22-year-old female, was in a major car crash and is approaching the trauma bay via an ambulance. You are aware that the patient’s condition is critical, so you do a quick run-through in your head about the approach that you will have to care for them once they arrive to your emergency department. What should your approach to a trauma patient be?

The ABCDE of Trauma Care

The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a clinically proven approach to any critically ill patient that needs emergent care and treatment. It has been proven to improve patient outcomes, optimize team performance and save time when patients are in life-threatening conditions [1]. This approach is applicable to all patients (both adults and children), regardless of their underlying condition. However, the ABCDE approach is not applicable to patients who are in cardiac arrest, in which case the cardiopulmonary resuscitation guidelines should be used [2].

With the ABCDE approach, initial assessment and treatment are performed simultaneously. Once the entire survey is completed, reassessment should be conducted until the patient is stable enough for the care team to be able to move on to the secondary survey and look for a definitive diagnosis.

A - Airway

First, the care team should assess if the patient’s airway is patent. If the patient responds to the team in a normal voice, then that is a good sign that the airway is intact. It is important to note that airway obstruction can be complete or partial, and can be caused by upper airway obstruction or reduced level of consciousness.

Signs of complete airway obstruction are lack of respiration despite great effort. Signs of partial airway obstruction include:
– Changes in the patient’s voice
– Snoring or gurgling
– Stridor (noisy breathing)
– Increased breathing effort

Assess the patient’s airway by looking for rocking chest wall motion and any signs of maxillofacial trauma or laryngeal injury. Perform the head-tilt and chin-lift maneuver to open the airway (note that caution should be conducted in patients with C-spine injury). If there is anything that is noticeably obstructing the airway, suction or remove it. If possible, remove foreign bodies that are causing airway obstruction. Provide high-flow oxygen to the critically ill patient and perform definitive airway if needed [1].

B – Breathing

Generally, airway and breathing are examined simultaneously. Determine if breathing is intact by assessing the respiratory rate, inspecting the chest wall movement for symmetry, depth, and respiratory pattern. Additionally, assess for tracheal deviation and use of respiratory muscles. Percuss the chest for dullness or resonance, auscultate for breath sounds and apply a pulse oximeter [1].

Injuries that impact breathing should be immediately recognized, and life-threatening injuries should be addressed and managed [3]. For example, tension pneumothorax must be promptly relieved by needle thoracocentesis, bronchospasms should be managed with inhalation and assisted ventilation should be considered if breathing continues to be insufficient [1].

C – Circulation

Conditions that threaten the patient’s circulation and can be fatal include shock, hypertensive crises, vascular emergencies such as aortic dissection and aortic aneurisms. These conditions should be immediately identified and managed [1].

Circulation can be assessed by looking at the general appearance of the patient, including signs of cyanosis, pallor, flushing and diaphoresis. Assess for any obvious signs of hemorrhage, blood loss and level of consciousness. Additionally, capillary refill time and pulse rate should be assessed. Auscultate the chest for heart sounds, and blood pressure measurement and electrocardiography should be performed as soon as possible [1].

Additionally, assess for signs of hypovolemia and shock. If these are identified, obtain an intravenous access and infuse saline to restore circulating volume [1]. If there are life-threatening conditions that are compromising the patient’s circulation, promptly identify and treat them as needed. For example, tension pneumothorax should be immediately treated with needle decompression and cardiac tamponade can be relived with pericardiocentesis.

D - Disability

The main disability in the primary survey to be assessed for is the brain. Abnormal neurological status can be caused by primary brain injury or systemic conditions that effect brain perfusion, such as shock, hypoxia, intoxication etc. Assess the level of consciousness by using the Glasgow Coma Scale [4], look for pupillary response and limb movement.

The best way to prevent injury to the brain is to maintain adequate airway, breathing and circulation. Glucose levels can be assessed at bedside for decreased level of consciousness due to low blood glucose levels, and corrected with oral or infused glucose [1].

E – Exposure

The exposure portion of the ABCDE approach involves assessment of the whole-body to avoid any signs of missing injuries. During this part of the management, undress the patient fully and examine the back for any signs of C-spine precautions. Additionally, check for clues for any signs of underlying conditions, such as:

  • Signs of trauma (i.e. burns, gunshot wounds, stab wounds)
  • Rashes
  • Causes of sepsis (i.e. infected wounds, gangrene)
  • Toxins and drugs (i.e. needle track marks, chemicals, patches)
  • Other wounds such as bite marks, insect bites, embedded ticks
  • Iatrogenic causes (i.e. catheters, tubes, implants, surgical sites and scars)

Concluding Remarks

The ABCDE approach to the critically ill patient is a strong and proven clinical tool for initial assessment and treatment of patients in medical emergencies. Widespread knowledge of this skill is critical for healthcare workers and any team providing emergent care to trauma patients. 

*Note that this is a general approach to the trauma patient. Always consult your care team for adequate management of trauma patients and resort to reliable resources for more information on the ABCDE approach. 

References and Further Reading

  1. Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine5, 117.
  2. Koster, R. W., Baubin, M. A., Bossaert, L. L., Caballero, A., Cassan, P., Castrén, M., … & Sandroni, C. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation81(10), 1277-1292.
  3. Subcommittee, A. T. L. S., & International ATLS Working Group. (2013). Advanced trauma life support (ATLS®): the ninth edition. The journal of trauma and acute care surgery74(5), 1363-1366.
  4. Sternbach, G. L. (2000). The Glasgow coma scale. The Journal of emergency medicine19(1), 67-71.
Cite this article as: Maryam Bagherzadeh, Canada, "Approach to the trauma patient – ABCDE of trauma care," in International Emergency Medicine Education Project, January 19, 2022, https://iem-student.org/2022/01/19/abcde-of-trauma-care/, date accessed: October 2, 2022

Question Of The Day #70

question of the day
712 - deep fore arm laceration
Which of the following is the most appropriate next step in management for this patient’s condition?  

This patient arrives to the hospital after a suicide attempt with multiple bleeding arm wounds, hypotension, tachycardia, and a depressed mental status. This patient is in hemorrhagic shock.

The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The airway and breathing status of this patient have been assessed with no acute issues as noted in the question stem.  On assessment of the patient’s circulation, he is tachycardic, hypotensive, and has an actively bleeding extremity wound.  The first step in managing a bleeding wound is to apply constant direct pressure to the site.  Direct pressure to the site for 15 minutes should control bleeding in most cases.  If the origin of the bleeding is difficult to identify for direct pressure application, or if direct pressure fails, the next step is to apply a tourniquet (Choice D).  If a tourniquet is not available, an easy alternative is to apply a blood pressure cuff proximal to the bleeding wound and inflate the cuff to 250mmHg or until the bleeding stops.  This will allow careful examination and repair of the bleeding wound.  Topical tranexamic acid (Choice A) and subcutaneous lidocaine with epinephrine injections (Choice B) can work as adjuncts to tourniquet application.  Suturing the area will also help tamponade the bleeding site and aid in clot formation after a tourniquet is applied.  Checking a serum toxicology screen (Choice C) may be helpful to evaluate for a concurrent overdose, but this is not as important as initial hemorrhage management.   

Other steps to hemorrhage control and treatment include establishing large bore IV access, administering IV fluids or blood products as needed, and reversing coagulopathy. Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #70," in International Emergency Medicine Education Project, December 31, 2021, https://iem-student.org/2021/12/31/question-of-the-day-70/, date accessed: October 2, 2022

Question Of The Day #69

question of the day
Neck injury with fish
Which of the following is the most appropriate next step in management for this patient’s condition?  

The neck is a compact anatomical area with many vital structures, including blood vessels that provide oxygen to the brain, the aerodigestive tracts (trachea and esophagus), nerves, and the apices of the lungs.  A penetrating injury to the neck can be catastrophic and requires prompt examination and appropriate management.  The neck is divided into 3 anatomical zones, and each zone houses different anatomical structures.  Zone 1 is from the clavicle to the cricoid cartilage, Zone 2 is from the cricoid cartilage to the mandible, and Zone 3 is from the angle of the mandible to the base of the skull.  See the reference below for pictures and further descriptions of each zone.

The presence of any “hard signs” of aerodigestive or neurovascular injury should prompt emergent operative management.  These “hard signs” include airway compromise, expanding or pulsatile hematoma, active and brisk bleeding, hemorrhagic shock, neurological deficit, massive subcutaneous emphysema, and air bubbling through the wound.  If the patient is hemodynamically stable and does not have any of these dangerous “hard signs”, it is reasonable to pursue CT angiography of the neck (Choice A) to evaluate for any vascular, aerodigestive, or neurologic injuries.  The fish should not be removed (Choice B) in the Emergency department as this may result in uncontrolled bleeding.  A more controlled environment, like an operating theater, is a more appropriate setting to remove a penetrating foreign body.  The patient in this case has 2 hard signs (bubbling through wound and airway compromise), so he will need operative management (Choice C).  However, the patient’s airway compromise is a more emergent and time-sensitive issue that needs to be addressed first with endotracheal intubation (Choice D).  Intubation is the next best step in management.  Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #69," in International Emergency Medicine Education Project, December 24, 2021, https://iem-student.org/2021/12/24/question-of-the-day-69/, date accessed: October 2, 2022

Question Of The Day #68

question of the day
Which of the following is the most appropriate next step in management?

This elderly man presents to the Emergency Department after a mechanical fall down the stairs with left flank pain.  He is on anticoagulation.  His chest X-ray shows 3 lower rib fractures.  The diagnosis of rib fractures is clinical in conjunction with imaging.  A history of rib trauma with pleuritic chest pain, tenderness over the ribs, and skin ecchymoses over the chest all support a diagnosis of rib fracture.  Chest X-ray is often performed as an initial test, but it should be noted that about 50% of rib fractures are not able to be visualized on chest radiography alone.  Bedside ultrasonography and CT scanning are more sensitive in detecting rib fractures than plain radiography.  Treatment for rib fractures is mainly supportive and includes pain management and incentive spirometry (or regular deep inspiratory breaths) to prevent the development of atelectasis or pneumonia as complications.  Many patients with rib fractures can be discharged home with these supportive measures.

Another important part of rib fracture management is evaluation for the complications or sequalae of rib fractures.  This includes pulmonary contusion, pneumonia, atelectasis, flail chest, traumatic pneumothorax or tension pneumothorax, hemothorax, and abdominal viscus injuries.  Elderly patients with multiple rib fractures are more likely to have poor outcomes and should be admitted for close observation.  Admission to the hospital for pain management (Choice A) may be needed in this case, but it is not the best next step.  Placement of a chest tube (Choice C) is not needed in this case as there are no signs of a pneumothorax.  Incentive spirometry (Choice D) is important to prevent atelectasis or pneumonia, but it is not the best next step.  The presence of multiple lower rib fractures (ribs #9-12) as seen in this case should prompt evaluation for abdominal injuries, such as hepatic or splenic lacerations.  Potential abdominal injuries should be of greater concern since this patient is on anticoagulation for his atrial fibrillation.  The best next step is a CT scan of the chest, abdomen, and pelvis (Choice B).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #68," in International Emergency Medicine Education Project, December 17, 2021, https://iem-student.org/2021/12/17/question-of-the-day-68/, date accessed: October 2, 2022

Question Of The Day #67

question of the day
SS Video 2  Large Pericardial Effusion

Which of the following is the most likely cause of this patient’s condition?

This patient arrives in the Emergency Department after sustaining penetrating chest trauma and is found to be hypotensive, tachycardic, and with a low oxygen saturation on room air. The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient’s ultrasound shows fluid in the pericardiac sac which in combination with the patient’s hypotension and tachycardia, this supports a diagnosis of cardiac tamponade.  See the image below for labelling.

Cardiac tamponade is considered a type of obstructive shock.  As with other types of obstructive shock, such as pulmonary embolism and tension pneumothorax, there is a state of reduced preload and elevated afterload.  This causes a reduction in cardiac output (Choice C) which leads to hypotension, tachycardia, and circulatory collapse.  High cardiac preload (Choice A), low cardiac afterload (Choice B), and high cardiac output (Choice D) do not occur in cardiac tamponade.  Treatment for cardiac tamponade includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #67," in International Emergency Medicine Education Project, December 10, 2021, https://iem-student.org/2021/12/10/question-of-the-day-67/, date accessed: October 2, 2022

Question Of The Day #66

question of the day
40.1 - Pneumothorax 1

Which of the following is the most likely diagnosis of this patient’s condition?

This man presents to the Emergency Department with pleuritic chest pain, shortness of breath after a penetrating chest injury. He has tachypnea and low oxygen saturation on exam, but he is not hypotensive or tachycardic.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

This patient should immediately be given supplemental oxygen for his low oxygen saturation.  The history of penetrating chest trauma and hypoxemia also should raise concern for a traumatic pneumothorax, and oxygen supplementation is part of the treatment for all pneumothoraces.  The patient’s chest X-ray shows a large left sided pneumothorax indicated by the absence of left sided lung markings.  There is some left to right deviation of the heart and the primary bronchi.  There is no large left sided pleural effusion in the costodiaphragmatic recess to indicate a pneumo-hemothorax.  There is also no deviation of the trachea, hypotension, or tachycardia to indicate a tension pneumothorax (Choice B).  The patient is hemodynamically stable, so he cannot be in hemorrhagic shock (Choice A) or have cardiac tamponade (Choice C).  Although the pneumothorax is large with mild deviation of the heart, the lack of hemodynamic instability supports the diagnosis of a traumatic non-tension pneumothorax (Choice D).  The treatment for this would include 100% oxygen supplementation and placement of a chest tube.  A CT scan of the chest is more sensitive imaging test than a chest X-ray and should be considered to evaluate for additional injuries (blood vessel injuries, rib fractures, etc.). Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #66," in International Emergency Medicine Education Project, December 3, 2021, https://iem-student.org/2021/12/03/question-of-the-day-66/, date accessed: October 2, 2022

Question Of The Day #65

question of the day
Longitudinal Orientation

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives in the Emergency Department after an assault with penetrating abdominal trauma and is hemodynamically stable on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has no free fluid between the right kidney and liver.  There also is no free fluid above the diaphragm to indicate a hemothorax. The question stem notes that all other FAST exam views are nonremarkable.  Therefore, this patient has a negative FAST exam.  See labelling of the FAST exam image below.

An exploratory laparotomy (Choice A) would be indicated in a patient with penetrating or blunt trauma, a positive FAST exam, and hemodynamic instability. This patient has a negative FAST exam and is hemodynamically stable.  Packed red blood cell infusion (Choice B) would be indicated in the setting of hemodynamic instability and trauma, as this is assumed to be hemorrhagic shock.  This patient is not tachycardic or hypotensive. A urinalysis to check for hematuria (Choice D) may be a helpful adjunctive investigation to evaluate for renal or bladder injury, but it is not the most crucial next step in management. Performing a CT scan of the abdomen and pelvis (Choice C) is the best next step as the patient is hemodynamically stable with a negative FAST exam and a penetrating abdominal injury.  The CT scan will help further evaluate for any internal injuries that may require operative repair.  See the algorithm below for further detail on an abdominal trauma work flow. Correct Answer: C

undifferentiated trauma patient
undifferentiated trauma patient

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #65," in International Emergency Medicine Education Project, November 26, 2021, https://iem-student.org/2021/11/26/question-of-the-day-65/, date accessed: October 2, 2022

Question Of The Day #64

question of the day
Left Upper Quadrant

Which of the following is the most appropriate next step in management?

This patient arrives in the Emergency Department after an assault and has pallor (paleness), hypotension, and tachycardia on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has free fluid between the left kidney and spleen in combination with hypotension and tachycardia.  This patient is in hemorrhagic shock until proven otherwise and needs prompt operative management.  See labelling of the FAST exam image below.

us image showing bleeding
us image showing bleeding

 

A CT scan of the chest, abdomen, and pelvis (Choice A) and a CT scan of the head (Choice C) may be helpful in the evaluation of this patient, but this patient is hemodynamically unstable.  Radiographic tests that require the patient to leave the Emergency Department should be avoided if the patient is unstable.  The specific location or cause of the hemodynamic instability can be diagnosed in the operating theater where there are opportunities to control the intraperitoneal bleeding (i.e., splenectomy, vessel ligation or cautery, etc.).  Bedside diagnostic peritoneal lavage (Choice D) is not indicated in penetrating abdominal trauma when there is a negative FAST exam and CT scanning is available.  This patient sustained blunt abdominal trauma, so a DPL is less informative.  The best next step for this patient is exploratory laparotomy (Choice B) in the operating theater.  Hemodynamically unstable patients with a positive FAST exam should always go to the operating theater for further diagnosis and treatment.  See the algorithm below for further detail.

 

undifferentiated trauma patient
undifferentiated trauma patient

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #64," in International Emergency Medicine Education Project, November 19, 2021, https://iem-student.org/2021/11/19/question-of-the-day-64/, date accessed: October 2, 2022

Question Of The Day #63

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient presents to the Emergency Department after a high-speed motor vehicle accident in the setting of alcohol intoxication.  On examination, he is intoxicated with a GCS of 14 (normal GCS is 15).  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.

After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.  This patient is intoxicated but is awake with a patent airway. Endotracheal intubation (Choice C) is not indicated.  Neurosurgical consultation (Choice D) is also not indicated at this stage as there is no concrete information to indicate a surgical emergency.  CT imaging may demonstrate a cervical spine fracture or intracerebral bleeding, but these results are not provided by the question stem.  A CT scan of the head without contrast (Choice B) is a reasonable test for this patient given his significant mechanism of injury and intoxication on exam.  However, both a CT scan of the head and cervical spine (Choice A) should be ordered due to the patient’s intoxication creating an unreliable physical exam.  Alcohol intoxication or drug use can alter a patient’s ability to sense pain and provide accurate information.  The presence of intoxication should always raise awareness for possible occult injuries. 

Of note, intoxication and altered mental status are indications to perform a CT scan of the cervical spine based on a well-validated decision-making tool known as the NEXUS criteria (National Emergency X-Radiography Utilization Study).  Other criteria on the NEXUS tool that support CT cervical spine imaging are midline spinal tenderness, the presence of a focal neurologic deficit, or the presence of a distracting injury (i.e., femur fracture). The Canadian C-Spine Rule and Canadian CT Head Rule are other validated decision-making tools to help a clinician decide on whether or not to order CT head or cervical spine imaging. Correct Answer: A

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #63," in International Emergency Medicine Education Project, November 12, 2021, https://iem-student.org/2021/11/12/question-of-the-day-63/, date accessed: October 2, 2022

Question Of The Day #62

627.15 - Figure 15 - lentiform epidural hematoma in the right hemisphere

Which of the following is the most likely diagnosis for this patient’s condition?

This patient presents to the Emergency Department after a high-speed motor vehicle accident.  On examination, he is tachycardic, mildly tachypneic, and has an altered mental status (somnolent).  The first step in evaluating this trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.

After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.  A noncontrast CT scan of the head is a reasonable test for this patient given his significant mechanism of injury and altered mental status on exam.  The CT scan shows a hyperdense (white) biconvex area on the right side of the brain.  This white area indicates the presence of fresh blood on the CT scan.  Keep in mind that CT scans are read as if you are looking up from the patient’s feet to their head.  This means left-right directionality is reversed.  See image below.

A hyperdense area with a sickled or crescent-shaped appearance would indicate an acute subdural hemorrhage (Choice A).  This is caused by tearing of the cerebral bridging veins.  Hyperdense areas throughout the brain tissue itself would indicate an intraparenchymal hemorrhage (Choice B).  Hyperdense areas around the sulci of the brain and a starfish appearance would indicate a subarachnoid hemorrhage (Choice D). Subarachnoid bleeding is caused by rupturing of a brain aneurysm or an arteriovenous (AV) malformation.  Subarachnoid bleeding can also be associated with trauma. 

This patient’s CT image shows an epidural hemorrhage (Choice C), indicated by the biconvex lens shaped area of blood.  This is caused by tearing of the middle meningeal artery.  Treatment of all types of intracranial bleeding involves general supportive care, airway management (i.e., endotracheal intubation for GCS < 8), elevating the head of the bed to 30 degrees to lower intracranial pressure (ICP), managing pain and sedation (lowers ICP), blood pressure maintenance (goal SBP <140mmHg), reversal of coagulopathy, neurosurgical evaluation for possible operative intervention, and providing ICP lowering treatments (mannitol or hypertonic 3% NaCl) when concerned about elevated ICP or brain herniation.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #62," in International Emergency Medicine Education Project, November 5, 2021, https://iem-student.org/2021/11/05/question-of-the-day-62/, date accessed: October 2, 2022

Question Of The Day #61

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the hospital after penetrating trauma to the right chest.  His initial examination reveals hypotension, tachycardia, tachypnea, and a low oxygen saturation.

All medical and trauma patients that arrive to the Emergency Department, especially those who are ill-appearing or with abnormal vital signs, should undergo the “ABCs”.  This is also known as the primary survey.  The primary survey aims to create a step-wise initial approach to patients where all life-threatening conditions are identified and treated early in the encounter with the patient.  The primary survey should be conducted prior to taking a full history.  In trauma patients, the primary survey is extended to include the “ABCDEFs”.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam.  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. 

Airway assessment involves checking for airway patency (clear voice, stridor, blood or vomitus in mouth, etc.) and applying cervical spine immobilization if needed.  Endotracheal intubation or a surgical airway may need to be placed during this step.  Breathing assessment involves auscultation of the lungs, checking the oxygen saturation, and providing supplemental oxygen to the patient if needed.  Abnormalities in the breathing exam (absent unilateral lung sounds, tracheal deviation, etc.) may prompt the placement of a chest tube or needle decompression.  It is during the breathing step that a pneumothorax, tension pneumothorax, or hemothorax is identified and treated.  Circulation assessment involves checking the heart rate and blood pressure, palpating all peripheral pulses, establishing IV access, and administering IV fluids or blood products.  It is during the circulation step that hemorrhage and shock is identified and controlled (pressure dressing applied to bleeding extremity wound, tourniquet applied to slow bleeding at amputated limb, etc.).  Disability assessment involves checking the patient’s neurologic status.  This involves calculating a GCS (Glasgow Coma Score), measuring the patient’s glucose level, and performing a focused neurologic exam.  Exposure involves removing all the patient’s clothes which may be obstructing view of other injuries.  This step involves rolling the patient to the lateral decubitus position to check the back and perineal areas for trauma.  The last step of the primary survey in trauma is the FAST exam (Focused Assessment with Sonography in Trauma).  The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. 

The question stem provides information regarding the airway of the patient, which is stated to be patent.  The next step in the “ABCDEFs” should be evaluation of the ‘Breathing’.  Administration of packed red blood cells (Choice A) is considered part of the “Circulation” assessment.  Removing the patient’s clothes to evaluate for occult injuries (Choice C) is important, but the “Breathing” assessment should be performed prior to the patient’s “Exposure” step.  Performing a FAST exam (Choice D) is also an important part of the primary survey, but it should be performed after the “Breathing” step is completed.  Auscultation of both lungs (Choice B) is the best next step, as this is part of the “Breathing” step after the “Airway” assessment.  During this step, the patient should be given supplemental oxygen and evaluated for abnormal or absent unilateral lung sounds.  This is important as this patient is at risk for a large pneumothorax, tension pneumothorax, or hemothorax after his penetrating trauma.   

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #61," in International Emergency Medicine Education Project, October 29, 2021, https://iem-student.org/2021/10/29/question-of-the-day-61/, date accessed: October 2, 2022

Focused Assessment with Sonography in Trauma (FAST): An Overview

Traumatic injuries are one of the leading causes of death, and intraperitoneal bleeds occur in approximately 12% of blunt traumas [1]. A quick assessment of trauma and detection of intraperitoneal fluid is increasingly essential in trauma patients’ assessment. The implementation of point-of-care ultrasound (POCUS) has had a significant impact on patient management, especially in a trauma setting. POCUS is easy to use at the bedside, non-invasive and inexpensive.

The Focused Assessment with Sonography in Trauma (FAST) is an ultrasound protocol used to assess hemoperitoneum and hemopericardium [2]. The FAST protocol is sensitive and specific for detecting intraperitoneal free fluid. According to previous studies, sensitivity ranges from 75-100%, and specificity ranges from 88-100% [3]. The FAST exam is rapid and can be completed in less than 5 minutes. It also has multiple advantages, including decreased time to interventions like surgery and length of stay at the hospital [4]. The Extended FAST (eFAST) protocol, which involves examinations of each hemithorax for hemothorax and pneumothoraces, has recently been introduced by several institutions [2].

Regions Examined

The FAST exam assesses the pericardium and multiple potential spaces within the peritoneal cavity for free fluid. The patient is often assessed in the supine position.

The right flank or right upper quadrant (RUQ) view assesses the hepatorenal recess (also known as Morrison’s pouch), as well as the right paracolic gutter, the hepato-diaphragmatic area, and the caudal edge of the left liver lobe [2]. The pericardial view, also known as the subcostal or the subxiphoid, is usually assessed next. The liver is commonly used as a sonographic window of the heart to evaluate pericardium. Ultrasound can detect little pericardial fluid with sensitivity and specificity approaching 100% [5]. The pericardial view also helps to differentiate between pleural and pericardial effusions and visualize right ventricular collapse during diastole [2]. Next, the left upper quadrant (LUQ) is used to visualize the splenorenal recess, the subphrenic space and the left paracolic gutter. If the eFAST protocol is being conducted, the RUQ and LUQ views are also used to examine the left and right hemithorax. Lastly, the pelvic or the suprapubic view is used to assess for free fluid in the rectovesical pouch in males and rectouterine and vesicouterine pouches in women [2]. The bladder acts as a sonographic window for this view.

Complications

While there are no complications related to the FAST exam itself, the use of ultrasound does have some limitations, one of which is the requirement for at least 150-200 cc of intraperitoneal fluid for an ultrasound to be able to detect. This can lead to false negatives when free fluid is in fact present [6]. False positives in the FAST exam may also occur and can be due to the presence of ascites, pre-existing pleural or pericardial effusions unrelated to the trauma, ruptured ovarian cysts or ruptured ectopic pregnancies [2]. Healthcare workers should be aware that POCUS and the FAST protocol have limitations dependent on the provider’s experience and the patient’s body habitus.   

Further Reading and Free Online Course

References

  1. Poletti, P. A., Mirvis, S. E., Shanmuganathan, K., Takada, T., Killeen, K. L., Perlmutter, D., Hahn, J., & Mermillod, B. (2004). Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?. The Journal of Trauma57(5), 1072–1081. https://doi.org/10.1097/01.ta.0000092680.73274.e1
  2. Bloom, B. A., & Gibbons, R. C. (2020). Focused Assessment with Sonography for Trauma. https://www.ncbi.nlm.nih.gov/books/NBK470479/
  3. Brenchley, J., Walker, A., Sloan, J. P., Hassan, T. B., & Venables, H. (2006). Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emergency Medicine Journal23(6), 446–448. https://doi.org/10.1136/emj.2005.026864
  4. Melniker, L. A., Leibner, E., McKenney, M. G., Lopez, P., Briggs, W. M., & Mancuso, C. A. (2006). Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Annals of Emergency Medicine48(3), 227–235. https://doi.org/10.1016/j.annemergmed.2006.01.008
  5. Mandavia, D. P., Hoffner, R. J., Mahaney, K., & Henderson, S. O. (2001). Bedside echocardiography by emergency physicians. Annals of emergency medicine38(4), 377–382. https://doi.org/10.1067/mem.2001.118224
  6. Von Kuenssberg Jehle, D., Stiller, G., & Wagner, D. (2003). Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. The American journal of emergency medicine21(6), 476–478. https://doi.org/10.1016/s0735-6757(03)00162-1
Cite this article as: Maryam Bagherzadeh, Canada, "Focused Assessment with Sonography in Trauma (FAST): An Overview," in International Emergency Medicine Education Project, September 20, 2021, https://iem-student.org/2021/09/20/sonography-in-trauma-fast/, date accessed: October 2, 2022