• Trauma is the leading cause of death in the first four decades of life.
• Of traumatic deaths, 50% occur immediately while 30% occur within one to a few hours after injury; this is known as the "golden hour" rule. Hemorrhagic shock is the leading cause of early death.

Initial assessment consists of a primary and secondary survey.

• Primary survey: Addresses the "ABCDE" – airway, breathing, circulation, disability, and exposure. Goal: Start resuscitation and control hemorrhage
  • Airway: Secure airway in an obtunded/comatose patient, GCS <8, or potential airway obstruction due to blood, facial fractures, etc.
  • Breathing: Determine adequacy of ventilation and respiratory quality. Look for cyanosis, retractions, stridor, flail chest, tracheal shift, breath sounds, subcutaneous emphysema
  • Circulation: Assess pulse rate, pulse pressure, BP, and peripheral circulation (capillary refill, temperature of extremity, color). Control hemorrhage and replace intravascular volume. Physiologic changes seen with degree of hemorrhage:
    • Stage 1 (<15% blood loss): Mild tachycardia (100–120 bpm); compensation with vascular constriction allows maintenance of BP, urine output, pulse pressure, respiratory rate, and mental status. Pallor may be noted, but capillary refill is generally normal.
    • Stage 2 (15–30%): Tachycardia, hypotension, decreased urine output, pulse pressure narrowing from rise in diastolic pressure, mild tachypnea, anxiety, sweating from sympathetic response, delayed capillary refill.
    • Stage 3 (30–40%): Classic signs of hypovolemic shock begin, including marked tachycardia (>120 bpm), hypotension, marked tachypnea (>30 bpm), altered mental status, sweating with cool, pale skin, worsening oliguria, delayed capillary refill.
    • Stage 4 (>40% blood loss): Weak pulse with severe tachycardia, severe tachypnea, dropping systolic BP (often <70 mm Hg), decreased level of consciousness, skin is sweaty, cool, and extremely pale, anuria.
• Secondary survey
  • Continue resuscitation
  • Continue search for, and repair of, potential injuries.
  • Perform lab tests and diagnostic studies. The serum hemoglobin and hematocrit are often not reliable indicators of acute blood loss (patients bleed whole blood).

• Neurological
  • Subdural/epidural hematoma
  • Cerebral contusion/concussion
  • Increased intracranial pressure (ICP) and imminent brain herniation
• Airway
  • Mandible, maxilla, larynx, trachea, dental trauma
• Respiratory
  • Pneumothorax (tension, hemothorax)
  • Pulmonary contusion
  • Acute respiratory distress syndrome (ARDS): Characterized by a PaO₂/FiO₂ ratio of <200 and patchy bilateral infiltrates on chest radiograph without evidence of cardiogenic etiology.
  • Diaphragmatic injury
  • Broken ribs: Ranges from a single rib to flail chest (several ribs broken in multiple places that results in paradoxical chest wall movements). Can result in pneumothorax or pulmonary contusion. Suspect severe mechanism of injury and other injuries whenever 1st rib fracture is seen.
  • Fat emboli from long bone fractures
• Cardiac
  • Shock is the clinical manifestation of decreased perfusion to end organs. It is characterized by hypotension, tachycardia, acidosis, large base-deficit, and increased serum lactate levels. Treatment includes fluids (crystalloids, colloids), blood products (packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate), vasopressors, and treatment of underlying cause (antibiotics for septic shock, blood for hemorrhagic shock). The endpoint of shock resuscitation is normalization of hemodynamic parameters, acidosis, lactate levels, and base-deficit.
  • Contusion: Can be associated with hypotension, leak of cardiac enzymes into serum, and dysrhythmias
  • Tamponade: If severe, can lead to Beck's triad (hypotension, distended jugular veins, and muffled heart sounds). Can see pulsus alternans on EKG and systolic BP drop by 10 mm Hg with deep inspiration (pulsus paradoxus)
• Vascular
  • Traumatic aortic dissection: Should be suspected whenever a widened mediastinum is seen on chest x-ray. Usually associated with severe deceleration injury pattern.
• GI
  • Aspiration of blood or gastric contents
  • Blunt/penetrating abdominal trauma
  • Abdominal compartment syndrome
  • Increased intestinal permeability
• Renal
  • Hematuria, urethral tract injury, bladder rupture
• Musculoskeletal
  • Fractures (open, closed)
  • Crush injuries
  • Compartment syndrome
  • Burns
• Inflammatory consequences. Major trauma has several inflammatory manifestations including severe tissue injuries, hemorrhagic shock, and ischemia-reperfusion consequences.
  • An uncontrolled inflammatory process may play a key role in the development of multiple organ dysfunction, resulting in an increase in post-traumatic delayed morbidity and mortality (1).
  • IL-6 levels increase and are sustained, representing a major determinant of the magnitude of the hypothalamic–pituitary–adrenal (HPA) axis responses, especially cortisol secretion to stressors (4).
  • Adrenocortical dysfunction and vasopressor dependency have been reported (2). Cardiovascular collapse can mimic septic shock. Cosyntropin stimulation testing can confirm the diagnosis and prevent unnecessary steroid administration (3). The cosyntropin stimulation test takes over an hour for results to be interpreted (baseline cortisol levels must be drawn and then compared to levels taken after 1 hour of injection of cosyntropin). In the OR, its applicability is limited; thus in extremis, where the BP is not responsive to vasopressors, adrenal insufficiency should be considered and treated with dexamethasone 10 mg IV (will not interfere with cosyntropin test) or preferably with hydrocortisone 100 mg.

• Depressed consciousness: Leads to hypoventilation, inability to protect airway, gastric aspiration, and limited history and physical exam that can lead to missed injuries.
• Premedication. Time permitting, nonparticulate antacid, H2 blocker, and/or metoclopramide should be considered.
• Monitors
  • Standard ASA monitors
  • Foley catheter
  • Peripheral nerve monitor
  • BIS monitor. Intraoperative awareness and recall can reach 43% in serious trauma compared with 11% is less serious cases (6).
  • ICP monitoring
    • Consider when mechanism of injury involves head trauma where cerebral edema and mass effect can lead to cerebral ischemia
    • Monitoring is important to establish hemodynamic parameters and institute medical/surgical treatments of elevated ICP to help prevent brain herniation
  • Initially, peripheral large bore IVs. Consider central access to aid with volume resuscitation or for additional IV access.
• Induction.
  • Preoxygenate with 3–5 large vital capacity breaths at an FIO₂ of 1.0 (or 5 minutes with tidal volume breathing).
  • IV induction is faster in patients with intravascular volume depletion and increased free concentration of drug (loss of plasma binding proteins). The induction agent needs to be chosen while considering the patient's overall volume status. Ketamine (sympathomimetic properties) and etomidate (stable hemodynamic parameters) are commonly chosen. Both, however, can cause hypotension in some situations; etomidate can impair adrenocortical function with a single induction dose.
  • Volatile anesthetics: Alveolar and brain concentrations increase quickly due to low cardiac output states.
  • Regional anesthesia: May be considered as a sole anesthetic in patients who have isolated orthopedic injuries or for postoperative analgesia. Prior to a neuraxial block placement, coagulation status should be assessed. Additionally, local anesthetics can block sympathetics and compound hypotension in already hypovolemic patients (5).
• Airway
  • No C-spine issues (gun shot or stabbing): Rapid sequence intubation with cricoid pressure and induction agent like succinylcholine or high-dose rocuronium.
  • C-spine injury should be suspected until proven otherwise in patients with altered levels of consciousness, tenderness to palpation or neck pain, distracting injury, neurological deficit, and intoxication.
    • Avoid neck hyperextension
    • Use jaw thrust maneuver for airway manipulation
    • Manual in-line stabilization to secure airway
    • Direct laryngoscopy may be difficult (prepare for Bullard scope, Airtraq, GlideScope, lightwand, intubating LMA, or fiberoptic bronchoscope)
    • Consider prepping and draping the neck for an emergent surgical airway prior to induction, if difficulty suspected
• Maintenance
  • Minimum alveolar concentration (MAC) in hypovolemic patients may be reduced by 25%.
  • IV scopolamine may be utilized for patients in extremis who cannot tolerate the hypotensive or sympatholytic effects of anesthetics. It is a good amnestic and has sedative properties.
• Hypothermia can result in coagulopathy and dysrhythmias as well as delayed emergence, decreased cardiac contractility, cold diuresis, impaired wound healing, and decreased metabolism of drugs
• Blood products
  • pRBC transfusion: Ideally transfuse type and crossed blood. If time does not permit, un-crossmatched O negative blood may be utilized
  • Complications of pRBC infusion: Hypothermia, hyperkalemia, allergic reaction, incompatibility, infection. Early transfusion (<24 hours from hospital admission) is also an independent risk factor for the development of ARDS (7).
  • Coagulopathy. Dilutional thrombocytopenia is the most common and should be considered whenever the blood volume that is transfused is equivalent to the patient's total blood volume. Coagulation factors also decrease during massive transfusion and contribute to coagulopathy. Transfusion should be guided by laboratory confirmed abnormalities.
  • Damage control resuscitation (DCR). A growing body of evidence shows that increased ratios of FFP:RBC and PLT:RBC transfusion improves survival in patients with severe hemorrhage. The optimal ratio remains unknown but "early and often" seems to be getting more attention to avoid coagulopathy, acidosis, and hypothermia (8).
• Always consider other undiagnosed injuries when hemodynamic parameters change for the worse or do not improve with resuscitation/surgery
• Intoxication
  • Acute alcohol ingestion can depress MAC, chronic alcohol abuse increases MAC, and risk of delirium tremens
  • Acute cocaine intoxication can cause hypertension and dysrhythmias.

Pregnancy Considerations

• Spinal Cord Injury
• Hypothermia
• Cocaine
• Blood Transfusion

• 958.4 Traumatic shock
• 959.9 Unspecified site injury

• T14.90 Injury, unspecified
• T79.4XXA Traumatic shock, initial encounter

Shreyas Bhavsar , DO