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As mentioned in the past, the entire concept of TEAM is for the participants of a trauma code to be expert in performing the primary and secondary survey. Trauma lll is the first portion of the primary survey. Trauma patients are assessed based upon established priorities. The priorities that have been stressed by the ACS Trauma department are the following:
• Degree of life threat
• Vital signs
• Mechanism of injury
Male or female, infant or geriatric patient, pregnant or celebrity, all categories of patients are treated the same. The goal is primary rapid evaluation with adjuncts and resuscitation of vital signs done simultaneously, followed by a detailed secondary survey and initiation of definitive care. The primary survey consists of the aforementioned ABCDE. As we observe each age group, there are focused areas that need to be addressed if we are to have successful resuscitation.
Children:
Trauma is the leading cause of death in children. One of the differences relates to our first priority – airway. When we examine a child, there are noticeable differences in their airway in that the larynx is cephaled and anterior and the trachea is short, making the intubation more difficult. This age group needs specific intubation equipment as well as the proper size endotrachial tube. According to PALS standards, in the in-hospital setting a cuffed ET tube is as safe as an uncuffed tube in infants. If the patient has poor lung compliance, high airway resistance or a large glottis air leak, a cuffed tube may be preferable. Determination of size has an accurate formula rather than more well known inaccurate approaches such as the diameter of the fifth finger. The formula for uncuffed ET tube is (the child’s age in years/4) + 4, while the formula for a cuffed tube is (age in years/4) + 3. We are looking at the mm diameter of the ET tube. Children have a vigorous physiological response; however, they have limited physiological reserve, therefore outcomes are dependent on early aggressive care. Children have a mobile mediastinum, which can result in a greater susceptibility for tension pneumothorax and pulmonary contusions. Worth mentioning here, and not found in the ATLS program, is the sensitivity of the entire team in dealing with the possibility of malignant hyperthermia. MH is more common in children and in first time general anesthetics, and if a depolarizing drug is to be used for an emergency surgical procedure, then it is essential for caregivers to be familiar with the protocols of MH and have a cart in the room for this eventuality. The only situation more terrifying than a severe pediatric trauma code is the addition of the unpredictable and lethal episode of MH. I would suggest that all trauma care givers have the opportunity to study the contents of a trauma cart and to become aware as to the contents. In particular, the pediatric trauma cart has different drugs, different doses, different supplies and equipment. I would also encourage that all participants take a PALS course as this will bring things home.
Special considerations with pregnancy:
Anatomy and physiology changes that accompany pregnancy will certainly modify our response to injury. It is important to take a fresh look at “Bates” and to determine based upon weeks of gestation just how high the uterus will be sitting in the abdominal cavity. There is an absolute need for fetal assessment by fetal monitor and the nurses are great to both remember and to do this; however, when we function on the team, we still need to maintain vigilance and to make this suggestion if someone has prioritized the victim and forgotten the fetus. It is clearly spelled out in the ATLS guidelines that the 1st priority is maternal resuscitation but knowledge of the fetal responses are still important and will affect the outcome of delivery in the future. As in all aspects of trauma, this situation requires early aggressive care.
We need to remember that there is a physiological anemia in this patient type that is created by an increase in plasma volume relative to RBC mass. Other considerations will include hyperventilation with low PCO2 , decreased gastric emptying, supine hypotension from compression of the vena cava by the uterus, the risk of Isoimmunization by the mother and extreme sensitivity to the placental circulation to maternal hypovolemia, which usually accompanies most trauma scenarios.
Special considerations for elders:
It is a real feat to be a member of this elite group of people, and their age has altered their response to trauma and medications because of multiple co-morbidities. This group has an increased possibility of heart disease, cancer, COPD and numerous other co morbidities as well as taking large doses of medications which all have side effects and contraindications. History is of great importance, and a list of medications can be crucial to their survival. Trauma is the leading cause of death in this sub-group with increased mortality rates in males. They have a diminished physiological reserve and response. Their medications aid the alteration of physiological response, and many may be on anticoagulants, to further create an emergency problem. The elderly require early invasive monitoring. During the primary survey, look and explore digitally for loose teeth, bridges and other appliances that can cause foreign body obstruction. This group, like all the others, needs early aggressive care to assure a positive outcome.
These are your patients in the trauma room, and all require a thoughtful and different approach, yet the essentials of the primary survey, ABCDE, always remain the same. Trauma IV will begin a deep look at the ABCs and additional knowledge.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
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