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Initial Evaluation of the Trauma Patient: Overview, Triage and Organization of Care, Initial Assessment
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Initial Evaluation of the Trauma Patient

Author: David J Dries, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF more...
Updated: Jan 31, 2014

Overview
The initial evaluation of a person who is injured critically from multiple trauma is a
challenging task, and every minute can make the difference between life and

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death.
Over the past 50 years, assessment of trauma patients has evolved because of an
improved understanding of the distribution of mortality and the mechanisms that
contribute to morbidity and mortality in trauma.
Mortality can be grouped into immediate, early, and late deaths. Immediate deaths
are caused by a fatal injury of the great vessels, heart, or neurologic system.[1]
Immediate mortality occurs at the scene of injury, as shown in the image below.

Immediate mortality in trauma occurs at the scene of the injury. Prevention of these deaths requires
a multidisciplinary public health systems approach. Courtesy of Kevin Kilgore, MD; Carson Harris,
MD; and David Hale, MD, Regions Hospital, St Paul, Minn.

Early deaths may occur from minutes to hours after the injury. These patients
frequently arrive at a hospital before death, which usually occurs because of
hemorrhage and cardiovascular collapse. Late trauma mortality peaks from days to
weeks after the injury and is primarily due to sepsis and multiple organ failure.
Organized systems for trauma care are focused on the salvage of a patient from
early trauma mortality, whereas critical care is designed to avert late trauma
mortality.[2, 3]
Early trauma deaths result from failed oxygenation of the vital organs, massive
central nervous system injury, or both. The mechanisms of failed tissue
oxygenation include inadequate ventilation, impaired oxygenation, circulatory
collapse, and insufficient end-organ perfusion. Massive central nervous system
trauma leads to inadequate ventilation and/or disruption of brainstem regulatory
centers. Injuries that cause early trauma mortality occur in predictable patterns
based on the mechanism of injury; the patient's age, sex, and body habitus; or
environmental conditions.
Recognition of these patterns led to the development of the Advanced Trauma Life
Support (ATLS) approach by the American College of Surgeons.[4] ATLS is the
standard of care for trauma patients, and it is built around a consistent approach to
patient evaluation. This protocol ensures that the most immediate life-threatening
conditions are quickly identified and addressed in the order of their risk potential.
The objectives of the initial evaluation of the trauma patient are as follows: (1) to
rapidly identify life-threatening injuries, (2) to initiate adequate supportive therapy,
and (3) to efficiently organize either definitive therapy or transfer to a facility that
provides definitive therapy.

Triage and Organization of Care

The objective of triage is to prioritize patients with a high likelihood of early clinical
deterioration. Triage of trauma patients considers vital signs and prehospital
clinical course, mechanism of injury, patient age, and known or suspected
comorbid conditions. Findings that lead to an accelerated workup include multiple
injuries, extremes of age, evidence of severe neurologic injury, unstable vital signs,
and preexisting cardiac or pulmonary disease.[5]
When performing a triage with patients who have different types of injuries, the
priorities of the primary survey (see Initial Assessment) help to determine
precedence (eg, a patient with an obstructed airway receives greater priority for
initial attention than a relatively stable patient with a traumatic amputation). In
trauma centers, a team of providers evaluates patients who are critically injured
and simultaneously performs diagnostic procedures (see the image below). This
parallel processing approach can dramatically reduce the time required to assess
and stabilize a patient with multiple injuries.[6]

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Trauma resuscitations involving simultaneous diagnosis and treatment by multiple providers

demand leadership and organization to function effectively. Courtesy of Kevin Kilgore, MD; Carson
Harris, MD; and David Hale, MD, Regions Hospital, St Paul, Minn.

The team approach to trauma is resource intensive[7] ; however, the available

personnel and resources can become overwhelmed quickly in nonhospital settings,
in smaller institutions, and in mass casualty situations. Under these conditions,
additional factors affect the triage process, including the number and skill levels of
available providers, the available equipment, and the provider's estimate of the
clinical probability of each patient's survival. The triage objective becomes how to
maximize the number of patients who are salvaged under the prevailing conditions.
This process can result in bypassing seriously injured patients until less critical
patients have been stabilized. Triage under conditions of limited resources is
difficult.[8]
Regardless of the clinical setting, the care team should be organized before patient
arrival. Leadership and unity of command are essential for directing a rapid and
efficient workup. In larger institutions with dedicated trauma services, general
surgeons form the core of the trauma team in close cooperation with the
emergency department staff. A physician from either service who is experienced in
the care of trauma patients serves as the team leader and directs evaluation and
resuscitation.
Additional physicians or midlevel providers are responsible for managing the
airway, conducting the primary and secondary surveys, and performing other
procedures as needed. Nurses and technicians monitor vital signs, gain
intravenous (IV) access, and obtain blood samples. Respiratory therapists and
radiology technologists should also be present. As consultants, neurosurgeons
and orthopedic surgeons must be available immediately to the trauma team. Early
consultation with a neurosurgeon is mandatory when significant central nervous
system injury is present. Specific procedures performed by both neurosurgeons
and orthopedists can be life saving.

Initial Assessment
[#target9]The initial evaluation follows a protocol of primary survey, resuscitation,
secondary survey, and either definitive treatment or transfer to an appropriate
trauma center for definitive care.[4] This approach is the heart of the ATLS system,
which is designed to identify life-threatening injuries and to initiate stabilizing
treatment in a rapidly efficient manner. Absolute diagnostic certainty is not
required to treat critical clinical conditions identified early in the process. When
resources are limited (eg, one clinician), do not perform subsequent steps in the
primary survey until after addressing life-threatening conditions in the earlier steps.

Primary survey
The steps of the primary survey are encapsulated by the mnemonic ABCDE
(airway, breathing, circulation/hemorrhage, disability, and exposure/environment).
The airway is the first priority. Assess it by determining the ability of air to pass
unobstructed into the lungs. Critical findings include obstruction of the airway due
to direct injury, edema, or foreign bodies and the inability to protect the airway
because of a depressed level of consciousness (see the image below). Treatment
simply may be secretion control with suctioning or may require endotracheal
intubation or placement of a surgical airway (eg, cricothyroidotomy (see the video
below), emergent tracheostomy).[9, 10]

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Establishment of a definitive airw ay may require emergency placement of a surgical airw ay w hen
facial trauma precludes orotracheal intubation. Courtesy of Kevin Kilgore, MD; Carson Harris, MD;
and David Hale, MD, Regions Hospital, St Paul, Minn.
Surgical cricothyroidotomy Seldinger. Video courtesy of Therese Canares, MD, and Jonathan
Valente, MD, Rhode Island Hospital, Brow n University.

Next, evaluate the breathing to determine patient ability to ventilate and oxygenate.
Critical findings include the absence of spontaneous ventilation, absent or
asymmetric breath sounds (consistent with either pneumothorax or endotracheal
tube malposition), dyspnea, hyperresonance or dullness to chest percussion
(suggesting tension pneumothorax or hemothorax), and gross chest wall instability
or defects that compromise ventilation (eg, flail chest, sucking chest wound). Treat
pneumothorax, hemothorax, tension pneumothorax, and sucking chest wounds
with a tube thoracostomy. Initial treatment for a flail chest is mechanical
ventilation, which frequently is required for other injuries associated with ventilation
and oxygenation deficits.
Evaluate the circulation by identifying hypovolemia, cardiac tamponade, and
external sources of hemorrhage. Inspect neck veins for distension or collapse,
determine whether the heart tones are auscultated, and determine whether the
external hemorrhage is identified and controlled. Initiate treatment of hypovolemia
by rapidly infusing a lactated Ringer solution via 2 large-bore, peripheral, IV
catheters. Place them preferentially in the upper extremities. Treat cardiac
tamponade by pericardiocentesis, or place a subxiphoid pericardial window,
followed immediately by surgery to explore and repair the source of bleeding.[11]
Control any external bleeding with direct pressure or surgery.
Determine the disability of the patient by performing gross mental status and motor
examinations. Determine whether a serious head or spinal cord injury exists.
Assess the gross mental status using the Glasgow Coma Scale (see the Glasgow
Coma Scale calculator). Examine the pupils for size, symmetry, and reactiveness
to light. Obtain an early assessment of spinal cord injury by observing
spontaneous movement of the extremities and spontaneous respiratory effort.
Pupillary asymmetry or dilation, impaired or absent light reflexes, and hemiplegia
or weakness suggest impending herniation of the cerebrum through the tentorial
incisura due to an expanding intracranial mass or diffuse cerebral edema.[12] These
findings indicate the need for emergency treatment of intracranial hypertension,
including administration of IV mannitol, hypertonic saline, sedatives, and muscle
relaxants, after obtaining a definitive airway. Urgent neurosurgical consultation is
mandatory.
In the absence of a depressed level of consciousness, paraplegia or quadriplegia
indicates spinal cord injury. Possibility of a spinal cord injury requires full spinal
immobilization. If inspiratory efforts are weak or when a high cervical cord lesion is
suspected, perform an endotracheal intubation.[13, 14]
The final step in the primary survey includes patient exposure and control of the
immediate environment. Completely remove patient clothes for a thorough physical
examination. Simultaneously, initiate treatment to prevent hypothermia, a condition
that is frequently iatrogenic in the exposed patient in an air-conditioned emergency
department. Treat prophylactically with the administration of warmed IV fluids,
blankets, heat lamps, and warmed air-circulating blankets as needed.

Other procedures
Perform several monitoring and diagnostic adjuncts in concert with the primary
survey.[4] Place ECG and ventilatory monitoring leads, and start continuous pulse

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oximetry as soon as possible. Monitors provide data that are critical to guiding
resuscitation. If the patient requires an artificial airway, perform a gastric intubation
to decompress the stomach and to lessen the likelihood of aspiration of gastric
contents. During the resuscitation phase, insert a urinary catheter to facilitate
measuring the response to fluid resuscitation. Placement of a Foley catheter is
contraindicated if urethral injury is evident. Signs of urethral injury include blood at
the meatus, ecchymosis in the scrotum or labium majora, or a high-riding prostate,
which can be identified during a rectal examination. Any of these findings mandate
a retrograde urethrogram to exclude urethral injury prior to bladder catheterization.

Resuscitation and Comprehensive Assessment

Resuscitation Phase
During the primary survey, when making diagnoses and performing interventions,
continue until the patient condition is stabilized, the diagnostic workup is
complete, and resuscitative procedures and surgeries are complete. This ongoing
effort involves monitoring patient vital signs, protecting the airway with assisted
ventilation and oxygenation as required, and providing resuscitation with IV fluids
and blood products.
Patients with multiple injuries may require several liters of crystalloid over the first
24 hours to sustain intravascular volume, tissue and vital organ perfusion, and urine
output. Administer blood for hypovolemia, which is unresponsive to crystalloid
bolus.[15] If ongoing blood loss is not controlled by direct pressure and transfusion
with blood or blood products, surgery or imaging-based procedures may be
required to attain hemostasis. The endpoints of resuscitation are normal vital
signs, absence of blood loss, adequate urine output (0.5-1 cc/kg/h), and no
evidence of end-organ dysfunction. Parameters, such as blood lactate levels and
base deficit on an arterial blood gas, may be helpful with patients who are severely
injured.[16]
An abundance of standard vital sign data guides evaluation and resuscitation of the
injured patient.
The Committee on Trauma for the American College of Surgeons has long
published categories of shock that allow the clinician to predict the likelihood of
significant blood loss and to anticipate the type and amount of fluid
requirements.[4]
The shock classification, as shown in the Table below, allows the clinician to
characterize the patients response to injury, as blood loss associated with injury
progresses, mental status deteriorates, heart rate increases, blood pressure falls,
and oliguria is apparent.[4] The patient with persistent vital sign evaluation
suggesting hypotension is at significant risk for loss of 30-40% of blood volume on
presentation.
Table. Estimated Fluid and Blood Losses Based on Patients Initial Presentation[4]
(Open Table in a new window)
Class I

Class II

Class III

Class IV

Up to 750

750-1500

1500-2000

>2000

Blood Loss (% blood

Up to 15%
volume)

15-30%

30-40%

>40%

Pulse Rate

< 100

>100

>120

>140

Blood Pressure

Normal

Normal

Decreased

Decreased

Pulse Pressure (mm Normal or

Hg)
increased

Decreased Decreased

Decreased

Respiratory Rate

14-20

20-30

30-40

>35

Urine Output (mL/h)

>30

20-30

5-15

Negligible

CNS/Mental Status

Slightly
anxious

Mildly
anxious

Anxious,
confused

Confused,
lethargic

Fluid Replacement
(3:1 rule)

Crystalloid

Crystalloid

Crystalloid and Crystalloid and

blood
blood

Blood Loss (mL)

Secondary Survey
Formally begin this survey after completing the primary survey and after starting
the resuscitation phase. At this time, identify all injuries by conducting a thorough
head-to-toe examination.
Review the patient's vital signs, and perform a quick repeat of the primary survey to
assess patient response to the resuscitation effort and to identify any deterioration.
Then, review the patient's history, including reports from prehospital personnel and
from family members or other victims.

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If the patient is able or other information sources are available, collect critical data,
including preexisting medical problems, current medications and allergies, tetanus
immunization status, time of last meal, and events surrounding the injury. These
data assist with focusing the secondary survey by identifying the mechanism of
injury, the likelihood of cold or heat injury, and the patient's general physiologic
status.

Subsequent Physical Examination

The dictum "fingers or tubes in every orifice" guides this examination.
Examine each region of the body for signs of injury, bony instability, and
tenderness to palpation.
Evaluate the head and face for maxillofacial fractures, ocular injury, and an open or
closed head injury, including a basilar skull fracture.

Periorbital ecchymosis, or "raccoon eyes," is a classic diagnostic sign of basilar skull fracture.
Courtesy of Kevin Kilgore, MD; Carson Harris, MD; and David Hale, MD, Regions Hospital, St Paul,
Minn.

Perform a detailed cranial nerve examination as part of a thorough neurologic

evaluation.
Inspect the neck anteriorly for evidence of airway or great vessel injury, and palpate
posteriorly for bony abnormality or tenderness suggestive of cervical spine injury.
In patients with blunt trauma and patients with an unknown mechanism of injury
(eg, "found down"), observe full spine precautions until injury to the spinal column
is excluded.

Chest examination
Palpate the chest wall for tenderness, instability, or crepitation, followed by
auscultation of the lungs and heart.
In the patient with penetrating trauma, perform a thorough search for additional
entry or exit wounds, including examining the axillae and back.
Assess chest tubes for output and air leaks, and use the portable chest x-ray to
evaluate for bony abnormalities, persistent pneumothorax, evidence of mediastinal
injury, and placement of tubes and lines.

Abdomen and pelvis examination

Inspect the abdomen for distension or other evidence suggesting gross intraabdominal bleeding or injury.
In patients with penetrating trauma, locally explore low-velocity wounds to
determine if the muscular fascia is penetrated.
Urgently explore high-velocity penetrating injuries in the operating room.
Palpate the iliac crests once for instability to detect significant pelvic fractures.
Use a portable anteroposterior (AP) radiograph to aid in detecting these fractures.
If a fracture is diagnosed, avoid additional manipulation of the pelvis to prevent
exacerbation of pelvic bleeding, which is notoriously difficult to control.[17]
Inspect for evidence of bleeding (ecchymosis) on the perineum, gross blood on the
vaginal and rectal examinations, and urethral injury, followed by placement of a
Foley catheter.
In patients with a suspected spinal cord injury, record the anal sphincter motor
tone.

Extremity evaluation
In this evaluation, identify long bone fractures that require stabilization, may cause
vascular compromise, and show evidence of a major nerve injury.
Perform plain x-ray films to identify deformity, tenderness, or instability.
Conduct temporary splint stabilization prior to moving the patient from the
emergency department.

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Immediately act on any evidence of vascular compromise, since ischemic injury to

an extremity can become irreversible in hours.

Neurologic examination
The elements of the neurologic examination frequently are completed during the
regional portions of the secondary survey; however, include a formal assessment of
the spine to complete the neurologic assessment.
Log roll the patient with inline stabilization of the head and neck.
Inspect the entire spine from the occiput to the sacrum for bony abnormalities,
deformities, and tenderness. At the same time, perform a detailed survey of the
back to identify penetrating injuries, ecchymoses, or other injuries. Back injuries
frequently are missed.

Imaging and Laboratory Studies

Radiographic imaging studies provide crucial diagnostic data that guide the initial
evaluation. The sequence and timing of these studies are important. Stage the
imaging studies so that lifesaving interventions identified in the primary survey and
resuscitation phases are not impeded. Also, ensure that the patient is
hemodynamically stable enough for transfer to the radiology suite.

Anteroposterior radiographs
The AP chest radiograph is the most common imaging study performed on trauma
patients. It can be easily obtained during the resuscitation phase, and it provides
information on the presence of a hemothorax, pneumothorax, or pulmonary
contusion. The AP chest radiograph also aids in the placement of chest and
endotracheal tubes, which are critical to the resuscitation effort and the primary
survey.[18]

This chest radiograph demonstrates bilateral pulmonary contusions in a trauma patient. Courtesy of
Kevin Kilgore, MD; Carson Harris, MD; and David Hale, MD, Regions Hospital, St Paul, Minn.

For patients with blunt trauma, a portable AP pelvis film can easily be obtained
during the resuscitation phase. This film can help confirm the presence of
significant pelvic fractures (as depicted in the image below), which are often the
sites of hemorrhage that require external fixation and/or angiographic embolization
for control.

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The anteroposterior pelvis radiograph quickly helps identify major pelvic fractures and joint
disruptions. Courtesy of Kevin Kilgore, MD; Carson Harris, MD; and David Hale, MD, Regions
Hospital, St Paul, Minn.

Focused abdominal sonogram

The focused abdominal sonogram for trauma (FAST) complements the portable
chest and pelvis films.[19] A trauma clinician who has been formally trained in the
technique quickly and easily performs this portable ultrasound examination in the
trauma resuscitation room. It is used to identify free fluid in the peritoneal cavity,
pericardial effusion, hemothorax, and pneumothorax.[19] Because of its speed,
sensitivity, and noninvasive character, FAST largely has supplanted other
techniques for rapid assessment of unstable trauma patients. This technique
requires a major commitment to attain proficiency; therefore, it is not frequently
used outside of major trauma centers.[20, 21]
Generally, do not perform diagnostic studies if the capability to act on the
information gained is not immediately present. For example, patients with blunt
trauma initially transported to small rural emergency departments frequently have
indications for advanced imaging. If an appropriately trained surgeon is not present
in the institution, then these studies are of questionable value, since they may
delay the transfer of the patient to a trauma center. Consequently, stage imaging
studies and prioritize them based on patient stability, the practical utility of the
data to be obtained, and the imperative need for early transfer to obtain definitive
care.

CT scan
The CT scan is the definitive radiographic study in most patients with trauma. CT
imaging of the abdomen, pelvis, chest, cervical spine, and head is the most
sensitive and accurate noninvasive diagnostic tool for identifying major injury.
Bedside assessment of blunt traumatic injury was recently evaluated to assess
the impact of CT scans.[22] Bedside evaluation was effective in ruling out serious
injuries in patients with low risk of serious injury. Overall diagnostic accuracy of
bedside assessment was low, however, suggesting that CT be utilized in highacuity patients to avoid missing injuries.[22, 23]
Over reliance on CT imaging can be detrimental if emergent operations are
delayed. One review of patients presenting with hypotension (systolic BP < 90 mm
Hg) and significant abdominal injury demonstrated greater mortality if surgery was
delayed by a CT scan.[24] Excessive radiation exposure is also a concern.[25]

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CT scan of the abdomen identifies significant soft tissue injury w ith high sensitivity and specificity.
A traumatic liver laceration due to blunt trauma w ith rib fragment penetration into the liver
parenchyma is show n. Courtesy of Kevin Kilgore, MD; Carson Harris, MD; and David Hale, MD,
Regions Hospital, St Paul, Minn.

Obtain a CT scan of the head to identify intracranial bleeding (as seen in the image
below) and to guide neurosurgical intervention.[26] Obtain a head CT scan for
trauma without IV contrast, and perform it first when indicated, prior to the injection
of an IV contrast for abdominal and pelvic scans. Many centers scan the cervical
spine at the same setting in patients receiving CT evaluation of the head.

The head CT scan for trauma identifies space-occupying lesions and directs operative evacuation.
The lenticular shape of this lesion identifies it as an epidural hematoma. Courtesy of Kevin Kilgore,
MD; Carson Harris, MD; and David Hale, MD, Regions Hospital, St Paul, Minn.

Obtain a CT scan of the chest to evaluate mediastinal injuries.[27] CT scanning is

replacing aortography as the state-of-the-art study for imaging mediastinal vascular
structures, particularly the aorta.[28] CT scanning is also more sensitive than AP
chest radiography in the detection of pneumothorax, rib fractures, pulmonary
contusion, and hydrothorax. For most patients with trauma, CT scans of the head,
chest, abdomen, and pelvis are sufficient to guide operative and nonoperative
management of injuries in their respective regions of the body.[29]
CT scans of the abdomen and pelvis usually are performed together, using both IV
and oral contrast.[30] Use this study to identify injuries to abdominal and pelvic
organs and to identify bleeding in the retroperitoneum and pelvis.
As the quality of CT scans continues to increase, the role of angiography
continues to focus to a greater degree on interventions rather than on diagnosis.[31]
A growing volume of data supports the aggressive use of CT scanning in the
evaluation of blunt trauma.[32, 33] For example, abdominal injury becomes more
likely with velocity changes of greater than 20 km/h. Extremes of age or extremity,
head, or spine injuries are predictive of abdominal trauma as well. The absence of
coincident injury decreases the risk of abdominal injury.[34] One review of aortic
injuries reveals an increased risk with lateral impacts and lack of seatbelt use.
Associated injuries were poor predictors.[35]

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Several reports from major trauma centers emphasize the value of CT scanning to
evaluate penetrating torso injuries. Patients requiring hospitalization or extended
periods of observation in the emergency department may now be sent home with a
late generation CT scan that demonstrates the benign track of a bullet wound or
stabbing injury.[36, 37, 38, 39] With increasing resolution, even small bowel and
mesenteric injuries are now readily identified. These injuries were previously
difficult to detect and can be a source of late morbidity for patients.[40]
A practice of early comprehensive multislice CT is rapidly evolving in urban trauma
centers. This use of advanced CT technology leads to a more accurate and faster
diagnosis with a reduction in resource utilization. Whether increasing radiation
exposure with the use of advanced CT technology will become a clinical and social
issue is unclear.

Spine evaluation
CT scanning is replacing plain radiographs in many patients being evaluated for
spine trauma.[41, 42] Current scanners offer the capability to reconstruct spine
images at the same time that scans are obtained of the chest, abdomen, and
pelvis.[43] Many clinicians will scan the cervical spine in patients with other
indications for scans of the head or the head and torso. Orthopedic and
neurosurgical consultants are making increased use of CT in evaluation of the
spine.
Obtain plain x-ray films of the spine in patients with high-energy blunt trauma and
in other trauma patients with known or suspected neurologic deficits if CT scanning
is unavailable or if a complimentary image is desired.[44]
For patients with a low likelihood of spinal injury, defer most or all of the spinal
radiograph series until the resuscitation phase is well underway and, if necessary,
after performing a lifesaving emergent laparotomy, craniotomy, or other operations.
If a greater-than-routine need to exclude cervical spine injury exists, perform a
portable lateral cervical spine (C-spine) film during the resuscitation phase. An
adequate lateral C-spine x-ray (eg, visualizing from the skull base to T1) helps
identify most C-spine fractures and subluxations. Ultimately, a full C-spine series
(ie, AP, lateral, and odontoid views) must be performed to exclude injury, and
virtually all trauma clinicians will request CT if any doubt exists.
The Advanced Trauma Life Support curriculum points out that, with identification of
a cervical spine fracture, the likelihood of another break in the spinal column is
10%. Controversy exists whether complete CT imaging is sufficient to rule out
cervical spine injury. If the patient cannot cooperate with a physical examination to
allow an assessment of ligamentous stability, many centers will perform MRI to
rule out ligamentous injury of the cervical spine, even if high-quality, multislice,
multidetector CT images fail to identify this injury.
For patients with a neurologic deficit but negative plain films and CT scans
(formerly called spinal cord injury without radiographic abnormality), conduct an
MRI of the spinal column and nerve roots. An MRI is the most sensitive method for
detecting this type of soft tissue injury, although CT scanning has become the
standard for acute evaluation of the vast majority of spinal column injuries.[14, 21,
45]

Angiography
Angiography can be both a diagnostic procedure and a therapeutic procedure, and
it is valuable in selected trauma patients. The most common indication for
emergent angiography in trauma is to identify and control arterial bleeding from
pelvic fractures or in the retroperitoneum. Contemplate emergent thoracic aortic
angiography when plain x-ray films or a CT scan of the chest reveals evidence of
atypical mediastinal bleeding. CT is now the diagnostic modality and stent grafting
the treatment for blunt aortic injury.[46, 47, 48] In aortic injury, angiography is the
historical standard for diagnosis and operative planning.[48] With suspected
bleeding in the retroperitoneum and pelvis, an angiographic embolization often is
quicker and safer than surgical approaches in these difficult difficult-to-access
areas; however, this is only true with arterial bleeding, while the more common
case of venous bleeding remains a difficult management problem.[46]
Angiography also facilitates nonoperative management of injury to the liver, spleen,
and kidney following blunt trauma. Specific criteria for angiography and
embolization have not been agreed upon.[49] A CT scan of the abdomen with
intravenous contrast frequently demonstrates areas of active bleeding, which may
be targeted by the interventional radiologist in the patient who is sufficiently stable
to tolerate the time delay required to obtain angiography and organ-specific
embolization of bleeding points.

Lab studies during the initial evaluation

The most important lab study is the type and crossmatch, which often can be
completed within 20 minutes of receipt of the blood sample.

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Arterial blood gases are also useful in the initial assessment period, although their
use for serial monitoring has declined since the introduction of continuous pulse
oximetry.
A baseline hemoglobin or hematocrit determination is useful on arrival, with the
understanding that in acute hemorrhage, a fall in hematocrit may not be apparent
until autogenous mobilization of extravascular fluid or administration of IV
resuscitation fluids commences.
Urine screens for drugs of abuse commonly are ordered in trauma centers. For
similar reasons, check blood alcohol and glucose levels to identify correctable
causes of a decreased level of consciousness. A recent review from the data of the
National Trauma Data Bank of the United States reveals a disturbing decline in
substance use screening, despite the importance of substance use as a
contribution to injury.[50] Early hyperglycemia has been linked to an increased risk
of infectious complications and mortality after injury.[51]
For most trauma patients, serum electrolytes, coagulation parameters, cell blood
counts, and other common laboratory studies are less useful during the first 1-2
hours than they are after stabilization and resuscitation.

Special Injuries
The foregoing discussion is applicable to most trauma patients with either blunt
trauma or penetrating trauma; however, patients with burns, cold injuries, and
electrical injuries have special considerations that must be addressed during the
initial assessment and resuscitation.

Burns
An early imperative is to stop the burning process, especially in the case of
chemical burns, in which the continued contact of the agent with the patient's skin
may not be readily apparent. This process may require repeated testing of the
patient's skin, specific chemical neutralization, and extensive lavage of the affected
areas. If full thickness burns of an extremity or the thorax are suspected,
escharotomies may be required to prevent compartment syndrome and impaired
ventilation, respectively.[52]
If the clinical history or the physical examination suggests that upper airway burns
or inhalation injury may be present, then early intubation and mechanical
ventilation are indicated.
Finally, patients with large burns require large volumes of IV crystalloid
resuscitation fluids. While this resuscitation can be delayed briefly while
performing lifesaving interventions, early commencement is beneficial.

Cold injuries
The dominant imperative is rewarming, particularly in the case of systemic
hypothermia, but it is equally applicable to cold injuries to the extremities (eg,
frostbite).[53] While mild hypothermia is managed as described above for the
primary survey (see Primary survey in Initial Assessment), treat severe cold
injuries with immersion in water warmed to 40C. Administer IV fluids only as
indicated, based on the patient's physiologic status (not on the wound size). In the
case of severe hypothermia with cardiac arrest and/or apnea, do not stop
resuscitation efforts until the patient is rewarmed thoroughly.[54]

High-voltage electrical injuries

Although sometimes considered as burn injuries, high-voltage electrical injuries
(eg, lightning strikes, power lines) present a different set of problems.[52] First,
much of the tissue injury from electrical injuries may not be apparent on physical
examination. Massive myonecrosis and damage to both soft tissue and bone may
be concealed beneath normal-appearing skin between the entrance and exit
wounds; therefore, maintain a low threshold for measurement of compartment
pressures and performance of decompressive fasciotomies. Carefully and
continuously monitor the urine output for evidence of myoglobinuria, which can lead
to acute renal failure if untreated. Likewise, provide continual cardiac monitoring to
the patient because of the risks of direct myocardial injury and hyperkalemia
arising from myonecrosis.

Perils, Pitfalls, and Controversies

A sudden, expected deterioration of an initially stable patient is a common problem
encountered during the care of multiple trauma patients. This situation is
especially problematic after performing thorough primary and secondary surveys
and instituting a resuscitation plan. The solution to these crises lies in the ABCs
(airway, breathing, and circulation) of the primary survey.[55]
Injuries can evolve from subclinical to clinically apparent over the course of a rapid
trauma workup, and even the best diagnostic workup is not perfect; therefore, it is

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trauma workup, and even the best diagnostic workup is not perfect; therefore, it is
necessary to ensure that the airway is clear, that ventilation is adequate, and that
the blood pressure and end-organ perfusion are sufficient. By rapidly rechecking
the elements of the primary survey first, easily corrected problems (eg,
malpositioned endotracheal tubes, tension pneumothorax, unsuspected
hemorrhage) can be rapidly identified and addressed.
Nevertheless, the survey may miss injuries, especially in seriously injured patients
who require intensive resuscitative and/or surgical procedures to stabilize. This
tendency is exacerbated by the focused priorities of the primary survey and
resuscitation phase. A simple remedy for this problem is frequent and thorough
reassessment. Perform a formal tertiary survey within 18-36 hours after admission.
It consists of a thorough head-to-toe examination in conjunction with a review of all
laboratory data and imaging studies obtained since admission. While the tertiary
survey does not reduce the incidence of injuries missed during the primary and
secondary surveys, it decreases their morbidity and mortality by earlier
identification and treatment.
A difficult aspect of treating multiple trauma patients is prioritizing between
competing injuries in the same patient. The 3 examples that follow illustrate
clinical dilemmas in decision making faced by surgeons caring for trauma victims.

Patient 1
A relatively straightforward example is an individual with a posterior dislocation of
the knee joint and concomitant vascular compromise below the knee. In this case,
the competing interests are the orthopedic repair of the knee joint versus the repair
of damaged vessels, presumably including the popliteal artery. Although a
disrupted knee joint is clearly an urgent problem, especially if the joint space is
open, the short viability of a devascularized limb (3-4 h) and the increasing risk of
compartment syndrome with increasing time of ischemia are the paramount
issues. Therefore, vascular repair usually is performed first, followed by the
orthopedic repair.

Patient 2
A more difficult dilemma occurs in the unstable hypotensive patient with abdominal
and head injuries. The need for operative exploration and control of abdominal
hemorrhage must be balanced against the need for a head CT scan to identify and
localize potentially fatal intracranial mass lesions for neurosurgical drainage. A rule
of thumb in situations such as these is that blunt head trauma alone usually does
not cause hypotension, and hypovolemia is the probable culprit. Preserving the
blood pressure and cerebral perfusion is essential to prevent secondary brain
injury; thus, measures to control hypotension and intra-abdominal bleeding often
are prioritized earlier than head injuries, which are prognostically more serious.

Patient 3
A final example lies in the timing of operative versus angiographic treatment of
blunt pelvic trauma with known or suspected hemorrhage from pelvic fractures. The
safety and efficacy of angiographic embolization must be balanced against the
knowledge that most causes of pelvic hemorrhage are venous in origin and,
therefore, are not amenable to angiographic embolization. Furthermore, the
resuscitation of the unstable patient is much more difficult in the angiography suite
than in the ICU. No simple rules apply, and only the good judgment of the senior
clinician responsible for the patient can identify the best approach in each case.

Contributor Information and Disclosures

Author
David J Dries, MD MSE, FACS, FCCP, Master FCCM, Professor of Surgery and Anesthesiology, John F
Perry, Jr, Chair of Trauma Surgery, University of Minnesota Medical School; Assistant Medical Director for
Surgical Care, HealthPartners Medical Group
David J Dries, MD is a member of the following medical societies: Alpha Omega Alpha, American College of
Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, Chicago
Medical Society, Illinois State Medical Society, Eastern Association for the Surgery of Trauma, Wound Healing
Society, Surgical Infection Society, Air Medical Physician Association, American Association for the Surgery of
Trauma, American Burn Association, American College of Chest Physicians, American College of Critical Care
Medicine, American Thoracic Society, Association for Academic Surgery, Phi Beta Kappa, Shock Society,
Society of Critical Care Medicine, Society of University Surgeons
Disclosure: Nothing to disclose.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate
Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital

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Initial Evaluation of the Trauma Patient: Overview, Triage and Organization of Care, Initial Assessment

and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics,
American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons
Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received
income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear
($1,500).
Chief Editor
John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of
Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School
of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American
Gastroenterological Association Fellow
John Geibel, MD, DSc, MSc, AGAF is a member of the following medical societies: American
Gastroenterological Association, American Physiological Society, American Society of Nephrology,
Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences,
Society for Surgery of the Alimentary Tract
Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for
consulting.
Additional Contributors
Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System,
Dallas
Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American
Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, Texas Medical
Association
Disclosure: Nothing to disclose.

References
1. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S.
than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier
surgery and further research. Sci Am. 1983 Aug. 249(2):28-35. [Medline].
2. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths:
a reassessment. J Trauma. 1995 Feb. 38(2):185-93. [Medline].
3. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive
transfusion in trauma: simple as ABC (assessment of blood consumption)?. J Trauma. 2009 Feb.
66(2):346-52. [Medline].
4. American College of Surgeons. Advanced Trauma Life Support Program for Physicians. 9th ed. Chicago,
IL: 2012.
5. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation
of the effect of trauma-center care on mortality. N Engl J Med. 2006 Jan 26. 354(4):366-78. [Medline].
6. Codner PA, Brasel KJ. Initial assessment and management. Mattox KL, Moore EE, Feliciano DV.
Trauma. 7th ed. McGraw-Hill; 2013. 154-66.
7. Soreide K. Strengthening the trauma chain of survival. Br J Surg. 2012 Jan. 99 Suppl 1:1-3. [Medline].
8. Hick JL, Hanfling D, Burstein JL, DeAtley C, Barbisch D, Bogdan GM, et al. Health care facility and
community strategies for patient care surge capacity. Ann Emerg Med. 2004 Sep. 44(3):253-61.
[Medline].
9. Glick DB, Cooper RM, Ovassapian A. The Difficult Airway. An Atlas of Tools and Techniques for Clinical
Management. New York: Springer; 2013.
10. Salvino CK, Dries D, Gamelli R, Murphy-Macabobby M, Marshall W. Emergency cricothyroidotomy in
trauma victims. J Trauma. 1993 Apr. 34(4):503-5. [Medline].
11. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003 Aug 14. 349(7):684-90. [Medline].
12. Swadron SP, LeRoux P, Smith WS, Weingart SD. Emergency neurological life support: traumatic brain
injury. Neurocrit Care. 2012 Sep. 17 Suppl 1:S112-21. [Medline].
13. Seder DB, Riker RR, Jagoda A, Smith WS, Weingart SD. Emergency neurological life support: airway,
ventilation, and sedation. Neurocrit Care. 2012 Sep. 17 Suppl 1:S4-20. [Medline].
14. Stein DM, Roddy V, Marx J, Smith WS, Weingart SD. Emergency neurological life support: traumatic
spine injury. Neurocrit Care. 2012 Sep. 17 Suppl 1:S102-11. [Medline].
15. Cotton BA, Gunter OL, Isbell J, Au BK, Robertson AM, Morris JA Jr, et al. Damage control hematology:
the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma. 2008
May. 64(5):1177-82; discussion 1182-3. [Medline].
16. Tisherman SA, Barie P, Bokhari F, Bonadies J, Daley B, Diebel L, et al. Clinical practice guideline:
endpoints of resuscitation. J Trauma. 2004 Oct. 57(4):898-912. [Medline].

emedicine.medscape.com/article/434707-overview

17/19

10/26/16

Initial Evaluation of the Trauma Patient: Overview, Triage and Organization of Care, Initial Assessment

17. Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L. Pelvic fractures: epidemiology
and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002 Jul. 195(1):1-10.
[Medline].
18. Moskowitz H. I.C.U. Chest Radiology. Principles and Case Studies. New Jersey: Wiley-Blackwell; 2010.
19. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for
the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998 Oct. 228(4):55767. [Medline]. [Full Text].
20. Dente CJ, Rozycki GS. Surgeon-performed ultrasound in acute care surgery. Mattox KL, Moore EE,
Feliciano DV. Trauma. 7th ed. New York: McGraw-Hill; 2013. 301-321.
21. Vachha BA, Tsai LL, Lee KS, Camacho MA. Diagnostic imaging in acute care surgery. Britt LD,
Peitzman AB, Barie PS, Jurkovich GJ. Acute Care Surgery. Philadelphia: Lippincott Williams & Wilkins;
2012. 104-26.
22. Smith CB, Barrett TW, Berger CL, Zhou C, Thurman RJ, Wrenn KD. Prediction of blunt traumatic injury in
high-acuity patients: bedside examination vs computed tomography. Am J Emerg Med. 2011 Jan. 29(1):110. [Medline].
23. Kimura A, Tanaka N. Whole-body computed tomography is associated with decreased mortality in blunt
trauma patients with moderate-to-severe consciousness disturbance: a multicenter, retrospective study. J
Trauma Acute Care Surg. 2013 Aug. 75(2):202-6. [Medline].
24. Neal MD, Peitzman AB, Forsythe RM, Marshall GT, Rosengart MR, Alarcon LH, et al. Over reliance on
computed tomography imaging in patients with severe abdominal injury: is the delay worth the risk?. J
Trauma. 2011 Feb. 70(2):278-84. [Medline].
25. Sise MJ, Kahl JE, Calvo RY, Sise CB, Morgan JA, Shackford SR, et al. Back to the future: reducing
reliance on torso computed tomography in the initial evaluation of blunt trauma. J Trauma Acute Care
Surg. 2013 Jan. 74(1):92-7; discussion 97-9. [Medline].
26. Fakhry SM, Trask AL, Waller MA, Watts DD. Management of brain-injured patients by an evidence-based
medicine protocol improves outcomes and decreases hospital charges. J Trauma. 2004 Mar. 56(3):492-9;
discussion 499-500. [Medline].
27. Stassen NA, Lukan JK, Spain DA, Miller FB, Carrillo EH, Richardson JD, et al. Reevaluation of diagnostic
procedures for transmediastinal gunshot wounds. J Trauma. 2002 Oct. 53(4):635-8; discussion 638.
[Medline].
28. Melton SM, Kerby JD, McGiffin D, McGwin G, Smith JK, Oser RF, et al. The evolution of chest computed
tomography for the definitive diagnosis of blunt aortic injury: a single-center experience. J Trauma. 2004
Feb. 56(2):243-50. [Medline].
29. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to
solid abdominal organs: a prospective study. Arch Surg. 2003 Aug. 138(8):844-51. [Medline].
30. Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, et al. Practice management guidelines
for the evaluation of blunt abdominal trauma: the East practice management guidelines work group. J
Trauma. 2002 Sep. 53(3):602-15. [Medline].
31. Maturen KE, Adusumilli S, Blane CE, Arbabi S, Williams DM, Fitzgerald JT, et al. Contrast-enhanced CT
accurately detects hemorrhage in torso trauma: direct comparison with angiography. J Trauma. 2007
Mar. 62(3):740-5. [Medline].
32. Poletti PA, Mirvis SE, Shanmuganathan K, Takada T, Killeen KL, Perlmutter D, et al. Blunt abdominal
trauma patients: can organ injury be excluded without performing computed tomography?. J Trauma.
2004 Nov. 57(5):1072-81. [Medline].
33. Weninger P, Mauritz W, Fridrich P, Spitaler R, Figl M, Kern B, et al. Emergency room management of
patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified
by an urban trauma center. J Trauma. 2007 Mar. 62(3):584-91. [Medline].
34. Brasel KJ, Nirula R. What mechanism justifies abdominal evaluation in motor vehicle crashes?. J Trauma.
2005 Nov. 59(5):1057-61. [Medline].
35. Michetti CP, Hanna R, Crandall JR, Fakhry SM. Contemporary analysis of thoracic aortic injury:
importance of screening based on crash characteristics. J Trauma. 2007 Jul. 63(1):18-24; discussion 245. [Medline].
36. Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D. Abdominal computed
tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative
management. J Trauma. 2005 Nov. 59(5):1155-60; discussion 1160-1. [Medline].
37. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, et al. Selective
nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006 Oct. 244(4):6208. [Medline]. [Full Text].
38. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Inaba K, et al. Use of computed tomography in
anterior abdominal stab wounds: results of a prospective study. Arch Surg. 2006 Aug. 141(8):745-50;
discussion 750-2. [Medline].
39. Alzamel HA, Cohn SM. When is it safe to discharge asymptomatic patients with abdominal stab
wounds?. J Trauma. 2005 Mar. 58(3):523-5. [Medline].

emedicine.medscape.com/article/434707-overview

18/19

10/26/16

Initial Evaluation of the Trauma Patient: Overview, Triage and Organization of Care, Initial Assessment

40. Malhotra AK, Fabian TC, Katsis SB, Gavant ML, Croce MA. Blunt bowel and mesenteric injuries: the role
of screening computed tomography. J Trauma. 2000 Jun. 48(6):991-8; discussion 998-1000. [Medline].
41. Griffen MM, Frykberg ER, Kerwin AJ, Schinco MA, Tepas JJ, Rowe K, et al. Radiographic clearance of
blunt cervical spine injury: plain radiograph or computed tomography scan?. J Trauma. 2003 Aug.
55(2):222-6; discussion 226-7. [Medline].
42. Grogan EL, Morris JA Jr, Dittus RS, Moore DE, Poulose BK, Diaz JJ, et al. Cervical spine evaluation in
urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll
Surg. 2005 Feb. 200(2):160-5. [Medline].
43. Sheridan R, Peralta R, Rhea J, Ptak T, Novelline R. Reformatted visceral protocol helical computed
tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated
in the evaluation of blunt trauma patients. J Trauma. 2003 Oct. 55(4):665-9. [Medline].
44. Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CV. Spiral computed tomography for the initial
evaluation of spine trauma: A new standard of care?. J Trauma. 2006 Aug. 61(2):382-7. [Medline].
45. Sclafani SJA. Diagnostic and interventional radiology. Mattox KL, Moore EE, Feliciano DV. Trauma. 7th
ed. New York: McGraw-Hill; 2013. 251-300.
46. Blackmore CC, Cummings P, Jurkovich GJ, Linnau KF, Hoffer EK, Rivara FP. Predicting major
hemorrhage in patients with pelvic fracture. J Trauma. 2006 Aug. 61(2):346-52. [Medline].
47. de Mestral C, Dueck A, Sharma SS, Haas B, Gomez D, Hsiao M, et al. Evolution of the incidence,
management, and mortality of blunt thoracic aortic injury: a population-based analysis. J Am Coll Surg.
2013 Jun. 216(6):1110-5. [Medline].
48. Demetriades D. Blunt thoracic aortic injuries: crossing the Rubicon. J Am Coll Surg. 2012 Mar.
214(3):247-59. [Medline].
49. Smith HE, Biffl WL, Majercik SD, Jednacz J, Lambiase R, Cioffi WG. Splenic artery embolization: Have
we gone too far?. J Trauma. 2006 Sep. 61(3):541-4; discussion 545-6. [Medline].
50. London JA, Battistella FD. Testing for substance use in trauma patients: are we doing enough?. Arch
Surg. 2007 Jul. 142(7):633-8. [Medline].
51. Laird AM, Miller PR, Kilgo PD, Meredith JW, Chang MC. Relationship of early hyperglycemia to mortality
in trauma patients. J Trauma. 2004 May. 56(5):1058-62. [Medline].
52. Herndon D. Total Burn Care. 4th ed. London: Saunders Elsevier; 2012.
53. Mohr WJ, Jenabzadeh K, Ahrenholz DH. Cold injury. Hand Clin. 2009 Nov. 25(4):481-96. [Medline].
54. Byrnes MC, Beilman GJ. Hypothermia: treatment and therapeutic uses. Britt LD, Peitzman AB, Barie PS,
Jurkovich GJ. Acute Care Surgery. Philadelphia: Lippincott Williams & Wilkins; 2012. 707-17.
55. Mackersie RC. Pitfalls in the evaluation and resuscitation of the trauma patient. Emerg Med Clin North
Am. 2010 Feb. 28(1):1-27, vii. [Medline].

Medscape Reference 2011 WebMD, LLC

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