What should be the initial workup for a patient with a suspected serious injury?

Initial Workup for Suspected Serious Injury

The initial workup for a patient with suspected serious injury should include portable chest and pelvic radiographs, FAST (Focused Assessment with Sonography for Trauma) examination, and contrast-enhanced CT scanning for hemodynamically stable patients, while unstable patients require immediate intervention based on initial findings. 1

Primary Survey and Initial Assessment

Immediate Evaluation

• Assess vital signs and hemodynamic status
• Perform physical examination focusing on:
  • Signs of external bleeding
  • Chest examination for pneumothorax or hemothorax
  • Abdominal examination for tenderness and distension
  • Pelvic stability
  • Neurological status
  • Perineal hematoma or blood at urethral meatus

Initial Imaging for All Trauma Patients

1. Portable Radiographs 1

   • Chest X-ray: To identify immediate life-threatening conditions such as tension pneumothorax, significant mediastinal injury, and to confirm line placement
   • Pelvic X-ray: To evaluate for unstable pelvic injuries and hip dislocations

2. FAST Examination 1

   • Primary role is triage; positive FAST with hemodynamic instability may lead to immediate surgical intervention
   • Evaluates for free fluid in peritoneal, pericardial, and pleural spaces
   • Note: FAST has lower sensitivity compared to CT and should not be used alone to exclude injuries

Management Based on Hemodynamic Status

For Hemodynamically Unstable Patients

• Immediate intervention based on findings from primary survey and initial imaging 1
• Patients with pelvic ring disruption in hemorrhagic shock should undergo immediate pelvic ring closure and stabilization 1
• Consider immediate surgical intervention or angiography for control of bleeding

For Hemodynamically Stable Patients

• Multi-phasic CT scan with intravenous contrast 1
  • CT of chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injuries compared to non-contrast CT 1
  • CT with 3D bone reconstructions helps reduce tissue damage during invasive procedures 1
  • Consider CT angiography of chest when there is concern for aortic or major vessel injury 1

Specific Considerations

Head and Maxillofacial Trauma

• Non-contrast CT of the head for patients with Glasgow Coma Score <13 or based on mechanism 1
• Consider CT of maxillofacial region for suspected osseous or soft-tissue maxillofacial injuries 1

Suspected Urinary Tract Injury

• Retrograde urethrogram or urethrocystogram with contrast CT scan is recommended in the presence of local perineal clinical hematoma and pelvic disruption 1
• For men with signs of urethral injury (blood at meatus, inability to urinate), perform retrograde urethral and bladder opacification before attempting urinary catheterization 1

Suspected Thoracic Injury

• Be vigilant for the "Deadly Dozen" thoracic injuries 2:
  • Lethal Six (require immediate identification): airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail chest
  • Hidden Six (require detection during secondary survey): thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragmatic tear, esophageal disruption, and pulmonary contusion

Whole Body CT (WBCT) Considerations

Consider WBCT for patients with high-energy mechanisms 1:

• High-velocity (>35 mph) motor vehicle collision (MVC)
• MVC resulting in rollover or passenger ejection
• Motorcycle trauma
• Bicycle injury
• MVC-pedestrian collision
• Fall from height >15 feet

Common Pitfalls to Avoid

1. Relying solely on physical examination - Clinical examination alone is not reliable for detecting many serious injuries, particularly thoracic and intra-abdominal injuries 1

2. Overestimating the value of normal initial imaging - A study found that 40% of patients with a "normal" chest radiograph had injuries detected on CT 1

3. Delaying definitive bleeding control - Time between trauma and definitive bleeding control inversely correlates with survival in patients with traumatic hemorrhage 1

4. Missing urethral injuries - Always check for blood at the urethral meatus before catheterization in male patients with pelvic trauma 1

5. Failing to recognize the limitations of FAST - While useful for triage, FAST has lower sensitivity for detecting certain injuries, particularly extraperitoneal and genitourinary injuries 1

The systematic approach to trauma workup should be tailored to the patient's hemodynamic status, with the primary goal being rapid identification and control of life-threatening injuries to reduce morbidity and mortality.