What is the initial management approach for patients involved in motor vehicle accidents (MVA) in the Emergency Department (ED)?

Initial Management of Motor Vehicle Accident (MVA) Patients in the Emergency Department

The initial management of patients involved in motor vehicle accidents (MVA) should follow a standardized, multidisciplinary approach with immediate triage as high-priority cases, following a predetermined institution-specific protocol that includes systematic assessment and treatment based on the Advanced Trauma Life Support (ATLS) principles. 1, 2

Primary Survey and Immediate Actions

• All MVA patients should be considered high-priority triage cases and evaluated using a structured, institution-specific trauma protocol 1
• Place the patient on a cardiac monitor immediately with emergency resuscitation equipment, including a defibrillator, nearby 1
• Follow the ATLS systematic approach for rapid initial assessment and primary management, starting from the time of injury and continuing through initial assessment, life-saving interventions, re-evaluation, and stabilization 2, 3

Airway and Breathing

• Assess airway patency and provide immediate intervention if compromised 1
• Evaluate breathing and provide supplemental oxygen as needed 2
• Consider early intubation for patients with compromised airway or inadequate ventilation 3

Circulation

• Control obvious external bleeding with direct pressure 1
• Establish IV access with two large-bore catheters 3
• Begin fluid resuscitation for patients showing signs of hemodynamic instability 4
• Monitor vital signs continuously 1

Disability

• Perform a rapid neurological assessment including Glasgow Coma Scale (GCS) 1
• Immobilize the cervical spine until injury is ruled out 1

Exposure

• Completely undress the patient to facilitate thorough examination while maintaining thermal control 2

Diagnostic Evaluation

Immediate Imaging

• Perform an ECG within 10 minutes of ED arrival for patients with chest pain or suspected cardiac injury 1
• For patients with suspected traumatic brain injury (GCS 14-15), obtain a non-contrast head CT scan 1
• Consider focused assessment with sonography for trauma (FAST) for initial triage; positive FAST with hemodynamic instability may lead to immediate surgical intervention 1

Laboratory Studies

• Complete blood count, electrolytes, blood urea nitrogen, creatinine, and glucose 1
• Prothrombin time (with INR) and activated partial thromboplastin time 1
• Cardiac-specific troponin for patients with chest pain or suspected cardiac injury 1
• Toxicology screen to detect cocaine and other substances 1
• Type and cross-match for potential blood transfusion 1

Special Considerations

Cardiac Injury

• For patients with chest pain, ECG abnormalities, or hemodynamic instability after MVA, suspect cardiac injury 1
• Patients with suspected cardiac injuries should undergo rapid cardiac assessment by echocardiography 1
• Cardiac chamber rupture, though rare, has high mortality and requires immediate intervention 1

Traumatic Brain Injury

• For patients with GCS 14-15 and history of head trauma, consider non-contrast head CT 1
• Up to 15% of patients with mild TBI (GCS 15) may have an acute lesion on head CT 1
• Patients with intraparenchymal lesions may have neuropsychological deficits similar to moderate TBI patients 1

Vehicle Telemetry Data

• If available, vehicle telemetry data can provide valuable information about crash dynamics 1
• Factors such as Delta V (change in velocity), direction of impact, and seat belt use are important predictors of injury severity 1

Disposition and Transfer Considerations

• Develop protocols for determining where to take MVA patients, with active involvement of local cardiologists and emergency physicians 1
• Patients with suspected polytrauma should be transported to trauma centers with appropriate capabilities 1
• Patients with known STEMI and/or cardiogenic shock should be sent directly to hospitals with interventional and surgical capability 1

Implementation of Structured Protocols

• Use structured protocols, checklists, or critical pathways for standardized evaluation of MVA patients 1
• The multifaceted, multidisciplinary, standardized approach provides clinical and cost-effective benefits 1, 3
• ATLS training has been shown to improve trauma patient outcomes, particularly in the first hour after admission 3
• Implementation of ATLS principles has demonstrated improvement from sub-standard to standard levels according to Major Trauma Outcome Study methodology 3

Common Pitfalls to Avoid

• Delaying critical interventions while waiting for diagnostic studies 1
• Failing to maintain cervical spine immobilization during the initial assessment 2
• Overlooking less obvious injuries due to focus on the most apparent trauma 1, 5
• Underestimating the severity of injury in patients with normal vital signs who may have occult bleeding 4
• Neglecting to consider cardiac injury in patients with chest trauma from MVAs 1