What's the initial approach to evaluating an adult trauma patient with no known medical history?

Initial Approach to Adult Trauma Patients

Begin with immediate assessment of hemodynamic stability (systolic BP ≥90 mmHg, heart rate 50-110 bpm) to determine whether the patient requires immediate operative intervention or can undergo imaging-based evaluation. 1

Primary Survey: The ABCDE Approach

Airway Assessment (First Priority)

• Assume every trauma airway is a difficult airway and prepare accordingly. 2
• Assess for airway compromise from traumatic injuries, altered mentation, or anatomical disruption 3
• Look specifically for: facial trauma, neck hematoma, stridor, hoarseness, subcutaneous emphysema, and tracheal deviation 3, 2
• Perform positioning maneuvers and suction to clear the airway while providing supplemental oxygen 3
• Prepare for definitive airway (endotracheal intubation or surgical airway) if any concern for airway compromise exists 3, 2

Breathing and Circulation

• In hypotensive trauma patients with active hemorrhage, prioritize circulation before intubation (CAB sequence) as early intubation increases mortality from post-intubation hypotension. 4
• Perform FAST (Focused Assessment with Sonography for Trauma) immediately to identify hemopericardium, pneumothorax, or free intraperitoneal fluid 1
• Obtain portable chest and pelvic radiographs in all trauma patients to identify immediately life-threatening injuries 1, 5

Hemodynamic Status Determines Next Steps

Hemodynamically Unstable Patients (SBP <90 mmHg)

• Proceed directly to operative management without CT imaging in most cases 1
• FAST examination guides immediate surgical decisions 1
• Consider whole-body CT only if resuscitation can continue during scanning and the information will change surgical approach 1
• Minimize on-scene and imaging time—target <10 minutes for transport to definitive care 6

Hemodynamically Stable Patients

• Use clinical judgment to determine between whole-body CT versus selective CT imaging, as evidence shows no clear mortality benefit for routine whole-body CT in stable patients 1
• However, maintain a low threshold for contrast-enhanced CT imaging, as unexpected significant injuries requiring intervention are occasionally identified 1
• CT chest/abdomen/pelvis with IV contrast is the gold standard when imaging is performed 1

Age-Specific Considerations (Critical for Triage)

Patients ≥55 Years Old

• Activate trauma protocol for all patients ≥55 years, as mortality risk increases significantly at this threshold and under-triage must be avoided 1, 7
• Use lower vital sign thresholds: heart rate >90 bpm and systolic BP <110 mmHg warrant full activation 1, 7
• Perform early blood gas analysis for baseline base-deficit or lactate to detect occult hypoperfusion 1, 7
• Assess frailty status using standardized tools, as frailty predicts outcomes better than chronological age alone 1, 7
• Document all anticoagulant and antiplatelet medications immediately, as these dramatically increase mortality risk 1, 8
• Maintain even lower threshold for CT imaging in elderly patients—diagnostic yield outweighs contrast nephropathy risk 1, 7

Essential Laboratory and Monitoring

• Obtain arterial or venous blood gas immediately for base deficit and lactate assessment 1, 7
• Perform serial base deficit measurements to guide resuscitation endpoints 1
• Rapidly identify and correct coagulation disorders from trauma or chronic medications 1, 8
• Obtain ECG and cardiac troponin if any concern for blunt cardiac injury 5

Imaging Algorithm

Initial Imaging (All Patients)

• Portable AP chest radiograph 1, 5
• Pelvic radiograph 1
• FAST examination 1

Advanced Imaging Decision Points

If chest X-ray is abnormal: Proceed directly to CT chest with IV contrast 5

If mechanism suggests high-energy trauma (fall >15 feet, high-speed MVC): Consider whole-body CT regardless of initial radiographs 5

If penetrating torso trauma with lower chest wounds: Diagnostic laparoscopy may be indicated over CT 1

Critical Pitfalls to Avoid

• Never delay intubation in hypotensive patients with active hemorrhage—prioritize hemorrhage control first to prevent post-intubation hypotension and death 4
• Do not rely on normal initial chest radiographs to exclude significant injury (sensitivity only 2-60% for diaphragmatic injuries) 1
• Never use age alone to limit treatment—assess frailty and comorbidities instead 1, 8
• Do not miss occult hypoperfusion in elderly patients who may maintain "normal" vital signs due to medications (beta-blockers, antihypertensives) 1, 7
• Continually repeat primary and secondary surveys to identify clinical deterioration 9

Resuscitation Priorities

• Establish meticulous triage criteria including physical examination, vital signs, blood gas analysis, and medication history to guide early coagulation support and minimize unnecessary fluids 1
• Target euvolemia rather than aggressive fluid resuscitation to optimize perfusion 8
• Maintain systolic BP >100 mmHg in patients with suspected head injury 8