ABCs of Trauma Care

Following the ABCs (airway, breathing, circulation) and DE (disability
and exposure) of trauma care prevents you from getting sidetracked by
the patient’s obvious injury (arm fracture, for example) and thereby
missing a more life-threatening but less obvious injury.
Airway
An open airway (i.e., the path from the nose/mouth to the lungs) is
vital for the patient to be able to breathe. You need to determine

quickly whether the airway is blocked. Blockage may be due to the
tongue, vomit, blood, or foreign bodies.
Signs of Airway Obstruction
In patients breathing on their own, signs of airway obstruction include
noisy breathing on inspiration and retractions of the supraclavicular
space (area above the clavicle) or intercostal space (between the
ribs) with attempts at respiration. In nonbreathing patients, it may be
difficult to diagnose airway obstruction. You must look directly into
the mouth and examine for signs of obstruction.
How to Maintain an Open Airway
• Clear out any blood or vomitus in the mouth.
• In an unconscious patient, the tongue may obstruct the airway because
of loss of tone in the muscles of the lower jaw (mandible).
• Proper patient positioning often relieves obstruction due to a posteriorly
displaced tongue.
• To position the tongue forward, gently lift the chin to bring the
mandible forward. Be careful not to extend the cervical spine (because
of concerns about possible undiagnosed cervical spine injury).
• An artificial oral or nasal airway tube can be useful, but in a conscious
patient it may cause gagging and agitation. Use with caution—
such devices are not comfortable.
• Intubation with an endotracheal tube is often the best way to maintain
an open airway.
• When intubation is impossible, a surgical airway (cricothyroidotomy
or tracheotomy) is required.
Surgical Cricothyroidotomy. A cricothyroidotomy is done only in
emergency situations when no other means is available to maintain an
open airway. The following guidelines are helpful:
1. The cricothyroid membrane can be located by running your finger
down the center of the neck and feeling the wide thyroid cartilage
(Adam’s apple). The depression just below the Adam’s apple is
where you want to place the incision. The rings of the trachea are
palpable just below this area.
2. Try to clean the area with Betadine.
3. If you have time, inject the skin with lidocaine and epinephrine to
decrease bleeding from the skin edges and to make the procedure a
little easier to perform.

                                                 












Emergency cricothyroidotomy. A, The larynx is stabilized between the left thumb
and middle finger. The tip of the index finger is inserted over the cricothyroid
membrane. Keep the index finger in this position to identify the position of the
cricothyroid membrane as you perform the procedure. B, The endotracheal tube
in position. (From Simon RR, Brenner BE (eds): Emergency Procedures and
Techniques, 3rd ed. Baltimore, Williams & Wilkins, 1994, with permission.)

4. The neck should be in neutral position with the chin held slightly
forward.
5. Hold the thyroid cartilage between your thumb and middle finger
(actually you are stabilizing the larynx). Use your index finger to
help identify the cricothyroid membrane.
6. Using a no. 15 knife blade, make a horizontal incision no more than
2 cm long, just below the Adam’s apple. Be sure to stay in the
center of the neck. Do not make this incision too large, or you may
injure a nearby vein, thereby causing significant bleeding and
making the procedure very difficult.
7. Staying in the midline, gently push the knife so that it goes through
the cricothyroid membrane. Do not push inward too far; use only
the knife tip. You do not want to injure the esophagus, which is immediately
behind the trachea.
8. Insert the back of the knife handle (not the blade) through the
opening that you have just made, and rotate the handle to enlarge
the opening.
9. Place the largest possible pediatric endotracheal tube through the
opening. Give oxygen and ventilate the patient through this tube.
10. Secure the tube in place with tape or sutures.

Breathing
Breathing relates to getting oxygen to the tissues. All patients with any
possibility of having sustained a head injury or with an altered level of
consciousness should be given supplemental oxygen, which usually
can be administered with a face mask or nasal prongs.
Listen for bilateral breath sounds, demonstrating that both lungs are inflated
(see “tension pneumothorax” below). Problems that interfere with
oxygen getting to the tissues are often related to significant chest trauma.
Circulation
Circulation pertains to the patient’s blood pressure and secure intravenous
access. Start an intravenous line with the largest available
catheter, and hang a liter of 0.9% saline.
The most common reason for hypotension (low blood pressure) in a trauma
patient is blood loss, either external or internal. Control obvious hemorrhage.
Be careful of scalp wounds—a lot of blood can be lost from
the scalp. A closed fracture of the femur can result in the loss of a
liter of blood into the tissues of the thigh, which may not be immediately
obvious.
A head injury in and of itself does not cause hypotension. Look for another
source. In contrast, a spinal cord injury can result in profound
hypotension without blood loss (see “Neurogenic shock” below) because
of loss of vascular tone.
How to Determine Blood Pressure
Without a Working Blood Pressure Cuff
Feel for palpable pulses at the wrist (radial artery), groin (femoral
artery), and neck (carotid artery).



Other Causes of Hypotension/Shock that Can Lead
to Death if not Quickly Diagnosed
Tension pneumothorax occurs when the lung has collapsed and air surrounds
the lung. If the air is not removed and the lung reexpanded, buildup
of pressure in the chest may cause the lung, great vessels, and even

heart to be compressed and pushed to the opposite side. This process impairs
blood flow to and from the heart and leads to hypotension.
Cardiac tamponade is a build-up of fluid in the sac around the heart. It
can lead to cardiac dysfunction and shock.
Neurogenic shock occurs with an injury that causes paralysis—i.e., a
spinal cord injury, not a head injury. Because of the loss of nerve input,
the blood vessels dilate. Even with minimal blood loss, the patient
cannot maintain proper vascular tone, and hypotension develops.
Acute myocardial infarction (heart attack) or any cause of cardiac dysfunction
can result in hypotension.
Disability
The following brief exam helps to evaluate patients for the presence of
a neurologic deficit:
1. Check the pupils. Are they equal, round, and reactive to light?
2. Is the patient conscious?
3. Can the patient move the fingers and toes?
4. For patients with a suspected head injury, the Glasgow Coma Score
(GCS) should be determined. Fifteen, the highest (best) score, indicates
that the patient is awake and alert; three, the lowest (worst)
score, indicates that the patient is unconscious and unresponsive.



Add up the points. An uninjured patient who is not intoxicated should
score 15 points. A score of 13 points may indicate minor injury; scores
of 9–12, moderate injury; and scores < 8, severe injury.

Caution: Do not assume that a low GCS is due to intoxication. Adrunk
person can definitely have a serious head injury. Do a thorough workup
(usually a computed tomography [CT] scan is required).
Exposure
All clothing should be removed so that the patient is fully exposed.
Removal of clothing allows you to examine the patient thoroughly for
signs of injury. It may seem silly, but you do not want to be fooled.
Patients usually are lying on their back during the evaluation. To examine
the back for evidence of spine injury, log-roll the patient (i.e.,
roll the patient in one motion, keeping the back straight and preventing
any twisting motion of the spine).