Crit Care Clin 20 (2004) 1–11

Initial management of the trauma patient

Christopher F. Richards, MDa,b,*,John C. Mayberry, MD, FACSc

aCenter for Policy and Research in Emergency Medicine, Oregon Health & Science University,

3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USAbDepartment of Emergency Medicine, Oregon Health & Science University,

3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USAcDivision of General Surgery, Oregon Health & Science University,

3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA

The management of severely injured patients can be complex and requires a

familiarity with a large body of clinical information that encompasses several

specialties. Thus, organized trauma systems with designated trauma centers and

trauma specialists have proven valuable for managing the multiply injured patient

[1,2]. Unfortunately, only 35 states have formal trauma systems [3]. Critical care of

the severely injured patient may therefore, at many centers, fall to other critical care

physicians. This article discusses the prehospital and initial management steps of

the multiply injured patient, focusing on established principles of therapy with

which a critical care specialist should be familiar.

Epidemiology

Trauma is one of the leading causes of critical illness and death in the United

States. In 2001, injury trailed only heart disease and deliveries as the most common

first-listed discharge diagnosis category at nonfederal hospitals (over 2.4 million

patients) [4]. In 2000, unintentional injury was the fifth leading cause of death

(97,900 people) [5]. The leading cause of injury in the United States is the motor

vehicle crash (MVC), which resulted in 3,033,000 injuries and 42,116 fatalities in

2001 [6]. About one third of trauma patients evaluated at a level 1 trauma center

will be admitted to a critical care unit, with a mean length of stay of 5 days [7].

Several reports have documented a trend toward increased age and comorbidities

0749-0704/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/S0749-0704(03)00097-6

* Corresponding author. Center for Policy and Research in Emergency Medicine, Oregon Health

& Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239.

E-mail address: richarch@ohsu.edu (C.F. Richards).

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–112

among trauma patients, both of which are known to increase the risk of trauma

morbidity and death [8].

Prehospital care

Regionalized trauma systems have a mandated ambulance destination policy

that instructs prehospital personnel to transport seriously injured patients to a

designated trauma center. Nontrauma designated medical facilities are bypassed

even when they are closer in proximity to the scene of the injury. Prehospital

personnel use well-defined mechanistic, anatomic, and physiologic criteria for

trauma system entry (Table 1). Most trauma systems allow paramedics consider-

able discretion to overtriage. Scoring systems such as the revised trauma score

(RTS) and the injury severity score (ISS) have not always been shown to be

superior to paramedic judgment [9]. Trauma systems use quality assurance

programs to periodically re-evaluate their entry criteria with the goal of minimizing

undertriage. Trauma systems have been shown to decrease morbidity and mortality

in urban areas, but the benefits have been harder to describe in rural areas [10].

The scope of care that paramedics deliver at the scene of the injury is

controversial. Mainstays of prehospital care include airway management, control

of external bleeding, immobilization of the spine, needle decompression of

suspected tension pneumothorax, and splinting of major extremity fractures. On-

scene delay usually is discouraged for interventions of unproven benefit [11–15].

Table 1

Oregon Health and Science University trauma activation criteria

Full trauma teama response Modified trauma teamb response

Airway problems (intubated or attempted intubation) GCS > 10 or GCS < 13

Breathing difficulty (RR < 10 or > 29) Two or more long bone fractures

Systolic BP < 90 Fall > 20 feet

GCS < 11 Ejection from vehicle

Penetrating injury to the head, neck or torso Death in same passenger compartment

Flail chest Extrication time > 20 minutes

Paralysis Rollover motor vehicle crash

Pelvic instability High-speed motor vehicle crash

Amputation proximal to the wrist or ankle Automobile versus pedestrian > 5 mph

Major crush injury to torso or upper thigh Special consideration age < 5 or > 65

Paramedic discretion

MCC, ATV, bike crash

Significant intrusion/impact

Hostile environment (cold, heat)

Pre-existing medical illness

Presence of intoxicants

Pregnancy

Abbreviations: ATV, all terrain vehicle crash; MCC, motorcycle crash; RR, respiratory rate.a The full trauma team includes the trauma surgeon, emergency medicine physician, critical

response nurse, anesthesiologist, and respiratory therapist.b The modified trauma team excludes the anesthesiologist and the respiratory therapist.

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–11 3

For example, the application ofmilitary antishock trousers (MAST) by paramedics,

once a standard component of prehospital care, did not prove beneficial in

randomized trial [16]. Many, but not all, trauma systems encourage endotracheal

intubation of the comatose trauma patient. Although more study is needed, recent

prospective studies of field intubation of patients with severe traumatic brain injury,

however, have uncovered a potentially harmful effect [17,18]. Prehospital intra-

venous (IV) crystalloid resuscitation of bluntly injured patients is recommended,

but aggressive IV fluid administration is discouraged in patients with penetrating

injury unless the patient manifests severe shock, or prolonged transport (more than

30 minutes) is expected [19].

Initial management

Optimal care of multiply injured patients includes a preplanned emergency

department (ED) phase. Predetermined response teams with defined roles and

expectations are necessary so that multiple therapeutic and diagnostic procedures

can be performed simultaneously. A physician team leader assesses the patient,

orders and interprets diagnostic studies, and prioritizes diagnostic and therapeutic

concerns. The team leader helps the team focus on the injuries that are immediately

life-threatening and formulates the plan for the evaluation of less threatening

injuries in sequence. Dividing the ED phase into the Advanced Trauma Life

Support (ATLS) recommended stages of the primary survey, initial imaging tests,

secondary survey, and transfer to definitive care is a well-tested means of

determining these priorities [20].

The primary survey

The primary survey is defined by the mnemonic ABCDE: Airway, Breath-

ing, Circulation, Disability and Exposure/Environment [20]. Although these com-

ponents are described sequentially, some components may be performed

simultaneously. Problems identified during this portion of the evaluation are

managed immediately.

Airway

The airway always is assessed immediately for patency, protective reflexes,

foreign body, secretions, and injury. This assessment may range from asking the

patient to open the mouth and phonate to suctioning secretions and assessing the

stability of midface, mandible, or dental injuries. Suction or manual clearing of

foreign bodies or vomitus is followed by careful inspection and palpation of the

facial structures, oropharynx, and neck. The patient’s level of consciousness is also

a primary indicator of airway stability. Patients with a Glasgow Coma Score (GCS)

of 8 or less are at risk for aspiration and hypoventilation.

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–114

If for any reason the clinician is not convinced of the patient’s ability to maintain

his or her own airway, the clinician proceeds to artificial airway control. The

appropriate method of establishing an airway depends upon the specific situation,

but some general rules apply. All trauma patients need manual cervical immobi-

lization during airway management to prevent movement of a potentially unstable

cervical spine injury. Rapid sequence induction is preferred in all but the most

moribund patients and oro–tracheal intubation is the preferred route. Naso–

tracheal intubation no longer is encouraged because of its difficulty to performance

and higher complication rate [21]. The concern that clinicians have had that oro–

tracheal intubation is potentially harmful in patients with potential cervical spine

fractures has been refuted by prospective studies [22–24]. Urgent or emergent

intubation should not be delayed to obtain radiographs of the cervical spine.

Stridor, hoarseness, or neck subcutaneous empysema are signs of a possible

laryngo–tracheal injury. Although many of these patients can be managed without

an airway, they all demand close observation in an ICU. If intubation is required

and time allows, a physician experienced in difficult intubations should be chosen.

Unsuccessful endotracheal intubation of a partial laryngo–tracheal tear may

transform it to a complete transection. Fiberoptic nasotracheal intubation should

be attempted only by experienced clinicians with the necessary equipment

immediately available. Even in this ideal situation, blood and secretions often

render fiberoptic intubation difficult or impossible.

Surgical airway management is indicated when either the oral route has failed or

is in the situation of massive facial injury. Percutaneous transtracheal ventilation

can be a temporizing measure before performance of tracheostomy or cricothy-

rotomy. Cricothyrotomy is easier to perform and is preferred over tracheostomy in

most situations; however, if there is a suspicion of a laryngeal fracture or tracheal

transection, tracheostomy is the method of choice [25–27].

Breathing

Breathing is assessed by determining the patient’s respiratory rate and by

subjectively quantifying the depth and effort of inspiration. Breath sounds should

be carefully auscultated bilaterally. Pulse oximetry is a mandatory adjunct and

end–tidal carbon dioxide monitoring is becoming a useful adjunct. Rapid respi-

ratory effort, the use of accessory muscles of respiration, hypoxia, hypercapnia,

asymmetric chest wall excursions, and diminished or absent breath sounds all

require treatment before proceeding. Needle decompression of tension pneumo-

thorax can be completed quickly at this stage with definitive tube thoracostomy

performed after completion of the primary survey.

Circulation

Assessment of the circulation begins with a quick evaluation of the patient’s

mental status, skin color, and skin temperature. Patients in significant hemorrhagic

shock will progress from anxiety to agitation and finally coma if their blood loss is

not abated. Because one of the immediate responses of the body to hemorrhage is

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–11 5

the activation of the sympathetic nervous system, the peripheral skin of a bleeding

patient will become pale, cool, and sweaty. Cyanotic or mottled peripheral skin is a

sign of severe hemorrhagic shock. Sluggish capillary refill of the toes and the

absence of blood in the superficial veins of the feet and hands also may be apparent.

Unfortunately, the traditional vital signs, heart rate, blood pressure, and respiratory

rate, are neither sensitive nor specific for hemorrhagic shock [28]. Young, healthy

patients in compensated shock may not be significantly tachycardic or hypotensive

until they have lost up to 30% of their blood volume. In addition, because of the

pain and anxiety that many injured patients experience, tachycardia and tachypnea

are common regardless of whether there is significant hemorrhage.

Direct pressure should be applied to external bleeding. Physicians should resist

the urge to clamp bleeding vessels, since significant additional damage can result,

and direct pressure is usually effective. A tourniquet will be required only in cases

of near or complete amputation with massive external bleeding.

The primary survey of circulation is not complete until adequate venous access

is obtained. If two large bore (16–14 gauge) IV lines cannot be obtained within

several minutes, a femoral venous central line should be inserted. If the patient is in

shock, an 8 French single lumen catheter should be placed, but the smaller diameter

triple lumen catheter is adequate for more stable patients. Because of the risk of

lower extremity deep venous thrombosis and central line infection, femoral venous

catheters placed in the ED should be removed within 24 hours.

Choices of fluids for resuscitation include crystalloid, colloid, and blood

products. Initial fluids should be crystalloids, either normal saline or Ringers

lactate. Ringers lactate is preferred when large volumes are required, as acidosis

can result from large volumes of normal saline [29]. Ringers lactate, however, is

hypotonic and hyponatremic compared with plasma and therefore may be contra-

indicated in cases of brain injury. Hypertonic saline (7.5% salt in 6% Dextran) in

small volumes has been used and shown to improve survival in hypotensive trauma

patients [30,31]; however, its use is not common.

Patients who do not respond to 1 to 2 L of crystalloid resuscitation or who appear

moribund should be transfused with type O uncross-matched blood. O-positive

blood can be used for most patients so that O-negative blood can be reserved for use

in women of child-bearing age. Because of the time delay, type-specific or fully

cross-matched blood is only indicated in less urgent situations.

Once therapy for shock has been initiated and external bleeding control initiated,

the search for sources of internal hemorrhage must begin. The three body regions

that will hide significant amounts of blood in cases of blunt injury include the chest,

abdomen, and pelvis. Chest and pelvic radiographs and a focused assessment with

sonography for trauma (FAST) or a diagnostic peritoneal lavage (DPL) are

mandatory screening studies for patients in shock. Computed tomography (CT)

scanning of patients in hemorrhagic shock is discouraged. Long bone fractures can

cause bleeding, but absent open fractures with significant external blood loss rarely

result in shock. Neurogenic shock is entertained as a diagnosis only after causes of

hemorrhagic shock have been eliminated. Patients with torso-penetrating injury

and shock should be taken urgently to the operating room by a qualified surgeon.

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–116

Selected patients with hypovolemic shock with circulatory collapse that is

unresponsive to fluid resuscitation can be considered for ED thoracotomy. This

procedure should be performed only by a qualified and experienced emergency

physician or surgeon. Only patients with a penetrating mechanism of injury and

loss of vital signs en route or after arrival should be considered. Patients with stab

wounds, gunshot wounds, and blunt mechanisms of injury have 16.8%, 4.3%, and

1.4% survival rates, respectively [32].

Disability

Disability should be assessed early so as to document neurologic deficits before

giving IV sedation or paralytics. The GCS and the gross motor and sensory status of

all four extremities should be determined and recorded. The physician also should

recognize the need for cerebro-protection measures in cases of brain injury. Brain

injured patients who are intubated should be sedated with a rapidly reversible agent

such as midazolam or propofol. Aggressive hyperventilation is not indicated, but it

is the most rapid method of transiently lowering the intracranial pressure (ICP) in

patients suspected of near-herniation [33]. Mannitol in a dose of 1.0 g/kg IV is

indicated in patients with low GCS and asymmetric pupils who are not in shock

[34,35].

Exposure/environment

The final portion of the primary survey is exposure and environmental control.

Exposure is particularly important in the patient with a traumatic mechanism of

injury where failure to identify a second or third injury may result in mis-

assessment of the clinical picture. Environmental control involves assessing the

core body temperature and preventing hypothermia. At a minimum, the room

should be maintained at a temperature as warm as possible and the patient covered

with blankets. Rapid infusion of blood products and crystalloid solutions should be

accomplished by way of a Level 1 (Level 1, Inc., Rockland, Massachusetts) fluid

warmer. Patients in shock may be normothermic initially, but nevertheless, they

will require active warming during the resuscitation phase.

Initial radiographs and procedures

Depending upon findings during the primary survey, initial portable radiographs

and indicated procedures should be performed immediately and not be delayed for

the secondary survey. A portable chest film is usually the only radiograph

necessary in cases of penetrating torso trauma. The placement of a chest tube on

the side of the penetrating wound before chest film is routine if the patient has of

shortness of breath, diminished breath sounds, or shock. Relatively routine

emergent radiographs in bluntly injured patients are the lateral cervical spine,

chest, and pelvis. The FAST exam can be used as a substitute for the DPL in a

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–11 7

patient who is in shock, but it should not be routine, as it has a low sensitivity in

hemodynamically stable patients [36].

Secondary survey

The secondary survey is a complete re-assessment of the patient and injuries. A

more complete and traditional history and physical exam is performed. Multiple

sources (friends, relatives, law enforcement, and emergency services personnel)

often are required to obtain a complete history. Much can be learned from the

mechanism of injury. The type and magnitude of the potential energy transfer

provides many clues to potential injury patterns. Patients with a history of high

energy transfer (eg, high speed crashes, falls from great heights) are at higher risk

for occult injury regardless of their initial clinical presentation. Single vehicle

crashes, unexplained falls, or potentially self-inflicted injuries will require assess-

ment of the patient’s underlying mental state and potential for further self-harm.

The physical examination commences at the head of the patient and proceeds

toward the toes. The experienced trauma specialist realizes that painful, distracting

injuries and a less than precise examination may leave some injuries unidentified.

Throughout this portion of the evaluation, the patient should be monitored

with continuous cardiac rhythm with pulse oximetry, frequent blood pressure

measurements, mental status exam, and clinical assessments of peripheral

perfusion. End–tidal carbon dioxide monitoring can be useful also. Invasive

monitoring by means of pulmonary artery catheters is rarely feasible in an ED

setting. If at any time during the secondary survey the patient’s clinical status

deteriorates, the examiner should return to the elements of the primary survey.

Once the secondary survey is completed, more specific imaging and diagnostic

studies can be obtained. If the patient is hemodynamically stable, and the physician

has a low concern for life-threatening injury, transport to the radiology department

or CTscanner for more accurate diagnostic testing is reasonable. The patient should

be accompanied and monitored by a nurse at all times until the initial evaluation

is complete.

Geriatric trauma

Because the general population of the United States is continuing to age, and

more Americans are remaining active for many years after they retire, trauma

centers are expected to admit increasing numbers of elderly patients. Most trauma

systems recognize that advanced age should lower the threshold for field triage

directly to a trauma center. The age cut-off for geriatric trauma has not been

standardized, but it generally ranges from age 55 or certainly beyond age 65. Age,

and especially comorbid medical conditions, are well-recognized risk factors for

adverse outcomes following trauma [8]. In spite of the risk of increased morbidity,

however, advanced age should not be used as the sole criteria for limiting trauma

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–118

resuscitation and procedures. Most elderly trauma patients admitted to trauma

centers will return to independent function.

Whether geriatric trauma patients should receive more aggressive invasive

monitoring in the ICU than younger, similarly injured patients is not clear. There

are insufficient data to support a level 1 evidence-based medicine recommendation

for the use or nonuse of a pulmonary artery catheter during resuscitation based on

age alone [8]. If the older patient has evidence of shock associated with a significant

injury, however, a pulmonary artery catheter-directed resuscitation is probably

wise, especially when chronic cardiovascular or renal disease is present. Older

patients with blunt thoracic trauma are certainly at risk for pulmonary deterioration

even if they initially appear compensated [37]. Pain control with an epidural

catheter and ICU-monitored pulmonary toilet for the first 48 hours is recommended

for any patient older than 65 years of age with multiple rib fractures [38].

Tertiary survey

Performing a tertiary survey on injured patients admitted to the ICU is necessary

to completely identify all of the potentially multiple injuries. [39] Injuries that have

not yet been detected or that have been set aside while more life-threatening issues

are managed are common, especially in blunt trauma. In addition, patients who are

intoxicated with alcohol or other chemicals and are unable to cooperate with the

diagnosis and management of their potential injuries may require rapid sequence

induction and endotracheal intubation just to facilitate their secondary survey and

diagnostic imaging. The tertiary survey consists of yet another head to toe physical

examination, an assessment of the patient’s response to resuscitation thus far, a

review of current radiographic studies with radiologist interpretation, a review of

all laboratory studies, and a effort if necessary to obtain a pre-injurymedical history

from family and friends who by this time should be arriving. Typically this would

be performed upon the patient’s arrival to the ICU. It is reasonable at this point to

order a new panel of labs that in the case of a multiply injured patient that would at

the least consist of a complete blood count, coagulation panel, arterial blood gas,

and serum lactate. The trauma specialist or intensive care specialist then decides

what invasive monitoring and IV access and what further radiographic studies are

necessary. A plan for sedation and analgesia is formulated.

Because delays in detecting all injuries are common in multiply injured

patients, the injury should not be considered significantly delayed or missed if

found within the first 24 hours. The experienced trauma specialist will suspect

fractures that are hidden easily from view (eg, in the cervical, thoracic, or lumber

spine). The authors’ routine practice is to obtain a cervical spine CT scan during

the patient’s second trip to the CT scanner (eg, during the second serial head CT

scan for patients with brain injury). A low threshold for a chest CT scan will

detect occult pneumothoraces, pulmonary contusion, and even aortic injury. The

potential development of extremity compartment syndrome should be considered

around all extremity fractures or soft-tissue injuries. Intra-abdominal pressure

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–11 9

should be measured on admission to the ICU and every 6 hours in the critically ill

trauma patient regardless of whether there is a known abdominal injury. The

aggressive fluid resuscitation associated with traumatic shock will lead to total

body edema and even ascites [40].

Two complications that will occur simultaneously and synergistically and that

should be expected during the tertiary survey are hypothermia and coagulopathy.

Hypothermia as the result of environmental exposure or shock complicates

resuscitation and treatment of trauma patients and increases morbidity and

mortality [41]. Iatrogenic causes of hypothermia include massive fluid resuscita-

tion and prolonged surgical procedures. Hypothermia exacerbates acidosis,

increases blood viscosity, decreases microvascular blood flow, and reduces platelet

aggregation. IV fluids should be warmed with a Level 1 transfuser (Level 1, Inc.,

Rockland, Massachusetts) beginning in the ED, and the patient should be covered

with a Bair Hugger (Arizant Health Care, Inc., Eden Prairie, Minnesota) and

blankets as much as possible. The combination of hypothermia and massive

transfusion may result in an uncorrectable coagulopathy unless both of these

problems are anticipated and treated. Most trauma centers initiate a massive

transfusion protocol as soon as it is predicted that more than ten units of packed

red cells will be transfused [42,43]. A clinical pathologist should come to the

patient’s bedside and directly assist the surgeon and intensive care specialist with

the ordering and delivering of procoagulation products.

Summary

Critical care specialists should be familiar with the initial management of

injured patients. Dividing the evaluation and treatment of the patient into the pri-

mary, secondary, and tertiary surveys ensures that the multiply injured patient will

be managed expeditiously. The primary survey identifies the acute life-threatening

problems that must be managed immediately. The secondary survey identifies the

remaining major injuries and sets priorities for definitive management. The tertiary

survey identifies occult injuries before they become missed injuries.

References

[1] Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review of published

evidence regarding trauma system effectiveness. J Trauma 1999;47(Suppl 3):S25–33.

[2] Mullins RJ, Mann NC, Hedges JR, Worrall W, Jurkovich GJ. Preferential benefit of implemen-

tation of a statewide trauma system in one of two adjacent states [discussion]. J Trauma 1998;

44(4):609–17.

[3] MacKenzie EJ, Hoyt DB, Sacra JC, Jurkovich GJ, Carlini AR, Teitelbaum SD, et al. National

inventory of hospital trauma centers. JAMA 2003;289(12):1515–22.

[4] Hall MJ, DeFrances CJ. 2001 National hospital discharge survey. Hyattsville (MD): National

Center for Health Statistics; 2003.

[5] Anderson RN. Deaths: leading causes for 2000. Hyattsville (MD): National Vital Statistics Re-

ports; 2002.

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–1110

[6] Traffic Safety Facts 2001. Washington (DC): National Center for Statistics & Analysis; 2001.

[7] Report of the Trauma Service. Washington (DC): Oregon Health & Science University; 2002.

[8] Jacobs DG, Plaisier BR, Barie PS, Hammond JS, HolevarMR, Sinclair KE, et al. Practice manage-

ment guidelines for geriatric trauma: the EAST practice management guidelines work group.

J Trauma 2003;54(2):391–416.

[9] Emerman CS, Shade B, Kubincanek J. A comparison of EMT judgment and prehospital trauma

triage. J Trauma 1991;31(10):1369–75.

[10] Esposito TJ, Sanddal TL, Reynolds SA, Sanddal ND. Effect of a voluntary trauma system on

preventable death and inappropriate care in a rural state. J Trauma 2003;54(4):663–9.

[11] Demetriades D, Chan L, Cornwell E, Belzberg H, Burne TV, Asensio J, et al. Paramedic vs private

transportation of trauma patients. Effect on outcome. Arch Surg 1996;131(2):133–8.

[12] Copass MK, Oreskovich OR, Bladergroen MR, Carrico CJ. Prehospital cardiopulmonary resus-

citation of the critically injured patient. Am J Surg 1984;148(1):20–6.

[13] Pepe PE, Copass MK, Joyce TH. Prehospital endotracheal intubation: rationale for training

emergency medical personnel. Ann Emerg Med 1985;14(11):1085–92.

[14] Eckstein M, Alo K. The effect of a quality improvement program on paramedic on-scene times for

patients with penetrating trauma. Acad Emerg Med 1999;6(3):191–5.

[15] Eckstein M, Chan L, Schneir A, Palmer R. Effect of prehospital advanced life support on out-

comes of major trauma patients. J Trauma 2000;48(4):643–8.

[16] Mattox KL, Bickell W, Pepe PE, Burch J, Feliciano D. Prospective MAST study in 911 patients.

J Trauma 1989;29(8):1104–11.

[17] Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. Endotracheal intubation in the field

does not improve outcome in trauma patients who present without an acutely lethal traumatic

brain injury. J Trauma 2003;54(2):307–11.

[18] Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, et al. The effect of para-

medic rapid sequence intubation on outcome in patients with severe traumatic brain injury.

J Trauma 2003;54:444–53.

[19] Martin RR, Bickwell WH, Pepe PE, Burche JM, Mattox KL. Prospective evaluation of pre-

operative fluid resuscitation in hypotensive patients with penetrating truncal injury: a preliminary

report. J Trauma 1992;33(3):354–61.

[20] Krantz BE. Advanced trauma life support for doctors. Chicago (IL): The American College of

Surgeons; 1997.

[21] Holley J, Jorden R. Airway management in patients with unstable cervical spine fractures. Ann

Emerg Med 1989;18(11):1237–9.

[22] Rhee KJ, Green W, Holcroft HW, Mangili JA. Oral intubation in the multiply injured patient: the

risk of exacerbating spinal cord damage. Ann Emerg Med 1990;19(5):511–4.

[23] Gerling MC, Davis DP, Hamilton RS, Morris GF, Vike GM, Garfin SR, et al. Effects of cer-

vical spine immobilization technique and laryngoscope blade selection on an unstable cervical

spine in a cadaver model of intubation. Ann Emerg Med 2000;36(4):293–300.

[24] Walls RM. Airway management in the blunt trauma patient: how important is the cervical spine?

Can J Surg 1992;35(1):27–30.

[25] Holmes JF, Panacek EA, Sakles JC, Brofeldt BT. Comparison of two cricothyrotomy techniques:

standard method versus rapid four-step technique. Ann Emerg Med 1998;32(4):442–6.

[26] Gussack GS, Jurkovich GJ. Treatment dilemmas in laryngotracheal trauma. J Trauma 1988;

28(10):1439–44.

[27] Fuhrman GM, Stieg 3rd FH, Buerk CA. Blunt laryngeal trauma: classification and management

protocol. J Trauma 1990;30(1):87–92.

[28] Victorino GP, Battistella FD, Wisner DH. Does tachycardia correlate with hypotension after

trauma? J Am Coll Surg 2003;196(5):679–84.

[29] Brill SA, Stewart TR, Brundage SI, Schreiber MA. Base defect does not predict mortality when

secondary to hyperchloremic acidosis. Shock 2003;17(6):459–62.

[30] Mattox KL, Maningas PA, Moore EE, Mateer JR, Marx JA, Aprahamian C, et al. Prehospital

C.F. Richards, J.C. Mayberry / Crit Care Clin 20 (2004) 1–11 11

hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multi-center Trial.

Ann Surg 1991;213(5):482–91.

[31] Maningas PA, Mattox KL, Pepe PE, Jones RL, Feliciano DV, Burch JM. Hypertonic saline–

dextran solutions for the prehospital management of traumatic hypotension [discussion]. Am J

Surg 1989;157(5):528–34.

[32] Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency depart-

ment thoracotomy: review of published data from the past 25 years. J Am Coll Surg 2000;

190(3):288–98.

[33] Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, et al. Adverse effects of

prolonged hyperventilation in patients with severe head injury: a randomized clinical trial.

J Neurosurg 1991;75(5):731–9.

[34] Schrot RJ, Muizelaar JP. Mannitol in acute traumatic brain injury. Lancet 2002;359(9318):

1633–4.

[35] The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint

Section on Neurotrauma and Critical Care. Use of mannitol. J Neurotrauma 2000;17:521–5.

[36] Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so fast. J Trauma 2003;54(1):

52–9.

[37] Bulger EN, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma

2000;48(6):1040–6.

[38] Wisner DH. A step-wise logistic regression analysis of factors affecting morbidity and mortality

after thoracic trauma: effect of epidural analgesia. J Trauma 1990;30:799–804.

[39] Biffl WL, Harrington DT, Cioffi WG. Implementation of a trauma survey decreases missed

injuries. J Trauma 2003;54(1):38–43.

[40] Mayberry JC, Welker KJ, Goldman RK, Mullins RJ. Mechanism of acute ascites formation after

trauma resuscitation. Arch Surg 2003;138(7):773–6.

[41] Ferrara A, MacArthur JD, Wright HK, Modlin IM, McMillen MA. Hypothermia and acidosis

worsen coagulopathy in the patient requiring massive transfusion. Am J Surg 1990;160(5):

515–8.

[42] Vaslef SN, Knudsen NW, Neligan PJ, Sebastian MW. Massive transfusion exceeding 50 units

of blood products in trauma patients [discussion]. J Trauma 2002;53(2):291–6.

[43] Lapointe LA, Von Rueden KT. Coagulopathies in trauma patients. AACN Clin Issues 2002;

13(2):192–203.