In a patient with severe or multiple trauma initial assessment is made at the same time as other things are initiated to stabilize the patient. Fluid therapy and shock treatment are started at the same time the patient is being evaluated. Survey asking a detailed history of the trauma incident may provide vital clues.

Time lapse since the trauma occurred is important information that has to be asked to the owners. Many times because of anxiety, the time lapse cannot be thoroughly determined, but whenever possible is a very useful data and can help with some actions to be taken.

Detailed inspection of the animal would reveal external or even internal injuries. Clipping the hair may facilitate visualization of bruises. Hypoxia and hemorrhage are two of the main causes of death among traumatized patients.

Every traumatized patient whom present in shock with no evidence of external bleeding, third space accumulation of blood must be assessed and ruled out.

The physical evaluation must be done in an orderly fashion, always keeping in mind the ABC concepts, no matter this subject has suffer modifications in the latest times: Respiratory, cardiovascular, nervous, digestive, and muscle / skeletal systems.

Main Goal: Brain, Lung, Heart

Initial Assessment

"A": Airway and Arterial Bleeding

 General observation

 Any penetrating injury should be addressed immediately

 Respiratory rate and character

 Movement and shape of the thoracic cage

 Rib fractures or Flail chest

 Hemoptysis - pulmonary contusions

 Diaphragmatic hernia, pneumothorax, or hemothorax

"B": Breathing

 Respiration rate and character

 Mucous membranes

 Auscultation

 Abnormal, increased or decreased lung sounds

"C": Cardiovascular

 Heart rate and rhythm

 ECG

 Blood pressure?

 Pulse rate, quality and association with heart rate

 Capillary refill time

 Internal or external hemorrhage

 Hypovolemic shock

"D": Disability

 Patient gait

 Mental status

 Neuro examination

 Paralysis

 Spinal cord lesions

 Evidence of fractures

Other: draw blood for preliminary lab data: blood work and chemistry panel, bladder catheterization: urine sample and UA, rectal palpation: pain, fractures

Questions to be Addressed and Answered

 Rectal temperature?

 Skin integrity and lesions?

 Adequate ventilation?

 Imbalance between ventilation and perfusion (V/Q)?

 Need tracheotomy?

 Pneumothorax? Thoracocentesis?

 Ruptured diaphragm?

 Hemo, hydro or chylothorax?

 Does any lesion require immediate surgery?

 Any external visible hemorrhage?

 Venous distention?

 IV catheter placement and open IV pathway

 Replace any volume deficiency

 Colloids requirements

 Does any lesion require immediate surgery?

 Has the patient received any medication that may alter the examination?

 Pathological changes in the central or peripheral nervous system?

Digestive System

 Abdominal trauma can be a challenge to diagnose. 50% of serious lesions are misdiagnosed in human being patients!!!!

 It is highly important to keep in mind a suspicion for abdominal trauma every time we deal with traumatized patients. Any signs of acute hemorrhage? Ruptured spleen? Other hemorrhage sources like kidneys, liver, mesenteric vessels?: abdominocentesis / diagnostic peritoneal lavage (DPL) GI tract assessment. Abdominal viscera exploration (i.e., urinary bladder, ureters, gall bladder, pancreas): Ultrasound scan, radiograph

 Possible peritonitis? Need for immediate exploratory laparotomy?

Muscle Skeleton System

 Gait abnormalities or lameness, any visible signs of open fracture or luxation? Joint exploration, Tendon laceration or avulsion?

Ancillary Diagnostics

X-rays must be taken if possible before any centesis or DPL is performed since these procedures may introduce air / fluid into the abdominal cavity.

 Plain or contrast studies? Ultrasound?

 CT scan or MRI? Do we always need such expensive studies?

Thorax

 Asses and palpate for thoracic movement and respiratory pattern

 Rib fractures. Do we need to pain treatment? Flail chest? Support bandages?

 Penetrating wounds. Locate heartbeat

Abdomen

 Look for pain. Evidence for free fluid or abdominal distention.

 Diagnostic peritoneal lavage more accurate (20ml/kg of warm saline or lactated Ringers). Identify every palpable organ whenever possible, retroperitoneal space evaluation.

Spine and Appendages

 Temperature of extremities

 Evaluate for fractures or luxations

 Check for wounds or any evident deformity

 Retroperitoneal space can be involved in spinal and / or pelvic fractures

Nervous System

 Evaluate aptitude to stand up and walk

 Position of the extremities and presence of paresis / paralysis

 Flaccidity or rigidity

 Cranial and peripheral reflexes

Head and Neck

 Blood loss coming from the natural openings?

 Look after injuries in the head, eyes, ears, nose and nostrils

 Check for pain and range of motion of the head

 Open the mouth and explore it for tongue or dental lesions. Remember palate fractures in high rise syndrome.

 Airway obstruction due to saliva and blood clots?

Secondary Evaluation

After life-threatening injuries have been addressed, the secondary evaluation is initiated, including a more detailed history from the owner, physical exam, and late diagnostics test. The central nervous system must to be check out at this time includes assessment of mentation and any spinal trauma.

Head trauma can cause central respiratory failure and decreased mentation, however, if decreased mentation persists, cerebral injury can be diagnosed. Pupils absent response to light, cranial nerve deficits, bleeding from the ears, skull or sinus fractures, and any significant facial soft tissue swelling can be related to a severe head trauma.

Thoracic radiography should be performed on patients with a multiple trauma injuries. Pulmonary contusion, pleural effusion syndrome and diaphragmatic hernia could not be evident and radiographs can help.

Patients in human emergency medicine, use to receive an focused abdominal sonogram for trauma (FAST) and is now a standard in many human emergency centers. This exam is normally run with a portable ultrasound machine and search for free abdominal fluid in specific areas of the abdominal cavity.

According to Boysen 2003 directions, areas of the abdomen evaluated for the presence of free fluid included:

 Just caudal to the xiphoid process

 On the midline over the bladder

 Over the most gravity dependent area of the right and left flank

Ultrasound exam in critically small animal patient is a quick, noninvasive test to diagnose patients with abdominal injury specially if there is free peritoneal fluid. In that case abdominocentesis is indicated. If there is an ongoing bleeding, may require emergent laparotomy, including renal vessel avulsion, splenic tears, or other major abdominal vessel rupture.

No blood peritoneal effusion could be biliary tract rupture, bladder rupture or bowel or gastric rupture. Traumatic pancreatitis is rarely seen injury in small animals than humans patients but should be considered in trauma patients that develop vomiting and abdominal pain.

Thoracocentesis should be performed in any patient who show respiratory distress after trauma episode and all the free air should be removed from the thoracic cavity. If more than two thoracocentesis are required, chest tube placement is indicated.

Ongoing Reevaluation and Definitive Care

After trauma patient has been stabilized and injury lesions diagnostics have been performed, continued reevaluation and therapy is very important to prevent unexpected worsening of clinical status. Monitoring should include continuous ECG, respiratory status, blood pressure, basic blood work: PCV and albumin, and whenever possible, blood gas measurements.

Perfusion evaluation, including mucous membrane color, capillary refill time, and pulse quality should be evaluated. ECG monitoring should detect in early stages the cardiac arrhythmias, often seen after blunt thoracic trauma. In the author experience, ventricular arrhythmias are common 24 to 72 hours after chest blunt trauma due to myocardial hypoxia, catecholamine effects, acidosis or electrolyte abnormalities as hyperkalemia. No matter if no arrhythmias are noted, continuous monitoring is indicated.

Specific treatment of cardiac arrhythmias is usually not necessary, and should be reserved for those patients with cardiovascular instability due to the arrhythmia itself, but those patients always should be treated for causes of the arrhythmia: adequate fluid therapy, analgesia, and oxygen supply.

Complete blood count, chemistry and coagulation parameters should be continued monitored in critically injured patient preventing complications as disseminated intravascular coagulation (DIC), systemic inflammatory response syndrome (SIRS), sepsis and septic shock, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).

Arterial blood gas analysis and frequent monitoring of respiratory status can help to identify development of respiratory failure while chemistry can help diagnose abdominal injury like urinary tract rupture, organ failure due to a sustained shock state, and biliary tract rupture.

Critically injured patients require not only emergent therapy for immediate life-threatening injury, but appropriate diagnostics and monitoring for the detection of occult injury and for the prevention of deterioration in clinical status. Monitoring should include both physiologic and serologic parameters, including assessment of cardiovascular stability, organ dysfunction, and oxygenation and ventilation status. Patients should be adequately assessed and treated for pain, and nutritional needs should be addressed. Treatment of critically injured patients is often rewarding, as many recover with appropriate intensive care and surgical intervention as necessary.

References

References are available upon request.