Tertiary Survey of the Trauma Patient in the Intensive Care Unit

This is the authors' abstract. We don't add key points for this paper.

The implementation of trauma systems has resulted in decreased mortality from traumatic injury. Trauma-system development has focused on prehospital systems (9-1-1) and the establishment of standards by which hospitals should be structured and staffed.6 As a result of this progress and improved capabilities for resuscitating the most severely injured patients, fewer patients are dying in the first “golden hour” following trauma. It may be reasonable to think of this golden hour as having expanded to include the period of time between injury and arrival in the ICU. Such patients may go on to survive even the most profound injuries provided a careful and efficient transition is made between the resuscitative and ICU phases of care. This second golden hour is the beginning of what may be a prolonged course of intensive care. Prevention of late mortality, the third peak in the bimodal distribution of trauma death, is the goal of this transition. Injuries that are life- and limb-threatening should be identified early in a patient's treatment course by the primary and secondary survey5; however, as injury complexity increases, diagnosis of significant injuries may be delayed or missed,17, 22 leading to disability or even death. Thus, for all trauma patients, especially critically injured patients who require intensive care, the tertiary survey is that process by which all injuries are identified and catalogued. Only when this process is complete can a comprehensive treatment plan be formulated. The process of identification involves a reassessment of known injuries, the confirmation of suspected injuries, and the identification of occult injuries by serial re-examination and further diagnostic study. Suspicion may be raised by knowledge of the mechanism of injury or physical findings. Reassessment and diagnosis involve frequent repeated physical examination, at a minimum. Repeated examination and clinical suspicion direct the performance of simple and complex diagnostic procedures, some of which can be performed in the ICU, whereas others require travel to other areas of the hospital. The “path” that the trauma patients travel on the way to the ICU affects the initial management and performance of the tertiary survey. Certain pitfalls are associated with each course, and trauma intensivists must appreciate these subtleties. Increased rates of missed injury have been noted in patients with head injury transferred from outlying facilities for definitive neurosurgical care,16 adults37 and children with blunt trauma requiring interfacility transport,20 and blunt-injured patients requiring immediate operation.1 Figure 1 summarizes these clinical scenarios.