Chapter 33. Overview of trauma resuscitation
On arrival at an accident, identify yourself to the other emergency services
Safety
The first priority at all times is to be safe: are you safe, is the scene safe, is the casualty safe? It is important to remember that the Fire service has overall responsibility for the safety of an accident scene.
Safety – self, scene, casualty
Assessment
The first role of the paramedic, particularly if the Ambulance service is the first emergency responder to arrive, is a brief assessment of the scene:
• Safety
• Hazards
• Casualties – numbers
• Mechanisms of injury
• Emergency services – present and required.
Communication
Report to ambulance control your arrival (if this is not automatic) and the situation as soon as you have made your assessment.
Patient management
The first and most important part of the management of any trauma victim is the primary survey. This must be performed rapidly, carefully and in a standard manner; it is the basis of all good trauma care.
Primary survey = identification of life threatening problems + treatment
On approaching the patient, an introduction is essential (and good manners), as is an explanation of what is about to happen.
The primary survey
<C> – Catastrophic haemorrhage must be addressed if present
A – Airway with cervical spine control
B – Breathing with ventilation
C – Circulation with control of overt haemorrhage
D – Disability with neurological assessment
E – Exposure and environment
Management of catastrophic haemorrhage
Obvious heavy external bleeding should be immediately controlled with direct pressure and elevation, pressure dressings, pressure point control and if necessary a tourniquet or haemostatic dressing.
Airway with cervical spine control
Maintain in-line cervical stabilisation from the outset.
If the patient is breathing quietly and comfortably, no other action may be necessary other than to apply oxygen at 12–15 L/min via a face mask with reservoir.
If the patient can speak, however incoherently, it means that the airway is clear and the patient is breathing; otherwise the first step is to assess the airway.
If the airway is at risk, either the insertion of an airway (nasopharyngeal or oropharyngeal) or putting the patient in the recovery position should be considered (remembering the possibility of a cervical spine injury).
If the airway appears obstructed or partially obstructed, any obvious removable obstruction should be removed digitally or by suction and simple airway manoeuvres should applied. These are chin lift and jaw thrust.
All trauma victims require high-flow oxygen
The airway takes precedence over the cervical spine and if it is absolutely necessary to compromise the cervical spine (e.g. by performing a head tilt) in order to achieve a patent protected airway, then this must be done.
Airway takes precedence over cervical spine
1. Airway clearance – manual and aspiration
2. Manual airway opening manoeuvres:
• Chin lift
• Jaw thrust
3. Oropharyngeal airway
4. Nasopharyngeal airway
5. Oral tracheal intubation
6. Cricothyroid ventilation.
Breathing with ventilation
When – and only when – the airway is patent and protected, it is possible to move on to the assessment of breathing. Assessment of breathing begins with the neck, look for:
• Tracheal shift
• Wounds
• Emphysema (surgical)
• Laryngeal crepitus
• Vein distension
• Swelling.
Penetrating neck wounds should be sealed with an occlusive dressing to reduce the risk of air embolism.
Then the chest must be assessed:
• LOOK for movement, instability, flail segments, wounds
• PALPATE for surgical emphysema, tenderness, wounds, paradoxical movement
• PERCUSSION for resonance or dullness
• LISTEN with a stethoscope for breath sounds.
Hyper-resonance with reduced breath sounds suggests a tension pneumothorax; dullness with reduced breath sounds is indicative of a haemothorax.
If the clinical signs suggest a tension pneumothorax, an intercostal needle thoracocentesis should be performed. Penetrating chest wounds should be covered with an Asherman seal or a dressing sealed on three sides.
Remember to examine the back of the chest
Life-threatening chest injuries (ATOMIC):
A – Airway obstruction
T – Tension pneumothorax
O – Open pneumothorax
M – Massive haemothorax
I – Fla il chest
C – Cardiac tamponade
• Chest wall contusion
• Pattern bruising
• Surgical emphysema
• Penetrating object
• Tension pneumothorax
• Rib fractures
• Flail chest
• Open chest wound (sucking)
• Open chest wound
• Simple pneumothorax
• Fractures of the clavicle/shoulder/scapula.
Circulation with control of external haemorrhage
The patient must be assessed for signs of shock; at the same time obvious external haemorrhage not controlled under <C> should be controlled by external pressure. In the trauma patient the causes of shock are:
• Hypovolaemic: due to bleeding, by far the most likely cause of shock in trauma
• Cardiogenic: may result from tension pneumothorax or cardiac tamponade, usually secondary to penetrating injury
• Neurogenic: (rare) never assume that shock is neurogenic, since any accident severe enough to cause spinal injury is also likely to be capable of producing haemorrhage from other associated injuries
• Septic shock: unlikely to be a problem in the trauma victim unless rescue is particularly prolonged (e.g. following a natural disaster such as an earthquake).
The golden hour is defined as the time from injury to definitive surgical treatment
Hypovolaemic shock
Haemorrhage may be divided into:
• External
• Internal.
Significant external haemorrhage is likely to be obvious but this is not always the case and an appropriate search should be made. The location of internal (concealed) haemorrhage may be:
• Chest
• Abdomen
• Pelvis
• Thigh.
Brief palpation of the abdomen and pelvis will aid the location of bleeding. Significant haemorrhage into the chest should already have been identified during the assessment of breathing. Severe shock may result from bleeding into the thighs from femoral fractures.
All patients with significant trauma should have an intravenous cannula inserted and should receive fluid replacement in order to maintain the presence of a radial pulse.
Intravenous access must never delay patient transfer
Isolated head injury is not a cause of shock in adults (shock occasionally occurs in babies due to bleeding into the layers of the scalp).
Disability
The patient’s conscious state is classified as follows:
A – Alert
V – Patient responds to voice
P – Patient responds to pain
U – Patient unresponsive
Check the pupils and make a brief assessment of limb movement and sensation.
Exposure and environment
The degree of exposure of the patient that is appropriate depends on the clinical situation. Exposure of the chest is always necessary for assessment of B and other exposure must be performed as necessary to ensure that no significant injury is missed.
Motorcycle leather trousers should only be removed after very careful consideration, as they may act to tamponade significant lower limb bleeding from pelvic or long-bone fractures.
Don’t ever forget to check glucose (DEFG) and record the patient’s temperature.
If the patient deteriorates, repeat the primary survey from the top
The secondary survey
It is seldom appropriate to complete a secondary survey in the prehospital environment. A brief check is however necessary to identify scalp lacerations, limb fractures and other injuries not found in the primary survey.
The secondary survey should follow a logical order, starting at the head and working towards the feet.
Examination of the limbs should include an assessment of neurovascular status.
Remember: chest injury + leg injury = abdominal injury
Having completed the secondary survey, all the findings (positive and negative) must be recorded.
If it isn’t written down, it wasn’t done
Preparation for transport
Transfer of the patient will begin before the secondary survey, at a time when only the primary survey has been completed and major injuries have been identified.
Major fractures, dislocations and soft tissue injuries should be identified during E of the primary survey and not during the secondary survey.
Whenever preparations for transport are made the principles remain the same.
Airway
The patient’s airway must be safe and secure during handling. The patient should continue to receive high-concentration oxygen and should be moved in such a way that the risk of spinal injury is minimised.
Breathing
The patient must be breathing or, if not, supported respiration must be in progress and maintainable during transfer. Cannulae or chest drains must be fastened securely.
Circulation
During transit, it is essential that the patient’s condition can be observed and that a central pulse is easily to hand. During short periods of transfer drips should be switched off and the fluid bags placed against the patient; alternatively infusion bags may be carried at shoulder height and handed into the vehicle.
Always tape a loop of the IV giving set to the patients arm to reduce the risk of the cannula being inadvertently pulled out.
Disability
Assessment of AVPU and pupillary reactions should be repeated as soon as the patient is in the back of the ambulance.
Exposure
The patient should be reasonably covered during transfer. It may be appropriate to remove clothes or blankets during transport to facilitate observations. Keep the back of the ambulance warm.
In hospital
Only the paramedic can give details of the accident and, most importantly, of the mechanism of injury. The ambulance service report form should be given (ideally) to a doctor or to the senior nurse involved with the case. A brief verbal handover is essential and hospital staff should have the courtesy to remain silent and listen.
The MIST system can be used as a basis for the handover:
M – Mechanism
I – Injuries
S – Symptoms and signs
T – Treatment given
For further information, see Ch. 33 in Emergency Care: A Textbook for Paramedics.
