Severe and multiple trauma

Published on 27/02/2015 by admin

Filed under Anesthesiology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1236 times

Chapter 66 Severe and multiple trauma

James A. Judson

Trauma can be defined as physical injury from mechanical energy. It is usually categorised as blunt or penetrating. In Western countries, severe blunt trauma is common, caused by road crashes, falls and, less frequently, blows and assault. Severe penetrating trauma, usually from stabbings and gunshots, is less common except in larger cities of the USA,1,2 South Africa and war zones. Blunt trauma is often more difficult to treat than penetrating trauma. Assessment is more difficult, because injuries are frequently internal, multiple and not obvious initially. The risk of missing serious injuries can only be lessened by a systematic approach and repeated assessments.3–5

ASSESSMENT AND PRIORITIES

TRIAGE

An important first step is triage – sorting patients with acute life-threatening injuries and complications from those whose lives are not in danger. The severity of total body injury is related to the number of separate injuries present, and to the severity of individual injuries. Assessment can be made either at the scene of injury or on arrival at hospital. As in any emergency, assessment, diagnosis and treatment need to be concurrent. There is limited time for detailed histories, examinations, investigations or well-considered diagnoses before starting emergency care. Most patients with severe injury can be distinguished early by the following:

• Depressed consciousness in the trauma patient can be related to brain injury, hypoxaemia, shock, alcohol or other ingested drugs, or precipitating neurological or cardiac events. Frequently, a combination of factors is present, and the precise extent of physical brain injury is not known initially. Initial treatment in any case is determined by the level of consciousness rather than its exact cause.
• Breathing difficulties are common in patients with trauma to the head, face, neck and chest. If rapid or distressed breathing is present, airway obstruction, laryngeal injury, pulmonary aspiration and lung or chest wall injury (especially pneumothorax and lung contusion) must be considered.
• Shock is almost always hypovolaemic from blood loss, but other types of shock occasionally occur in trauma (see below).

PRIORITIES

A trauma patient often has multiple problems requiring attention. Determining priorities is not always easy. In general, the priorities are to:

• Support life: the patient is kept alive with resuscitative techniques, while the various injuries and complications are attended to
• Locate and control bleeding, which may be varied (see below)
• Prevent brainstem compression and spinal cord damage
• Diagnose and treat all other injuries and complications

BASIC TREATMENT PRINCIPLES

A systematic approach to managing severe and multiple trauma is important. Effective programmes developed by the American College of Surgeons are now well established.6 A number of basic treatment principles apply to all severe trauma patients.

EMERGENCY ASSESSMENT (PRIMARY SURVEY)

The following must be recognised and treated before anything else:

• A – Airway obstruction: suggested by noisy (or silent) breathing, with paradoxical chest movements and breathing distress, and inadequate airway protection from impaired gag reflexes in patients with depressed consciousness.
• B – Breathing difficulty: suggested by tachypnoea, abnormal pattern of breathing, cyanosis or mental confusion.
• C – Circulatory shock: manifested by cold peripheries with delayed capillary refill, rapid weak pulse or low blood pressure (see below).

OXYGEN AND VENTILATORY THERAPY

High-flow oxygen by mask is given to all trauma patients. However, patients with severe trauma frequently require ventilatory support. A restless uncooperative patient should be intubated under a rapid sequence induction to facilitate resuscitation.

BLOOD CROSSMATCH AND TESTS

Six units of red cells should be crossmatched urgently, but it is impossible to predict the amount of blood that will be required. Blood is concurrently sent for baseline haematological and biochemical tests, including blood ethanol level. Blood ethanol is clinically useful in assessing individual patients with depressed consciousness, quite apart from epidemiological and preventive medicine,7 and legal considerations.

FLUID RESUSCITATION

Resuscitation fluids are given (see below). If necessary, two or three large 14- or 16-gauge i.v. cannulae are inserted in upper limb, external jugular or femoral veins.

ANALGESIA

Analgesia is easily overlooked. Opioid agents should be titrated i.v., and not given i.m. or subcutaneously. Large doses may be needed.

URINE OUTPUT

A urinary catheter is inserted unless a ruptured urethra is suspected (because of blood at the urinary meatus, severe fractured pelvis or abnormal prostate position on rectal examination), in which case a suprapubic catheter is indicated. Urine output monitoring is an important guide to resuscitation.

OTHER INJURIES

All injuries should be evaluated.

CLINICAL EVALUATION OF INJURIES (SECONDARY SURVEY)

Injuries are easily missed in an emergency, especially when one injury is obvious. A secondary, and even a tertiary, survey should be performed.5 The back and the front of the patient should be examined. Special attention is paid to regions with external lacerations, contusions and abrasions. All body regions are examined systematically.

HEAD

Neurological observations are made. The ears and nose are inspected for cerebrospinal fluid and blood, and the scalp is examined thoroughly.

FACE

Bleeding into the airway should be excluded, and the face and jaws tested for abnormal mobility.

SPINE

A cervical spine fracture or dislocation is assumed in all patients with depressed consciousness until proved otherwise. Signs of spinal cord injury should be sought (e.g. warm dilated peripheries from loss of vasomotor tone, diaphragmatic breathing, paralysis, priapism and loss of anal tone). The thoracic and lumbar spine should be inspected and palpated.

THORAX

Fractured ribs in themselves are not usually life-threatening but haemothorax, pneumothorax, lung contusion and chest wall instability (flail chest) will require attention if present. Less common but very serious injuries can occur to the heart and great vessels (see Chapter 69).

ABDOMEN

The spleen, liver and mesenteries are often damaged. Retroperitoneal haemorrhage is common. Injuries to the pancreas, duodenum and other hollow viscera are less frequent, and may be missed until signs of peritonitis occur. Renal injury with retroperitoneal haemorrhage is suggested by haematuria and loin pain (see Chapter 71).

PELVIS

Pelvic fractures may be difficult to detect clinically, especially in the unconscious patient. Blood loss may be massive, particularly with posterior fractures involving sacroiliac dislocation. Ruptured bladder and ruptured urethra may occur with anterior fractures.

EXTREMITIES

A litre or more of blood may be lost into a fractured femur. Long bone fractures are more serious when they are open, comminuted or displaced, or if associated with nerve or arterial damage.

EXTERNAL

Contusions may be extensive and serious, especially in falls from heights, and may be overlooked if the victim’s back is not examined. Road crash victims may sustain serious burns or abrasions.

SHOCK IN THE TRAUMA PATIENT

The earliest, most constant and reliable signs of shock are seen in the peripheral circulation. A patient with cold, pale peripheries has shock until proved otherwise. Tachycardia is not always present and hypotension is a late sign of shock. The commonest form of shock in trauma is hypovolaemic shock.

HYPOVOLAEMIC SHOCK

If the neck veins are empty, hypovolaemic shock should be inferred. Possible sites of blood loss causing shock are:

• External loss, which is obvious clinically from blood-soaked clothing and pooled blood.
• Major fractures, which are obvious clinically by deformity, swelling, crepitus, pain and tenderness (e.g. femurs) or seen on a plain X-ray (e.g. pelvis).
• Pleural cavity, detected on urgent chest X-ray. Intrapleural drains will reveal the amount and rate of blood loss.
• Peritoneal cavity, detected by laparotomy, diagnostic peritoneal lavage, computed tomography (CT) scan or ultrasound. Clinical examination of the abdomen can be misleading when the patient is intoxicated, has depressed consciousness or has multiple injuries. A single clinical examination is of limited value: changes over time are more important.
• Retroperitoneum, detected at laparotomy or by CT scan, or inferred when all the above are negative, especially in the presence of pelvic or lumbar spine fracture.

CARDIOGENIC SHOCK

If the trauma patient with shock has distended neck veins, possible causes are tension pneumothorax, concurrent myocardial infarction, cardiac tamponade or myocardial contusion.

NEUROLOGICAL SHOCK

Patients with paraplegia or tetraplegia from spinal cord injury may have low blood pressure with warm dilated peripheries accompanied by lax anal tone and by priapism in the male (see Chapter 70). This is a diagnosis of exclusion and all causes of hypovolaemic shock (see above) must be sought.

SEPTIC SHOCK

Occasionally, patients with pulmonary aspiration may develop septic shock. This is unlikely to confuse the initial trauma assessment soon after injury, but may require consideration some hours or a day or two later.

ABDOMINAL ULTRASOUND

Technological advances in ultrasound scanning and the increasing availability of FAST (focused assessment with sonography for trauma) scanning in emergency departments make this modality attractive in trauma, and it is becoming increasingly used. However:

• It is operator-dependent
• It may have an unacceptably high false-negative rate
• There is a small but important false-positive rate for intra-abdominal bleeding8
• It is unable to diagnose ruptured bowel
• It is not good for bleeding in the pelvis

Its main usefulness is probably in the unstable patient when it is positive, to indicate the need for laparotomy without the necessity to proceed to diagnostic peritoneal lavage (DPL).9 FAST scans performed by enthusiastic amateurs in emergency departments without a treatment algorithm can be misleading and therefore worse than useless.

DIAGNOSTIC PERITONEAL LAVAGE

Diagnostic peritoneal lavage is indicated to diagnose intra-abdominal bleeding

• In shocked patients who are not proceeding straight to laparotomy
• In patients without shock when repeated clinical examination of the abdomen for 6 hours is not possible because of sedation or anaesthesia

Caution is needed with pregnancy, previous abdominal surgery or massive pelvic injury. Isotonic saline 1 l (or 10 ml/kg) is instilled into the peritoneal cavity, after drainage of the stomach and bladder. The presence of more than 10 ml frank blood on catheter aspiration necessitates immediate laparotomy; otherwise a lavage fluid specimen should be examined for red and white cell counts and amylase concentration. A red cell count over 100 000 per mm3, white cell count over 500 per mm3, or an increased amylase concentration suggests bleeding or viscus injury, and laparotomy should be undertaken immediately. These absolute figures are debatable and lower values are accepted in penetrating trauma.6,10 Peritoneal lavages inevitably result in some false-positive laparotomies. However, in severe trauma, morbidity of a non-therapeutic laparotomy (i.e. no definitive surgery) is small compared with the dire consequences of missing significant intra-abdominal injury.11

CT ABDOMEN

Abdominal CT is not indicated in shock, but can be useful in the stable patient. Improved availability of CT scanning, and technological advances with reduced scanning times and better definition, is increasingly favouring CT abdomen over DPL in patients who are sufficiently stable to tolerate the procedure safely. It needs to be performed quickly and safely, with gastric and i.v. contrast, and interpreted by radiologists experienced in trauma. Visualisation of abdominal and pelvic organs and haemorrhage is excellent,12,13 but results can be misleading and disastrous with poor technique.4

FLUID RESUSCITATION

FLUIDS

Almost all patients who are hypotensive or noticeably vasoconstricted will need blood transfusion. However, as crossmatched blood is not immediately available, other fluids are used first. Uncrossmatched group O Rh-negative blood is occasionally indicated in the exsanguinating patient, but in general transfusion of large quantities of blood is wasteful while bleeding is uncontrolled. The place of hypertonic fluids in trauma resuscitation is unresolved.

Isotonic saline or a balanced salt solution should be the first fluid infused. Shocked patients may need 2–3 l in the first few minutes. One litre bags or bottles and giving sets with in-line pumps should be used on all i.v. lines. If fluid resuscitation is likely to be extensive, warmed fluids and rapid infusion devices should be used. Albumin solutions (and probably other colloid resuscitation fluids) are contraindicated in trauma patients, since the SAFE study, conducted in ICU patients, showed higher mortality in patients given albumin, in the predetermined trauma subgroup, particularly in those with traumatic brain injury.14 By 20–30 minutes crossmatched red cells should be available. Platelets and fresh frozen plasma are reserved for documented or suspected coagulopathy (i.e. dilutional coagulopathy from fluids deficient in haemostatic factors, and disseminated intravascular coagulopathy (DIC) from prolonged shock).

All resuscitation fluids have a high sodium concentration, similar to that of extracellular fluid. Glucose 5% and glucose–saline solutions are not effective resuscitation fluids. Few trauma patients actually require them in the first day.

LIMITED FLUID RESUSCITATION

In penetrating trauma, there is some evidence that extensive fluid resuscitation prior to haemostasis may be detrimental, presumably because of higher blood pressure, displacement of blood clot and dilution of coagulation factors.15

In blunt trauma, there is no such evidence. Furthermore, it is not appropriate to generalise the evidence from penetrating trauma to blunt trauma because these two types of trauma are quite different. In penetrating trauma, the bleeding is often from single arteries without extensive tissue injury, and complete haemostasis can often be easily achieved.

In contrast, in blunt trauma, the bleeding is often venous as well as arterial, with capillary oozing into the soft tissues which may continue for hours. It can often not be controlled, or can be only partly controlled, by operative surgery, interventional radiology or reduction and fixation of fractures. Accordingly, fluid resuscitation in the face of continuing blood loss is an important part of the treatment of circulatory shock in blunt trauma (see section on Inadequate resuscitation). Nevertheless, fluid resuscitation is not an alternative to haemostasis and must not be used as an excuse for delaying haemostasis in blunt trauma.

Furthermore, traumatic brain injury is often present in blunt trauma, which frequently involves several body regions. Hypotension is disastrous to an already injured brain, and must not be prolonged by deliberate underresuscitation (see Chapter 67, section on Traumatic brain injury – Emergency treatment).16–18

URINE OUTPUT

Hourly urine output is a useful guide to resuscitation from shock. Minimal acceptable urine output is 0.5 ml/kg per hour, but 1–2 ml/kg per hour is more adequate. Furosemide has no place in initial resuscitation. Apart from adequate resuscitation, diuresis can be due to ethanol, mannitol, dopamine, nephrogenic or neurogenic diabetes insipidus, or non-oliguric renal failure. Polyuria may mask early recognition of acute renal failure.

INADEQUATE RESUSCITATION

Patients in shock have depleted interstitial fluid as well as circulating blood volume, and need trauma resuscitation fluid volumes greater than the actual volume of blood lost. With blunt injury, volume losses often continue for 24–48 hours. Prolonged shock from delayed and inadequate resuscitation leads to renal failure, acute respiratory distress syndrome (ARDS), sepsis, DIC and multiple organ dysfunction.19,20

PULMONARY OEDEMA

Pulmonary oedema during resuscitation may be related to fluid overload, direct lung trauma, aspiration of gastric contents, pulmonary responses to non-thoracic trauma and reactions to resuscitation fluids. They can all cause leaky capillaries and produce non-cardiogenic pulmonary oedema.

RADIOLOGY FOR TRAUMA PATIENTS

Patients with depressed consciousness, breathing difficulties or unstable circulation should be X-rayed in the emergency department, and not sent to a radiology department remote from skilled resuscitation facilities. Conversely, extensive imaging examinations of shocked patients in the emergency department are unacceptable. Only three examinations should be requested in the emergency department.

CHEST

This is the only X-ray ever justified in an unresuscitated patient. A supine film is usually sufficient. An erect film is better for showing intrapleural air or fluid, ruptured diaphragm, free abdominal gas and for defining an abnormal mediastinum, but is often impractical in shock or suspected spinal injury. It can be done later if feasible. An obvious pneumothorax does not require a chest X-ray before insertion of an intercostal drain.

LATERAL CERVICAL SPINE

This should be performed in all patients with head injury or multiple injuries because cervical spine fractures are often missed. With head or facial injuries, a cervical fracture should be assumed initially and a cervical collar applied. The lateral cervical spine X-ray can be taken later. It is only an initial screening examination for cervical spine fractures and does not ‘clear’ the spine.

PELVIS

Unexplained blood loss can be due to a missed pelvic fracture. A dislocated hip can be missed in multiple injuries. A pelvic X-ray is not needed in awake patients with no pelvic abnormalities.

OTHER RADIOLOGICAL INVESTIGATIONS

Other X-rays should be performed after adequate resuscitation in the radiology department, operating room or intensive care unit (ICU):

• Skull: plain skull X-rays do not guide immediate treatment. A CT scan of the brain is a more useful urgent investigation.
• Extremities: X-rays of the extremities to assess bony injuries are not urgent unless there is vascular injury. Therefore, these films should not be taken in the emergency department for diagnosis, unless the patient is going directly to the operating room for fracture fixation.
• Spine: X-rays of thoracic or lumbosacral spine are seldom indicated in the emergency department.
• Abdomen: a plain abdominal X-ray is of limited value in the initial evaluation of trauma.
• CT abdomen: this can be valuable to evaluate a patient who is haemodynamically sufficiently stable to tolerate the procedure safely (see above).
• CT head: this is vital in the treatment of traumatic brain injuries.
• CT neck: The most reliable way to exclude or delineate cervical spine injuries is by a CT neck scan,4,21 which can conveniently be done when the patient is going to the CT scanner for other examinations.
• CT thorax: apart from diagnosis of aortic injury, CT thorax is of limited value in the trauma patient. Visualisation of thoracic structures is excellent but it seldom discovers important undiagnosed injuries which affect patient treatment.22 If aortic injury is suspected, multislice CT is the current definitive diagnostic test. The use of aortic stent grafts for this injury, in locations where this technology is available, means that CT is not only the best diagnostic test, but necessary for preoperative planning.23 Aortography is no longer the definitive diagnostic test for traumatic aortic rupture.
• Urethrography is used when urethral injury is suspected. Properly done CT abdomen may well demonstrate bladder injury, otherwise cystography is used.
• Interventional radiology: percutaneous transcatheter embolisation is therapeutic rather than diagnostic. It can provide life-saving haemostasis in massive retroperitoneal haemorrhage associated with pelvic fracture.24 The logistics of managing such haemodynamically unstable patients in the radiology department are formidable.

THE EXSANGUINATING PATIENT

With exsanguination secondary to penetrating thoracic injury, there is a place for Emergency Room thoracotomy, but this approach has little place in blunt trauma.25 The exsanguinating blunt trauma patient needs rapid intubation, volume resuscitation, bilateral intrapleural drains or thoracostomies, chest and pelvic X-ray, and a rapid trip to the operating room if it seems likely that the bleeding is in the thorax or abdomen.

TRAUMATIC BRAIN INJURY (SEE CHAPTER 67)

Injuries to the head region are common, but those requiring urgent cranial operations are less so. Traumatic brain injury may initially be obvious amongst multiple injuries, but may not be the most important injury. Conversely, traumatic brain injury may seem unimportant initially. Traumatic brain injury is a major determinant of outcome in critically injured patients.

EMERGENCY TREATMENT

Resuscitation measures, as in the Emergency assessment (primary survey) section above, are undertaken. Victims with one or both dilated unreactive pupils, or a rapidly deteriorating level of consciousness not due to hypoxia or shock, should be given mannitol 1 g/kg i.v. to relieve brainstem compression, until definitive diagnosis and treatment can be arranged. Mannitol should be given only if the patient has been adequately volume resuscitated as it may add to hypovolaemia. There is much interest in hypertonic saline, particularly in head trauma, and concentrated salt may eventually turn out to be a better agent than mannitol in this setting because it does not produce hypovolaemia.26,27

Shocked trauma patients with or without traumatic brain injuries require the same crystalloid resuscitation fluids. Treatment of shock and maintenance of cerebral perfusion are vital, as hypotension is disastrous to an already damaged brain.16–18 Contrary to common belief, sodium-containing fluids are not inherently dangerous in traumatic brain injury. However, after adequate resuscitation, further sodium administration is usually not indicated. Excessive (free) water is potentially dangerous, as it can lead to hypo-osmolar brain swelling.28

NEUROLOGICAL EVALUATION

Factors such as hypoxaemia, shock, alcohol, analgesics, anaesthetic agents, muscle relaxants and other drugs depress consciousness and confound neurological signs. Clinical neurological evaluation includes the Glasgow Coma Scale (GCS)29,30 and a search for lateralising signs.

CT scanning is indicated in all patients who will not obey verbal commands, especially if they are rendered neurologically inaccessible by sedative and relaxant agents. Lateralising motor or pupillary signs with a deteriorating level of consciousness are indications for immediate CT scanning (or, if unavailable, emergency burr holes). In an unstable patient, a laparotomy for intra-abdominal haemorrhage should take priority over a head CT scan.31

SEVERITY AND MORBIDITY OF TRAUMA

Severity of injury is measured by the abbreviated injury scale (AIS), updated over the years, most recently in 2005.32–34 AIS divides the body into six regions: head and neck, face, thorax, abdomen, pelvis and extremities, and external. Specific injuries in each body region are coded on a scale of 1 (minor), 2 (moderate), 3 (serious, not life-threatening), 4 (severe, life-threatening, survival probable), 5 (critical, survival uncertain) and 6 (unsurvivable). The AIS was designed for motor vehicle injuries, but has been validated for blunt and penetrating trauma. It can provide a basis for research, education, audit and allocation of resources.

Severity of trauma is related not just to the severity of individual injuries, but also to the combined effects of multiple injuries. Multiple injuries are graded by the injury severity score (ISS), which is an empirical system based on the AIS grades for the three worst body regions.35,36 ISS gives a score between 0 and 75 for total body injury; 16 or more indicates major trauma. Death with an ISS below 24 should be rare. Above an ISS of 25, there is a stepwise increase in mortality, with very high rates over 50.37,38

AIS and ISS study mostly the anatomy of injury. Other factors influence trauma mortality and morbidity, including age, pre-existing health, degree of physiological derangement, standard of prehospital and early hospital care and complications. Degree of physiological derangement can be measured by the revised trauma score,39 which is computed from the coded values of GCS, systolic blood pressure and respiratory rate, usually at admission to the emergency department. The TRISS severity index is based on the revised trauma score, ISS, and patient age.40 It correlates well with outcome, and has been used to compile survival norms for blunt and penetrating trauma.37,38 Physiological scoring systems such as APACHE (acute physiology, age and chronic health evaluation) do not work well for trauma patients (see Chapter 3).41,42 Preinjury illness (comorbidity) has a profound effect on trauma outcome.43

Shock influences trauma mortality and morbidity. The ‘golden hour’ is a catchy concept based on the observation that the longer the patient is in shock, the higher the probability of immediate or delayed complications. However, the specific timeframe of an hour has no real validity. Complications of shock include renal failure, acute respiratory distress syndrome, sepsis, liver failure and multiorgan dysfunction.19,20,44 Acute oliguric renal failure on the first day after trauma is now rare, but non-oliguric renal failure is often seen 2–4 days later, caused by the shock and delayed or inadequate resuscitation. It is often heralded by polyuria, which is misinterpreted as a sign of adequate resuscitation.

EPIDEMIOLOGY OF INJURIES

Only a minority of victims of severe trauma reach hospital alive.45,46 The majority of deaths are immediate (within minutes) at the scene of injury. Some deaths are early (within hours) in the emergency department or the operating room, and a few are late (after days or weeks) and occur in the ICU or ward.47 Those in the ICU are mostly from severe head injury within a few days and, less commonly, multiorgan dysfunction later.

Of trauma admissions to hospital, only a minority have severe or multiple trauma.48 In order of frequency, life-threatening injuries involve the head, abdomen and chest (Table 66.1), and are often multiple. The hospital services which this small number of severely injured patients use out of proportion to their numbers are major surgery, intensive care, radiography and CT scanning.48 Major trauma outcome studies in the USA,37 the UK38 and Australia49 offer valuable epidemiological data. The USA study found that the mortality of direct admissions is strongly related to serious head injury.

Table 66.1 Percentage of ICU trauma patients with grades of injury in different body regions

image

ORGANISATION OF TRAUMA CARE

Many of the problems of trauma care are organisational. Problems faced by health authorities are the provision of advanced care at the scene of injury, rapid transportation to hospital, policies on which hospitals should receive trauma patients, systems for rapid evaluation and decision-making in hospitals, and rapid, safe patient transfer between hospitals. If survival from major trauma is to be maximised, prehospital and hospital care must be coordinated.

Regionalisation of trauma care has become an accepted concept.2,51 Trauma centres are designated hospitals which meet certain requirements. Main prerequisites are rapidly available experienced surgeons, anaesthetists and neurosurgeons, and a minimum number of patients seen annually for staff expertise. Regionalisation involves the concept of ambulances bypassing non-designated hospitals.2 Helicopters are used increasingly to speed patient transportation.52 Trauma teams are teams of surgeons and intensivists or anaesthetists who immediately attend the trauma victim on arrival at hospital.2–444

Trauma registries and databases are important tools in organising and improving trauma care. The UK major trauma outcome study38 showed that the doctors in charge of resuscitation were often junior, delays in performing urgent operations were common, and the number of preventable deaths was significant. A hospital may not see enough trauma patients to justify a trauma team or supply adequate experience for its staff, and may not have all the facilities required by trauma patients. Transfer to a trauma hospital may be desirable, but geography and limited transport facilities may make such transfers hazardous.

In Western countries, trauma is a leading cause of death and disability under the age of 38 years.37 Reduction of mortality and morbidity depends on public education, new legislations, on-site advanced care, rapid evacuation (see Chapter 4), hospital trauma expertise and coordination of services.53,54

REFERENCES

1 Trunkey DD. Trauma. Sci Am. 1983;249:20-27.

2 Trunkey DD. Overview of trauma. Surg Clin North Am. 1982;62:3-7.

3 Trunkey DD. Initial treatment of patients with extensive trauma. N Engl J Med. 1991;324:1159-1263.

4 Enderson BL, Maull KI. Missed injuries: the trauma surgeon’s nemesis. Surg Clin North Am. 1991;71:399-418.

5 Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of tertiary trauma survey. J Trauma. 1998;44:1000-1006.

6 Committee on Trauma, American College of Surgeons. Advanced Trauma Life Support (ATLS) Program for Physicians, 7th edn. Chicago: American College of Surgeons, 2004.

7 Soderstrom CA, Cowley RA. A national alcohol and trauma center survey: missed opportunities, failures of responsibility. Arch Surg. 1987;122:1067-1071.

8 Shackford SR, Rogers FB, Osler TM, et al. Focused abdominal sonogram for trauma: the learning curve of nonradiologist clinicians in detecting hemoperitoneum. J Trauma. 1999;46:553-564.

9 Branney SW, Moore EE, Cantrill SV, et al. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma. 1997;42:1086-1090.

10 Day AC, Rankin N, Charlesworth P. Diagnostic peritoneal lavage: integration with clinical information to improve diagnostic performance. J Trauma. 1992;32:52-57.

11 Weigelt JA, Kingman RG. Complications of negative laparotomy for trauma. Am J Surg. 1988;156:544-547.

12 Trunkey DD, Federle MP. Computed tomography in perspective [editorial]. J Trauma. 1986;26:660-661.

13 Padbani HR, Watson CJE, Clements L, et al. Computed tomography in abdominal trauma: an audit of usage and image quality. Br J Radiol. 1992;65:397-402.

14 Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247-2256.

15 Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105-1109.

16 Chestnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216-292.

17 Wilden JN. Rapid resuscitation in severe head injury. Lancet. 1993;342:1378.

18 Brain Trauma Foundation. Guidelines for the Management of Severe Traumatic Brain Injury. Brain Trauma Foundation, New York, 2007. http://www.braintrauma.org/.

19 Cowley RA, Trump BF. Editors’ summary: Organ dysfunction in shock. In: Cowley RA, Trump BF, editors. Pathophysiology of Shock, Anoxia, and Ischaemia. Baltimore, MD: Williams & Wilkins; 1982:281-284.

20 Faist E, Baue AE, Dittmer H, et al. Multiple organ failure in polytrauma patients. J Trauma. 1983;23:775-787.

21 Daffner RH, Sciulli RL, Rodriguez A, et al. Imaging for evaluation of suspected cervical spine trauma: a 2-year analysis. Injury. 2006;37:652-658.

22 Paul A, Blostein PA, Hodgman CG. Computed tomography of the chest in blunt thoracic trauma: results of a prospective study. J Trauma. 1997;43:13-18.

23 Nzewi O, Slight RD, Zamvar V. Management of blunt thoracic aortic injury. Eur J Vasc Endovasc Surg. 2006;31:18-27.

24 Panetta T, Sclafani SJA, Goldstein AS, et al. Percutaneous transcatheter embolisation for massive bleeding from pelvic fractures. J Trauma. 1985;26:1021-1029.

25 Boyd M, Vanek VW, Bourguet CC. Emergency room resuscitative thoracotomy: when is it indicated? J Trauma. 1992;33:714-721.

26 Suarez JI, Qureshi AI, Bhardwaj A, et al. Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med. 1998;26:1118-1122.

27 Prough DS, Zornow MH. Mannitol: an old friend on the skids? Crit Care Med. 1998;26:997-998.

28 Fishman RA. Effects of isotonic intravenous solutions on normal and increased intracranial pressure. Arch Neural Psychiatry. 1953;70:350-360.

29 Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81-84.

30 Jennett B, Teasdale G. Aspects of coma after severe head injury. Lancet. 1977;1:878-881.

31 Thomason M, Messick J, Rutledge R, et al. Head CT scanning versus urgent exploration in the hypotensive blunt trauma patient. J Trauma. 1993;34:40-45.

32 American Medical Association Committee on Medical Aspects of Automotive Safety. Rating the severity of tissue damage: I – the abbreviated scale. JAMA. 1971;215:277-280.

33 Committee on Injury Scaling. The Abbreviated Injury Scale – 1980 Revision. Morton Grove, IL: American Association for Automotive Medicine, 1980.

34 Committee on Injury Scaling. The Abbreviated Injury Scale – 2005 Revision. Des Plaines, IL: American Association for Automotive Medicine, 2005.

35 Baker SP, O’Neill B, Haddon W, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187-196.

36 Baker SP, O’Neill B. The injury severity score: an update. J Trauma. 1976;16:882-885.

37 Champion HR, Copes WS, Sacco WJ, et al. The major trauma outcome study: establishing national norms for trauma care. J Trauma. 1990;30:1356-1365.

38 Yates DW, Woodford M, Hollis S. Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study. BMJ. 1992;305:737-740.

39 Champion HR, Sacco WJ, Copes WS, et al. A revision of the trauma score. J Trauma. 1989;29:623-629.

40 Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. J Trauma. 1987;27:370-378.

41 McAnena OJ, Moore FA, Moore EE, et al. Invalidation of the APACHE II scoring system for patients with acute trauma. J Trauma. 1992;33:504-507.

42 Roumen RMH, Redl H, Schlag G, et al. Scoring systems and blood lactate concentrations in relation to the development of adult respiratory distress syndrome and multiple organ failure in severely traumatized patients. J Trauma. 1993;35:349-355.

43 Sacco WJ, Copes WS, Bain LW, et al. Effect of pre-injury illness on trauma patient survival outcome. J Trauma. 1993;35:538-543.

44 Cowley RA, Dunham CM, editors. Shock Trauma/Critical Care Manual. Baltimore, MD: University Park Press, 1982.

45 Baker CC, Oppenheimer L, Stephens B, et al. Epidemiology of trauma deaths. Am J Surg. 1980;140:144-150.

46 Smeeton WMI, Judson JA, Synek BJ, et al. Deaths from trauma in Auckland: a one year study. N Z Med J. 1987;100:337-340.

47 Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38:185-193.

48 Streat SJ, Donaldson ML, Judson JA. Trauma in Auckland: an overview. N Z Med J. 1987;100:441-444.

49 Cameron P, Dziukas L, Hadj A, et al. Major trauma in Australia: a regional analysis. J Trauma. 1995;39:545-552.

50 Data updated from that published inGardiner JP, Judson JA, Smith GS, et al. A decade of ICU trauma admissions in Auckland, New Zealand. N Z Med J. 2000;113:326-327.

51 Eggold R. Trauma care regionalisation: a necessity. J Trauma. 1983;23:260-262.

52 Freeark RJ. The trauma center: its hospitals, head injuries, helicopters, and heroes (1982 AAST presidential address). J Trauma. 1983;23:173-178.

53 Judson JA. Trauma management: modern concepts [editorial]. N Z Med J. 1985;98:8-9.

54 Trunkey DD. On the nature of things that go bang in the night. Surgery. 1982;92:123.

Related posts:

Physiotherapy in intensive care Principles of antibiotic use Spinal injuries Valvular and congenital heart disease Therapeutic plasma exchange and intravenous immunoglobulin immunomodulatory therapy Imaging the chest