Severe and multiple trauma

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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

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