Chapter 20. Trauma
The trauma patient requires rapid assessment and management prior to transport to hospital for definitive care. This early evaluation and resuscitation must be structured and methodical and must identify time-critical cases where patients have life-threatening injuries. These patients need the urgent services of a major receiving hospital, trauma team and trauma surgeons. The medical history of the patient and the mechanism of the injury are the two essential requirements of the trauma history and must be obtained at a speed appropriate to the clinical state of the patient.
Taking a history from a trauma patient
• History-taking must not delay immediate resuscitation within the primary survey where this is clearly required
• After an appropriate introduction, the patient should be asked about what has happened
• A positive and appropriate response will also provide the information that the patient is conscious, has a patent airway, sufficient tidal volume to speak and sufficient cardiac output to provide an adequate cerebral circulation
• The major complaints and location of pain must be sought next, followed by accompanying symptoms such as breathing difficulty and nausea
• Any episode of altered level of consciousness and any events or symptoms preceding the accident, such as chest pain, must be established
• The mnemonic AMPLE is a helpful aide-mémoire for the components of the trauma history when under pressure
• Knowledge of medications such as beta-blockers or warfarin will alter the management of the patient
• The past medical history is important in that patients who have previous significant illnesses (particularly cardiac or respiratory) have a relatively poor prognosis following injury
• It is always wise to assume that an injured patient has a full stomach and that there is a constant risk of vomiting and aspiration
• Some environmental factors to consider are the temperature, the presence of toxic substances (chemicals and radiation) and material which may contaminate a wound
• Identification of a chemical contaminant is the responsibility of the fire service.
The mechanism of injury
The hospital trauma team has little or no perception of the clues at the scene that relate to the nature, direction and force of injury. Therefore, ambulance personnel are the ‘eyes and ears’ of the emergency department and they are privileged to know far more about the mechanism of injury – this understanding should be conveyed in the handover.
Consider taking Polaroid photographs of the scene for the Emergency Department.
Road traffic collisions
• Certain mechanisms of injury, such as side-impact collisions, can be used to predict the pattern of injury found in an individual patient
• The paramedic should therefore assess the pattern of damage to the vehicles – a process known as ‘reading the wreckage’
• Ejection from the vehicle in a road traffic collision increases the likelihood that the patient has sustained spinal cord and other serious injuries and is associated with a threefold increase in mortality rate
• Death of another occupant of the vehicle implies that the live patient has been subject to a high-energy collision and is therefore at risk of major injury even if injuries are not immediately apparent
• Entrapment for over 15 minutes is associated with an increased magnitude of injury severity
• Rollover incidents tend to be associated with an increase in cervical spine injuries. This is consistent with the forceful lateral bending and flexion–extension forces involved and the increased likelihood of axial loading of the spine.
Falls from a height
• Falls from a height inevitably involve sudden deceleration on impact. The distance of the fall, type of surface contacted and anatomical points of impact will determine the injury pattern
• Most adult falls involve lower limb fractures, often including the calcaneum, femur and, by transmitted force, the pelvis
• Lower limb injury is commonly bilateral although the patient may only complain of pain in one limb
• The spine, in particular the lumbar and thoracic areas, is frequently affected, often with multiple crush fractures of the vertebral bodies
• Any complaint of back pain should raise the suspicion of vertebral fractures
• Even trivial falls may cause serious injury in the elderly, particularly where disease has rendered the patient vulnerable to injury
• The elderly man who falls down two or three stairs and strikes his forehead on the ground may hyperextend his relatively rigid cervical spine enough to produce a fracture.
Penetrating trauma
Knife wounds
• Knife wounds cause direct injury in the direction of blade penetration. The damage depends on the length of the blade and the degree of penetration hence a description of the weapon will be of use to the surgeons
• Knife wounds to the neck and chest may be particularly dangerous owing to the presence of important blood vessels and organs
• Chest wounds may involve abdominal structures and vice versa
• A wound in the epigastrium may penetrate the diaphragm, causing ventricular puncture and pericardial tamponade.
Bullet wounds
• Civilian bullet wounds in the main tend to be from either a handgun or a shotgun
• Lethal damage from these injuries depends largely on the anatomical area of injury and the type of projectile; e.g. if a projectile breaks up during the first few centimetres of penetration it will cause increased tissue injury
• The energy transferred from the missile along its wounding path will depend on the density and elasticity of the tissue. High-energy transfer is likely if the missile strikes bone.
Blast injuries
Six patterns of injury are commonly associated with explosions:
1. Primary blast injury: the shock wave
Primary injury commonly causes damage to cavities within the body: the ears, lungs and gastrointestinal tract. The injuries to the lung range from pinpoint haemorrhages to massive intrapulmonary haemorrhage (‘blast lung’)
2. Secondary blast injury: injuries from flying debris
Secondary blast injuries are directly related to the types of flying debris and the sites of penetration
3. Tertiary blast injury: injuries due to the blast wind such as amputations
4. Crush injury
5. Flash burns
Flash burns tend to affect those nearest to the site of the explosion and will burn exposed areas of skin (often hands and face)
6. Psychological trauma.
For further information, see Ch. 20 in Emergency Care: A Textbook for Paramedics.
