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.
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