Trauma

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CHAPTER 12 TRAUMA

Introduction 306
Primary survey 306
Exposure and secondary survey 308
Intensive care management 309
Head, face and neck injuries 310
Spinal cord injuries 311
Thoracic injuries 313
Abdominal injuries 316
Skeletal injuries 317
Fat embolism 318
Peripheral compartment syndromes 319
Rhabdomyolysis 320
Burns 320
Electrocution 322
Near drowning 323
Outcome following trauma 324

INTRODUCTION

The successful management of major trauma requires early identification and treatment of life-threatening injuries followed by systematic evaluation and treatment of all other injuries. Best outcomes are achieved by a coordinated team approach and protocol-based management.

Depending upon local policy, you may be called to assist in the initial resuscitation of major trauma victims. Although an A&E doctor or trauma surgeon will generally lead trauma resuscitation, you should be familiar with advanced trauma life support protocols.

PRIMARY SURVEY

The purpose of the primary survey is to identify and begin the treatment of any immediately life-threatening injuries. These include:

image airway obstruction
image tension pneumothorax
image cardiac tamponade
image massive haemorrhage.

The principal elements of the primary survey are A, B, C and D, as follows.

(A) Airway (with cervical spine control)

Assess the adequacy of the airway. Clear the upper airway with suction and simple airway manoeuvres and provide 100% oxygen using a mask with reservoir bag.

If necessary, secure the airway by intubation or cricothyroidotomy, depending on the clinical situation and degree of urgency. (See Spinal cord injury, p. 311.)

image The cervical spine should be assumed to be unstable and must be protected at all times. Use in-line immobilization during airway manoeuvres. A cervical collar should be applied and sandbags and tape used to preventunnecessary movement of the cervical spine.

(B) Breathing

Support ventilation if necessary. Expose the chest and examine for adequacy of respiration. Identify and treat life-threatening conditions such as flail chest, open wounds, tension pneumothorax or massive haemothorax.

(C) Circulation

image Stop major haemorrhage by direct pressure.
image Assess the adequacy of circulation; in particular, pulse rate, BP, and capillary refill.
image Insert two 14-gauge peripheral intravenous cannulae. If this is not possible, then cannulate the internal jugular or femoral vein, or consider peripheral venous cut-down (e.g. saphenous vein). In ATLS doctrine, CVP lines are used for monitoring and not for resuscitation purposes. Adapt practice dependent on local skills, kit and expertise.
image Send blood for cross-matching.
image Commence fluid resuscitation with 2–3 L of crystalloid. If there is an ongoing fluid requirement, continue with blood / blood products. Colloids remain controversial in this setting, with growing evidence they may contribute to increased bleeding. Fully cross-matched blood is preferable but group-specific, or non-cross-matched O negative can be used, depending upon circumstances.
image If volume loading does not restore perfusion, consider an adrenaline (epinephrine) infusion.

image Evidence suggests that following trauma, early over aggressive fluid resuscitation may worsen outcome. Where surgical haemostasis cannot be immediately achieved, the goal of fluid resuscitation should be to only restore the circulating volume sufficiently to achieve a blood pressurecompatible with critical organ perfusion (see below).

(D) Disability (neurological assessment)

image Assess conscious level, pupil size and note any obvious neurological deficit. A deteriorating Glasgow Coma Score, or a GCS of 8 or below, is an indication for intubation and ventilation. (See Immediate management of brain injury, p. 274.)

Reassessment

image Reassess A, B, C and D to ensure continued stability and appropriate response to treatment before moving on to the secondary survey.

EXPOSURE AND SECONDARY SURVEY

Once the initial survey is complete and the patient is stabilized, ensure that appropriate monitoring is established and that necessary investigations have been organized (Box 12.1).

Box 12.1 Investigations and monitoring

Routine investigations Monitoring
FBC ECG
U&Es, glucose Blood pressure (non-invasive or invasive)
Arterial blood gases Pulse oximeter
(Pregnancy test) CVP
ECG Urine output
Lateral cervical spine X-ray  
Chest X-ray  
Pelvic X-ray  
Urine (stick test)  

Ensure that an adequate medical history has been obtained. At a minimum, this should include the patient’s past medical history, medications, allergies, time of last meal and the mechanism of injury. The mechanism of injury is particularly important in providing important clues as to the likely injuries that may have been sustained.

image Completely expose the patient, while at the same time taking steps to avoid hypothermia.
image Systematically examine the patient from head to toe, looking for other injuries.
image Log roll the patient to examine the back and spine, and perform rectal and vaginal examinations.
image A urinary catheter and nasogastric tube may be inserted if there are no contraindications.

Following resuscitation, stabilization and re-evaluation of the patient, further management can be planned. This may include immediate surgery for life-threatening injuries, or further investigations such as ultrasound or CT scan.

Ultrasound is increasingly used to identify free fluid (blood) in the peritoneal, pleural and pericardial spaces. In this context, its value is in identifying a problem (e.g. peritoneal fluid) rather than the definitive diagnosis (e.g. ruptured spleen). There is much current interest in the use of ‘focused’ ultrasound examinations in trauma, which are easily learned and reliably performed by non-specialist medical staff (e.g. the ‘FAST’ scan) (Trauma Ultrasonography. The FAST and Beyond. http://www.trauma.org/archive/radiology/FASTintro.html).

Many larger centres also now routinely perform CT scanning of chest, abdomen, head and spine in all patients with a significant history of major trauma. With modern fast scan times such approaches are increasingly seen to optimize care in these vulnerable patients; occult injuries are often found.

Blunt versus penetrating trauma

Blunt and penetrating trauma produce different patterns of injury. Blunt trauma is associated with significant soft-tissue injury and haemorrhage into tissues and body cavities. In penetrating trauma, tissue injury may be quite localized and haemorrhage may be tamponaded by clot or the presence of a foreign object. There is ongoing debate about resuscitation strategies in the two groups.

Aggressive intravenous fluid resuscitation with blood, colloid or crystalloid may raise blood pressure, disturb blood clots and restart bleeding. There is some evidence, particularly in penetrating trauma, that restrictive fluid strategies, which limit the volume of resuscitation fluid given until surgical control of bleeding can be achieved, are associated with better outcomes. Similar considerations may apply in other surgical situations, such as leaking aortic aneurysm.

INTENSIVE CARE MANAGEMENT

Patients with multiple injuries frequently require transfer to an ICU after initial resuscitation, stabilization and surgery. Care of the multiply injured patient is essentially no different to care of any other ICU patient. Multiple trauma is by its nature a multisystem disorder, rather than a collection of isolated injuries. Treatment is generally supportive, with appropriate intervention for problems as they are identified.

Multiple organ failure

Multiple organ failure is common after massive trauma. Typically patients develop a systemic inflammatory response syndrome (SIRS), 24–48 h after apparently adequate resuscitation, which then progresses to multiple organ failure. Tissue damage, activation of the immune system and massive blood transfusion are all implicated but exact mechanisms are still not fully understood. Treatment is largely supportive. Possible sources of any ongoing inflammatory response, including necrotic tissue and foci of infection, must be excluded. (See Multiple organ failure, p. 329, and SIRS, p. 326.)

The management of specific groups of injuries is discussed below.

HEAD, FACE AND NECK INJURIES

Head injury

(See Traumatic brain injury, p. 274.)

Facial injury

In the unconscious or obtunded patient the airway should be secured early by intubation. With time, swelling may make subsequent reintubation or airway manipulation impossible. In severe injuries consideration should be given to early tracheostomy. In the presence of facial or base-of-skull fractures, avoid nasal intubation or nasogastric tubes as these may pass into the cranium. Use the oral route.

Heavy bleeding from facial injuries should not be underestimated. Bleeding from the nose may require nasal packing to tamponade bleeding. Seek ENT / maxillofacial surgical advice. Injuries to the jaw often require internal fixation and jaw wiring. Do not be afraid to cut the wires in the event of airway problems. When extubating these patients, ensure they are awake and have full return of protective reflexes before removing the endotracheal tube.

Broken or dislodged teeth may be aspirated. These are usually visible on X-ray, but are not usually densely radio-opaque unless there are amalgam filling present. Careful scrutiny of films is required and a lateral film may help to confirm position (note position of NG tube to delineate the oesophagus). Rigid bronchoscopy may be required for the location and removal of radiolucent teeth / fragments. (See Airway obstruction, pp. 138, 309.)

Cervical spine injury

(See Spinal cord injury, below.)

Cervical soft-tissue injury

Direct injury to soft tissues of the neck can result in airway compromise, due either to haematoma / tissue swelling causing compression of the airway or to direct injury to the larynx or trachea. Secure the airway by early intubation and seek expert surgical help. Vascular injuries in the neck may compromise the cerebral circulation. Dissection of the carotid arteries by blunt injury from seatbelts or other trauma is rare but easily missed. Bleeding may track down into the chest, resulting in haemothorax or haemomediastinum and rarely cardiac tamponade. Carotid dissection can be identified using ultrasonography, CT scan or angiography.

SPINAL CORD INJURIES

Spinal cord injury may occur as a result of trauma, vertebral collapse, infection, tumours, infarcts and other pathologies. The classic features of complete spinal cord injury are total loss of motor and sensory function below the level of the injury. (In the acute setting, the apparent level of the injury may be higher than actual due to inflammation and oedema around the site of injury.) A number of patterns of incomplete injuries are also recognized (Table 12.1).

TABLE 12.1 Patterns of spinal cord injury

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Complete cord injury Total paralysis and loss of sensation below level of injury
Cord hemisection, Brown–Séquard syndrome

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