Trauma

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Chapter 14 Trauma

Trauma in Australia and New Zealand is the leading cause of death in the first four decades of life. Fortunately, injury-related deaths have declined over the past 20 years; however, they continue to be a significant burden on health resources. The identification and management of seriously ill patients requires a coordinated approach that includes pre-hospital management, emergency management and definitive surgical care. The development of the Early Management of Severe Trauma Course and the Definitive Surgical Trauma Course, both available in Australia and New Zealand, has provided the platform for improved trauma management.

PREPARATION

Effective communication between the pre-hospital personnel and the receiving hospital is paramount. The history of the injury and pre-hospital management is extremely important and this should be relayed via the MIST system:

M Mechanism, e.g. fall, motor vehicle accident, pedestrian

I Injuries, e.g. abdominal tenderness, chest injury, fractured long bone

S Signs, e.g. pulse, systolic blood pressure, respiratory rate, conscious level

T Treatment, e.g. cervical spine immobilisation, oxygen, intravenous therapy, drugs

This information enables the trauma team to prepare and focus their attention on specific early interventions that may be life-saving for the given situation. For example, the multitrauma victim with abdominal injuries who remains hypotensive after 2 litres of intravenous fluids in the field will need uncrossmatched group O blood via a rapid warmer to be available on arrival and will probably require early transfer to the operating suite for definitive care.

It is often best to prepare for the incoming trauma patient by mentally working your way through the airway, breathing and circulation management (ABCs) and thinking about what equipment/personnel may be necessary for each area of concern. Knowledge of the mechanism of injury enables some prediction of possible injury/injuries. Standard precautions are a must—goggles, mask, impervious gown and gloves. The early donning of lead gowns enables potentially crucial X-rays to be performed in a timely and appropriate fashion without significant interruption to resuscitation efforts once the patient arrives.

PRIMARY SURVEY

During the primary survey you need to simultaneously identify and manage immediately life-threatening injuries. The priorities of the primary survey, in order, are:

The primary survey needs to be continually repeated throughout the initial phase of management. The key to good trauma care is directed assessment, followed by appropriate and timely intervention and subsequent directed reassessment—the AIR (assessment, intervention, reassessment) approach.

Six key injuries that need to be excluded during the primary survey can be remembered by the mnemonic At This Moment Find Ominous Conditions:

Airway obstruction

Tension pneumothorax

Massive haemothorax

Flail chest

Open pneumothorax

Cardiac tamponade.

3 Circulation and control of external haemorrhage

The maintenance of adequate tissue perfusion, especially of the brain, is the primary objective of the circulation component of the primary survey. Hypotension is almost always due to blood loss in the trauma setting. You must stop the bleeding. This may simply require the application of pressure to a site of external haemorrhage or it may necessitate transfer to the operating suite for an immediate laparotomy. Early application of a pelvic binder in the appropriate setting may be life-saving.

Examination

Assessment of a patient’s circulatory status does not require waiting for the blood pressure reading. Information gained from examination of the patient’s pulse, skin and level of consciousness is enough to make immediate resuscitation decisions, and the only equipment required is your eyes and your fingers. Remember to interpret your findings in the context of each individual you are assessing—the young, fit male who can compensate well despite considerable blood loss versus the elderly female with multiple comorbidities on numerous physiology-altering medications are two entirely different scenarios. Beware of patients who are hypotensive in the supine position—they have lost in excess of 30–40% of their blood volume and will require urgent resuscitation (Table 14.1).

Pulse. The pulse rate and character should be determined as an initial assessment of the circulatory status. Tachycardia with a small volume pulse is due to hypovolaemia until proven otherwise. Patients with systolic blood pressure less than 80 mmHg frequently have absent peripheral pulses.

Skin perfusion. Pale, cool, clammy skin with a capillary refill time greater than 2 seconds is an early indicator of hypovolaemia.

Level of consciousness. A decreased level of consciousness is an indicator of poor cerebral perfusion and, again, is presumed to be due to hypovolaemia until proven otherwise.

Priorities

Deteriorating haemodynamic status may be due to:

Immediate directed re-examination for tension pneumothorax and cardiac tamponade should be performed. Frequently neck veins will be collapsed in hypovolaemia; however, if the jugular venous pressure is raised, this suggests increased intrathoracic pressure. Having clinically ruled out these two conditions, you are then faced with the challenge of determining the source of ongoing blood loss.

Major blood loss can occur from the following five sites:

Focus on these sites particularly when dealing with the trauma patient who remains hypotensive despite intravenous fluid resuscitation and other appropriate measures. It is imperative to remember that, at this stage of the resuscitation, determining the site of blood loss is far more important than trying to determine which specific organ is bleeding.

External haemorrhage can be visualised and then controlled with appropriate pressure. Long bone fractures can be determined by clinical examination and then splinted to limit further blood loss. Significant blood loss into the chest can be ruled out by clinical examination and with the aid of an early chest X-ray. Likewise, significant blood loss from the pelvis can be ruled out by clinical examination and with the aid of an early pelvic X-ray. The abdomen/retroperitoneum is, by default, the only other site of blood loss left to contend with and, in the context of haemodynamic instability, this usually means an emergency laparotomy is in order.

Always remember, however, that the patient may bleed into multiple sites simultaneously, making such an ‘orderly’ assessment difficult in practical terms. The role of bedside ultrasonograpy as an adjunct to the clinical examination in the trauma patient has been developing for many years throughout the world and is rapidly expanding in Australia, replacing diagnostic peritoneal lavage in many centres. It has the advantage of being rapid, safe, non-invasive and, most importantly, repeatable.

Code Crimson activation can be simplified to the following four steps:

The use of ultrasound in a directed and limited manner by performing a focused assessment with sonography in trauma (FAST) examination is now commonplace. Its primary role is to look for free fluid in the abdomen by examining the hepatorenal, splenorenal and retrovesical regions. In the appropriate circumstances examination for fluid in the pericardial sac may also be carried out. It should be performed by an experienced team member and should not distract the trauma team from the other components of the primary survey.

Remember: It is a rule-in test—if it is negative all bets are off.

RESUSCITATION

As the initial assessment is performed and airway and breathing issues are attended to, intravenous fluids should be given in volumes appropriate for the estimated extent of hypovolaemia. In general, hypotensive patients should have 20 mL/kg of warmed intravenous fluids infused rapidly. An adult patient who requires more than 2 litres of intravenous fluids and remains hypotensive should have blood as the next resuscitation fluid. Ideally, crossmatched blood should be given, but group-specific or uncrossmatched group O blood may need to be given, depending on the patient’s clinical status.

The above traditional approach is being challenged, particularly with regard to the critically ill trauma patient who is shocked and has an acute coagulopathy on arrival at the emergency department, with some suggesting ‘damage control resuscitation’ using plasma/blood products and minimal volume resuscitation until surgical control of bleeding is achieved. The role of factor VIIa is yet to be determined. Fortunately, such complex patients are a small percentage of trauma admissions.

While placing intravenous lines, draw blood for the following investigations. Note that not all will be necessary in every situation.

The timing of radiological studies will vary depending on the urgency of the situation. In major trauma patients, however, the early performance of a trauma series (chest X-ray/pelvis/lateral C-spine) is appropriate and usually takes place as the team is performing the primary survey. The most logical order for the films is:

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