Trauma

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Chapter 14 Trauma

Martin Duffy, Karon McDonell, Anthony J. Grabs

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.

DEFINITION OF MAJOR INJURY

Numerous trauma scoring systems are presently used throughout the world in an attempt to define the severely injured patient. Unfortunately, all have their advantages and disadvantages, with one of the key problems being the need to collect data ‘after the fact’. Scoring at the time of presentation may underestimate the severity of the injury and lead to undertriage. Major injury has previously been defined as having an injury severity score (ISS) in excess of 15, as it was associated with a chance of dying in excess of 10%. Most trauma centres would now define major injury as:

• ISS > 15

• requirement for urgent surgery

• intensive care admission

• inpatient stay longer than 3 days

• head injury requiring assisted ventilation for more than 24 hours

• death.

Patients with major injuries need to be triaged early, with activation of a coordinated trauma response from emergency, anaesthetics, intensive care and surgery.

PRE-HOSPITAL TRIAGE

Pre-hospital assessment and management by ambulance services now enables the initial triage of patients to regional or major trauma services. The overriding goal is to get the right patient to the right hospital at the right time. Patients meeting the following criteria should be considered as having potentially life-threatening injuries requiring the services of an appropriately designated trauma centre. These criteria are also used by many hospitals as triggers to activate a trauma team response for an incoming patient, and include:

• respiratory distress—rate < 10 or > 30, or cyanosis

• systolic blood pressure < 90 or no palpable radial pulse in children

• reduced level of consciousness

• serious trauma to any region of the body

• burns (partial or full thickness) > 20% in adults or > 10% in children.

The definition of serious trauma to any body region includes the following.

• Penetrating injury of:

• one or both pupils dilated

• open head injury

• severe facial injury

• Abdominal injury with:

• distension

• rigidity

• Spinal injury with:

• weakness

• sensory loss

• Limb injury with:

• vascular injury with ischaemia of limb

• amputation

• crush injury

• bilateral femur fractures

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.

SYSTEMATIC ASSESSMENT AND MANAGEMENT

The care of the injured patient by a trauma team is somewhat different to traditional medicine, with diagnosis, investigations and management frequently occurring simultaneously and performed by more than one doctor. A team leader should direct the overall management, including:

When caring for the paediatric trauma patient, the priorities are the same as for the adult patient. Allowances must be made for the child’s size and physiology but the approach to assessment and management is otherwise identical. Beware of differences in injury patterns and the child’s ability to compensate. Don’t forget the parents—modify your approach to include family in the resuscitation room.

Care of the pregnant patient follows a similar line. Again, allowing for differences due to the anatomical and physiological changes of pregnancy, assessment and management are the same as for the non-pregnant patient. Positioning of the mid-late pregnant woman is important as the gravid uterus may compress the vena cava. To avoid this position, try tilting the pelvis to the left side using a rolled towel underneath, if not contraindicated. Early use of fetal monitoring is important, but good care of the mother equals good care of the fetus, so remain focused on the following priorities as outlined for the adult patient.

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:

1. airway maintenance with cervical spine protection

2. breathing and oxygenation

3. circulation and control of external haemorrhage

4. disability—brief neurologic examination

5. exposure with environment control.

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:

1 Airway maintenance with cervical spine protection

Patients with a decreased level of consciousness or inadequacy of protective reflexes are prone to airway obstruction and aspiration. All patients should be considered to have a cervical spine injury until proved negative—this has significant implications for airway management. The head and neck should be supported at all times, especially during logrolling. The first priority is to establish a patent and protected airway. This may require:

• the removal of blood, vomitus and foreign bodies by posturing, suction or Magill’s forceps

• jaw thrust and chin lift manoeuvres

• the insertion of an oropharyngeal/nasopharyngeal airway

• endotracheal intubation

• establishment of a surgical airway.

A high concentration of oxygen should be administered to all patients. Patients with a decreased level of consciousness associated with a traumatic brain injury should be considered for early endotracheal intubation.

Nasotracheal intubation is rarely required in acute management and should only be performed by staff experienced in the procedure. A surgical airway is only indicated if there is an inability to perform bag and mask ventilation or failure to intubate.

2 Breathing and oxygenation

Once the airway has been deemed patent and protected, the adequacy of ventilation should be assessed. This is achieved by:

• exposure of the chest

• inspection for cyanosis, tachypnoea, chest movement and chest wall integrity

• palpation of the tracheal position, subcutaneous emphysema and chest wall integrity

• percussion

• auscultation for the presence and symmetry of air entry

• oxygen saturation ± arterial blood gases.

The team should identify and provide immediate management for the following life-threatening injuries well before a chest X-ray has been obtained:

• tension pneumothorax

• large haemothorax

• large flail segment

• open pneumothorax.

However, an early chest X-ray may provide vital warning of a potentially life-threatening chest injury not yet detected by clinical examination.

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).

Table 14.1 Estimated fluid and blood losses based on patient’s initial presentation (for a 70-kg patient)

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

1. Control of external haemorrhage. This may require direct digital pressure over a wound, suturing/stapling of briskly bleeding scalp wounds, the reduction of facial fractures and nasopharyngeal packing.

2. Establishment of intravenous access. Two large-bore cannulas (14- or 16-gauge) should be inserted, usually into the cubital fossa of each arm. In patients with severe upper limb or chest trauma, one large-bore cannula should be above the diaphragm and one below the diaphragm. Intraosseous needles have traditionally been used in children under 8 years old with life-threatening injury if venous access cannot be established within an appropriate timeframe. Purpose-made intraosseous needles for adult patients are now commonly available. Large-bore cannulas may also be placed in the subclavian or jugular position or into the femoral vein if necessary. The use of ultrasound to find appropriate intravenous access in the difficult patient is becoming more common.

3. Resuscitation fluids. Warmed intravenous fluids should be given at a rate appropriate for the clinical situation at hand. Minimal volume resuscitation may be appropriate in some circumstances in an attempt to avoid ‘popping the clot’ before surgical control of bleeding has been achieved. Anticipate the need for transfusion early as fully cross-matched blood takes at least 40 minutes to organise. Be prepared to use group-specific or uncrossmatched group O blood in urgent cases.

4. Stop the bleeding. Fluid resuscitation does not replace the need to control ongoing bleeding—get the patient to the operating suite at the right time.

‘Code Crimson’ is a protocol designed to facilitate the rapid transfer to operating theatres (OTs) of massive exsanguinating trauma or vascular emergencies. This involves bypassing resuscitation cubicles, which may waste valuable time while carrying out monitoring and radiology. It has been shown that, although each minor task may individually consume barely minutes, together they accumulate some 20 minutes to ready the patient.

Deteriorating haemodynamic status may be due to:

• ongoing blood loss

• tension pneumothorax

• cardiac tamponade.

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:

1. external haemorrhage

2. long bone fracture/s

3. chest

4. pelvis

5. abdomen/retroperitoneum.

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:

1. Pre-hospital notification by ambulance service of major trauma (‘batphone’).

2. Switchboard sends a major trauma page to trauma team.

3. Team leader (most senior emergency doctor) upgrades to Code Crimson on patient arrival, in consultation with surgical registrar.

4. Switchboard sends Code Crimson page to surgical and anaesthetic teams.

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.

4 Disability: brief neurological examination

A decreased level of consciousness is due to hypoxia or hypovolaemia until proven otherwise. Beware of hypoglycaemia. However, once these issues have been addressed, the priority is to determine the presence or absence of an intracranial injury that requires urgent neurosurgical intervention. The pupils should be assessed for size, symmetry and response to light and the patient’s level of consciousness should be quickly assessed using the AVPU method, i.e. is the patient:

• Alert?

• responding to Verbal stimuli only?

• responding to Painful stimuli only?

• Unresponsive?

The Glasgow Coma Score (GCS) may also be used to assess the level of consciousness at this stage, or can be deferred until the secondary survey is performed. In conscious patients, all limbs should be assessed for movement and sensation to detect possible spinal injury.

All patients with a GCS of less than 12 should have aggressive ABC management, including consideration for early intubation. This will enable controlled ventilation/oxygenation and allow the team to focus on the circulatory status, thus attending to two key factors responsible for adverse outcomes in traumatic brain injury—hypoxaemia and hypotension.

5 Exposure with environment control

Patients who have sustained a major injury should have all their clothing cut off without delay to allow adequate assessment of the entire body. Remember, however, that hypothermia kills trauma patients. Unless your resuscitation room has dedicated temperature control capabilities, as soon as your examination and any required procedures have been performed the patient needs to be covered. A warming mattress and a Bair Hugger may also be needed to control the patient’s temperature.

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.

• Full blood count

• Electrolytes/urea/creatinine

• Glucose

• Liver function tests

• Amylase/lipase

• Coagulation studies

• Group-and-hold/crossmatch

• Blood alcohol level—including an appropriate sample for the police when

required

• Beta-human chorionic gonadotrophin (hCG)

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:

1. chest X-ray—as an adjunct to ‘B’ and ‘C’ assessment

2. pelvis—as an adjunct to ‘C’ assessment

3. lateral C-spine—because this film on its own will not exclude a C-spine injury, it may be delayed if necessary while continuing immobilisation measures (and is often replaced by CT).

During the resuscitation phase, a urinary catheter should be passed to assess urine output. A urinary catheter is contraindicated if there is blood at the external meatus, blood in the scrotum or per rectum (PR), the prostate cannot be palpated or is high riding. In general, a urethrogram is indicated in these circumstances and an urgent urological opinion should be sought. A suprapubic bladder catheter is an option in the presence of significant urethral trauma.

A nasogastric tube should be placed in all intubated patients and patients who have sustained significant abdominal trauma. This is to prevent gastric aspiration and the development of acute gastric dilatation. In the presence of head or facial injuries the tube should be placed via the mouth.

The relief of discomfort is an important component of trauma care, and analgesia should be provided in an appropriate form and amount depending on the clinical state of the patient. In most circumstances this will equate to the provision of an intravenous opioid delivered in small aliquots and titrated to effect while monitoring for adverse events.

Consider tetanus immunisation and prophylactic antibiotics as required.

The ongoing resuscitation status should be monitored by:

• respiratory rate and effort

• pulse oximetry

• peripheral perfusion

• pulse rate/ECG rhythm

• blood pressure—with particular attention to pulse pressure

• Glasgow Coma Score

• arterial blood gases (ABGs)—base deficit and lactate

• urine output.

Persistent haemodynamic instability should again raise the possibility of:

• continued blood loss

• tension pneumothorax

• cardiac tamponade

• other conditions—e.g. myocardial injury, spinal cord injury etc

• equipment problems—e.g. blocked or displaced intercostal catheter, dislodged peripheral or central access resulting in extravasation of fluids, malfunction of ventilation equipment etc.

At this stage the trauma team leader should decide whether the patient should be transferred immediately to the operating suite for a resuscitative thoracotomy and/or laparotomy.

MANAGEMENT OF LIFE-THREATENING CONDITIONS

As previously stated, life-threatening conditions should be suspected and identified during the primary survey. The management of these conditions may be based in the emergency department or may require immediate transfer to the operating suite.

Tension pneumothorax

A 12- or 14-gauge cannula should be inserted into the 2nd intercostal space in the mid-clavicular line as an initial treatment to decompress the chest. This should be followed by an intercostal catheter in the 4th or 5th intercostal space just anterior to the mid-axillary line.

Open pneumothorax

A large combine should be placed over the defect and secured in position with an op-site dressing. At the same time, a large intercostal catheter needs to be inserted to treat the now ‘closed’ pneumothorax and to prevent the possible development of a tension pneumothorax.

Massive haemothorax

A large intercostal catheter (minimum 28 Fr) should be inserted into the 4th or 5th intercostal space just anterior to the mid-axillary line and directed posteriorly. An initial drainage of greater than 1500 mL should signal the team to consider early thoracotomy, especially in penetrating trauma.

All intercostal catheters should be connected to an underwater sealed drain and have low wall suction applied. A stat dose of prophylactic antibiotics (a first-generation cephalosporin for the non-allergic patient) should reduce the risk of an infective complication.

Flail segment

Flail segments frequently result in inadequate ventilation/oxygenation and are prone to the collection of air or blood in the pleural cavity. Associated pulmonary contusions are the major cause of morbidity and can result in progressive deterioration in respiratory function. Adequate drainage of the pleural cavities should be ensured by a large intercostal catheter; otherwise the management remains largely supportive with adequate analgesia via an appropriate route (including such options as a thoracic epidural) and assisted ventilation/oxygenation (ranging from non-invasive techniques such as bi-level positive airway pressure (BiPAP) to endotracheal intubation).

Ongoing blood loss

These patients should be considered for early transfer to the operating suite for a resuscitative thoracotomy and/or laparotomy. If pelvic bleeding is suspected the immediate application of a pelvic binder for pelvic stabilisation and early angiography should be considered.

Cardiac tamponade

The diagnosis should be suspected clinically and confirmed with FAST ultrasound if possible. Management revolves around adequate resuscitation and performing a left anterolateral thoracotomy to release the fluid within the pericardial sac. This should be undertaken by the most experienced trauma team member. Needle pericardiocentesis should only be considered in smaller hospitals if experienced staff are not available. Needle pericardiocentesis may be life-saving but rarely drains the pericardial sac adequately and is associated with significant complications.

Pulseless electrical activity

This is sometimes called electromechanical dissociation and in the context of trauma is usually caused by exsanguination, tension pneumothorax, massive haemothorax or cardiac tamponade. Pulseless electrical activity should be managed by immediate intubation, ventilation, bilateral chest drains, the administration of at least 3 litres of intravenous fluids and consideration for an open thoracotomy and pericardial release. This is of special importance in penetrating chest injuries.

HISTORY

A nominated member of the trauma team should obtain further information that will allow the acute event to be managed in the context of the patient’s premorbid state. A simple way to cover most of the important areas is to use the AMPLE approach:

A Allergies

M Medications—particularly anticoagulants!

P Past history—particularly diseases that alter clotting ability; pregnancy

L Last food/fluid; last tetanus injection

E Event details

This history may not be available directly from the patient and other sources may need to be questioned, e.g. pre-hospital personnel, relatives, friends, the local doctor, old medical records etc. In the unconscious patient always remember to look for a medical alert bracelet or any pertinent information on the person or in a wallet/handbag.

Details of the mechanism of injury are vitally important. Conceptually, injury is the result of a transfer of energy to the body’s tissues. The severity of injury is dependent upon the amount and speed of energy transmission, the surface area over which the energy is applied, and the elastic properties of the tissues to which the energy transfer is applied. In the Australian setting, the most common cause is blunt trauma; however, penetrating trauma is on the increase. Common causes of blunt trauma include:

1. motor vehicle crashes

2. pedestrian–motor vehicle accidents

3. falls

4. industrial accidents

5. assaults.

Specific injuries may be predicted from the mechanism of injury.

1 Injuries in motor vehicle crashes

• Frontal impact—cervical spine fracture, anterior flail chest, traumatic aortic disruption, pneumothorax, myocardial contusion, ruptured spleen or liver, posterior dislocation/fracture of hip/knee.

• Lateral impact—cervical spine fracture, lateral flail chest, traumatic aortic disruption, pneumothorax, diaphragmatic injury, ruptured spleen or liver, renal injury, fractured pelvis.

• Rear impact—cervical spine injury.

• Ejection—increased risk for any injury.

• Rollover—increased risk for any injury.

Important information from pre-hospital personnel that provides some idea of the energy transfer involved includes details of the estimated speed, impact, damage to vehicle, entrapment, use of restraint devices, deployment of airbags etc. Nowadays, digital photos of the scene are an invaluable source of information.

2 Injuries in pedestrian–motor vehicle accidents

• Remember the injury triad—impact with the bumper, impact with the bonnet and windscreen, and subsequent impact with the ground.

• Bumper—lower limb fractures, fractured pelvis, torso injuries in children.

• bonnet/windscreen—head injury, torso injuries.

• Ground—head injury, spinal injuries.

Again, pre-hospital information that gives some idea of the energy transfer involved is important.

3 Injuries in falls

• The predominant underlying mechanism of injury is deceleration.

• Important considerations include the height of the fall, the landing surface, and the position of the patient on impact.

• Injuries include head, spine, torso and multiple fractures (calcaneus, ankle, tibial plateau, hip and vertebral column).

4 Injuries in industrial accidents

• May be blunt or penetrating.

• Other mechanisms need to be considered—blast, thermal, chemical.

• Injuries will depend on the above mechanisms.

5 Injuries in assaults

• Unfortunately a common cause.

• May be blunt or penetrating.

• Determine the energy transfer—weapon, fists, stomping.

• Injuries will depend on the above mechanisms.

• Stabbings are low energy injuries—severity determined by organs injured, e.g. major vascular injury versus muscle.

• Gunshot injuries vary in energy level—increased bullet velocity equals increased injuries secondary to cavitation.

Knowledge of the mechanism of injury provides ‘advanced warning’ regarding possible injuries—it is a useful guide, but remember there are always exceptions.

SECONDARY SURVEY

The secondary survey is a detailed systematic head-to-toe examination in order to detect all injuries and enable planning of definitive care. This should not commence until the primary assessment and management have stabilised the patient. During the secondary survey all components of the primary survey should be repeated and the team should be responsive to any new findings. Unless the patient has been transferred immediately to the operating suite, the secondary survey should be undertaken in the emergency department.

Head. Assess the scalp for lacerations, contusions, fractures and burns. Examine the ears for haemotympanum and cerebrospinal fluid (CSF) leakage. Check the eyes for visual acuity, pupil symmetry and response to light, movements, lens injury; always check for the presence of contact lenses and remove them early.

Face. Assess for lacerations, contusions, fractures and burns. Check cranial nerve function. Examine the mouth for bleeding, loose teeth and soft tissue injuries.

Cervical spine and neck. Assess for tenderness, bruising, swelling, deformity, subcutaneous emphysema and tracheal deviation. Beware of carotid dissection.

Chest. Assess for evidence of rib fracture, subcutaneous emphysema, open wounds, haemothorax and pneumothorax. Check for evidence of myocardial injury, and perform a 12-lead ECG.

Abdomen. Assess for bruising of the anterior abdominal wall, distension, tenderness and guarding, rebound, rectal and vaginal examinations.

Back. All trauma patients need to undergo a logroll with cervical spine immobilisation to examine the entire length of the spine, looking for tenderness, bruising or deformity. This should be done early so the patient can be removed from the spinal board, improving patient comfort and decreasing the risk of pressure injuries in patients with spinal cord injuries and altered sensation/awareness. A PR examination should be done at this time.

Limbs. All limbs need to be examined for fractures, lacerations, haematomas, peripheral pulses and neurological deficits. All fractures should be reduced and splinted and consideration given for intravenous antibiotics and tetanus prophylaxis.

SPECIFIC INJURIES

Head trauma

(See also Chapter 15, ‘Neurosurgical emergencies’.)

Traumatic brain injury is common. Unfortunately, despite this fact, there is a scarcity of good evidence in the literature upon which to base investigation and management decisions, particularly with regard to the patient with mild head injury. It is important to determine at an early stage whether your facility can provide the appropriate care necessary for the patient’s severity of injury or whether urgent transfer to another hospital will provide the best possible care.

Classification systems abound and all have their limitations, but the following GCS-based system is a useful guide:

• mild head injury—GCS 14–15

• moderate head injury—GCS 9–13

• severe head injury—GCS 3–8.

Neck injuries

The accurate assessment and management of neck injuries is important, not only because of the potentially devastating effects of cervical spine/spinal cord injuries, but also because of the life-threatening potential of injuries to other vital structures such as the airway/larynx and vascular anatomy. A detailed search for swelling, expanding haematoma formation, subcutaneous emphysema, tracheal deviation, hoarseness, stridor and carotid bruits should be performed.

Key points in management include:

1. Ensure airway patency. Repeated examinations are essential and early intubation may be life-saving.

2. Blunt injury to vascular structures can be ‘occult’. Maintain a high degree of suspicion and proceed to further investigation, e.g. ultrasound, angiography.

3. Beware of penetrating injuries. If the platysma is breached the right place for the patient to be further examined and treated is in the operating suite with on-table angiography facilities.

4. Clear the cervical spine. Patients suffering blunt trauma who meet the following five criteria can be classified as having a low probability of cervical spine injury and can be cleared on clinical grounds. No radiological imaging is required if the patient has:

• normal alertness

• no intoxication

• no painful, distracting injury

• no midline cervical tenderness

• no focal neurological deficit.

Alternative guideline for clearing the cervical spine is the Canadian C-spine rule; see Figure 14.1.

Figure 14.1 The Canadian C-spine rule

For patients with trauma who are alert (as indicated by a score of 15 on the Glasgow Coma Scale) and in a stable condition and in whom cervical-spine injury is a concern, the determination of risk factors guides the use of cervical-spine radiography. A dangerous mechanism is considered to be a fall from an elevation of ≥ 3 feet (1 metre) or 5 stairs; an axial load to the head (e.g. diving); a motor vehicle collision at high speed (> 100 km/h) or with rollover or ejection; a collision involving a motorised recreational vehicle, or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.

Abdominal trauma

The abdomen is renowned for its reputation as an ‘occult’ source of blood loss in the trauma victim. Add to this reputation the poor sensitivity and specificity of the physical examination in this setting and it is not hard to see why investigation and management decisions can seem daunting. As stated previously, during the initial assessment of such patients it is important to keep in mind that it is more important to determine the site of bleeding as opposed to the specific organ injured. Remember the full ‘extent’ of the abdomen when assessing a patient—the anterior borders are the trans-nipple line superiorly, the inguinal ligaments and pubic symphysis inferiorly, and the anterior axillary lines laterally.

The most common mechanism of abdominal injury in the Australian setting is blunt trauma, usually in the context of a motor vehicle crash. Penetrating abdominal trauma is on the increase though, and the differences in the biomechanics of low energy versus high energy injuries need to be taken into account. However, regardless of the mechanism, the initial assessment and management need to follow the same principles of airway, breathing, cardiovascular, drug therapy (the ABCDs).

Blunt abdominal trauma

Key points in the management include:

1. Remember that the physical examination is unreliable.

2. By a process of elimination the abdomen/retroperitoneum can be diagnosed as the site of blood loss—if it is not external, long bones, chest or pelvis, the abdomen/retroperitoneum is the only site left.

3. If the patient is haemodynamically stable, a CT scan is an appropriate investigation to confirm your clinical suspicion (Table 14.2).

4. If the patient is haemodynamically unstable do not go to CT—go to the operating suite!

5. For the patient ‘in between’, a FAST examination or a diagnostic peritoneal lavage may be invaluable (Table 14.2).

6. Remember that a FAST examination can only rule in the presence of free fluid. If it is negative, all bets are off.

7. Be appropriately aggressive with resuscitation fluids—the right amount for the right patient at the right temperature.

8. Stop the bleeding—for some patients this will mean immediate transfer to the operating suite.

Table 14.2 Imaging in abdominal trauma

Penetrating abdominal trauma

Advice regarding resuscitation and imaging is as for blunt trauma (see above). Other important points include:

• The entry wound can be a misleading predictor of the trajectory of penetration and potential underlying injury/ies—do not rely on it.

• Anterior abdominal stab wounds with hypotension, peritonitis or evisceration of omentum or small bowel require no further imaging or investigation—they need to go to the operating suite for a laparotomy.

• Local exploration of stab wounds under sterile conditions and local anaesthesia may be performed by the skilled surgeon in stable patients, searching for a breach in the anterior fascia. If a breach is present the patient is at increased risk of an intraperitoneal injury, and common practice in Australia is to proceed to laparoscopy.

• The value of repeated examinations should not be underestimated.

Thoracic trauma

The majority of chest injuries can be managed in the emergency department with the use of supplemental oxygen, an appropriately placed intercostal catheter and the judicious use of analgesics via an appropriate route. Hence, it is important that doctors working in such an environment develop the skills to assess and manage these patients correctly.

Often when the patient first arrives, the examination and chest X-ray are performed in the supine position, and allowances must be made for this in terms of exam technique and film interpretation. For example, percussion should be performed in an anterior to posterior direction for detecting the presence of a haemothorax—and the chest X-ray will have a generalised increase in radiodensity on the affected side as compared to the usual meniscus on an erect film. Watch out for the patient with a widened mediastinum on chest X-ray suspicious for a contained rupture of the aorta—if you don’t have cardiothoracic facilities, transfer the patient without delay so further investigation and treatment can take place at the right hospital.

Keep in mind the presence of common intercurrent diagnoses that may impact on a patient’s ability to cope with their chest injury, such as chronic airflow limitation and asthma, not to mention smoking status.

Given the important structures within the chest, it is not surprising patients can suffer a large number of possible life-threatening injuries, including those previously discussed under the primary survey, as well as the following:

Pulmonary contusion. Commonly associated with many of the other injuries and is often the main cause of deteriorating lung function. Develops over hours to days. May require increasing supplemental oxygen, non-invasive ventilatory support or subsequent intubation/ventilation.

Haemothorax. Drainage via an appropriately sized and placed intercostal catheter is important as noted previously. Transfer to the operating theatre needs to be considered in any patient who drains more than 1500 mL immediately or continues to drain more than approximately 200 mL/h for 2–4 hours.

Simple pneumothorax. There is some controversy as to how some of these injuries should be managed depending on such factors as the size of the pneumothorax, associated injuries, need for positive pressure ventilation, need for transfer to another facility, and coexistent respiratory diseases; most would still advocate drainage via an appropriately sized intercostal catheter.

Blunt cardiac injury. Suspect in the patient who remains haemodynamically unstable. There is no one clear diagnostic test—the ECG, cardiac markers and other imaging modalities such as echocardiography are all adjuncts to the clinical examination.

Traumatic aortic disruption. Most patients die at the scene. If they survive to reach hospital, there is a window of opportunity to investigate and treat them at a facility with cardiothoracic capabilities. Signs to look for on the chest X-ray include a widened mediastinum, obliteration of the aortic knob, deviation of the trachea to the right, obscuration of the aortopulmonary window, depression of the left main stem bronchus, deviation of the oesophagus (nasogastric tube) to the right, widened paratracheal stripe, widened paraspinal interfaces, presence of a pleural or apical cap, left haemothorax, or fractures of the first and second ribs or the scapula. Early surgical consultation is important.

Tracheobronchial tree disruption. An unusual injury; patients usually die at the scene. Suspect if a large air leak persists after placement of an intercostal catheter for a pneumothorax. Early surgical consultation is important.

Traumatic diaphragmatic injury. Often missed; interpret X-rays with care. Early surgical consultation is important.

Traumatic oesophageal disruption. Rare; fatal if missed because of subsequent mediastinitis. Suspect if there is a left pneumothorax or haemothorax without a rib fracture, pain or shock out of proportion to the injury (usually a blow to the lower sternum or epigastrium), or if there is particulate matter in the intercostal catheter. Early surgical consultation is important.

However, having noted the above injuries, do not underestimate the significant morbidity and potential mortality associated with the most common of chest injuries—rib fractures! Important points in the management of this everyday problem include:

1. The ability of X-rays to detect rib fractures is poor—even if the films are read accurately!

2. If the patient has a good history and significant pain, rib fracture is probably the diagnosis.

3. The role of the chest X-ray is to help exclude complications such as a pneumothorax, haemothorax, pulmonary contusion, atelectasis, subsequent pneumonia.

4. It is clear from the above that ‘rib views’ are therefore not necessary.

5. The presence of intercurrent disease may influence management decisions.

6. Adequate analgesia that allows deep breathing and coughing is paramount to the successful management of patients with these injuries:

• Start with simple oral therapy—paracetamol.

• Add other oral options—NSAIDs/tramadol/oxycodone—being alert for respiratory depression.

• Use parenteral therapy—tramadol/opioids—again being alert for respiratory depression.

• The use of patient-controlled analgesia may be appropriate in many circumstances.

• Consultation with the anaesthetic/pain management service with the view to other alternatives—intercostal blocks/epidural anaesthesia.

7. Paramedical services play an important role—physiotherapy.

8. Use non-invasive ventilatory support such as BiPAP early.

9. Closely monitor the patient’s progress—respiratory rate and effort, pulse oximetry, ABGs.

10. Be prepared for the patient who, despite the above measures, continues to struggle—intubation with controlled ventilation/oxygenation may be necessary.

11. With few exceptions elderly patients with fractured ribs require inpatient care.

Pelvic trauma

Pelvic injuries can range in severity from simple pubic rami fractures to unstable injuries with associated life-threatening exsanguination. It is important to appreciate the magnitude of force required to fracture the pelvis—and hence the high association with other potentially life-threatening injuries.

Three common mechanisms of injury are:

1. anteroposterior compression, e.g. crushing injury

2. lateral compression, e.g. motor vehicle crash

3. vertical shear, e.g. fall from a height.

Be suspicious of significant pelvic injury with the above mechanisms and perform a careful clinical examination, noting any lower limb shortening or rotation (in the absence of a lower limb fracture) and any pain or movement on palpation of the pelvic ring. Compression-distraction of the pelvic ring is controversial and at most should be performed once only as part of this examination because of the risk of exacerbating any bleeding. The early performance of a pelvic X-ray as part of the trauma series will assist decision making.

Important points in the management of these injuries include:

1. Major pelvic disruption with haemorrhage should be suspected from the mechanism of injury, e.g. motorcycle crash, pedestrian–motor vehicle accident, fall from a height or a direct crushing injury.

2. Significant injuries are usually clinically apparent.

3. Be alert for and understand the potential for major blood loss—from the ends of fractured bones, from injured pelvic muscles and from the pelvic veins/arteries—and fluid resuscitate the patient appropriately.

4. Simple measures to control bleeding in the emergency department include:

• bringing the lower limbs back out to length with traction

• internally rotating the lower limbs and strapping them together

• the application of a pelvic binder—this may be as simple as wrapping a sheet around the pelvis.

5. Early consultation with the angiography/orthopaedic teams is paramount.

Always remember the possibility of associated urological injury. Suspicious examination findings include blood at the external urethral meatus, scrotal or perineal bruising, and an impalpable or high riding prostate on PR exam (all contraindications to catheterisation, as previously noted). In the multi-injured patient with a significant pelvic fracture, the bladder and/or urethra may be injured. In this setting the urethra is more commonly injured above the urogenital diaphragm. The patient is often in ‘retention’. The usual approach to management includes:

1. Assess and treat for other life-threatening conditions.

2. Perform a urethrogram and treat accordingly.

3. Suprapubic catheterisation in selected patients.

4. Urological consultation.

Musculoskeletal trauma

Musculoskeletal trauma is very common. Fortunately most injuries are neither limb- nor life-threatening, although they can on occasion look very dramatic. It is important not to be distracted by the injury and to manage all these patients in an orderly fashion with meticulous attention to the ABCs first. Some important points in the management of such injuries include:

1. Musculoskeletal injuries that are potentially life-threatening need to be recognised early and managed appropriately:

• Major arterial haemorrhage. These injuries may be as obvious as an avulsed limb or as subtle as the bleeding associated with a long bone injury or major joint dislocation. Do not blindly clamp open injuries—use direct pressure. Limb realignment and splinting are important measures that help reduce blood loss. Carefully assess the limb for the presence of distal pulses—absence equals arterial injury until proven otherwise. It is important to contact the surgical team early with a view to transfer to the operating suite for urgent exploration and/or angiography on the operating table.

• Crush syndrome. Be alert for this potential problem in any patient who has had a significant portion of a limb trapped for a period of time. The associated rhabdomyolysis and release of toxic byproducts can lead to life-threatening hyperkalaemia, hypovolaemia, metabolic acidosis, hypocalcaemia and disseminated intravascular coagulation. Resuscitate the patient with large volumes of normal saline aiming for a urine output of approximately 200 mL/h in an adult. Alkalinisation with sodium bicarbonate and the use of osmotic diuretics have also been advocated, although evidence is limited.

2. Most other injuries can be diagnosed and treated as part of the secondary survey.

3. Carefully examine the limb—skin integrity, colour, bruising, haematoma formation, neurovascular status, bony tenderness, function.

4. Be thorough—it is easy to overlook extremity injuries; therefore repeated examination is important.

5. Only proceed to imaging once the patient is stable and all life/limb threats have been addressed. Image the joints above and below the suspected fracture site.

6. Limb realignment and splinting reduces movement at the injury site, limits further bleeding and reduces pain. Always re-examine the neurovascular status of a limb if you have performed manipulation or applied a splint.

7. Early elevation of the injured limb reduces oedema formation.

8. Provide adequate analgesia, usually in the form of intravenous opioids titrated to effect.

9. Consider tetanus and antibiotic prophylaxis for open injuries.

10. Always be on the alert for complications—any site where muscle is contained within a closed fascial space has the potential to develop compartment syndrome.

Compartment syndrome

• This is a time-critical diagnosis—you have 4–6 hours at most to save the ischaemic contents of the compartment! It is potentially devastating if missed.

• Commonly occurs in the leg, forearm, foot, hand, gluteal region and thigh.

• Suspect the diagnosis in any patient who has pain greater than expected and that typically increases when the involved muscles are passively stretched—most of the other clinical signs are insensitive or develop late in the disease process.

• Warning—the distal pulse is usually present!

• Measure compartment pressures—greater than 35 mmHg in a normotensive patient is abnormal (lower pressures in the hypotensive patient may be significant). The trend in repeated measurements is generally more helpful than a one-off reading.

Treatment

1. Release any constricting bandages, casts etc.

2. Urgent fasciotomy if no improvement.

3. Treat complications, e.g. rhabdomyolysis.

DEFINITIVE CARE

Definitive care in all trauma patients needs to be directed by the trauma surgeon or the team leader.

Definitive care involves:

1. specific investigations, e.g. CT scan of the head/chest

2. consultation with speciality teams

3. documentation of all injuries and treatment

4. specific management plans from all appropriate teams

5. definitive placement to appropriate speciality team.

Tertiary survey

The tertiary survey is a complete review of the patient performed within the first 24 hours of their admission to hospital, aimed at detecting any further injuries or problems that may have been overlooked in the excitement of the initial resuscitation. It includes a further thorough head-to-toe clinical examination as well as a complete review of all investigations and treatments performed thus far.

Trauma service performance improvement

Care of the injured patient requires the services and skills of many different individuals. Trauma service performance improvement refers to the evaluation of the quality of care provided by a trauma service. Hospital-based performance improvement programs generally focus on the following aspects of health care.

• Safety—the extent to which risks and inadvertent harm are minimised

• Effectiveness of care—does the treatment/intervention achieve the desired outcomes?

• Appropriateness—is the selected treatment/intervention likely to produce the desired outcome?

• Consumer participation—engaging consumers in planning and evaluating health care services

• Efficiency—maximal total benefit is derived from the available treatments/resources

• Access—the extent to which an individual or population can obtain health care services

Performance improvement in trauma relies on the continual efforts of the multidisciplinary trauma team to measure, monitor, assess and improve both processes and outcomes of care. Trauma performance improvement programs are based on the following elements:

• a trauma registry/database to identify problems and the results of corrective actions

• multidisciplinary peer review of care, including morbidity and mortality analysis

• incident monitoring

• use of specific statistical methods for mortality analysis (e.g. Revised Trauma Score and Injury Severity Score—TRISS and A Severity Characterisation of Trauma—ASCOT)

• classification of deaths and complications as preventable, potentially preventable, non-preventable

• clinical indicators to measure current practice against accepted benchmarks

• use of evidence-based clinical guidelines, protocols and pathways

• evidence of ‘loop closure’—that is, evidence that the process/outcome needing improvement is remeasured following corrective action and that improvement is demonstrated.

Clinical practice guidelines and protocols

Clinical practice guidelines and protocols are outlines of accepted management approaches based on best available evidence and are designed to assist clinical decision making. Clinical pathways are multidisciplinary plans of best clinical practice for specified groups of patients with a particular diagnosis that aid the coordination and delivery of high quality care.

Clinical indicators

Clinical indicators are measures of the process or outcomes of care. They are not designed to be exact standards, but rather act as ‘flags’ to alert clinicians to possible problems in the system or opportunities for improvement. For clinical indicators to be effective they must be relevant and clearly defined. Development of a set of clinical indicators is interactive. Indicators are reviewed on an ongoing basis with reference to the usefulness of the data and the resources required to collect it. Trauma service indicators are used to monitor process and outcomes of care from the pre-hospital phase through to rehabilitation and discharge. Close analysis of data is required as there may be valid reasons why an event occurs differently from an expectation.

Examples of trauma service clinical indicators are:

• proportion of patients with a documented GCS < 9 who do not receive an endotracheal tube (ETT) within 10 minutes of documentation of that score

• proportion of head-injured patients with a documented GCS < 12 who do not have a CT scan of the head within 4 hours of arrival in the emergency department

• proportion of trauma patients transported to hospital by ambulance (not entrapped at the scene) who have a documented scene time of > 20 minutes.

Outcome measures

Historically, trauma services have focused on the issue of preventable deaths as the main outcome measure. Outcome analysis in trauma is slowly expanding. Trauma services are now beginning to analyse other outcomes such as morbidity, functional impairment, quality of life and patient satisfaction. Comparison of outcomes across different sites relies on use of standardised, reliable outcome measures. Similarly, morbidity analysis requires tight definitions of problems with rate comparisons potentially confounded by demographic differences between hospitals.

A large number of measures exist for outcomes analysis in trauma. These include:

• Glasgow Outcome Scale (GOS) for head injured patients

• Disability Rating Scale (DRS)

• Short Form (SF)-36 survey

• sickness impact profile

• Hospital Anxiety and Depression Scale (HADS)

• functional independence measure (FIM).

CONCLUSION

The patient suffering multiple injuries is often a distressing sight and can at times seem like an overwhelming challenge to manage. By approaching care of such patients in a directed manner, prioritising the assessment and management of life-threatening injuries as outlined above, hopefully both you and your patients can look forward to the best outcomes possible. Appropriate and timely intervention is the key.

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