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:

• head
• neck
• chest
• abdomen
• perineum
• back

• Head injury with:

• 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:

1. primary survey
2. resuscitation
3. history
4. secondary survey
5. definitive care.

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:

Airway obstruction

Tension pneumothorax

Massive haemothorax

Flail chest

Open pneumothorax

Cardiac tamponade.

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)

image

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
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