Trauma

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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4 Trauma

Trauma remains the leading cause of death in the first four decades of life. Deaths following trauma occur in a trimodal distribution. The first peak is caused by deaths occurring within seconds to minutes of the injury, usually due to non-salvageable conditions such as brain lacerations, major aortic and other vascular injuries. The only way of reducing these deaths is prevention. The second peak occurs within minutes to hours of the injury. The third peak is a broad shape and accounts for deaths occurring weeks to months after the trauma as a result of complications of the injuries and treatment. The advanced trauma life support (ATLS) method of trauma care, developed in Nebraska in the 1970s, is now widely accepted as the optimum approach to treating injured patients.

ATLS protocols focus on reducing the second peak, and optimum care in the so-called ‘golden hour’ undoubtedly reduces late deaths from complications.

Initial assessment

Primary survey

Table 4.1 outlines the priorities for the first few minutes of treating an injured patient. Each of the ‘ABCDE’ priorities is paired with an equally important task. The usual sequence of history, examination, investigation and treatment seen in non-emergency situations is abandoned. Treatment of immediately life-threatening conditions is instigated simultaneously with ongoing assessment.

Table 4.1 Sequence and priorities for primary survey

Airway	Cervical spine control
Breathing	100% oxygen
Circulation: assess heart rate and blood pressure, establish IV access	Control of external haemorrhage
Disability (neurological state)	Pupils
Exposure: undress patient	Temperature control

If time permits, the more formal Glasgow Coma Score should be determined (see Table 4.5). Observe the pupils for dilatation and reactivity. A fixed, dilated pupil suggests an expanding intracranial haematoma or cerebral oedema (the third nerve becomes compressed along the edge of the tentorium cerebelli as the brain herniates downward, allowing unopposed sympathetic pupillary dilatation).

Exposure

The patient must be undressed fully but hypothermia prevented by adequate covers or warming devices.

Box 4.1 outlines conditions that must be detected or excluded by the end of the primary survey. The mnemonic ‘ATOM Football Club’ may help.

Box 4.1 Conditions that are either detected or excluded at the end of a primary survey – ‘ATOM Football Club’

Adjuncts to primary survey

Monitoring

ECG monitoring and continuous pulse oximetry are vital.

X-rays

X-rays of the chest, pelvis and lateral cervical spine are required for all seriously injured patients, in addition to other studies that may be indicated. The chest film is the most useful as haemo/pneumothoraces are often identified that were not obvious on clinical examination but which require chest drainage. Note that a normal lateral cervical spine film alone does NOT exclude a neck injury, especially in an unconscious patient.

Nasogastric tube

This reduces the likelihood of aspiration of gastric contents. If a facial or basal skull fracture is suspected, the oral route should be used; a tube passed nasally may end up in the cranium.

Urinary catheter

Urine output is a useful indication of renal perfusion and blood volume and is required in all severely injured patients. Transurethral catheterisation is contraindicated if there is evidence of urethral trauma, in which case a retrograde urethrogram is required. Signs suggestive of urethral damage include:

• blood at the urethral meatus

• scrotal/perineal bruising/haematoma

• high riding prostate on rectal examination

• pelvic fracture.

Log roll

The log roll is a manoeuvre where the patient is rolled onto one side without rotating any part of the spine. It allows full exposure and inspection of the back of the patient’s body without exacerbating any undiagnosed spinal injury. The precise timing in the resuscitation sequence is not fixed. Four trained personnel are required.

Shock

Shock is defined as acute circulatory collapse causing inadequate perfusion and resultant tissue hypoxia and is extremely common in trauma. Haemorrhagic shock is the most common cause in trauma. Other causes of shock and their clinical features are outlined in Table 3.3 (see pages 50-52).

Haemorrhagic shock

Severe haemorrhagic shock, characterised by tachycardia, hypotension, cold peripheries and oliguria, is straightforward to recognise, but the early stages may be less obvious, especially in a young and fit patient who can maintain a normal systolic pressure surprisingly well until further bleeding precipitates sudden collapse. Any trauma patient who is tachycardic and has cool peripheries must be assumed to be shocked until proven otherwise.

Haemorrhage is classified into four levels (Table 4.2), which are useful when estimating likely blood loss but are rarely clearly defined in practice. In true emergency situations patients are considered as responders, transient responders and non-responders, depending on the change in circulatory status following infusion of the initial bolus of 2000 mL warm crystalloid solution. Rapid responders who remain stable after the initial bolus do not need transfusion. Transient and non-responders need urgent blood transfusion and surgical intervention to identify and stem ongoing bleeding. When tracking down major haemorrhage in a hurry it is helpful to remember blood loss can only be in four places (and how to identify each in parentheses):

• chest (CXR, CT, in the chest drain)

• abdomen/pelvis (FAST ultrasound scan, X-ray of the pelvis, CT, DPL)

• surrounding long bone fractures (plain X-ray)

• on the floor (on the floor, witness accounts).

Table 4.2 The four classes of haemorrhaglc shock