Trauma life support
Introduction
Trauma remains the leading cause of death among those under 40 years of age and it is suggested that after cardiovascular disease and cancer, traumatic injury is the leading cause of death across all ages in the developed world (O’ Reilly 2003 Span et al. 2007, Greaves et al. 2009). Injuries kill some 5 million people each year, equating to 9 % of worldwide deaths, and young people between the ages of 15 and 44 account for approximately 50 % of global mortality due to trauma (Middleton 2011). There are an estimated 20 000 cases of serious/multiple injuries in England annually (National Audit Office 2010) resulting in approximately 5400 deaths and a significant proportion of victims suffer permanent disability. It is important to acknowledge that these serious injuries, commonly referred to as ‘major’ trauma, represent a small proportion of workload annually for most Emergency Departments (EDs) – approximated at 0.2 % of normal activity (National Audit Office 2010). In the current economic climate some may question why such an emphasis is placed upon this area of emergency care. The rationale for this may be explained by considering the age group most affected by this epidemic. People under 40 years who may be in gainful employment could work until 65 or more years of age. This employment reflects tax revenue and personal expenditure. This in effect supports the national economy. The loss of those individuals from society from a purely financial perspective is significant. Effective care and treatment may prevent death or disability. It is crucial that quality of care and resources reflect the needs of this demographic. As Cole (2004) notes, the human cost of trauma on society is incalculable.
Reflecting a concept described by the Resuscitation Council (UK) (2010) the ‘chain of survival’ in trauma care is important when attempting to reduce mortality/morbidity from serious injury (Lott et al. 2009). The continuum of care from scene of accident to definitive care should remain intact. Put simply, communication and standards of care are crucial. The Advanced Trauma Life Support (ATLS®) programme (American College of Surgeons 2008), which follows a sequence of priorities of care, with the objective of minimizing mortality and morbidity, has been widely adopted for trauma patients throughout the world. The adoption of this international system offers many benefits for both the practitioner and patient. ATLS is utilized throughout the UK; a practitioner working in London, for example, should expect to be able to operate the same principles of trauma care in Aberdeen. The system in effect is a language – improving communication between professionals.
The initial assessment component of the system comprises:
The application of these components and maintenance of the chain of survival is reliant upon excellent teamwork. The composition of the team will vary from hospital to hospital. The principles however remain unchanged:
• good organization and communication
• excellent cooperation between all medical specialists involved (Lott et al. 2009).
Much of the emphasis on trauma care is on medical assessment and intervention, and defining the role of the nurse within the trauma team can be difficult (Table 2.1 ).
Table 2.1
Nursing roles within the trauma team
| Assessment | Observation of respiratory rate, pulse, BP, capillary refill time, GCS |
| Intervention | Basic airway management, insertion of vascular access, phlebotomy, i.v. fluid/blood product administration, application of splinting |
| Monitoring | ECG/cardiac monitoring, arterial lines, capnography, repetition of observations and documentation |
| Communication | Reassurance and information for the conscious patient, liaison between team members/specialist involvement, communication with tertiary/specialist centres |
| Leadership | Activating trauma team, coordinating nursing care (including care of relatives/significant others) |
Preparation
High-quality care is important in the pre-hospital phase of trauma care and time spent on scene with the patient should be kept to the minimum (Pre-Hospital Trauma Life Support Committee 2002). Much debate remains regarding the extent to which pre-hospital practitioners should instigate advanced trauma interventions – the so-called ‘scoop and run’ versus ‘stay and play’. Smith & Conn (2009) contend that there has been no proven benefit to the patient of advanced interventions, e.g., chest drain insertion or rapid sequence induction and endotracheal intubation. This evidence, however, was specific to urban environments, and its validity to more remote incidents may be questionable. The focus of pre-hospital care should be on airway management, control of haemorrhage, immobilization and transfer of the patient to the nearest and most appropriate facility. In many instances, the ambulance service alerts the ED to the impending arrival of a multiply injured patient. This allows time for appropriate preparation of personnel and environment. Irrespective of the level of staffing, a systematic approach to care should apply on every occasion and it should be constantly monitored to maintain optimum effectiveness and efficiency (Sexton 1997). Equally, safety measures are imperative for both staff and patients to ensure no needless harm is caused (see Table 2.2).
Table 2.2
Safety measures during trauma care∗
| Minimum safety requirements for team members | Gloves Aprons Goggles Lead aprons, where appropriate |
| Patient safety | Effective infection control measures Maintenance of temperature e.g., blankets or provision of Bair Hugger© |
∗It is assumed that all staff have been immunized against hepatitis B
Primary survey
The ATLS approach requires a two-stage approach to the management of the patient. The first stage, or primary survey, follows an adapted ABCDE format similar to the initial assessment applied in medical emergencies (Resuscitation Council (UK) 2010). The adaptation introduces cervical spine control, control of haemorrhage and, importantly, environmental control (American College Surgeons 2008). Environmental control should be interpreted as the prevention of hypothermia. The importance of this will be discussed later in this chapter. It may help to remember the adapted approach as AcBDE. The addition of the letter ‘F’ as Fahrenheit may help some remember the need for temperature control (Table 2.3).
Table 2.3
| Activity | |
| Ac | Airway with cervical spine control |
| B | Breathing |
| C | Circulation and control of haemorrhage |
| D | Disability |
| E | Exposure |
| F | Fahrenheit – control of environment |
The primary survey is a rapid assessment aiming to detect life-threatening problems and dealing with them as they are discovered. Although the survey would appear to occur sequentially, i.e., Ac, B then C etc., in fact in the team context each component may be assessed simultaneously. In many cases in the UK an anaesthetist may assess and manage the airway while another member assesses breathing, another controls haemorrhage, and so on.
Airway with cervical spine control
The management of a patient’s airway takes precedence over all other aspects of patient care. Cervical spine control should be instigated simultaneously. The ability of the patient to answer simple questions confirms that the airway is patent and that sufficient oxygen is perfusing the brain to elicit a reply. A physical examination of the airway should still be undertaken (American College of Surgeons 2008).
If the patient does not respond to a simple question, airway obstruction should be assumed and measures should be taken to relieve this immediately. The most common reason for obstruction in the unconscious patient is partial or complete occlusion of the oropharynx by the tongue. Saliva, vomit and blood may exacerbate the problem. Interventions should begin with the simplest, progressing to the more complex if necessary. A chin lift or jaw thrust should pull collapsed soft tissues out of the airway. Any debris or foreign bodies must be physically removed. Suction can be very effective, using a tonsil tip/rigid (Yankeur) suction catheter. Cole (2004) recommends the tip of the Yankeur suction catheter be kept in sight to ensure it is not inserted too deeply causing the patient’s gag reflex to be stimulated. Equally, blind finger sweeps should not be used as this may further push foreign objects into the airway.
More active measures may be required for those who are unable to maintain their own airway. A nasopharyngeal airway will ensure patency in the conscious patient, without causing a gag reflex. This may be particularly useful for those with a fluctuating conscious level. Caution should be exercised, however, in patients with a head injury. The presence of a fracture of the base of skull precludes the use of this device, as accidental placement of the airway in the cranial vault is a possibility (Greaves et al. 2009). For the unconscious patient, an oropharyngeal (Guedel) airway may be helpful; however, its use increases the risk of vomiting.
A definitive airway should be established if there is any doubt about the patient’s ability to maintain airway integrity (American College of Surgeons 2008). After any intervention the patency of the airway should be re-checked. A cuffed tube placed in the trachea is the gold standard for securing and protecting the airway. However, the laryngeal tube airway and the intubating laryngeal mask airway (LMA) are recent advances in airway management that can facilitate intubation in the patient with a difficult airway (American College of Surgeons 2008, Stoneham et al. 2001).
Breathing
A patent airway does not automatically mean that the patient is able to breathe properly. The patient’s chest should be watched carefully, for the rise and fall of the chest wall, on both sides. The assessor should listen for breath sounds and feel for exhaled breath. If the patient is not breathing or is breathing inadequately, mechanical ventilation using a BVM system with high-flow oxygen should be instituted. This is usually more effective when performed by two people, one to seal the airway and one to squeeze the self-inflating bag.
Efficiency of breathing should be established by applying the acronym RIPPA: Respiratory rate, Inspection, Palpation, Percussion and Auscultation (Table 2.4).
Table 2.4
Assessment of breathing (RIPPA)
| Respiratory rate | Observing rate and peripheral oxygen saturation |
| Inspection | Symmetry of chest expansion, cyanosis, use of accessory muscles, tracheal shift from the midline, engorged neck veins, any sucking chest wounds |
| Palpation | Crepitus, surgical emphysema, sites of tenderness |
| Percussion | This may help determine the presence of haemothorax or pneumothorax |
| Auscultation | Bilateral air entry, presence of abnormal or absence of sounds |
Breathing that is unequal or asymmetrical may indicate bony injury or an underlying pneumothorax. Pulse oximetry is a valuable monitor, as peripheral oxygen saturation is a good measure of breathing efficiency; however, it must be remembered that the reading may not be accurate in a shocked, hypothermic, or burned trauma patient (Casey 2001). Where the patient is intubated, the use of colorimetric carbon-dioxide-measuring devices is regarded as essential to ensure correct tube placement. All trauma patients should receive high-flow oxygen (American College of Surgeons 2008). Metabolic demand following serious injury increases significantly. Inadequate oxygen delivery to cells can result in cell damage. In some cases this can result in an inflammatory response known as systemic inflammatory response syndrome (SIRS) similar to that seen in the septic patient (Adams & Osborne 2009). This can further complicate the condition of a seriously injured patient. A concentration of approximately 95% arterial saturation can be achieved by administering oxygen at 15 L/min through a non-rebreather oxygen mask.
Sucking chest wounds should be covered. Chest decompression will be required immediately in the event of a tension pneumothorax, as this dramatically compromises ventilation and circulation. Equipment for inserting a chest drain should be prepared following a needle thoracentesis. A large flail segment with pulmonary contusion or a massive haemothorax should be treated straight away. If the patient is unable to maintain adequate ventilation unassisted, endotracheal intubation may be required, with mechanical ventilation. After any manoeuvre is used to correct inadequate ventilation, breathing should always be rechecked.
Circulation with haemorrhage control
The most significant contributions to developments in trauma care in recent years have emanated from military medical/nursing care (Champion & Leitch 2012). Conflicts in Afghanistan and Iraq in particular have forced military surgeons to adapt and improve interventions to improve outcomes in the most extreme injuries (Duncan & Moran 2009
