4How to initially manage acute trauma

Dr Ammar Naser is Specialist Registrar in Anaesthesia, North Central

Thames Rotation

Dr Robert CM Stephens is Consultant in Anaesthesia, Uni ersity College

Hospitals NHS trust !on"on# Dr Rita Das, is Consultant in $mergency Me"icine, The %hittington Hospital NHS trust, !on"on

Introduction A trauma team shoul" consist o& two to &our "octors, three to &i e nurses an" a ra"iologist ' ra"iographer an" porters# (e&ore the patient arri es the team lea"er shoul" assign each member a speci&ic role be&ore the patient arri es, )inclu"ing someone to "ocument &in"ings an" organise in estigations*, gowns an" glo es shoul" be put on an" e+uipment chec,e"# The patient is most ulnerable "uring the &irst hour )-gol"en hour.* o& resuscitation# /t is important to use a systematic metho" o& e0amination an" treatment to ensure that li&e threatening in1uries are promptly i"enti&ie"# The stan"ar" approach is base" on A" ance Trauma !i&e Support )AT!S* metho"ology which consists o&2 3rimary sur ey an" resuscitation2 A4 Airway an" cer ical spine control B4 (reathing 5 entilation C4 Circulation an" haemorrhage control D4 Disablilty2 Central Ner ous System "ys&unction E4 $0posure ' $n ironmental control Secon"ary sur ey2 -hea" to toe. De&initi e treatment Tertiary sur ey2 Ne0t "ay to ensure nothing is misse"#

(ecause o& the large range o& possible pathologies an" treatments, to a oi" being "i"actic we ha e presente" -treatment options. to be consi"ere" in each section# This article is inten"e" &or the non4specialist as an introduction to the hospital management o& acute trauma# %e woul" encourage all 1unior "octors who may manage trauma to atten" an AT!S course#

Primary survey
6nce the patient arri es, everyone shoul" listen to the han"o er &rom the ambulance crew# The organi7e", systematic AT!S primary sur ey protocol shoul" be use" to i"enti&y an" treat li&e threatening in1uries# /& ital signs change, the primary sur ey shoul" start again at the -top. ie airway an"

procee" "own# /n this way the team lea"er continuously re4e aluates his'her &in"ings as patients may "eteriorate or change rapi"ly# /& the patient is on a spinal boar" or scoop &or immobilisation, it must be remo e" using a -scoop to s,i. techni+ue as prolonge" use o& this "e ice can cause serious pressure sores# Airway management with cervical spine control The patient shoul" recei e high &low 60ygen# An anaesthetist shoul" assess an" manage the airway2 i& the patient can tal,, the airway is li,ely to be clear can breath, and has cerebral perfusion. /& they ha e a re"uce" conscious le el the patient may not be able to maintain their airway# Soot in the airway, hoarseness, stri"or, &oreign bo"ies, bloo" an" lacerations shoul" alert you to impen"ing airway problems# Assume cer ical spine in1ury an" maintain the spine in neutral position )har" collar, tape" with san" bags wither si"e o& the hea"* until pro en otherwise clinically an" ra"iologically# During intubation it is acceptable to remo e the har" collar to ai" 1aw mo ement so long as someone per&orms -manual in line immobilisation. o& the hea" an" nec,# Airway management with cervical spine control treatment options inclu"e2 68 a"ministration (asic airway manou ers2 chin li&t9 1aw thrust 6ropharyngeal or nasopharyngeal airway4 but caution with blee"ing $n"otracheal intubation Surgical airway ie Cricothyroi"'Tracheostomy

Breathing & Ventilation The chest must be e0amine" by inspection, palpation, percussion an" auscultation# Trachea position )central or "isplace"*, nec, ein "istension, cyanosis, respiratory rate an" pattern, breath soun"s, 6 8 saturation, isible woun"s ' &lail chest, surgical emphysema, an" chest symmetry shoul" be sought# !i&e threatening chest in1uries such as tension pneumothora0, open pneumothora0, car"iac tampona"e, &lail chest an" massi e haemothora0 must be i"enti&ie" an" rapi"ly treate"# Breathing treatment options inclu"e2 $n"otracheal intubation an" entilation Nee"le "ecompression Chest "rain 3ericar"ial "rainage Thoracotomy A"e+uate analgesia

Circulation and haemorrhage control Two intra enous cannulae )grey, :;g or bigger* shoul" be inserte", an" basic obser ations ta,en )bloo" pressure, heart rate, 6 8 saturation* on a regular basis# Tachycar"ia an"'or hypotension a&ter traumatic in1ury is assume" to be "ue to signi&icant )<=>? bloo" olume* bloo" loss until pro en otherwise# Stopping haemorrhage with rapi" haemostatic techni+ues )eg compression, ban"age, pel ic splint, &racture re"uction, inter entional angiography or laparotomy* is the &irst priority in the treatment o& traumatic haemorrhagic shoc,, with concomitant &lui" resuscitation )&lui" an" bloo"* to maintain per&usion an" organ &unction# 6ne approach to in4hospital resuscitation &or the treatment o& trauma patients with haemorrhagic shoc, is the rapi" in&usion o& two litres o& crystalloi", Howe er many e0perts a" ocate gi ing less an" obser ing the response ie halt blee"ing while maintaining a"e+uate tissue per&usion2 this is a contro ersial area# This may be &ollowe" by bloo" trans&usion with bloo" )uncrossmatche" bloo" ie 64negati e, A(6 type speci&ic or &ully crossmatche" "epen"ing on urgency an" a ailability* i& there is e i"ence o& ongoing hypo olaemia or anaemia# @resh &ro7en plasma an" cryoprecipitate shoul" be consi"ere" early in massi e haemorrhage# The resuscitation en"points )how to tell i& you ha e gi en enough* that ha e been e aluate" inclu"e restoration o& bloo" pressure, heart rate an" urine output, capillary re&ill, lactate, base "e&icit, mi0e" enous o0ygen saturation, an" entricular en"4"iastolic olume# Remember, patients can compensate &or hypo olaemia )by asoconstricting* an" so "elay the appearance o& tachycar"ia an" hypotension# (lee"ing can occur e0ternally or be &rom the thoracic, ab"ominal or pel ic ca ities, long bones or spine# Diagnosis can be ai"e" by ultrasoun" )eg -@AST. scan2 @ocuse" Assessment with Sonography &or Trauma*, CT, A4ray, angiography, "iagnostic peritoneal la age an" bloo" tests )@(C, U 9 $, bloo" gasses*#

System
Car"io ascular

Sign
/ncrease" heart rate /ncrease" capillary re&ill time Decrease" bloo" pressure )late sign* Decrease" pulse pressure Cool an" Clammy s,in /ncrease" respiratory rate Con&usion' Agitation Decrease" conscious le el

Respiratory Neurological

6ther

Decrease" urine output

Signs o& hypo olaemia

Circulation and haemorrhage control treatment options inclu"e2 %arm &lui"s )crystalloi" ' colloi"* %arm bloo" an" bloo" pro"ucts )eg @resh @ro7en 3lasma*, Arrest blee"ing by "irect local pressure Arrest blee"ing by splinting pel is Central line i& inotropes ' asopressors are nee"e" Urinary catheter Surgery )-"amage control. or "e&initi e*

Disability Dys!unction o! the central nervous system A +uic, neurological assessment is an essential part o& the primary sur ey# /n general i& the patient is tal,ing appropriately he'she has clear airway, a"e+uate entilation an" intact cerebral &unction# 6& course this can change, hence the nee" &or repeating the primary sur ey shoul" "eterioration occur# The Blasgow Coma Scale )BCS* can be use" to gi e a reliable, repeatable an" ob1ecti e way o& recor"ing the conscious state o& the patient# Always try to ma,e an assessment be&ore intubation as se"ation inter&eres with consciousness# Recor" the three alues separately )eg $=C=MD* as well as their sum are recor"e"# The lowest possible BCS )the sum* is = )"eep coma*, while the highest is :D )&ully awa,e person*# A "rop o& 8 in the BCS usually re+uires in estigation eg CT hea"#

"lasgow Coma Score Best Eye #pening $E% Best Verbal &esponse $V% Best 'otor &esponse $'% 4ESpontaneous =ETo oice 8ETo pain :ENone DENormal con ersation 4EDisoriente" con ersation =E%or"s, but not coherent 8ENo wor"s######only soun"s :ENone ;ENormal DE!ocali7es to pain 4E%ith"raws to pain =EDecorticate posture 8EDecerebrate :ENone

Disability treatment options inclu"e2 68 a"ministration /ntubation )to ensure normal p>8 an" pC>8* /notropes ' asopressors )to ensure a"e+uate cerebral per&usion* Hea" up, ensure enous "rainage $mergency imaging o& brain or spine Neurosurgery

E(posure ) environmental control @ully un"ress the patient, allowing a thorough secon"ary sur ey# A oi" hypothermia which can ha e "e astating conse+uences )coagulopathy, aci"osis* by acti ely warming the patient# Chec, bloo" sugar# Initial Investigations @(C, U9$, glucose, cross match, bloo" gas Chest an" pel is plain ra"iographs A3, !ateral an" 6"ontoi" peg iew cer ical spinal ra"iographs

Secondary survey
The secon"ary sur ey occurs a&ter all li&e4threatening in1uries &rom the primary sur ey ha e been i"enti&ie" an" treate", an" parallel initial in estigations per&orme" )see bo0*# /t aims to i"enti&y all the in1uries sustaine", in ol es a thorough hea" to toe e0amination inclu"ing &ull neurological e0amination, e0amination o& the spine, log rolling an" per&orming a 3R e0am# Ta,e a complete history &rom the patient, parame"ics, police or relati es# Fey +uestions stem &rom the mnemonic AM3!$ GAllergies, Me"ication, 3ast me"ical history, !ast meal )rele ant &or surgery*, an" $ ent an" $n ironment relate" to in1uryH# As a result o& the secon"ary sur ey &urther in estigations may nee" to be ta,en#

De!initive care
De&initi e care starts once the patient has been resuscitate" an" any li&e threatening in1ury "ealt with# /t inclu"es &urther surgical inter ention, antibiotics, tetanus immunisation an" may in ol e trans&er to a tertiary centre# Trans&erring a trauma patient is ery ris,y an" shoul" in ol e the most appropriate "octor, traine" in trans&er# /"eally a tertiary sur ey shoul" be per&orme" the ne0t "ay to ensure nothing has been misse" in the initial sur eys )eg small but &unctionally important "igital in1uries*# 3atients with certain in1uries may sometimes nee" trans&er be&ore the secon"ary sur ey or e en "uring the primary sur ey eg isolate" hea" in1ury or polytrauma patients re+uiring car"iothoracic surgery#

Summary:
Trauma is a lea"ing cause o& "eath an" "isability especially amongst young people# A well rehearse" an" systematic -AT!S. approach to hospital resuscitation can sa e li es as well as limiting the conse+uences o& the trauma# /t shoul" be remembere" that the primary sur ey shoul" be repeate" whene er an inter ention has been ma"e an" i& changes in the patient.s clinical state occurs, to a oi" the -tria" o& "eath. )hypothermia, aci"osis an" coagulopathy* an" to be aware o& the gol"en &irst hour o& trauma resuscitation2 "elays in treatment can ,ill#