Initial management of the poly-trauma patient

Scandinavian Journal of Surgery 91: 23–33, 2002 23

INITIAL MANAGEMENT OF THE POLY-TRAUMA PATIENT:

A PRACTICAL APPROACH IN AN AUSTRALIAN MAJOR
TRAUMA SERVICE

S. K. D’Amours, M. Sugrue, S. A. Deane

Departments of Trauma and General Surgery, Liverpool Hospital, Sydney, Australia
Department of Surgery, Southwestern Sydney Clinical School, UNSW, Sydney, Australia

ABSTRACT

The initial management of the poly-trauma patient is of vital importance to minimizing

both patient morbidity and mortality. We present a practical approach to the early man-
agement of a severely injured patient as practiced at Liverpool Hospital in Sydney, Aus-
tralia. Specific attention is paid to innovations in care and specific controversies in early
management as well as local solutions to challenging problems.
Key words: Trauma; resuscitation; trauma systems; quality assurance; Australia

INTRODUCTION though the resources of these differing institutions

The initial assessment and management of a patient
with multiple injuries is critical toward decreasing
both morbidity and mortality and aiding recovery.
Initial management includes care in both prehospi-
tal and hospital environments. Prehospital care and
organized systems of trauma care will only be dis-
cussed in this paper with reference to immediate pa-
tient management issues. Both play a crucial role in
the delivery of optimal care to the injured patient
(1, 2). Preparation for patient arrival in terms of sys-
tems, designated trauma centres, training of person-
nel and communications is as important as specific
patient interventions (3).
Institution of an organized approach to the injured
patient such as that taught in the Advanced Trauma
Life Support (ATLS®) Course of the American College
of Surgeons improves trauma patient care and out-
comes (4–8). A similar philosophy has been adapted
by prehospital care providers to optimize care of the
patient before delivery to a medical facility (1, 9, 10).
The initial management of trauma patients is car-
ried out in all types of health care facilities from the
small rural clinic to the major trauma centre. Al-
Correspondence:
Stephen A. Deane, M.D.
Division of Surgery
Liverpool Hospital Locked Bag 7103
Liverpool BC NSW 1871 Australia
Email: stephen.deane@swsahs.nsw.gov.au
may vary greatly, the way in which they deliver ini-
tial care to the injured patient should be highly stand-
ardized. Such is the way that courses such as ATLS®
have defined an optimal means of assessing and
treating an injured patient or triaging and treating
multiple patients (11). The simplicity of the overall
approach can be adapted to the available resources
so that initial care and management can be optimized
for any given patient with the tools at hand. ATLS®
was introduced into Australia as EMST (Early Man-
agement of Severe Trauma) by the Royal Australasi-
an College of Surgeons (RACS) in 1988 and has sub-
sequently become the national standard for initial
care of the injured patient (4).
Liverpool Hospital is the Major Trauma Service
(MTS) in southwestern Sydney Australia, serving a
population of > 750,000 people. This MTS designa-
tion was made by the New South Wales Health De-
partment within a trauma plan for the city of Syd-
ney (12). More than 4500 injured patients are admit-
ted each year to one of six hospitals in the region (13).
Liverpool Hospital, being the largest of these hospi-
tals and the designated MTS, receives more patients
directly than any of the regional hospitals and also
receives transfers of the more seriously injured pa-
tients after initial assessment at a regional centre (Ta-
bles 1 and 2). Surgeons at Liverpool Hospital have
had a strong interest in trauma care in Australia es-
pecially pertaining to development of trauma teams,
trauma education, registry, and better practice guide-
lines (14–18).
24 S. K. D’Amours, M. Sugrue, S. A. Deane

Using the ATLS® approach as a platform, we will place for optimal care of injured patients (19) Major
outline and address some of the challenges faced and Trauma Services were originally established in the
approaches used in the initial management of poly- state of New South Wales with the implementation
trauma patients in southwestern Sydney as well as of a state trauma service plan in 1992 (20). A “by-
discuss some of the most current initial assessment pass” system was central to the plan and directed
and management strategies for these patients. Pre- ambulance crews to bypass the nearest hospital and
senting this local viewpoint offers a practical tem- take injured patients with the highest risk to a Major
plate, and allows global comparisons. Trauma Service (12). More than 96 % of patients in
our region that meet bypass criteria are correctly
being transported to Liverpool Hospital instead of
PREPARATION the nearest facility (13). Liverpool Hospital was re-
cently the first MTS in Australia to be visited by the
TRIAGE, TRAUMA CENTRE VERIFICATION AND TRAUMA Site Survey Team of the RACS Trauma Committee
BYPASS as part of a pilot verification project. This process
The triage process begins in the prehospital phase of identified strengths and weaknesses in the initial
care when transport decisions are made to take the management of the poly-trauma patient and in the
seriously injured patient to the nearest, most appro- proposed verification process. The weaknesses iden-
priate facility. No perfect triage system exists. How- tified were the low seniority of some of the trauma
ever, the American College of Surgeons Committee team members and the lack of a formal admitting
on Trauma has set reasonable criteria for field triage service for trauma. The former is especially impor-
in Resources for Optimal Care of the Injured Patient. The tant in the initial management of trauma patients.
receiving facility ideally has some kind of designa-
tion to receive seriously injured patients and the re- COMMUNICATION
sources and expertise to adequately manage their in-
juries (8). A verification process for facility designa- Coordination and communication between prehos-
tion is an important step towards ensuring resources, pital and hospital care providers is the key to timely
personnel and a quality assurance programme are in preparation and mobilization of resources. Liverpool
Hospital has established direct communication links,
using a government radio network, between prehos-
TABLE 1 pital care providers and the resuscitation room, to
facilitate the transfer of information and to allow di-
Number of trauma admissions per year to each hospital in the South rected preparation of the trauma team response (21).
Western Sydney Area Health Service (SWSAHS).
This radio link is used to advise the trauma team
Hospital 1995 1996 1997 1998 1999 Total when a patient with haemodynamic instability is to
be expected and to outline suspected injuries and
Liverpool 1703 1848 1809 1959 1906 9225 treatment initiated. The majority of our prehospital
Bankstown 1015 0817 1093 1005 1009 4939 transport times are less than 20 minutes (13), how-
Campbelltown 0779 0916 0798 0860 0884 4237
Fairfield 0526 0537 0558 0584 0528 2733 ever, when pre-hospital transport times are long
Bowral 0300 0306 0356 0342 0352 1656 there may also be benefit to medical direction given
Camden 0170 0139 0220 0191 0127 0847 by the same communication link (22).
Total 4493 4563 4834 4941 4806 236370
TRAUMA TEAM
From: South Western Sydney Regional Trauma Registry Report
1995–1999 Activation of a prepared trauma team results in bet-
Reprinted with permission: Trauma Department, Liverpool Hos- ter patient care and improved patient survival (23).
pital The ability of prototype Australian trauma teams to

TABLE 2
Mechanism of injury (grouped) annually for trauma admissions to hospitals in the South Western Sydney Area Health Service (SWSAHS).

SWSAHS 1995 % 1996 % 1997 % 1998 % 1999 % Total %

Road vehicle 576 12.8 548 0.12 617 12.7 627 12.7 626 13.1 2995 12.7
Pedestrian/Cyclists 216 04.8 253 05.5 278 05.7 281 05.7 286 05.9 1314 05.6
Interpersonal Violence 291 06.5 356 07.8 367 07.6 364 07.4 336 0.7 1714 07.3
Falls 19610 43.7 18180 39.8 20410 42.2 19890 40.3 18540 38.8 9663 40.9
Industrial 474 10.6 438 09.6 411 08.5 385 07.8 309 06.5 2017 08.5
Recreation 234 05.2 156 03.4 238 04.9 493 0.10 567 11.9 1688 07.2
Burns 094 02.1 116 02.5 116 02.4 126 02.6 107 02.2 0559 02.4
Other 646 14.4 878 19.2 766 15.8 676 13.7 688 14.4 3654 15.5

Total 44930 4563 48340 4941 48060 236370

From: South Western Sydney Regional Trauma Registry Report 1995–1999

Reprinted with permission: Trauma Department, Liverpool Hospital
 Initial management of the poly-trauma patient
respond and triage patients effectively was critical
prior to widespread development and implementa-
tion of similar teams in other major Australian cen-
tres (14, 15). Liverpool Hospital established a trau-
ma team in 1989 and has previously published on its
performance (16, 17).
Activation of the trauma team begins with identi-
fication of specific triggering criteria (incorporating
assessments of injury mechanism, physiological sta-
tus, evident injuries) and a group trauma call is put
out by switchboard operators resulting in attendance
of registrars from Surgery, ICU, and the Emergency
Department (17). Additionally, the trauma fellow,
trauma nurse coordinator, and radiographers receive
calls and attend. Three nurses from the Emergency
Department, a ward orderly and social worker also
attend. The charge nurse in operating theatres also
receives a page so that if a theatre is urgently re-
quired, maximal warning has been given. The trau-
ma team is led by a registrar from the Emergency
Department or ICU. These two registrars alternate
between team leading and a role as the airway doc-
tor on a fortnightly basis. The team leader’s role is to
lead the team at arm’s length and plan interventions
and treatment based on information produced by the
bedside team. The surgical registrar takes the role as
circulation and procedure doctor as well as doctor
performing secondary survey. The team leader, in
consultation with the surgical registrar, then plans
and prioritizes interventions and investigations. The
trauma fellow plays both an advisory role to the team
leader and acts as an extra team member if needed.
The active participation of a trauma fellow has been
previously shown to promote optimal patient care
even when not in the role of team leader (24). If re-
quired by the instability of the patient or inexperi-
ence of the rostered team leader, the trauma fellow
or emergency department consultant assumes the
role of team leader. The consultant surgeon is auto-
matically paged for any patient with prehospital hy-
potension and as required for other injuries. If more
than one patient is expected, several teams are as-
sembled using the emergency department consultant
and trauma fellow to team lead. If several teams are
needed, the role of team leader can be assumed by
either the airway or procedure doctor in addition to
their regular role. The hospital disaster plan is acti-
vated for the arrival of more than 5 or 6 unstable and
seriously injured patients or at the discretion of the
consultant in the resuscitation room. The multidis-
ciplinary membership of the trauma team has been
previously identified as having a positive effect on
trauma team function (16). We have paid special at-
tention to the role of the trauma team leader to avoid
a “COCUP” or Consortium Of Care for Urgent Pri-
orities. This pitfall is an easy one to fall into with the
poly-trauma patient when there are many injuries
and subspecialist consultants involved. It results in
care that is fragmented, poorly integrated, unduly
complex and therefore prone to errors (25).
All trauma team members arriving in the resusci-
tation room prepare by putting on splash-resistant
and lead gowns, eye protection and gloves. Airway
equipment, suction, monitors and IV cannula carts
25
are rechecked and warmed IV fluids are positioned
and lines primed. Other preparation is based on
available prehospital information and may include
opening of chest tube and thoracotomy trays if sig-
nificant chest injury, penetrating chest wounds or vi-
tal signs suggest an urgent need for intervention.
TRAUMA EDUCATION AND TRAINING
The role of a teaching hospital in preparing trauma
team leaders and educating younger doctors is an
important one. It has been previously identified that
errors occur in the early part of trauma resuscitations
and can contribute significantly to avoidable deaths
(26, 27). Trauma team leaders with greater clinical
experience yield more optimal resuscitations (24) and
our teaching programmes, trauma audit meetings,
performance improvement initiatives and quality as-
surance filters are strategies to give our trauma team
members the best clinical experience possible. Most
recently we have established a new method of ori-
enting and training new surgery, ICU and ED regis-
trars to the Liverpool Hospital trauma system by
combining classroom and interactive web-based
teaching modules (28). This has permitted both train-
ing and assessment of new trauma team leaders
prior to their assumption of the team leader role. The
role of the internet and reputable web sites in trau-
ma education is just beginning to be realized and has
not yet reached its full potential (29, 30). One must
seriously ask if it is acceptable to have a doctor
treating trauma patients if only minimal standards
are adhered to in terms of trauma education and
orientation.
PRIMARY SURVEY
Unlike many areas of medicine where all informa-
tion is gathered, synthesized and a comprehensive
treatment plan is undertaken, trauma requires that
injuries that may kill a patient in seconds or minutes
be immediately addressed. The injuries most likely
to kill a patient quickly must be excluded before
moving onto a more comprehensive examination.
Frequent reassessment is required, since previously
unrecognized or seemingly insignificant injuries may
become more prominent mandating immediate treat-
ment. The ‘ABCDE’ of the primary survey is, in es-
sence, a quick examination to exclude injuries that
are immediately life-threatening along with concur-
rent treatment to permit resuscitation and further
examination. At Liverpool Hospital, the airway doc-
tor in the trauma team undertakes the primary sur-
vey and reports the findings to the team leader. De-
cisions are made for immediate interventions as the
primary survey proceeds commencing with airway.
PATIENT ARRIVAL AND HAND-OVER
When the trauma team is activated by prehospital
communication, the trauma team arrives and is
standing by and prepared for patient arrival (Fig. 1).
As the patient is transferred from ambulance to re-
26 S. K. D’Amours, M. Sugrue, S. A. Deane
suscitation stretcher the ambulance officer gives ver-
bal hand-over directly to the trauma team leader
loud enough for all other team members to hear. The
information transfer is succinct and follows the
‘MIST’ format:
• Mechanism of injury
• Injuries suspected
• Vital Signs
• Treatment en route to hospital
We have shown that this method of information
transfer is successful for most trauma patient arriv-
als (31). The airway doctor begins the primary sur-
vey as the patient is being transferred and connec-
ted to monitoring equipment.
AIRWAY AND CERVICAL SPINE PROTECTION
Airway is the first priority in assessment and man-
agement of the poly-trauma patient as without a pat-
ent airway, ventilation and delivery of oxygen to al-
ready-depleted cells will fail resulting in poor patient
outcome. Rapid assessment consists of quickly exam-
ining the patient for signs of airway compromise. The
patient is asked a simple question. Absence of re-
sponse, stridor, confusion or a hoarse reply may in-
dicate airway compromise. Foreign bodies, blood,
vomitus and a decreased level of consciousness are
most commonly responsible for airway obstruction.
Facial or laryngotracheal fractures may also result in
acute airway obstruction. Patients with facial burns
and inhalation injury may have compromised air-
ways or be at risk of rapidly losing a marginally pat-
ent airway. Early intubation of burn patients with
stridor, carbonaceous sputum, oropharyngeal and
massive facial burns can prevent later loss of airway
and ability to ventilate.
During early assessment of the airway, we take
care to protect the cervical spinal cord by immobi-
Fig. 1. Liverpool Hospital trauma team
transferring a new patient.
lizing the cervical spinal column. Although treatment
of cervical spine injury is not part of the primary sur-
vey it is important to realize that an existing injury
can be worsened (32). Exclusion of cervical spine in-
jury is impossible in the early stages of examining
and treating the multiply injured blunt trauma pa-
tient; therefore all patients are assumed to have cer-
vical spine injury and only later is this excluded or
investigated definitively. We do not make clinical or
radiological clearance of the cervical spine a part of
the primary survey in the poly-trauma patient. The
head and neck are maintained in a neutral position
by the airway doctor using in-line immobilization
until external immobilization is fitted. Immobiliza-
tion of the cervical spine is effected by a semi-rigid
collar alone in most patients. This is effective in the
short term and can be easily removed with in-line
stabilization when improved access to the head and
neck is required (e.g. with intubation) (33–35).
A patient with absent ventilatory effort is quickly
assessed for oropharyngeal foreign bodies, oropha-
ryngeal secretions and vomitus are suctioned, and a
jaw thrust is performed to relieve airway obstruction
secondary to decreased oropharyngeal muscle tone.
Relief of airway obstruction by these simple manoeu-
vres usually permits spontaneous ventilation. An
oropharyngeal (Guedel) airway helps if upper airway
obstruction is a result of decreased level of conscious-
ness. Supplemental oxygen is given to all of our poly-
trauma patients. Of the trauma patients admitted to
Liverpool Hospital over the past 5 years, 75 % re-
quired no airway intervention and just over 11 % re-
quired endotracheal intubation (13). We intubate pa-
tients for the following reasons:
• Inadequate ventilation and oxygenation
• Impending or actual airway obstruction second-
ary to injury
• Brain injury with a Glasgow Coma Scale (GCS)
of less than 8
 Initial management of the poly-trauma patient
• Inability to adequately protect the airway from
aspiration
We may intubate patients in the following settings:
• Severe multi-system injury or haemodynamic
instability
• Facial burns or inhalation injury
• Inability to closely monitor during ongoing re-
suscitation and investigation (e.g. angiography
and CT scanning)
• Uncooperative or combative behaviour
• Infant or child unable to cooperate with inves-
tigations
Once the decision to intubate has been made, the des-
ignated airway doctor (ICU or ED registrar) under-
takes the procedure with the assistance of the airway
nurse. If the initial attempt fails then the patient is
oxygenated with a bag-valve mask and the attempt
is repeated. A second failure requires attendance of
the in-house consultant or registrar in anaesthesia
before a third attempt. If the intubation is not emer-
gent (still able to oxygenate patient in some way) and
a difficult airway is anticipated (facial swelling, pos-
sible laryngeal fracture or difficult anatomy) then in-
tubation is performed by the in-house anaesthetic
registrar or consultant.
Endotracheal intubation remains the gold stand-
ard for control of the airway and ventilation/oxygen-
ation of the unstable poly-trauma patient (36, 37).
There may be a role for other techniques such as the
laryngeal mask airway and combitube (38) but their
role in trauma is unclear (39) and we have not yet
used them in our resuscitation room. All haemody-
namically unstable poly-trauma patients are intuba-
ted using a rapid sequence induction technique em-
ploying pre-oxygenation, cricoid pressure, thiopen-
tone and succinyl choline. These drugs are chosen as
they have a rapid onset and short half-life along with
minimal effect on blood pressure. The short half-life
allows quick recovery should the attempted intuba-
tion fail. A combination of narcotic (usually fentanyl)
and midazolam is occasionally used in an otherwise
stable patient if major haemorrhage is not present
and transient hypotension is of little or no conse-
quence.
Attempts at endotracheal intubation or laryngo-
scopy in a patient with unrecognized laryngeal frac-
ture or partial upper airway transection can be cata-
strophic by precipitating complete obstruction or air-
way transection. Although sometimes difficult to an-
ticipate, it is important to have a high index of sus-
picion for these types of injuries, based on mecha-
nism of injury or subtle signs on physical examina-
tion, and to be prepared to perform a rapid surgical
airway should complete obstruction be precipitated.
The surgical registrar or trauma fellow is standing
by with equipment readied to perform a cricothy-
roidotomy should complete airway obstruction result
and ventilation become impossible.
Cricothyroidotomy is our emergency surgical air-
way of choice in a hypoxic patient who cannot be
ventilated by other means (spontaneous or assisted)
27
and has failed two intubation attempts or has com-
plete upper airway obstruction. Airway obstruction
may be due to disruption of the airway, fractures, tis-
sue loss, burns or other maxillofacial injury. This life-
saving procedure is actually required quite uncom-
monly but when needed, any delays potentially
worsen outcome. The surgical registrar or trauma fel-
low performs the procedure with assistance from the
airway doctor and nurse. Although we do have pre-
packaged kits available, a scalpel and endotracheal
tube alone are sufficient to accomplish the task. Only
4 emergency surgical airways have been required
over the past 5 years (~0.1 % of trauma admissions)
at Liverpool Hospital. Over that same time period
there were a total of 32 laryngotracheal injuries but
the majority of these patients’ airways were able to
be managed without surgical intervention (13). This
reflects the advanced airway skills of ICU, emergency
and anaesthesia doctors and is one of the benefits of
a multi-disciplinary trauma team.
BREATHING AND VENTILATION
The assessment of breathing and ventilation natur-
ally follows the securing of an airway. Providing ox-
ygen to cells and eliminating carbon dioxide is the
central aspect of this part of the treatment algorithm.
Both blood circulation through the pulmonary ves-
sels and gas circulation through the alveoli are re-
quired.
During the primary survey we seek and treat any
immediately life-threatening chest injuries that will
prevent proper ventilation:
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
A tension pneumothorax will be immediately decom-
pressed with a needle while the surgical registrar be-
gins chest tube placement; an open pneumothorax
results in simultaneous placement of a chest tube and
occlusive dressing. Massive haemothorax is treated
with one or more chest tubes. The blood drained
from the chest can be collected in chambers that per-
mit autotransfusion although this is not without risk
and can be cumbersome to use (40) especially when
needed infrequently. At Liverpool Hospital we gen-
erally opt for rapid transport of the patient to the
operating suite for thoracotomy and transfusion
when acutely placed chest tubes drain >1500 ml or
>150–200 ml/hour. Massive flail chest can be very
problematic. Ventilation is impaired by a malfunc-
tioning chest wall and oxygen uptake impaired by
an injured and edematous alveolar-capillary gas ex-
change surface. The impact of this type of injury is
often initially underestimated (41). All of these pa-
tients require careful fluid administration and anal-
gesia and often need ventilatory support. Even with
this support, optimal oxygenation can be difficult to
achieve. As a result, all patients with flail chests at
Liverpool Hospital are managed in our intensive care
or high dependency units.
28 S. K. D’Amours, M. Sugrue, S. A. Deane
CIRCULATION AND BLEEDING
Urgent and early attention must be paid to any ex-
ternal haemorrhage. While our trauma team’s airway
doctor is assessing and securing an airway, the sur-
gical registrar and procedure nurse are assigned to
apply pressure dressings on any obvious external
sites of bleeding. We give particular attention to the
following:
1. Scalp lacerations can bleed extensively and result
in hypovolaemic shock even when no other inju-
ries are present. If external pressure does not ar-
rest bleeding immediately, we use a running
locked suture to quickly control blood loss.
2. PASG (pneumatic anti-shock garment) trousers are
not used by us to arrest lower extremity bleeding
or splint fractures. These devices can ultimately
worsen patient outcome although they may tran-
siently appear to decrease bleeding. Direct pres-
sure, fracture reduction and other external
splinting techniques are used instead. There is also
evidence showing increased patient mortality
when the PASG is used in patients with penetrat-
ing thoracic injury (42, 43).
3. Fractured long bones are reduced and traction-
splinted to decrease ongoing blood loss and pain
as well as to prevent further local injury and restore
flow to potentially ischaemic distal extremities.
4. We do not attempt to blindly clamp vessels in
bleeding wounds or use tourniquets as they often
worsen ischaemia and damage adjacent/distal
structures. A pressure dressing is applied instead
and the patient taken to the operating room as
soon as possible.
5. We use Foley catheters to tamponade bleeding
from the nasopharynx when anterior nasal pack-
ing fails; a catheter is passed through the nares into
the nasopharynx, the balloon is inflated with 10–
15 mls of water or normal saline and gentle trac-
tion is applied on the catheter to lodge the balloon
in the nasopharynx and to tamponade bleeding.
Bilateral catheters can be used if needed and if
haemorrhage is resulting from non-reduced max-
illary and cranial-base fractures (44). Angiography
and embolization can also be used if packing fails
and some hospitals use this technique more
aggressively.
Hypotension in a trauma patient is always initially
assumed to result from haemorrhage until this is ex-
cluded. Cardiogenic, septic and neurogenic shock are
less common causes of hypotension in the trauma
population. Patients at extremes of age, athletic pa-
tients or pregnant patients may not manifest classi-
cal signs and symptoms of hypovolaemia; these pa-
tients may bleed extensively and lose a great deal of
their intravascular volume without the usual objec-
tive findings. In patients taking prescription or illicit
drugs, vital signs may not be reliable (tachycardia in
cocaine users and absence of tachycardia in patients
taking beta-blockers).
Adequate intravenous access is confirmed or es-
tablished by the procedure doctor while airway and
breathing are being assessed by the airway doctor.
Ideally, we place two large bore (14 or 16 gauge) IV
cannulas in the upper extremities. Otherwise, a large
bore femoral vein catheter or saphenous vein cut-
down is utilized depending on the experience of the
surgical registrar. We avoid lower extremity cannu-
las and femoral lines in patients where there is con-
cern about possible iliac vein or IVC injury (major
pelvic fractures and abdominal trauma especially
with a distended abdomen). Subclavian and internal
jugular veins are only used if no other options are
available. In children under the age of 6, intraosseous
infusion devices are utilized only in shocked patients
when two peripheral access attempts have failed or
90 seconds pass without successful placement of a
cannula. Regular cannulas are then inserted follow-
ing adequate resuscitation and the intraosseous nee-
dle is removed. A pump set is always included as
part of the IV tubing used for all trauma patients. We
prepare rapid-infusing devices for IV fluid adminis-
tration whenever there is prehospital notification of
hypotension or massive blood loss. We avoid the
long double and triple lumen central venous cathe-
ters and opt for short 7.5–8.5 French catheters for our
femoral lines to maximize infusion speed.
The optimal type of fluid to be administered to
trauma patients continues to be debated (45). In Aus-
tralasia gelatin-based colloids are available for use
whereas hetastarch-based solutions are not. Patients
who arrive to Liverpool Hospital without evidence
of massive haemorrhage or shock are usually com-
menced on a crystalloid solution at a maintenance
rate of ~100 ml/hour in the average adult. In a
shocked patient or patient with suspected Class III
or IV haemorrhage we use a gelatin-based colloid so-
lution initially. It has been shown that fluid admin-
istration without control of ongoing haemorrhage
can worsen outcomes in patients suffering penetrat-
ing torso trauma (46) and in this situation we estab-
lish at least two large bore cannulas but limit fluid
resuscitation until the patient is taken to the operat-
ing room and the haemorrhage is controlled. The end
point of resuscitation in this preoperative situation
is maintenance of vital organ perfusion (e.g. patient
awake and able to converse) which usually requires
less than 500 ml of fluid. In all other shocked patients
initial boluses of gelatin-based colloid are used as the
return to “normal” haemodynamics may be faster
and with lower volumes than with crystalloid (45).
We give blood to patients with ongoing haemody-
namic instability after initial fluid boluses exceed 2L
and occasionally earlier when transfusion is deemed
to be inevitable (unstable patients with severe pelvic
fractures, more than two long bone fractures, esti-
mated total blood loss exceeding 40 % and for lesser
injuries when combined with a serious head injury).
This is especially true in patients with concomitant
head injury where the overriding principle is to en-
sure that the brain receives adequate perfusion and
oxygen delivery to prevent secondary brain injury
(47–49). Patients are given cross-matched or type-spe-
cific (ABO and Rh groups) blood if available but if
transfusion is required before matched blood is avail-
able, we will give type O Rh negative blood to fe-
males (of child-bearing years or younger) and all oth-
 Initial management of the poly-trauma patient
ers will receive type O Rh positive blood. Rapid op-
eration and prevention of further blood loss is the
most important principle.
The specific role of hypertonic saline has not yet
been fully determined although there is some evi-
dence that it may have a role in the early manage-
ment of patients with severe traumatic brain injury
(50, 51). The smaller volumes infused allow rapid in-
creases in mean arterial pressure without increasing
interstitial oedema and potentially increasing intra-
cranial pressures. Some studies, however, have not
shown any difference when compared to crystalloid
resuscitation (52). We have not yet started treating
patients with severe brain injuries at Liverpool Hos-
pital using hypertonic saline although it is being con-
sidered.
Cardiac injury as a cause of shock is considered
only after hypovolaemic shock has been excluded in
a patient who has risk factors for cardiac injury (flail
chest, multiple rib fractures, sternal fracture with
new precordial murmur or ventricular arrhythmias,
penetrating chest injury). Cardiac ultrasound is used
at Liverpool Hospital in all of these situations to as-
sess the heart for evidence of injury. Cardiogenic
shock can arise from contusion causing myocardial
dyskinesia, acute valvular rupture leading to a de-
creased ejection fraction or from the compressive ef-
fects of a haemopericardium that greatly reduces car-
diac filling, thereby decreasing cardiac output.
DISABILITY
At this point in the primary survey the airway doc-
tor does a quick neurological assessment by deter-
mining level of consciousness using GCS as well as
examining pupils for indirect evidence of massive
intracranial haemorrhage. GCS is used as a baseline
determination of neurological function and frequent
re-examination is necessary. A complete neurologi-
cal exam is not appropriate at this time. We are care-
ful to avoid the following pitfalls or errors that can
result in poorer patient outcomes:
• Attributing any neurological changes to alcohol
or illicit drug use without specifically exclud-
ing injury.
• Assuming that anisocoria is secondary to direct
eye trauma or previous eye (especially cataract)
surgery.
• Not recognizing a decreasing level of conscious-
ness in a patient with minimal initial evidence
of brain injury.
EXPOSURE/ENVIRONMENT
All patient clothing is removed for complete exami-
nation. We avoid worsening patient hypothermia by
removing wet or blood-soaked bedding, giving IV
fluids warmed to 39°C and using blood warmers for
transfusing and external warming (warmed blankets
with all patients and forced, heated air or radiant
warmers as needed). Patients at both extremes of age
are less able to compensate for heat loss and we take
special care with these patients to reduce heat loss.
29
ADJUNCTS TO PRIMARY SURVEY
MONITORING
Equipment for continuous monitoring of pulse, blood
pressure and respiratory rate is always put into place
as the primary survey begins. Temperature, pulse
oximetry and end-tidal carbon dioxide monitoring
(in the intubated patient) are routine at Liverpool
Hospital. We use arterial lines for blood pressure
monitoring in the resuscitation room for patients
with severe head injuries. We do not use central ve-
nous pressure monitoring in the resuscitation room.
TUBES AND CATHETERS
We place a urinary catheter in all poly-trauma pa-
tients following examination for evidence of a ure-
thral injury (meatal blood, perineal/scrotal haemato-
ma, high-riding prostate on digital rectal exam). If
any evidence of injury is found, we perform a ure-
throgram to exclude injury prior to placing an ind-
welling catheter. If the patient is stable this is done
in the radiology suite but it can be performed in the
resuscitation room if required. If the urethrogram is
positive, a urological consultation is obtained and a
catheter is guided into the bladder after direct visu-
alization using cystoscopy, or a suprapubic catheter
is placed with delayed repair of the urethra. If there
is no evidence of injury, we pass a catheter into the
bladder via the urethra so that urine output can be
monitored. Urine output is the method we use most
frequently to determine adequacy of end-organ tis-
sue perfusion.
We place a nasogastric tube (orogastric if any sus-
picion of basal skull or cribriform plate fractures) in
all intubated trauma patients, patients with shock,
spinal injury and severe head, chest or abdominal
injuries. Decreasing gastric distension lowers the risk
of aspiration and the gastric access can be used to
administer a contrast agent for CT scanning. In chil-
dren, gastric dilatation is common and decompres-
sion assists resuscitation.
X-RAYS
Routine X-rays at Liverpool Hospital are done dur-
ing the primary survey while the airway doctor is
undertaking the primary survey. The radiographers
place film cassettes under the resuscitation stretcher
prior to patient arrival to expedite the process. All
unstable patients will have an immediate chest and
pelvic X-ray. Previous study in this hospital has de-
termined a median time of less than 9 minutes to
chest X-ray and 13 minutes to pelvic X-ray for trau-
ma activations (17). In a stable patient with isolated
injury and no pelvic tenderness we may not perform
the pelvic X-ray or delay it until secondary survey is
completed. These X-rays are performed to identify
major hidden threats to airway and breathing (e.g.
unrecognized tension pneumothorax, haemopneu-
mothorax), hidden sources of substantial bleeding
(massive haemothorax, major pelvic fracture) and
30 S. K. D’Amours, M. Sugrue, S. A. Deane
radiological signs of other early threats to life (e.g.
aortic arch injury). These findings can modify the
planning and urgency of subsequent investigations
and therapeutic manoeuvres. We still include the lat-
eral cervical spine X-ray in the initial radiology se-
ries but recognize that in the unstable poly-trauma
patient with a possible head injury that we will not
use the information to determine immediate priori-
ties or make decisions. An unstable spine injury is
always assumed at this point and appropriate pro-
tection is undertaken until injury is later excluded
(53). Ideally, all X-rays in the resuscitation room
should now be digital. This allows for optimum pic-
ture quality and immediate quality assurance and
review.
ULTRASOUND AND DPL
We do no other investigations until completion of
the secondary survey. The only exception to this is
the need to rapidly exclude the abdomen as site of
major bleeding in a haemodynamically unstable pa-
tient suffering blunt trauma. Focused abdominal
sonography (FAST) by an experienced individual
(usually the trauma fellow or another accredited
person) is appropriate at this point and if ultra-
sound is not available, diagnostic peritoneal lavage
is required. A rapid technique of lavage was devel-
oped at Liverpool Hospital and continues to be used
successfully here (54). An unstable patient with ev-
idence of free intraperitoneal fluid on ultrasound or
a grossly positive lavage will undergo immediate
laparotomy and control of haemorrhage. Remember
that DPL in an unstable patient is looking only for
frank blood. If the DPL does not reveal gross blood,
then the search must be continued for another site of
blood loss.
CONSIDERATION FOR INTERHOSPITAL
TRANSFER
Although all injuries may not have been diagnosed
and resuscitation of the patient may be continuing,
it is important to consider early the potential need
for transfer of the poly-trauma patient to an institu-
tion where definitive care can be undertaken. Trans-
fer must be considered early when the needs of the
patient exceed the capabilities and resources of the
referring institution (11). This requires well-devel-
oped working relationships between hospitals with
a regionalized trauma care plan. It is also assisted by
mutually agreed trauma patient transfer protocols.
In the South Western Sydney Area Health Service
(SWSAHS) a regional trauma care plan was devised
with Liverpool Hospital designated as the Major
Trauma Service (12, 20). The SWSAHS administra-
tion established a trauma committee including input
from all area hospitals, the New South Wales Am-
bulance Service and the Medical Retrieval Unit; this
committee has devised locally appropriate protocols
and indications for trauma patient transfer. Im-
proved methods of transfer of patient and informa-
tion within SWSAHS have been developed and are
showing promise with respect to improving the saf-
ety of transfer and shortening the time to definitive
care (55). Better Practice Guidelines have been recen-
tly developed for trauma patient transfers within
SWSAHS and these detail the indications for bypass
of other SWSAHS hospitals, indications for interhos-
pital transfer, the transfer process itself and perform-
ance indicators and audit filters (56).
The need for interhospital transfer can usually be
determined early based on known injuries and pat-
terns of injury. Patient retrieval and transfer often
take time to organize and should therefore be com-
menced as soon as the need is recognized. Once the
transfer process is activated complete patient exami-
nation and resuscitation can continue. A haemody-
namically unstable poly-trauma patient who has an
indication for laparotomy should undergo immedi-
ate operation if surgical services are available (dam-
age control at minimum) even if early transfer is re-
quired for further definitive care.
Once the Major Trauma Service at Liverpool Hos-
pital is contacted regarding a need for possible trans-
fer of a trauma patient from another SWSAHS hos-
pital, it immediately becomes our responsibility to
promptly provide comprehensive assistance.
SECONDARY SURVEY
The surgical registrar undertakes the secondary sur-
vey as soon as primary survey, interventions and
adjuncts to the primary survey are completed. Al-
though the examination is thorough, systematic, and
standardized, it is important to recognize patterns of
injury and to examine carefully for injury combina-
tions guided by both pattern and mechanisms of in-
jury (11).
Complaints of pain by the patient can be a helpful
guide to examining for injury but often the multi-
trauma patient will be intubated, sedated, or other-
wise unable to assist or guide the examiner. Full pa-
tient exposure and careful inspection, palpation, per-
cussion and auscultation are the best approach. Spe-
cifically, we take special care to examine body re-
gions where injuries are easily missed or underesti-
mated:
• Back of head and scalp
• Neck beneath semi-rigid collar
• Back, buttocks and flanks
• Groin creases, perineum and genitalia
As with the primary survey, many things are done
simultaneously, especially when a well-staffed trau-
ma team is available. For instance, identification of a
long bone fracture with deformity leads to reduction
and splinting as the examination continues. Bleeding
from a scalp laceration leads to a pressure dressing
or suturing; identification of an “open book” pelvic
fracture with haemodynamic instability will lead to
attempts at decreasing pelvic volume (external fixa-
tion or sheet tied around pelvis) or urgent angiogra-
phy and embolization (57–59).
Pain relief is important to achieve and we ensure
adequate analgesia by administering IV morphine as
 Initial management of the poly-trauma patient
needed. Manipulation of any fracture or joint dislo-
cation requires analgesia prior to the procedure. Tet-
anus and antibiotic prophylaxis should be given
when indicated.
During all phases of care it must be emphasized
that frequent re-evaluation is required. We will spe-
cifically re-examine known injuries for evidence of
expanding haematomas, worsening perfusion of
limbs, developing compartment syndromes and
evolving brain injury. Any patient who becomes un-
stable or begins to develop new symptoms is reas-
sessed starting with airway and continuing with
breathing and circulation as was undertaken during
the primary survey.
TERTIARY SURVEY
At Liverpool Hospital we have incorporated a “ter-
tiary survey” into the evaluation of all trauma pa-
tients admitted after trauma team activation. A study
determined that clinically significant injuries were
missed during the secondary survey in 14.5 % of ad-
missions (30 of 206 patients) resulting in complica-
tions in 5 % of admitted trauma patients and contrib-
uting to death in 1 % of the same admissions (60).
Tertiary survey consists of a repeat of the primary
and secondary survey examinations, reassessment of
the functions of all tubes and catheters, and review
of all X-rays. It is routinely performed on the morn-
ing after the patient’s admission.
INVESTIGATIONS AND DEFINITIVE CARE
RADIOLOGY
Investigations following the secondary survey are
directed towards abnormalities identified during the
secondary survey, exclusion of injuries suspected by
mechanism of injury and the planning of the defini-
tive care of diagnosed injuries. These may include:
• Plain radiographs
• CT scanning
• Contrast studies
• Angiography
• Ultrasound (including plain sonography,
echocardiography and colour-flow Doppler)
• Endoscopy
We do not commence these investigations until the
primary and secondary surveys are completed and
immediately life-threatening injuries are treated. Ide-
ally the patient should be exhibiting haemodynamic
and ventilatory stability although in the poly-trau-
ma patient, stability must be defined with reference
to a given patient over a specific time frame and not
arbitrary values such as “systolic BP > 100 and
pulse < 100.”
The best way of investigating specific types of in-
jury is beyond the scope of this paper. It is impor-
tant to note that many investigations require mov-
ing the patient from the resuscitation area to areas
where there are often fewer personnel, less working
31
space and less equipment to manage potentially life-
threatening complications. If the patient is haemody-
namically stable then we will move the patient out
of the resuscitation room to the radiology suite where
investigations can proceed. We will not move a pa-
tient anywhere other than to an operating theatre if
ongoing haemodynamic instability is present. The
one exception to this is the patient with an unstable
pelvic fracture, no other known injuries and suspec-
ted ongoing pelvic arterial bleeding where transfer
to the angiography suite for angioembolization is
considered and supported for this selected subgroup
of patients (59, 61, 62).
BLOOD TESTS
The drawing of venous blood for investigation usu-
ally occurs with IV cannula placement but is other-
wise completed by the end of the secondary survey.
The most important tube of blood that we send is the
one for cross-matching for transfusion. All other
blood tests are useful as baseline studies but are rar-
ely helpful for early management decisions involving
the poly-trauma patient. New South Wales State law
also requires blood alcohol testing for any person
(driver, pedestrian, or cyclist) involved in road trau-
ma. Serial arterial blood gas determinations are used
in the haemodynamically unstable trauma patient to
monitor resuscitation efforts in the injured patient by
quantifying base deficit and acidemia which reflect
the adequacy of tissue perfusion (63, 64). At Liver-
pool Hospital we do not have an arterial blood gas
machine in the resuscitation room although we can
get results fairly quickly through the main hospital
laboratory.
DEFINITIVE CARE
Definitive care begins once the immediately life-
threatening injuries are excluded or treated, the sec-
ondary survey completed, a plan of action has been
decided upon and the prioritizing of investigations
and treatments has been determined. Resuscitation
is a dynamic process that is partially determined by
the response of the patient. Although definitive care
is the ultimate goal of trauma patient treatment, it
can only proceed once all of the above steps have
been taken to increase chances of patient survival and
to decrease patient morbidity. Occasionally trauma
resuscitations are suspended in the primary survey
by an urgent need for operative intervention (e.g. a
patient rapidly exsanguinating secondary to massive
haemothorax). In this situation, secondary survey
must be resumed after the immediately life-threat-
ening injury is addressed.
JUDGEMENT AND DECISION-MAKING
Judgement and decision-making by caregivers play
an important role in trauma patient care. Both have
been shown to be important in trauma patient triage
(15), the timely formulation of definitive care plans
(24), and with respect to overall patient morbidity
and mortality (26, 27, 65, 66). In South Western Syd-
32 S. K. D’Amours, M. Sugrue, S. A. Deane
ney and at Liverpool Hospital we continue to work
on improving our delivery of care, making better and
more rapid decisions, and reducing provider-related
errors in judgement as informed by our audit and
review processes. Our trauma registry and data col-
lection system has specific filters that flag patients
for review when a specific point relating to patient
care is not met (13). These errors, omissions and de-
lays are then corrected when possible or investiga-
ted for further action. We are commencing a new in-
itiative toward “closing the loop” and providing
feedback to our registrars and consultants when er-
rors in care were made and specific audit filters were
flagged. Trauma patient deaths are immediately re-
viewed with a de-briefing of involved care-givers
and we also have a multi-disciplinary death audit
process to review and examine all in-hospital trau-
ma patient deaths for system and provider errors
(67). Our quality assurance programme also includes
a weekly multidisciplinary trauma audit meeting
where specific trauma patients are reviewed and
their resuscitation and investigations are critiqued.
This is also used for education of our ICU, emerg-
ency and surgical registrars in aspects of judgement
and decision-making during trauma resuscitation.
Currently at Liverpool Hospital we use videotapes
of specific aspects of trauma resuscitation and intra-
operative management as teaching tools. Continuous
video recordings of resuscitations have been used by
other authors to determine errors in the process of
care and to improve trauma care delivery (68, 69);
this is a challenge that we hope to add to our arma-
mentarium of processes which are designed to de-
liver better trauma care to our patients.
SUMMARY AND FUTURE DIRECTIONS
Although there are always variations in the algo-
rithms that are used to resuscitate and treat trauma
patients, the “ABC” principles of immediate care of
the poly-trauma patient have remained remarkably
static. The concepts taught in courses such as ATLS®
(Early Management of Severe Trauma in Australa-
sia) provide a good structure by which the majority
of critically injured patients can be treated safely and
quickly. With specific mechanisms and patterns of
injury, there are alterations to these algorithms that
can be made to better optimize patient care. We are
beginning at Liverpool Hospital to explore many ar-
eas that pertain to the initial care of the poly-trauma
patient. These include hospital credentials and veri-
fication of all hospitals accepting trauma patients and
not just the larger centres, the expansion of our web-
site for trauma scenario teaching and team leader-
ship skill development, as well as the use of video
for resuscitation audit and performance improve-
ment. Local issues of injury demography, resources
and logistics often lead to differences in the detailed
implementation of ATLS® protocols and algorithms
and this paper has attempted to portray the ap-
proaches used in the Major Trauma Service at Liver-
pool Hospital in Sydney’s Southwest.
Emerging concepts and research provide ideas that
may further enhance immediate trauma care and
treatment algorithms. Trauma care is a difficult area
in which to conduct controlled research but what we
learn from data gathered in large databases and our
own trauma registries can lead to improvements in
practice which will potentially increase our ability to
minimize injury occurrence and better treat the inju-
ries which continue to occur.
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Received: August 16, 2001