Principles of trauma management
Good trauma management recognises the importance of a number of key issues (General principles of good trauma management).
Trauma as a disease
Injury is a major economic burden to societies such as Australia. The most recent estimates from the late 1990s put the total economic burden on Australia's economy annually at A$13.3 billion, including both direct and indirect costs. Injury is the most frequent cause of death in Australians less than 45 years of age, and is a major cause of death in all age groups. It accounts for more years of productive life lost than cancer and heart disease combined. The major impact of injury deaths and disability is borne by the young adult segment of the population and disproportionately by males. Of injury-related admissions to Major Trauma Services, approximately 30% are road traffic related. These account for approximately 75% of those with serious injury and about 75% of those who die in hospital from injury.
Many of the advances in trauma care in recent years have been derived from experience with injuries suffered in war or with penetrating injuries resulting from interpersonal violence, particularly in the United States. However, the proportion of patients admitted to hospitals in Australia with injuries resulting from gunshot wounds or stabbings is low, varying between 2% and 7%. Even within this population, stabbings predominate and gunshot wounds to the head are often the result of suicide attempts.
Traditionally, much emphasis has been placed on deaths in quantifying the injury problem, and in more recent times there has been a very significant emphasis on injury surveillance and prevention; however, it also needs to be recognised that for every patient who dies from injury, 10 more are admitted to hospital and 2 will suffer significant long-term disability.
Trauma system planning
When examining deaths due to injury, there has been a fairly consistent finding worldwide that where systems of trauma care have not been specifically organised, 15–30% of the deaths can be deemed to have been possibly preventable. In addition, approximately twothirds of deaths in the absence of serious head injury have been deemed to be possibly preventable. Much has been done to improve this situation with respect to education, standardised care, and re-organisation, but more progress is still needed.
Considerable attention has been given internationally in recent years to the appropriate design of regional trauma care systems that enable patients with potentially serious injuries to access a process that minimises the time from injury to definitive care. The aim is to ‘get the right patient to the right hospital in the right time’. Implementation of such plans is quite advanced in some parts of Australia. The essential components of such a plan are outlined here.
Triage is the process of grouping injury victims according to risk of death or other adverse outcome. Prehospital care providers can be trained to carry out this process according to a predetermined checklist of criteria or a system of injury severity scoring. This triage of trauma patients usually depends on three simple groups of factors:
- Physiology: the vital signs (e.g. pulse >120/min, systolic blood pressure <90 mmHg, Glasgow Coma Scale score [GCS] <15)
- Anatomy: the immediately evident injuries (e.g. fractured long bones, spinal cord injury, penetrating injury)
- Mechanism of injury: e.g. fall >5 m, injury to two or more body regions, vehicle crash with ejection
Pre-hospital treatment and transport decisions
On the basis of the triage process, certain predetermined decisions are made, which attempt to direct the transport of patients to the most appropriate hospital. Certain basic life support or advanced life support interventions may also be prescribed on the basis of triage criteria. Sometimes, the most appropriate hospital is not necessarily the nearest hospital as not all hospitals have the resourcing nor expertise to care for all types of injuries. That situation requires that the pre-hospital triage process identify patients that need to bypass the nearest hospital for one that is better able to manage the identified injuries.
Categorisation of hospitals
The role of a hospital within a regional trauma care system is designated by the appropriate health authority. A Major Trauma Service (Level 1) has the facilities and internal organisation to support its role as the most appropriate primary destination for patients with potentially serious injuries, which make up only about 10–15% of the total injured population. The remaining 85% of patients in a local community should be treated within the nearest community hospital. In the semi-rural, rural and remote environments, strategically located ‘Regional Trauma Services’ (Levels 2–4) are required. These smaller trauma services must have strong links with a Major Trauma Service. Even in remote environments trauma care education, trauma service planning, and strong links with the rest of the regional trauma care network need to be continuously promoted.
Trauma response and trauma teams
Another expression of the planning that helps to ensure efficient initial assessment of trauma patients is an organised trauma response within a hospital. The aim is to minimise the time from injury to definitive care by eliminating the traditional linear sequence of mobilising medical staff of progressively increasing seniority and progressively increasing subspecialty expertise. Such trauma responses or teams have a predetermined multidisciplinary membership, a triage device to trigger mobilisation, predetermined roles for members, and standardised approaches to the performance of primary survey, resuscitation, secondary survey and investigations.
Certain natural or man-made disasters can result in multiple casualties in the presence of limited resources. Pre-planned disaster responses are essential to ensure that the principles of good injury management are applied to the greatest possible number of casualties using standardised approaches that minimise the stress experienced by medical and paramedical personnel. In situations such as this and in war-time situations, the triage services have to consider not only the severity of injuries and the risk of death for individual victims, but also the limited resources and the chances of achieving good outcomes.
Blunt and penetrating mechanisms of injury
The nature of injuries relates to the mechanisms that cause them. The severity of injuries relates to the amount of energy transferred in the injury process and the amount of the body across which the energy is transferred. Serious injury from blunt trauma is typified by victims of traffic-related injury or by falls from a significant height (greater than 5 m). In these situations, large amounts of energy are often transferred across broad and multiple regions of the body without breaching the walls of the body cavities. Accordingly, certain injury patterns can only be broadly anticipated and, initially, occult injuries are not uncommon. A broader range of investigative tests are often necessary compared with penetrating trauma.
Penetrating injuries are divided into those that result from gunshot wounds and those that result from stabbings. A further small group are patients who suffer impalement. It is important to recognise that the interpersonal violence that results in gunshot wounds or stabbings often results in multiple shots being fired or multiple stab wounds, or accompanying blunt injury (e.g. from a fist or a boot). Possible injuries from stab wounds can often be fairly confidently predicted, and guidelines for the management of stab wounds in particular body regions are generally straightforward. However, gunshot wounds can pose additional difficulties because the missile path may not be predictable. Secondary missiles (e.g. fragments from a shattered bone) can cause gross destruction of surrounding soft tissues, and the physical features of the missile (velocity, size, mass, impact surface) contribute to the amount of energy transferred. Because of the uncertainties posed by these features and the potentially serious nature of possible injuries, a lower threshold usually exists for comprehensive investigation or surgical exploration in the presence of gunshot wounds than with stab wounds.
Goals of assessment and resuscitation
The management of a trauma patient should allow the following aims to be met.
- Minimise the time from injury to definitive care.
- Don't allow the obvious injury to distract you from diagnosing other, less obvious injuries.
- No patient should leave the resuscitation area without a clear management plan.
- There should be no need for further clinical guesswork after 2 hours from arrival of the patient.
The sequence of goals in the initial assessment of an individual trauma patient are:
- Save life. This requires knowledge of the causes of death.
- Prevent major disability. This requires knowledge of the causes of disability.
- Diagnose and appropriately manage all injuries.
- Avoid unnecessary investigations or interventions.
Deaths from injury can be broadly divided into four groups that link the cause of death to the time from injury to death: death at the scene; death within ‘minutes’; death within ‘hours’; and death over ‘days’ (some examples are given in Causes of death from injury). Many patients in the fourth group are recognised as ‘late septic complications’ or ‘multiple organ failure’. However, the foundations for these late complications are often laid in the first hour or two following injury; they relate to the extent and duration of physiological disturbance. It is therefore clear that they can also relate to the promptness and completeness of early assessment and resuscitation measures. Prevention of death can be linked broadly to the principles in Prevention of death.
Disability principally relates to:
- manipulation skills
- chronic pain.
While definitive care of the actual injuries plays a major role in preventing these categories of disability, it must be recognised that ensuring adequate oxygen delivery to brain and to muscle groups also plays a major role, especially in the first hour or two after injury. As with death, prevention of disability is linked to specific measures (as shown in Prevention of disability).
Efficient initial assessment of a trauma patient derives from the broad principles outlined previously in General principles of good trauma management, a clear understanding of the patterns of death and disability (Causes of death from injury, Prevention of death and Prevention of disability) and recognition of the following factors:
- Trauma patient assessment is different from that of the usual patient. The traditional approach of taking a full history, doing a full physical examination, determining a provisional diagnosis and a list of differential diagnoses, and deriving a logical plan for investigation and treatment needs to be laid aside in order to first ensure a patient's survival and then to ensure the smallest possible risk of major complications (see below).
- There is a need to minimise the time from injury to definitive care, particularly so that continuing bleeding is arrested.
- Physiological responses and consequences of injury are often changing and any static set of physiological values (e.g. pulse, respiratory rate, GCS and blood pressure) is of limited value.
- Life-threatening injuries may be occult, multiple lifethreatening injuries may coexist in different body regions, and the injuries that appear most dramatic may not be those that pose the most risk.
- The concept of the ‘golden hour’ is important; a 1-2-hour period during which all opportunities need to be taken to discover injuries that may cause death within minutes and then to discover injuries that may cause death within hours.
- Treating doctors can be under considerable stress and will be assisted by pre-planned protocols or evidencebased guidelines.
Acute trauma management procedure outlines a well-accepted approach to the first 24 hours of injury management. The term ‘initial assessment’ applies particularly to the elements of primary survey, resuscitation, secondary survey, monitoring/reassessment and specific investigations. The term ‘definitive care’ relates to specific treatment (operative or non-operative) aimed at establishing the optimal conditions for the healing of specific injuries.
Primary survey and resuscitation
The strategy for primary survey and resuscitation is outlined in Outline of strategy for primary survey and resuscitation.. The ABCDE sequence prioritises the importance of specific injuries and assists clinical performance. Primary survey is the process used to assist the recognition of acutely life-threatening injuries and should proceed concurrently with resuscitation. As the primary survey assessment scheme is followed, intervention should be taken immediately to correct the problems that are identified with each step. Note the emphasis given to using simple measures to protect the cervical spine when attending to the adequacy of the airway. External bleeding must be controlled; direct pressure is usually effective.
In a hospital with a major trauma service and an effective trauma-team response there will be enough team members to perform some parts of the primary survey concurrently, together with the necessary resuscitative interventions. However, when resources are limited the framework illustrated in Outline of strategy for primary survey and resuscitation. assumes even greater importance. Extensive worldwide experience with this approach to primary survey and resuscitation has led to a widespread confidence that even the most apparently difficult trauma scenario becomes readily manageable by following these guidelines.
Primary survey and resuscitation provides further detail regarding primary survey and resuscitation. Effective primary survey requires awareness of a limited number of lifethreatening entities, rapid and simple systems of physiological assessment, and awareness of a menu of interventions that can be applied to correct the identified problem. Some aspects of care during the primary survey need special emphasis.
|Airway||Direct trauma: disruption/oedema||Cyanosis||Gloved finger, light, suction|
|Blood and vomitus||Stridor||Chin lift/jaw thrust|
|Soft tissue oedema||Confusion||Oropharyngeal airway|
|Deteriorating consciousness||‘Respiratory distress’||Nasopharyngeal airway|
|Air movement||Orotracheal tube|
|C-spine||Unstable fracture||Assume if:||Semi-rigid collar|
|Head injury||Manual in-line immobilisation|
|Open pneumothorax||Confusion||Needle thoracentesis|
|Massive flail||‘Respiratory distress’||Tube thoracentesis|
|Reduction in level of consciousness/poor effort||Shallow respiration||Tracheal intubation|
|Poor expansion||Cover open wound|
|High spinal cord injury||Asymmetric expansion|
|External (scene, bed, floor)||Pale, clammy, cool||Oxygen|
|Chest (chest X-ray)||Peripheral cyanosis||Intravenous access (large ×2)|
|Abdomen (FAST or DPL)||Confusion||Warmed crystalloid/colloid/blood|
|Pelvis (X-ray)||Tachycardia||Haemorrhage control (direct pressure or surgery)|
|Femurs (clinical examination)||Low pulse volume|
|Combination||Slow capillary refill||Pressure infusion|
|Neck veins||Blood warming|
|Heart sounds (muffled)||Gastric tube|
|Tension pneumothorax||Needle/tube thoracentesis|
|DISABILITY (CNS)||Secondary brain injury||Alert||A, B, C|
|Intracranial haematoma||Voice response||C-spine protection|
|Exposure||Concealed injuries||Prepare for secondary survey||Remove all clothes|
|Environment control||Hypothermia||Warm fluids|
There are three X-rays that are often considered to be within the scope of the primary survey. The most common of these is a chest X-ray, which should ideally be performed in the upright position although this is frequently not feasible in patients with severe injuries because of haemodynamic instability or potential associated injuries. A lateral cervical spine X-ray is used to screen for injuries in patients where physical examination is unreliable. However, if other measures to maintain in-line immobilisation of the neck are feasible (most commonly with a semi-rigid cervical collar), then the cervical spine X-ray can be delayed until after the completion of the primary survey or later if other injuries or unstable physiology take priority. A pelvis X-ray is commonly performed but is not routinely necessary as part of the primary survey. Its early role is in patients whose physical examination is unreliable and in whom major pelvic fracture is a possible cause of apparent major blood loss.
A primary goal in minimising death and disability is to ensure adequate oxygen supply to peripheral tissues. The most urgent threat to achieving this is interruption of oxygen supply (airway). The next most urgent threat is interference with alveolar oxygen exchange (breathing). The third most important threat is failure of peripheral delivery of oxygen (via the circulation). The adverse effects of shock occur at the microcirculation level, and early recognition of shock depends upon clinical observations of:
- the microcirculation of the skin (pale, cold, clammy)
- the brain (level of consciousness: confusion, agitation, anxiety etc.)
- the kidneys (timed urinary output via urinary catheter).
The acid-base status of the patient, as manifested in the results of arterial blood gases (ABG), gives an indication of the magnitude of the microcirculatory failure and is an invaluable tool for assessing shock and the response to resuscitation in a critically injured patient.
From time to time, injured patients present in actual or impending cardiac arrest. It is generally agreed that attempted resuscitation of patients who have no vital signs at the scene of injury will not restore life except in some circumstances where hypothermia is extreme.
Victims of blunt trauma who arrive at hospital without vital signs will not be salvaged by the most aggressive resuscitation. However, some patients who have suffered penetrating injury can be salvaged. These patients require aggressive management and a wellorganised system to respond quickly.
When patients who have arrived with recordable vital signs deteriorate rapidly so that cardiac arrest is imminent, there is no time even to carry out a rapid systematic primary survey. Management is simplified by rapidly instituting the maximum response to potential problems with airway and breathing and circulation. This involves endotracheal intubation and controlled ventilation with 100% oxygen, insertion of bilateral large-calibre (36F) intercostal catheters with underwater seal drainage, and insertion of two or three largecalibre intravenous cannulas to facilitate pressure infusion of high volumes of colloid and uncross-matched group O blood. External bleeding must be rapidly controlled by direct pressure. External cardiac massage will only be fruitful if restoration of vascular volume can lead to cardiac filling. The components of the usual medical cardiac arrest response may have some role after the initial trauma-orientated response, but will not be successful if instituted as the principal therapeutic approach.
Insertion of a nasogastric tube can be a life-saving manoeuvre if it is used to decompress a full stomach and avoid aspiration of gastric contents. A nasogastric tube should be inserted, usually towards the end of the primary survey in all trauma patients with major abdominal injury, major chest injury, spinal injury, brain injury, major burns and shock. Gastric distension is particularly common in injured children. Patients with a high likelihood of basal skull or cribriform plate fractures should only have a gastric tube placed by the oral route.
There is no great urgency to insert a urinary catheter but it is helpful if used in patients with potentially serious injury and is inserted at the end of the primary survey. The observation of gross haematuria or documentation of microscopic haematuria may have important diagnostic implications. However, once the bladder is empty, monitoring of the hourly urine output is an important part of assessing the response to intravenous fluid resuscitation. Careful inspection of the perineum and assessment of prostate position (in males) is required before a urinary catheter is positioned to avoid worsening an existing urethral injury.
The emphasis in secondary survey is on identifying anatomical injuries and providing clinical information that will determine the need for plain X-rays and other special investigations. It is a careful and methodical physical examination from head to toe. It requires close inspection, careful palpation and appropriate auscultation. Common omissions resulting in missed injuries include examination of the entire scalp, careful inspection of the back (often needing a log-roll), inspection of the perineum, inspection of the axillae and digital rectal examination.
Secondary survey: look! listen! feel! outlines a useful sequence for the execution of the secondary survey. It also indicates the common general abnormalities that may be observed and highlights some simple procedures that assist with pain relief, reduce the risk of infection and lead into the definitive-care phase of early trauma management.
|Glasgow Coma Scale||Seek the following|
|Ears (including tympanic membranes)||Lacerations (including entry, exit wounds)|
|Eyes (including pupils, acuity, fundi)||Swelling (including haematoma)|
|Facial bones||Structural deformity (i.e. bones)|
|Mouth (including teeth)||Discolouration (e.g. bruising)|
|Neck (C-spine, soft tissues, trachea)||Crepitus (including subcutaneous)|
|Clavicles||Ischaemia (i.e. limbs)|
|Chest wall||Visceral (lungs, heart, bowel)|
|Chest movement||Musculoskeletal neurological|
|Abdomen||Proceed with the following|
|Pelvis||Digital photo (or polaroid) of major wounds|
|Hips||Sterile pad on wounds|
|Thighs||Pressure on bleeding sites|
|Legs||Traction splints where indicated|
|Ankles||Splinting of specific pelvic fractures (open book)|
|Upper arms||Tetanus prophylaxis|
|Elbows||Antibiotics as advised|
|Back and flanks (log-roll)|
Because injuries may be multiple and occult, and because of the physiological derangements that follow injury, close monitoring is essential, particularly in the first 24 hours following injury. An airway that is patent in a sitting patient with a fractured mandible can become acutely obstructed if the patient lies down. A small pneumothorax can become a life-threatening tension pneumothorax. Apparently small pulmonary contusions can progress to major alterations in pulmonary compliance and oxygen exchange. Small intracranial haematomas can enlarge. Contained vascular disruptions can undergo free rupture. Arterial intimal injuries can lead to thrombosis. Crushed or reperfused muscles in the extremities can lead to compartment syndromes.
The monitoring strategy varies with the known injuries, co-morbidity and age factors, other anticipated injuries and the potential consequences or complications of the known injuries or their management.
Monitoring of oxygenation (airway and breathing) may include skin colour, level of consciousness, respiratory rate and depth, physical examination of the respiratory system, chest X-rays, pulse oximetry, capnography, arterial blood gases and ventilation pressures.
Monitoring of the circulation may include pulse rate, blood pressure, skin colour and temperature, level of consciousness, urinary output, jugular venous pressure, central venous pressure, pulmonary artery wedge pressure and cardiac output, serial haemoglobin, ABG status, outputs from drains (e.g. chest tube), as well as repeated physical examination of the abdomen and wound dressings.
Monitoring of the central nervous system relies heavily on physical examination and serial head computed tomography (CT) scans where indicated. When CT scans reveal significant injury, placement of an intracranial pressure (ICP) monitoring device is required. Serial documentation of the GCS score is imperative in patients who are not sedated and paralysed.
Early detection and explanation of fever is important in limiting septic complications.Avoidance or detection and reversal of hypothermia are important in limiting its adverse consequences (e.g. coagulopathy).
Repeated physical examination, particularly in regions of known injury, is of great importance in order to detect ischaemia of skin or deeper tissues and adequacy of distal pulses.
Definitive care is the phase of early trauma management when particular injuries receive their specific treatment. Much of this takes place in the operating theatre, and in situations of multiple major injuries a number of surgical subspecialty teams may be involved. Acute trauma management procedure emphasises the need for resuscitation to be continuing, and for monitoring and re-assessment of a patient's responses to resuscitation to be conducted, throughout this and all other phases of care. Any deterioration in a patient's physiological status should lead to urgent reassessment of the primary survey priorities and immediate intervention when acutely life-threatening events are identified.
Definitive care continues through any necessary stay in the intensive care unit (ICU) and through early convalescence on the hospital ward. As our systems of trauma care improve, the interface between acute care and rehabilitation should become progressively more invisible.
The tertiary survey is a repeat clinical examination along the lines of the primary and secondary surveys. It is performed with the aim of identifying injuries that have been missed during initial assessment. It is best performed after the early phase of definitive care and is most likely to be done if viewed as the first routine clinical task on the morning after admission of the patient to hospital. In addition to clinical examination, all Xrays and CT scans should be reviewed and new X-rays requested as indicated from the physical examination.
Injuries that may be missed during primary survey and that need to be identified during the tertiary survey often have great functional importance and impact the return of the patient to normal occupational, family and social functions. They usually pose little threat to life but often would lead to locomotor or manipulative disability if undetected and untreated. Examples include cervical spine injury without neurological deficit, fractures of small bones in the hands and feet, ligamentous injuries to the knee or ankle, dislocated acromioclavicular joint and peripheral nerve injuries. Review of previous X-rays will sometimes result in a new diagnosis of pneumothorax, widened mediastinum, pelvic fracture or rib fractures that require specific management. Occult visceral injury, in particular small bowel injury, may be suspected at this stage on the basis of increasing pulse rate, increasing temperature and localised abdominal tenderness. Subtle signs of brain injury must be sought.
Prevention of deaths and disability
In accordance with the above strategies, deaths that are avoidable can usually be prevented. Diagnosis of any problems must be early. Surgery must be prompt. Application and extension of the principles outlined for prevention of death will also succeed in minimising disability.
Trauma registries and performance improvement
It is critical that any mature or maturing trauma system establish a computerised trauma registry that incorporates information on injuries sustained and specific criteria of initial assessment and management that can also be used as markers indicating adequate or inadequate care. Additionally, it is important that details of complications and information on outcomes and lengths of stay are included. It is only with this information that objective comparisons can be made and assessments of adequacy of care can be undertaken.It is only with quality data from a functioning registry that a system of trauma care can be assessed. Performance improvement refers specifically to a process whereby care is objectively assessed and strategies are implemented to either better the process of care or to result in better patient outcomes. This approach requires objective collection of information, a robust system of review or audit, strategies to ameliorate demonstrated deficiencies, and repeated collection of data to assess efficacy of changes. It is only with repeated cycles of assessment and change that better overall results and outcomes can be achieved.