Introduction
Our world faces extensive amount of trauma-related morbidity and mortality every day.
India adds more lives in the road accidents. The care of injured in all scenarios
like road traffic, assault, or in disaster situation is getting viewed sincerely by
the Indian Medical Association and by the Government today.[1]
Every doctor irrespective of the specialty needs to have the knowledge in life support
and skills in saving the trauma victims. The honorable Supreme Court of India has
directed all health establishments in our country to provide initial care for emergency
and trauma victims and not to refuse treatment.[2] The Central and State Governments are taking significant initiatives in road safety
and trauma care. The “Platinum ten minutes” (immediate 10 minutes from the minute
of injury) is the purview of first responders including fire rescue officers, police,
paramedics, and knowledgeable bystanders with initial stabilization and bringing the
victims to the nearest clinical establishments irrespective of the dimension (scoop
and run). Providing the golden hour trauma care (very first hour after injury) and
shifting them to the higher center after stabilization is doctors' responsibility.
However, the golden hour is individualized whether it is minutes or entire hour as
per the injuries and needs of each patient.[3]
[4]
It is well proven that the initial timely care will increase the chance of survival
of the trauma victims and of course significantly reduce the morbidity after injury.
Patients with life threatening injuries are increasing today. When these critically
ill patients get the following initial life saving measures promptly before reaching
the hospital, then the possibility of their survival is good.
Prehospital Trauma Care
The steps involved in prehospital trauma care are as follows:
When the trauma patients arrive at the clinical establishments, every clinician while
taking care of the trauma victims should comprehend following subjects well.
Systemic Response to Trauma
Any injured patient will have a local and a systemic response which is the real disease
of trauma. Conventionally, this response is described as an initial catabolic, hypermetabolic
phase, followed by an anabolic phase of recovery, all largely due to the effect of
the endocrine response to trauma which is far more complex.
It consists of multiple linked responses or cascades with multiple alternative pathways
so that intervention in one response usually leads to bypass others. We should intervene
to stop the process at source, i.e., stopping the hemorrhage, correcting the hypoxia,
and clearing the contamination as soon as possible after injury and support organ
function till the recovery takes place.
Trimodal Death Distribution in Trauma
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The first peak of death occurs at the time of injury which happens in seconds to minutes
of injury. The reasons mainly are apnea after severe head injury, high spinal cord
injury, rupture of the heart, and major vessels. Only prevention of trauma can reduce
this peak of trauma-related deaths.
-
The second peak lasts from the end of this first peak to several hours after the injury
has taken place. Deaths that occur during this period are usually due to subdural
and epidural hematoma, hemopneumothorax, splenic rupture, liver injury, pelvic fracture,
and other injuries which contribute to major blood loss.
-
The third peak of trauma death occurs several days or weeks after the initial injury.
It is often due to sepsis and multiorgan failure.
The development of standardized trauma training, better prehospital care, and the
implementation of trauma care systems with established protocols to care for injured
patients will appreciably alter the said picture. The awareness of trauma care and
all the facts related to trimodal distribution of mortality and their morbidity after
injury, significance of medications, blood transfusion, longevity of hospital stay,
and rehabilitation should be explained to the society well. This strategy has to be
applied by the medical professionals in association with the government and nongovernment
organizations.
In-Hospital Golden Hour Trauma Care
Every physician/doctor/specialist should be acquainted with the following important
aspects of trauma care which are the “MIST”—from the ambulance paramedical staff,
primary survey, resuscitate and re-evaluate, secondary survey, definitive care, tertiary
survey, cardiopulmonary resuscitation (CPR), and safe transportation of trauma victims.
The “MIST” Handover
____________________________________________
M Mechanism of injury
I Injuries observed
S Vital signs
T Therapy established
_______________________________________________
At the Clinical Establishment
Primary survey and initial trauma care:
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Ascertaining a patent airway with cervical spine control.
-
Sufficient ventilation.
-
Maintaining circulation which includes cardiac function and intravascular volume.
-
Evaluating the overall neurological status.
Airway and Spinal Immobilization
It is well proven that the initial timely care will increase the chance of survival
of the trauma victims and of course significantly reduce the morbidity after injury.
In severe trauma, resuscitation and assessment are performed simultaneously to detect
and treat conditions that may be rapidly fatal. Diagnosing a threatened airway, clearing
it, and if necessary, providing a definitive airway is the first priority, because
an obstructed (threatened) airway can be fatal within 3 to 5 minutes. Common causes
are head injury-induced coma (Glasgow Coma Scale [GCS] <9), severe shock (systolic
blood pressure <70 mm Hg), unstable fracture maxilla, bilateral fracture mandible,
inhalational burns, and less commonly, tracheal or laryngeal injury.
Airway Assessment
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A talking patient has a clear airway.
-
Apnoeic patients are dying hence immediate orotracheal intubation is warranted.
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Maintain the immobilization of spine until cleared.
-
Look: Air hunger, restlessness, coma (unresponsive to painful stimuli), penetrating injury
to the throat. Cyanosis is a late sign.
-
Listen: Stridor, gurgling in the throat, snoring.
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Feel: Facial fractures, surgical emphysema of the neck.
-
Decide: Threatened airway or not. If not threatened, provide oxygen by face mask. If threatened,
provide a definitive airway.
Breathing
Once the airway is defined as clear, or controlled (cuffed tube in the trachea), one
can assess and treat the seven threats to life in the chest. Most are due to deficient
breathing. These are:
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Tracheal injury
-
Tension pneumothorax
-
Sucking chest wound
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Massive hemothorax
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Flail chest + pulmonary contusion
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Cardiac tamponade
-
Contained rupture of the aorta
Management for the threats to life are performed by looking, feeling, listening, and
immediately acting as mentioned below:
-
Look: For external injury to the neck or chest, cyanosis, air hunger, sucking chest wounds,
asymmetry of chest movement.
-
Feel: Trachea centra, surgical emphysema, fractured ribs, and flail segment.
-
Listen: Air entry left and right.
-
Decide: Is there a threat to life?
-
Act: Needle thoracentesis or not, three-way dressing or not, intercostals drain or not,
intubate and ventilate or not, pericardiocentesis or not.
-
X-ray: The only other threat to life is a contained rupture of the aorta, which will be
picked up on X-ray chest.
Treatment
-
Tracheal injury: Definitive airway.
-
Tension pneumothorax: Needle thoracentesis (14 Jelco) into second interspace midclavicular line, followed
by intercostals drain.
-
Massive hemothorax: Intercostals drainage—immediate drainage >100 mL = immediate thoracotomy. Clamping
the drain is of no benefit.
-
Flail chest: Three or more ribs fractured in two or more places. Intubation and ventilation depending
on blood gas analysis.
(PO2/FIO2 <200, PCO2 >45 mm Hg, respiratory rate >30/min, use of accessory muscles on maximal FIO2(65% X face mask).
Circulation
You have to integrate a lot of facts simultaneously. To make lifesaving decisions
and act rapidly, you need to follow a system:
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Identify the presence or absence of shock.
-
Define the class of shock.
-
Define the cause of shock.
-
Volume resuscitation.
-
Act to control the cause.
-
Presence or absence of shock: A patient with tachycardia >100/min after trauma is in shock until proven otherwise.
-
Look for anxiety, restlessness, aggression, depressed level of consciousness, external
hemorrhage, distending abdomen, and obvious fractures.
-
Listen to the heart sounds (muffled or not, tachycardia or not), systolic blood pressure
(BP), and peripheral pulses.
-
Feel for scalp lacerations, trachea central or not, chest wall as above, abdomen tender
or not, pelvis stable or not, limb fractures or not.
Class of shock:
Class 1: <750-mL blood loss. Requires control of the cause and crystalloid infusion.
Class 2: 750 to 1,500-mL blood loss. Requires urgent control of the cause and crystalloid
infusion.
Class 3: 1,500 to 2,000-mL blood loss. Requires urgent surgical intervention to control the
cause.
Treatment: Crystalloid infusion (2,000 mL maximum), you may consider colloid (2,000 mL maximum),
then blood transfusion. By this time, the patient should be on his way to theater.
Class 4: Blood loss >2,000 mL. Most serious injuries are possible and consider ER thoracotomy
in penetrating trauma.
The diagnosis of shock is based on clinical signs. Drop in BP is a late sign, indicating
greater than 40% mortality.
Identification of the Cause of Shock
For trauma victims, 90% of the shock is due to hemorrhage shock. This is either: external/compressible,
or internal/noncompressible.
Cardiogenic shock occurs after cardiac tamponade, tension pneumothorax, rarely blunt
cardiac injury, and in elderly patients, myocardial infarction (often precipitated
by hemorrhagic shock). Septic shock may occur within 6 hours after injury—beware of
the patient subjected to delayed transfer.
Neurogenic shock occurs after transecting the autonomic spinal fibers—e.g., high paraplegia.
The cause of shock should be controlled.
Hemorrhagic Shock
Hemorrhagic shock is either compressible or noncompressible. The immediate step is
to control compressible hemorrhage, e.g., bleeding lacerations, gunshots limbs, fractures,
and degloving injuries.
Immediate action is required!
Lacerations: Compressive bandage→pack with swabs and suture under tension.
Fracture: Reduce, immobilize splint, and apply compressive bandage to bleeding compound fractures.
Tourniquet is applied if it is a matter of life before limb, i.e., all other methods
of hemorrhage control have failed, or BP <70 mm Hg.
Pelvis: Stable or not, step over symphysis or not. If pelvis is unstable, circular compression
can be achieved by tightly tying a sheet around the pelvis at the level of trochanters.
Commercial binders are also available at other centers. If a vertical shear injury
is noted, the hemipelvis should be reduced with traction first before circular compression.
Medical anti shock trousers (MAST) suits (pneumatic antishock garments) are rarely
available for use these days.
The above are all temporary measures—get the patient to the operation theater as soon
as possible!
Noncompressible Hemorrhage
-
Dictum: Intracranial injury is never a cause of hypotension; scalp injury is a common cause
of hypotension.
-
Neck: For penetrating neck injuries, put the patient in the Trendelenburg position to
prevent air embolism, control the airway with an ET tube, inflate a Foleys catheter
in the cavity, and suture the laceration under tension.
-
Chest: See breathing—call a surgeon.
-
Abdomen: See abdominal injuries—call a surgeon.
-
Volume resuscitation: Immediately act in establishing two wide bore (14–16 G) venous access in the cubital fossa—if
not injured and same time drawing blood for investigations. With hypovolemic shock,
vascular access and volume replacement are critical to get time till bleeding can
be controlled. Access to central veins can be achieved by means of internal jugular
or subclavian vein puncture, the former being safer. In patients with neck or arm
injuries the intravenous line should be inserted on the opposite side to avoid extravasation
of the infused fluid from a proximal venous injury. The infusion rate depends on the
length and diameter of the catheter and not on the size of the vein.
-
Fluid therapy: Ringers lactate 1,000 to 2,000-mL bolus intravenous (IV) stat, followed by maximum
of 2,000-mL colloid (Voluven, Gelofusine). Thereafter delusional coagulopathy occurs.
BP is maintained at no more than 90 mm Hg for penetrating injuries to avoid vasodilatation,
dislodgement of clot, and rebleeding. Head injured patients need all the cerebral
perfusion they can get to avoid secondary brain injury—keep the BP as normal as possible.
-
Blood: Low titer 0 Rh negative: no need for typing or cross-matching. For life-threatening
blood loss only. Use of 0 Rh + blood acceptable for males.
-
○ Red-labeled: Typing but no cross-matching. Ready in approximately 10 to 15 minutes.
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○ Crossmatch and hold: Available within 10 minutes once cross-matched, but not charged until called for.
-
○ Fully typed and cross-matched: Ready in approximately 30 minutes.
Ordering the blood is guided by the severity of trauma and the patient's response
to resuscitation. If more than 2 units of blood are required for resuscitation, then
order blood products at the ratio of 1:1:1 for PRC:FFP:PLT (packed red blood cells:
fresh frozen plasma: platelets). If whole blood is available, it is preferable. The
massive blood transfusion can be modified later with the evaluation of coagulation
system. At that stage other blood products like cryoprecipitate may be added. Leucocyte
depleted red blood cells are preferred.
Disability
The aim is to define the immediate threats to life due to brain injury, spinal cord
injury; and to protect against secondary brain or spinal cord injury (due to hypo
perfusion or hypoxia). Concentrate head-and spinal cord injury. Following a protocol
avoids missing injuries.
Assessment of the Level of Consciousness (GCS)
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Identifying localizing signs.
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Protecting the brain and spinal cord against secondary injury (oxygen and perfusion).
-
Deciding not to obtain a CT-scan.
Assessment of the level of consciousness—GCS is a more elegant way; however, AVPU
scale is the quickest way to assess the suspected neurological injury.[5]
A: Alert.
V: Responds to verbal stimuli only.
P: Responds to painful stimuli only.
U: Unconscious and unresponsive to painful stimuli.
-
Localizing signs.
-
Protecting the brain.
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○ Intubate and ventilate if not responsive to painful stimuli (= GCS 8/15).
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○ Ventilate to PO2 >100, and PCO2 30 to 35.
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○ Maintain the systolic BP as high as possible.
-
○ Consider mannitol IV.
-
○ CT scan or not.
Mandatory for GCS< 14, lateralizing signs, and epileptic fit.
It is advised for all significant head injury with loss of consciousness (depending
on facilities). Especially in high-risk patients (on warfarin, antiplatelet therapy,
bleeding disorders, elderly, worsening posttraumatic headaches, retrograde amnesia,
etc.).
Exposure
By protocol, all clothing must be removed immediately to allow full examination during
primary and secondary survey. If necessary, clothing is cut away.
Hypothermia is a fatal complication of trauma. Core temperature <35°C increases the
mortality of major trauma to 35% (from 18%), and to 100% if core temperature is below
32°C. Use warm fluid, warm gas, and a warm environment from the start. The external
re-warming device of choice is a Bair Hugger. If not available, wrap the patient in
plastic bags. If intubated, wrap the head as well. The head accounts for up to 28%
of heat loss.
-
Remove all clothing/exposure.
-
At this stage, oxygen saturation monitor is applied.
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Two-wide bore lines, Ringers lactate IV at maximum speed.
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Arterial blood gas collected.
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Echocardiography monitor connected.
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Logroll, rectal, and perineal examination.
While logrolling, a rapid secondary survey of the back can be performed—see below:
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Urinary catheter if perineum intact.
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Nasogastric (or orogastric) tube if required.
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Analgesia and sedation.
-
X-ray chest, pelvis, and focused assessment of sonogram in trauma (FAST scan).
Secondary Survey and Continuing Resuscitation with Monitoring
The patient is examined in detail from head to foot and front to back. If the patient
stabilizes, then he/she has to be shifted safely to a higher center for further management
with continuous monitoring and life support. If your clinical establishments have
infrastructure to manage further, then a secondary survey and diagnostic studies are
performed. However, if the patient remains unstable, he or she should be taken immediately
to the operating room to achieve surgical hemostasis or to the surgical intensive
care unit.
Tertiary Survey and Documentation
Full examination again with investigations are done so that injuries are not missed.
The complete repetition of survey is important along with documentation.
Management of Penetrating and Crushed Trauma
It is good practice to place metallic objects, such as paper clips, on the skin pointing
to the various wounds on the chest wall, which aid the surgeon in determining the
missile track. This also can be useful for stab wounds. Tracking the missile helps
the surgeon to determine which visceral organs may be injured and, in particular,
whether or not there is a potential transgression of the diaphragm and/or mediastinum.
It is recommended that an “unfolded” paper clip could be placed on any anterior penetrating
injury, and a “folded” one on any posterior injury.
Amputations—Massive Limb Trauma: Life versus Limb
Presently, the decision of amputation based on Ganga Hospital Open Injury Scoring
system is made.[6] The management of the mangled limb remains a multidisciplinary approach and involves
the combined skills of the orthopaedic, vascular, plastic, and reconstructive surgeons.
This will prevent persistent painful debility or an insensate or flail limb is still
the outcome. Successful limb salvage is defined by the overall function and satisfaction
of the patient.
Management of Poly/Major Trauma[7]
[8]
The ideology of the management for patients suffering from major trauma must be a
multidisciplinary approach with following key essentials:
-
Synchronized and repeated assessment with resuscitation.
-
Diagnostic studies if the patient becomes hemodynamically stable.
-
Lifesaving surgery/damage control surgery.
Cardiopulmonary Resuscitation
Whenever faced with a victim who seems to be dead/dying, CPR is an essential first
step.
-
Call for help if any is available.
-
Tilt the head back and listen for breathing. If not breathing normally, pinch nose
and cover the mouth with yours and blow until the chest rises. Give two breaths. Each
breath should take 2 seconds.
-
If the victim is still not breathing normally, coughing, or moving, begin chest compressions.
Push down the chest between 1 and 0.5 to 2 inches 15 times right between the nipples.
Pump at the rate of 100/min.
-
Continue with two breaths and 15 pumps until help arrives. This ratio is the same
for one-person and two-person CPR. In two-person CPR, the person pumping the chest
stops while the other gives mouth-to-mouth breathing.
-
Vomiting is the most frequently encountered complication of CPR. If the victim starts
vomiting, turn the head to the side and try to sweep out or wipe off the vomit. Continue
with CPR.
In children
-
If alone with the child, give one minute of CPR before calling for help.
-
Use the heel of one hand for chest compressions.
-
Press the sternum down 1 to 1.5 inches.
-
Give one full breath followed by five chest compressions.
Prehospital Care with Triage and Safe Transporting Victims
Under massive trauma incidents, priorities should be set judiciously amongst the injured
victims preferring greater attention to more deserving individuals than the less deserving
ones. This is “triaging”—sorting of patients based on the need for treatment and the
available resources. Patients with the greatest chance of survival with the least
expenditure of time, equipment, and personnel are to be managed first.
Initial Care of Injured in Summary
The golden hour trauma care is important, and the goal of initial trauma management
is to restore adequate oxygenation and tissue perfusion in the shortest possible time,
rapidly treating all the injuries well. The trauma mortality is not only associated
with prehospital time but with injuries, transfers from primary care, probably deficient
care.[9] The trauma care is lifesaving but expensive. A structured trauma care system will
reduce the cost and save many lives.[10]
[11]
To improve survival after major trauma, enhancement of resources for resuscitation
and capacity building of doctors at all levels including primary centers to secondary
and tertiary care centers should be the priority in all countries having more trauma.
It has been much stressed by the World Health Organization with guidelines.[11]
[12]
