Trauma Management - Part 1

1st December, 2006

Summary

A casualty with multiple traumatic injuries needs to be rapidly and methodically assessed to preserve life and to reduce any longterm disability. Road traffic incidents, assaults, gunshot wounds, stabbings, and burns are disturbing but common traumatic events that many nurses deal with the world over. Although the media might portray these injuries as glamorous, reality is different and often distressing.

Within the hospital environment it is essential to have sound preparation and planning for dealing with trauma victims. The best way to achieve this is to have a sound relationship with the local ambulance service that will provide the trauma team with precise (or as near as) details of the incident. Preparation within the department is also essential in order to allow the management of the patient to run smoothly. This involves the following;

Trauma Management - Preparation within the department
Prepare: Space – clear the non-essential cases where possible.
Staff – alert them to the possibility of sensitive situations.
Supplies & equipment – you don’t want to run out of essentials.
Triage: “possible” or “impossible” – heads up on extent of injuries & other disciplines required.
Safety: Staff: environment /universal precautions – especially when dangerous or hazardous materials involved.

A complete trauma team usually consists of four doctors, five nurses, and a radiographer. In many parts of the world (including parts of the United Kingdom) however, this is not possible, and the trauma team consists of two or three doctors and a similar number of nurses. A team leader should be chosen, preferably ATLS© trained (Eaton 1999) before the patient arrives and a role assigned to each individual. Some degree of overlap is inevitable and flexibility is essential. In order to avoid chaos and disorganisation, no more than four people should be touching the patient at any given time.

In difficult circumstances such as trauma resuscitation, you may only have your five senses, plus common sense, as diagnostic aids to assess casualties and the situation. Use all six!

  • talk to the casualty - listen to the response
  • listen for abnormal airway noises
  • feel for air movement & smell his breath
  • look at his colour, respiratory effort & for obvious injuries & bleeding
  • the smell of fear - reassure!
  • is the situation dangerous (i.e. petrol soaked clothes from RTI)? Use common sense and know-how..... all of this takes a few seconds

Primary survey and resuscitation

The primary survey is a structured assessment that aims to identify and treat immediate and life threatening problems. Each patient is assessed in the same way and the routine should be familiar to everyone who works in a clinical setting (Gwinnutt and Driscoll 2003). It is essential that within the hospital environment the team leader re-evaluates his or her findings on a continuous basis, as patients may deteriorate rapidly. In fact, impaired consciousness is the most commonly missed diagnosis in trauma patients (Skinner et al1996).

The most effective way of dealing with trauma patients is by following the ABCDE principles (ATLS©1976):

The ABCDE principle
A Assessment of the patient whilst approaching
A Airway (with cervical spine control)
B Breathing
C Circulation (with control of external bleeding)
D Disability of the nervous system
E Exposure of the patient with environmental control

Assessment

In the pre-hospital environment things are slightly less controlled and dangerous, therefore before diving head first into a road traffic incident (RTI) at the scene, STOP and THINK. Do not rush in yourself or let other group members become another casualty (Eaton 1999). Look at the accident setting and assess any particular hazards such as running water, smoke, traffic, falling rocks. Remember that some hazards are invisible, for example the risk of fire or explosion. Assess the number and severity of all casualties if more than one person is injured. If absolutely necessary carefully remove the casualty to a place of safety (“scoop and run”). If possible find out what has happened and how and why it happened. This also may be helpful in the search for injuries. Within the controlled environment of the resus room the same principles should initially be applied (Gwinnutt and Driscoll 2003). STOP and THINK. Listen to the team leader or most senior member of staff. Observe and apply universal precautions including the correct use of protective gloves and other barriers to protect yourself from blood-borne diseases such as Hepatitis B and HIV. The procedure for assessing trauma patients should be followed along the lines of this following lists based upon an ATLS© (1976) model.

Airway

Assess without moving the neck if possible. Get someone else to hold the head still, if help is available. You should assume a neck injury is present if there is any significant injury above the collarbones (Gwinnutt and Driscoll 2003). Apply a rigid neck collar if available, or stabilise the neck in other ways.

Look for, and remove, any obvious obstruction but do not poke fingers blindly into the mouth (there is a risk of inducing vomiting or being bitten). Open the airway using chin lift or jaw thrust. Portable suction, if available, may be used to remove vomit and secretions. Consider simple airway devices such as:

Guedel airway
Naso-pharyngeal airway (it is unlikely that intubation equipment will be available on an expedition, however some people may consider a laryngeal mask airway - LMA)

Look at the neck for injuries which may compromise the airway/breathing:

  • Swelling, deformity, neck wounds
  • Deviation of the trachea to one side.

Breathing

Once the airway has been checked (and opened if necessary), assess breathing. Look, listen and feel for breathing (10 seconds). If respiration is absent start artificial respirations. Give oxygen – preferably at 15L/min via non-rebreather mask with oxygen reservoir, but any supplementary oxygen is better than none. Check the breathing rate; if greater than 25/minute or there are signs of respiratory distress, examine the chest – look for symmetrical chest movements, open chest wounds, a flail segment, listen to the breath sounds:

  • Penetrating objects should be left in position
  • A flail segment should be stabilised.
  • A tension pneumothorax (signs of shock and severe respiratory distress, trachea deviated away from collapsed lung, ‘barrelling’ of the chest and absent
    breath sounds).

Circulation care with haemorrhage control

  • Look for any major external bleeding. If present, control with direct pressure and elevation.
  • Check for signs of shock – cold, pale, clammy skin.
  • Measure the pulse rate and assess pulse character (thready/bounding). If the pulse is absent start CPR.

Assess the blood pressure:

  • Carotid pulse (neck) - Systolic blood pressure at least 60 mmHg
  • Femoral pulse (groin) - Systolic blood pressure at least 70 mmHg
  • Radial pulse (wrist) - Systolic blood pressure at least 80 mmHg
  • Capillary refill should be less than 2 seconds in a warm casualty.

Treat shock:

  • Keep the patient flat
  • Raise the legs (unless leg, pelvic or spinal injuries are suspected)
  • Keep warm and reassure
  • If indicated and once prescribed, commence an intravenous infusion and remember to replace lost blood according to local protocols (Gwinnutt and Driscoll 2003).
  • Monitor pulse and blood pressure.

Disability

Briefly assess the patient’s neurological status using the AVPU scale (Gwinnutt and Driscoll 2003)

  • A Alert
  • V Responds to verbal command
  • P Responds to pain
  • U Unresponsive

Assess the size of pupils and reaction to light. Ask the patient if they can feel you squeezing their fingers and toes. Ask the patient to squeeze your hand and wriggle their toes. Exposure and environmental control Where possible, examine the casualty in a warm, light environment. Be GENTLE, unnecessary roughness may aggravate the problem. Be aware of hypothermia which can compound shock associated with trauma resuscitation.

Secondary survey

The aim of primary survey is to simultaneously identify and treat life-threatening problems. Secondary survey is a methodical head-to-toe search for all injuries that may be present. It may be possible to conduct a full secondary survey where the patient is found, but in a wilderness setting it is likely that the patient will need to be protected from the environment using a group shelter or tent. If the patient must be moved remember the possibility of spinal injury and try to conduct a limited secondary survey first.

Medical history

In injury cases take a brief history using the AMPLE formula:

  • A Allergies
  • M Medicines
  • P Past medical history
  • L Last meal
  • E Events leading to the injury

Examination

The casualty should be undressed to enable a complete head-to-toe examination. Examine the whole body in the following order:

• Head • Neck • Chest • Abdomen • Pelvis • Legs • Arms • Spine & back

Examination of the Head

Examination of the Head
Scalp bleeding, swelling, deformity
Concious level measure using the Glasgow Coma Scale
Eyes pupil size and reaction to light, if conscious assess vision
Nose look for discharge (cerebrospinal fluid (CSF) leak), bleeding
Ears discharge (CSF leak), bleeding, haemotympanum
Face feel the face on both sides, looking for deformities and tenderness
Mouth abnormal smell (e.g. alcohol)? any broken teeth or broken jaw?

Examination of the neck

The patient may complain of limited or painful neck movements or limb tingling/weakness. Look and feel down the neck for any tenderness, abnormal ‘step’ or swelling. If there is any possibility of a neck injury the casualty’s neck and back must be kept ‘in-line’ during evacuation.

Examination of the chest

Look for tracheal deviation, asymmetrical chest movements (flail chest), open wounds, bruising - and is there tenderness on rib springing? Listen for reduced air entry on one side of the chest.

Examination of the abdomen and pelvis

  • Look for bruising, open wounds.
  • Feel in all four abdominal quadrants for localised tenderness, particularly rebound tenderness.
  • Listen for bowel sounds.
  • Gently spring the pelvis to elicit pain/movement.
  • Examination of the limbs
  • Look for bruising, swelling, deformity, wounds, shortening.
  • If injuries are found check movement, circulation and sensation (M, C + S).
  • Apply splints to immobilise fractures.

Examination of the spine

  • If a spinal injury is suspected do not move the patient unnecessarily.
  • Log-roll and use neck immobilisation.
  • Look for loss of movement or sensation .
  • Feel for swelling, tenderness.
  • In males an involuntary erection of the penis (priapism) indicates a spinal injury.

Monitoring and Reassessment

Continuously monitor and record the vital signs during treatment:

  • Airway
  • Breathing - rate
  • Circulation - pulse and blood pressure
  • Disability - Glasgow Coma Scale
  • Drug and fluid administration

Conclusion

This article has looked at the need for the trauma patient to be rapidly and methodically assessed in order to preserve life and to reduce any long-term disability.

Part 2 next month will look at the mechanisms of injury involved with specific types of trauma, which shall underpin the most appropriate treatment.

Part 3 will go on to examine the various treatments appropriate to specific situations.

References

ATLS (1976) American College of Surgeons Committee on Trauma Report. Chicago.
Eaton JC (1999). Essentials of Immediate Medical Care. (2nd Ed), London: Churchill Livingstone.
Gwinnutt C, Driscoll P (2003). Trauma Resuscitation – The Team Approach. (2nd edn), Oxford: BIOS Scientific Publishing.
Skinner D, Driscoll P, Earlam R. (1996). ABC of Major Trauma. (2nd edn), London: BMJ Books.

Dr Greig Ferguson, MD, DSc, BN(Hons), Dip IMC RCSEd, ALS, ATLS, PHTLS,
Tutor CB Training Ltd.
www.cb-training.com