Trauma: Primary
Survey
Trauma care has been much improved with systematic protocols that enable
effective prioritisation of treatment. The first time one sees a trauma patient
arriving in the Emergency Department can be confusing and intimidating as there
are many things going on simultaneously.
Treatment priority
The ABC order of treatment
reflects the relative importance of the different things that can go wrong.
Under most circumstances, Airway problems will kill the patient before Breathing
problems, before lems.
Problems are treated as they are
found. If a problem is found and treated, or the patient deteriorates, one
starts again with A and works through B and C.
Cervical spine protection is given
highest priority to avoid catastrophic spinal injury.
Trauma team
Major trauma is managed by a trauma
team of up to five doctors and nurses, led by a senior doctor. Team members
perform specific roles, e.g. airway management, procedures. The role of the
leader is to stand back and have an overview rather than perform procedures,
but in a smaller Emergency Department this is not always possible.
Penetrating vs non-penetrating
trauma Penetrating trauma, caused
by knives and guns, is relatively rare in Europe and Australia, where most
trauma is ‘blunt’, e.g. motor vehicle crashes, falls, crush injuries. In
penetrating trauma (and ruptured abdominal aortic aneurysm or ectopic
pregnancy), blood may be lost faster than it can be replaced: it is essential
for ongoing bleeding to be controlled immediately. This may require wound
compression, tourniquets to stop bleeding, or immediate surgery.
Ambulance transfer and handover
Trauma patients are prepared for
transfer by placing them onto a spinal board with their head and neck
immobilised. When the ambulance arrives, the trauma team listens carefully to
their struc- tured handover: DeMIST.
•
Demographics:
age, sex, background.
•
Mechanism of injury.
•
Injuries sustained.
•
Signs and symptoms.
•
Treatment given.
The key points should be summarised
back by the team leader to confirm understanding and prevent errors.
A: Airway and cervical spine protection
If a patient is not talking, check for
stridor, or obstruction with blood/teeth/food, and normal chest wall movement
with breath- ing. The tongue can fall back and cause an obstructed airway in a
supine, unconscious patient.
Interventions
•
Oxygen: 15 L/min
using a mask with a reservoir bag.
•
Inspect mouth
and suction: only suck down side of mouth.
•
Does the patient
need a definitive airway? See Chapter 6.
•
Cervical
spine immobilisation (see opposite).
B: Breathing and ventilation
While there are many potential
injuries to the chest, there are four breathing problems that are immediately
life-threatening.
1 Tension pneumothorax
Tension pneumothorax occurs when a
lung injury pumps air into the pleural space, building up pressure. Hypotension
and respiratory difficulty are caused by high intrathoracic pressure and
kinking of the great vessels. This causes distended neck veins, loss of breath
sounds, and a trachea deviated away from the pneumothorax. Tension
pneumothorax is a clinical diagnosis, not a radiological one. Insert a
large (16 or 14 G) intravenous cannula perpendicularly into the anterior chest
wall in the second intercostal space in mid-clavicular line. A hiss of escaping
air will be heard: leave in place and insert a chest drain as soon as possible.
2 Massive haemothorax
The patient may be in shock, and may
have reduced air entry and dull percussion note, although this is often
difficult to detect with the patient supine.
Ensure good intravenous access before
placing a large bore (e.g. 32 Fr) chest drain, as draining the blood may
precipitate bleeding, which may require resuscitation and immediate surgery. 3
Open pneumothorax
A large open chest wound gives a
collapsed lung, loss of breath sounds and ‘surgical emphysema’ (air in the
subcutaneous tissues that gives a crinkly feel).
Treat by applying an occlusive
dressing over the wound that is secured on three sides only, thus acting as a
one-way valve.
4 Flail chest
If multiple ribs are broken in more
than one place, a segment of chest wall can move paradoxically, i.e. in the
opposite direction to the rest of the chest during respirations. This markedly
increases the work of breathing.
If a patient is becoming tired,
intubation is necessary. If the flail segment is small, and respiratory
function is good, analgesia can be achieved by an epidural or nerve blocks, but
the patient should be closely monitored.
C: Circulation
Pulse and blood pressure are the key
information – shock is described in Chapter 3.
Intravenous access should be a minimum
of two 16 G cannulae. Blood should be sent to the laboratory for FBC (full
blood count), U+E (urea and electrolytes), clotting, group and save, cross-
matching, depending on clinical status of patient.
Stop the bleeding, warm the patient
Obvious bleeding sites should be
compressed and dressed. Litres of blood can be lost into the pelvis or into
femoral shaft fractures. A pelvic sling should be applied if there is a pelvic
injury. Pelvic stability should never be assessed by compressing the pelvis. A
traction splint, e.g., Thomas splint, stabilises and reduces pain and bleeding
resulting from a femoral shaft fracture.
Pericardial tamponade
This produces similar signs to tension
pneumothorax, with shock and distended neck veins, but no tracheal deviation.
Heart sounds and ECG complex size may be reduced. Focused abdominal scanning in
trauma (FAST) ultrasound scan should detect tamponade. Treatment depends on the
nature of the trauma and clinical status of the patient, but is likely to
require urgent thoracotomy.
Disability and neurological status
The Glasgow Coma Scale is described in
Chapter 10.
