الفهرس 
Initial Approach at Trauma Site to Polytraumatized PatientOnly 14 pages are availabe for public view
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Abstract
Injuries are nowadays the principle cause of death in the population under 45 years of age, more so than cardiovascular or cancer diseases for example. As such, trauma represents a heavy socioeconomic problem for all countries throughout the world. Patients exposed to high velocity injuries are subject to a large pattern of lesions ranging from neurologic injuries, cervicofacial, thoracic, abdominal, spine and so on. If one considers these different organs, the osteoarticular system is by far the most frequently concerned, with a fracture probability above 75% in polytraumatized patients.
Management of trauma requires broad knowledge, sound judgment, technical skills and leadership capabilities. Most trauma victims are healthy, young individuals who, if salvaged, have a normal life expectancy. Critical care specialists play a vital role in stabilization and diagnostic phases of trauma care. We must believe that: what happens in this prehospital period often determines the outcomes of care.
Resuscitation and evaluation of the trauma patient begins at the injury site. The goal is to get the right patient to the right hospital at the right time for definitive care. First responders provide rapid basic trauma life support (BTLS) and are followed by paramedics with advanced trauma life support (ATLS) skills. Medical control is ensured by pre-established field protocols, radio communication with a physician at the base hospital, and subsequent trip audits.
Time is important in the on-scene treatment of severely injured trauma patients. Applying organized trauma systems and protocols help us to carry out a correct patient assessment, resuscitation, stabilization and transportation within a short timeframe. Every action must have lifesaving purpose. Any actions that increase scene time but are not potentially lifesaving must be omitted. If you fail something twice do not attempt it a third time. Use the simplest and fastest method first to ensure the best for your patient within the shortest time.
Pre-hospital trauma scores have been devised to identify critically injured trauma victims, who represent about 10% to 15% of all injured patients. When it is geographically and logistically feasible, critically injured patients should be taken directly to a designated level I trauma center or to a level II trauma center if a level I trauma center is more than 30 minutes away. The currently available field trauma scores, however, are not entirely reliable for identifying critically injured patients.
The aim of the primary survey is to find and correct life threats. We must note that most obvious or dramatic injury usually is not what is killing the patient. If life threat can’t be corrected, we need to support oxygenation, ventilation, perfusion and transport to the nearest trauma center.
Airway is the first priority in assessment and management of the poly-trauma patient as without a patent airway, ventilation and delivery of oxygen to already- depleted cells will fail resulting in poor patient outcome. Rapid assessment consists of quickly examining the patient for signs of airway compromise. The patient is asked a simple question. Absence of response, stridor, confusion or a hoarse reply may indicate 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 airways or be at risk of rapidly losing a marginally patent 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.
Urgent and early attention must be paid to any external haemorrhage. While our trauma team’s airway doctor is assessing and securing an airway, the surgical registrar and procedure nurse are assigned to apply pressure dressings on any obvious external sites of bleeding.
When the trauma team is activated by pre-hospital communication, the trauma team arrives and is standing by and prepared for patient arrival.
As the patient is transferred from ambulance to resuscitation stretcher the ambulance officer gives verbal hand-over directly to the trauma team leader loud enough for all other team members to hear.
Airway is the first priority in assessment and management of the poly-trauma patient as without a patent airway, ventilation and delivery of oxygen to already- depleted cells will fail resulting in poor patient outcome. During early assessment of the airway, we take care to protect the cervical spinal cord by immobilizing the cervical spinal column. Although treatment of cervical spine injury is not part of the primary survey it is important to realize that an existing injury can be worsened.
Once the decision to intubate has been made, the designated airway doctor (ICU or anesthetist) undertakes 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 anesthesia before a third attempt. If the intubation is not emergent (still able to oxygenate patient in some way) and a difficult airway is anticipated (facial swelling, possible laryngeal fracture or difficult anatomy) then intubation is performed by the in-house anaesthetic registrar or consultant. Endotracheal intubation remains the gold standard for control of the airway and ventilation/oxygenation of the unstable poly-trauma patient.
Clinically evident shock in a trauma patient must be presumed to result from blood loss and, as soon as immediately life-threatening problems with Airway and Breathing are reversed, the clinical strategies must be directed towards two critical goals: stop the bleeding and restore oxygen delivery. The surgeon must be notified for rapid assessment for source of bleeding and for operating Team (OT) notification if needed.
A large IV lines placed, the fluid warmer should be primed and is functioning, a crystalloid/colloid fluid bolus should be given, crossmatching of blood (Group O, Group specific, full crossmatch) haemodynamic monitoring as pulse oximetry, BP, urine Output and a NG tube for aspiration of stomach.
In case of cardiac arrest CPR requirements should be ready as ETT, artificial ventilation, bilateral chest tubes, large IV’s (multiple), large fluid bolus, operating theatre must be ready. In this situations a clear strategies regarding ER thoracotomy must be established. We must not that a ”medical” cardiac arrest response will not be successful and that a trauma patient must have a blood volume response. The main aim is to stop bleeding.
Injuries, which can cause death within minutes, include; airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, massive flail (crush) and pericardial tamponade.
These injuries require early recognition and intervention in the Primary Survey phase and before investigations. The last five of these are the anatomic consequences of the definitive injuries and are the anatomic basis of life threatening physiological implications. There are two further traumatic causes of poor breathing which require recognition along with the above injuries the poor respiratory effort from depressed level of consciousness and high spinal cord injury. Injuries, which can cause death within hours includes; aortic rupture, tracheo-bronchial rupture, diaphragmatic rupture, oesophageal rupture, pulmonary contusion and myocardial contusion All of these are definitive anatomic diagnoses requiring some investigation, beyond clinical observations, to give rise to their suspicion, confirm their presence and dictate the appropriate interventions.
Penetrating injury are either due to low velocity (e.g. stab wounds) or high velocity energy transfer e.g. gunshot wounds. Due to temporary cavitation and secondary missiles, high velocity injury results in organ damage far wider than the tract of the bullet. Damage due to bullets can extend to 30 times the diameter of the projectile. Stab wounds cause visceral injury limited to the tract of the weapon. Blunt visceral injury results from direct crushing e.g. ruptured liver due to massive force applied to the right hypochondrium, rupture of hollow viscera etc, or deceleration with shearing between fixed and relatively mobile parts of organs e.g. spleen, liver.
Recent research has shown that unilateral or bilateral papillary abnormalities do not result from compression of the third cranial nerves, as previously thought, but from compression of the brain stem, with resulting brain stem ischaemia. Therefore, administration of mannitol is effective because it not only decreases ICP but also increases cerebral blood flow (CBF) through modulation of viscosity. Because mannitol is not used to dehydrate the body, all fluid losses through diuresis must be replaced immediately or even preventively, especially in patients suffering shock as a result of blood loss.
To ensure optimal cerebral oxygenation, CPP, haemoglobin concentration, and oxygen saturation should be optimised; vessel diameter should be maximised; and viscosity should be in the low range. The haematocrit and viscosity are inversely related, and a balance must be established to ensure optimal oxygenation. If the haematocrite is too high, viscosity increases; if the haematocrite is too low, the oxygen-carrying capacity of blood decreases. Maintaining the haematocrit between 30% and 35% is recommended: below 30%, the oxygen-carrying capacity falls without a significant change in viscosity, and above 35%, the viscosity increases out of proportion to the oxygen-carrying capacity.
Spinal cord injury is a devastating injury due to disability, the cost of rehabilitation and the cost of chronic care of the spinally injured patient. Quality of care of the spinally injured can be measured by the incidence of incomplete spinal lesions emanating from a centre. It may be a measure of the degree to which no further harm (secondary injury) is caused to the spinal cord after injury. An estimated 47 % of spinally injured patients suffer associated injuries, involving head (26%), chest (24%) or long bones (23%). These injuries may affect spinal cord perfusion, oxygenation and limit rehabilitation.
In fractures and dislocations; we examine for associations with vascular injury, nerve injury, skin ischaemia. Early reduction is very important (expertise preferable).Pelvic Fractures can cause major bleeding. It is recommended to limit attempts to diagnose clinically with respect to use of X ray, external fixation, angiographic immobilization, laparotomy, open reduction/fixation. There is possibility of association with bladder and urethral injuries. There is also possibility of bleeding, expanding haematoma, and distal ischaemia.Crush Syndrome with rhabdomyolysis, myoglobinuria, hyperkalaemia, acidosis are big problems associated with fractures of extremities.
Some authors have proposed that abdominal perfusion pressure (APP) should be used rather than bladder pressure to document intra-abdominal hypertension and hence Abdominal Compartment Syndrome, arterial pH, base deficit, serum lactate, and urinary output.
In 1976, the American College of Surgeons (ACS) developed the first field triage decision scheme to help guide EMS providers through four major steps for deciding where to transport injured patients. Since then, the field triage decision scheme has been updated multiple times to include new information and research. The most recent update began in 2005 when the Centers for Disease Control and Prevention (CDC), working closely with ACS and the National Highway Traffic Safety Administration, convened meetings of experts to look at the latest research and to develop recommendations for updating the decision scheme. These experts—the National Expert Panel on Field Triage—had more than 100 years of experience combined and reviewed more than 160 research articles. The result was the (2006) Field Triage Decision Scheme: The National Trauma Triage Protocol.
Polytrauma management underwent tremendous evolution in the past decade in the assessment, diagnosis, treatment and team approach algorithms. An important milestone marking the commencement of structured and organized major trauma management dates back to 1978 when the first ATLS Course was conducted to address the deficiency in major polytrauma management in the tragic small plane crash of the family of Dr Jim Styner (an orthopaedic surgeon of Nebraska of USA) in 1976.( Kortbeek et al; 2008) The classic management priorities can be modified from ABCDE to PDABCDE.
Another new approach to combat the lethal triad of trauma (hypothermia, coagulopathy & acidosis) related to massive transfusion in uncontrolled bleeding is the damage control resuscitation (DCR) comprising of three major components. .Permissive hypotension aims to defer or restrict the fluid resuscitation until hemorrhage is controlled to minimize the risk of hydrostatic dislodgement of the temporary clots in bleeding vessels prior to operation to stop the internal bleeding. Consequently, a short period of suboptimal organ perfusion will occur with the target to maintain the vital organ perfusion (brain & heart) with a systolic BP of around 80-90 mmHg. The atypical short pre-hospital time & very young age-mix render the study generalization difficult. Cochrane review has not shown mortality difference between early & delayed fluid resuscitation.
Damage control surgery (DCS) aims to restore or optimize the physiology instead of definitive anatomical repair. It encompasses stopping bleeding by simple methods including temporary clamping, ligation, shunting or packing if definitive operation is not possible liked multiple & extensive liver lacerations or unduly prolongs laparotomy & raise the hypothermia risk. Next is the decontamination of the injured body cavities such as bowel perforation by temporary closure or resection without anastomosis. Third is the rapid closure surgical.
Trauma resuscitation and the subsequent operation may not be able to save lives or fully restore the body functions (brain or limb), leaving not only death, permanent disability, scars, pain but burden in all forms including and not limited to physical, psychological, financial and social.Injury prevention has to receive an escalated recognition and higher resources. Proficient trauma care is not confined to the golden hours of resuscitation, but begins with efficient pre-hospital bystander and ambulance services and continues with the in-patient critical care followed by high quality rehabilitation program reinforced by future prevention for the injured and primary prevention for the at risk groups. While operation is the definitive care for trauma, prevention is the best therapy.
The world in which healthcare professionals practice is changing and patient-care is becoming team based rather than managed by individuals. The increasing trends in specialization and division of labour in health professions training and practice, as well as the expanding scope of the concept of health and the corresponding interdisciplinary work it thus encompasses, have resulted in the emergence of such team based healthcare. In this background, successful teamwork is being recognized as a necessity for many aspects of effective healthcare, from acute care settings to shared care in primary or chronic care settings.
The trauma team is an organized group of professionals who perform initial assessment and resuscitation of critically injured patients. The composition of the trauma team, level of response, and responsibilities of each member are hospital-specific, and should be predetermined through established guidelines, policies, or procedures.
Teamwork is the keyword in the modern care of poly-traumatized patients.