Trauma


Initial management of the trauma patient 

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60SecondPatientAssessment.txt
The 60 Second Patient Assessment in Trauma
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Annotation or Definition  <br>
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Treatment or management 


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BLOOD TESTING GUIDELINES FOR TRAUMA PATIENTS
These guidelines apply to all trauma patients who are managed by the
trauma team. They are evidence-based, and are designed to reduce
unnecessary testing without compromising the quality of patient care.
The Trauma Team Leader is
responsible for determining
which tests should be ordered,
and should generally follow the
guidelines. However, they may
deviate from the guidelines if
sound clinical reasons exist.
Patients should be considered
under one of three categories,
depending on injury severity.
Some modifications occur for co-morbidities.


<br><br>


1. Mild To Moderate Injury

<br><br>


Airway, breathing and circulation are stable and not predicted to
deteriorate.
No blood tests required unless there are specific medical
indications.
<br><br>



2. Serious Injury

<br><br>


Airway or breathing may be compromised. Circulation is stable,
with less than 2 litres fluid requirements.
· Full Blood Count (FBC)
· Group and Hold
· Urea, Electrolytes, Creatinine (UEC) only if >60 years or
known pre-existing co-morbidity.

<br><br>


3. Serious Injury Obviously Requiring Transfusion.

<br><br>


Patient has poor perfusion or ongoing haemodynamic instability.
· FBC
· UEC
· Cross Match -
O Negative or
O Positive blood may be required whilst
awaiting
cross-match.
BLOOD ALCOHOL
The NSW Motor Traffic Act 1990 (white certificate) legislates mandatory
blood alcohol testing for all drivers, motor cyclists, pedestrians,
pedal cyclists, skateboarders, rollerbladers, horseriders etc. who
present to hospital following an incident on a public property and are
aged 15 years or greater. The Rail Safety Act 1993 and Marine Act
1991 cover boat drivers and train drivers requiring care following an
accident (mustard certificate). Medical or nursing staff may complete
the certificate and requirements. The packs are self explanatory
and the serial number should be recorded in the nursing flow
chart and trauma sheet.

<br><br>

OTHER GENERAL GUIDELINES

<br><br>


1. Amylase – rarely indicated.
2. Coagulation studies – not indicated acutely unless the patient is
taking warfarin (then INR should be done).
3. CPK – only indicated to confirm rhabdomyolysis – so please do
not order routinely, it is useless!
4. Cardiac enzymes – only if myocardial ischaemia suspected (CPK
has no role in managing “myocardial contusion”. Troponins are
more useful).
5. Liver enzymes – only if hepatic injury suspected.
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SECTION 3
6. Arterial Blood gases – indications:
a. Seriously injured patient with abnormal breathing or
poor perfusion.
b. 15 minutes after instituting mechanical ventilation.
c. Elderly patient.
d. Blood gases are under utilised – they are very useful
indicators of:
· Oxygenation status,
· CO2 (ventilation status), and especially
· perfusion.
They may be the only indicator of underperfusion and
hypovolaemia.
Please do a blood gas routinely on trauma patients > 65
years. Look at their base deficit, if abnormal, think “this
patient is potentially worse than I recognise”.
7. Serum lactate - like ABG’s, serum lactate may provide a useful
monitor of perfusion – if abnormal, repeat every 2 hours and
assess the trend.
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SECTION 3
FAST See Page 155.
DPL See Page 161.

<br><br>


RADIOLOGY

<br><br>


The use of radiology within the resuscitation room should conform
with guidelines published by the Department of Health with regard to
Radiation Safety.
“…mobile x-ray equipment be used only for examinations where it is
impractical or not medically acceptable to transfer patients to a
stationary radiological installation and only after proper attention has
been given to the radiation protection measures required in its use”
International Atomic Energy Agency-SS115, II.16.c, 1996.
“There are some patients who cannot or should not be moved from
their beds, although some seriously ill patients can often be transported
to the Radiology Department without detriment to their condition for a
much improved radiographic result. Every effort must be made to
ensure that patients are not radiographed unnecessarily or more
frequently than necessary and that radiation to staff and other patients
in adjacent areas is minimised.” NHMRC, Radiation Health Series No14,
paragraph 54, 1985.
Staff essential to patient care during an x-ray examination must wear
a radiation protective lead apron. Pregnant women must never be
called on for this purpose.
The trauma team should actively consider whether it is safe for a
patient to be transferred from the resuscitation room for further
investigation (see page 243).
In resuscitation, think of the cells –
blood gases and lactate are the best
monitor of cellular function at present.
<br><br>


All patients transferred for further investigation require an appropriately
skilled nursing escort. Appropriate cardiorespiratory monitoring should
be in place prior to transfer. Suction, oxygen supply and an appropriate
oxygen delivery device must accompany the patient. If appropriate,
the drug and treatment pack should accompany the patient. Where
there has been documented hypotension or where there is the potential
haemodynamic instability, a medical member of the trauma team skilled
in resuscitation must accompany the patient.
Ventilated patients must be accompanied by a medical member of the
trauma team who has specific airway skills. The medical officer must
remain with the patient during transfer and while the patient is
undergoing further investigation. The use of continuous pulse oximetry
and ETCO2 monitoring is mandatory in the ventilated patient.
Investigation with CT scan, angiography, duplex or cardiac echo may
be appropriate for an individual patient (see Management Algorithms
page 105)
REFERENCES:
1. Emergency Department Orientation Handbooks for RMO / Interns
and Registrars, Liverpool Hospital, 2002.
2. Blood Testing Guidelines for Trauma Patients, in Liverpool
Hospital Policy and Procedure Manual, 2000.
<br><br>
PRIORITIES AND SEQUENCING Chapter 7
The trauma victim requires a multidisciplinary approach to care.
Coordination between ED, surgery, ICU, anaesthetics, orthopaedics
and other subspecialties is a complex task requiring knowledge,
confidence, speed and diplomacy. This is the role of the Trauma Team
Leader.
A good Trauma Team Leader inspires confidence in the team by
anticipating problems and giving clear direction. This process begins
from the initial notification of impending patient arrival. Anticipation of
the patient’s likely requirements allows a smoother, faster, safer
movement through the system. For example, if a patient is coming
from an MVC in 10 minutes with hypotension and a GCS of 6, a
number of things can be put in place:<br><br>
1. Arrange the trauma team and make sure roles are well defined.<br><br>
2. Team to put on splash gowns, gloves, goggles and lead gowns.<br><br>
3. Contact Trauma Surgeon on call.<br><br>
4. Follow an A,B,C approach to organisation, therefore:<br><br>
A---Get airway drugs drawn up, check tubes, laryngoscopes,
O2 saturation monitor, chest tube trolley standing by
B---CXR plate in place before the patient arrives.
C---Prime Level 1™ infuser, organise IV lines, warmed fluids
D---Contact CT to tell of patient and notify theatre / neurosurgeon.<br><br>
Then make sure there is quiet for the MIST hand-over and minimise
any unnecessary external noise.<br><br>
The Trauma Team Leader must have the knowledge base to anticipate
which algorithm each patient will require. Each subspecialty team will
have different priorities so the team leader must negotiate the
appropriate investigations and treatment. This is a dynamic situation
and will require vigilance and regular updating as well as discussion
with the Trauma Fellow, Trauma Surgeon and involved subspecialists.<br><br>

TYPES OF FLUID AVAILABLE
<br><br>

Debate remains on which fluid or fluids are the most appropriate to
restore volume and tissue oxygenation, and whether the specific
choice of fluid has any impact on morbidity or mortality. The only two
indisputable facts are that in comparison with colloid, larger volumes
of crystalloid are required to restore intravascular volume, and
colloids, but not crystalloids, can cause anaphylaxis.
CRYSTALLOIDS
Solutions containing approximately
isotonic concentrations of sodium (e.g.
0.9% saline, Hartmann’s solution) will
distribute rapidly across most of the
extracellular space. It is estimated that
1500 ml to 2000 ml of crystalloid is
needed to replace an acute blood loss
of 450 ml over 1 hour, depending on
how fast normal blood volumes are
reached. Thus, when replacing blood
loss with crystalloid, a volume 3-4 times
greater than the blood lost is required.
EMST (ATLS©) recommends lactated
Ringer’s (Hartmann’s) rather than
saline as the initial fluid for trauma
patient resuscitation. The rationale for
this is that large volumes of saline will
induce a hyperchloraemic metabolic
acidosis. Whether this acidosis is potentially harmful is uncertain. In
comparison with plasma, Hartmann’s has a lower osmolality and large
volumes of Hartmann’s will reduce serum osmolality and may contribute
to cerebral oedema. This effect is enough to encourage the use of
0.9% saline rather than Hartmann’s in head-injured patients.
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SECTION 3
<br><br>

COLLOIDS
<br><br>

Colloids contain particles that are large enough to exert an oncotic
pressure. In comparison with crystalloids, they have greater
intravascular persistence.
Gelatin solutions (Haemaccel®,
Gelofusine®)
Gelatin polypeptides are derived from
bovine collagen. They are modified
chemically to increase molecular size
and intravascular retention. Gelatins may
induce an anaphylactoid reaction but
these appear to be rare in the trauma
patient population. Gelatin solutions
remain a very popular fluid for
resuscitation in Europe and Australia.
Dextrans
Dextran reduces blood viscosity, reduces platelet adhesiveness, and
enhances fibrinolysis. These properties make dextran useful for
prophylaxis against thromboembolism but unpopular in the trauma
setting. They may cause anaphylaxis and are not used in trauma
patient resuscitation.
Hydroxyethyl starch
Hydroxyethyl starch (HES) solutions are modified natural polymers of
amylopectin. Some HES is extravasated into the interstitial space where
a proportion is taken up by the reticuloendothelial system. HES may
cause coagulopathy by the reduction of Factor VIII and von Willebrand
factor. There is preliminary evidence suggesting HES reduces the
capillary leak associated with the systemic inflammatory response
syndrome. HES is not available in Australia at this time.
Albumin
Human albumin is a single polypeptide. The use of albumin in critically
ill patients has not been shown to improve outcome and is expensive.
It is provided in glass bottles and is not used during acute resuscitation
of trauma patients.
<br><br>

HYPERTONIC FLUIDS
<br><br>

Hypertonic 7.5% sodium chloride produces a transient increase in
intravascular volume of many times the volume infused. This may be
an advantage in the pre-hospital setting where storage and the ability
to carry weight are limited. Hypertonic saline causes an increase in
heart rate and contractility, and a reduction in peripheral vascular
resistance and the addition of colloid extends its intravascular
persistence. Several pre-hospital trials of hypertonic fluids are
ongoing.
Haemoglobin-based oxygen carriers
A number of haemoglobin-based oxygen carriers (HBOC) are now at
advanced stages of development. The main sources of HBOCs are
bovine blood, out of date human blood, and recombinant biotechnology.
For the immediate future, human donor blood will remain the only
method with which to provide an increase in oxygen carrying capacity.
<br><br>

Blood
<br><br>

A full blood cross match will take at
least 45 minutes (not including
transport times). Type specific blood
is available in about 20 minutes.
Un-crossmatched blood (2 units of
O-ve and 4 units of O+ve ) is available
in the blood fridge in ED resuscitation
area. Blood should be administered
after 2 litres (adults) or 40 ml/kg
(children) of crystalloid or colloid
have failed to stabilise the patient, or
where there is obvious exsanguinating
haemorrhage.

<br><br>

TEMPERATURE

<br><br>

Hypothermia, defined as a core temperature of less than 35°C, results
from exposure, hypoperfusion, and infusion of cold fluids. In trauma
patients, hypothermia is a significant predictor of mortality. Hypothermia
causes a reduced heart rate and cardiac output and increases
arrhythmias. Hypothermia shifts the oxyhaemoglobin dissociation curve
to the left, impairing peripheral oxygen delivery in the hypovolaemic
patient at a time when it is most needed. Shivering increases the lactic
acidosis. Hypothermia contributes to coagulopathy by retarding the
function of enzymes in the clotting cascade, enhancing plasma
fibrinolytic activity, and reducing platelet aggregation. Even mild
hypothermia increases peri-operative blood loss and appears to be
associated with an increased incidence of infectious complications.
All IV fluids should be warmed. Use of high capacity fluid warmers,
such as the Level 1™, in seriously injured patients will minimise the
hypothermia associated with fluid resuscitation. Forced air warming
blankets are very useful in patients with mild or moderate hypothermia
and all other measures must be taken to prevent hypothermia.
RAPID INFUSION DEVICES
The Level 1™ fluid warmer is capable of warming fluids and blood
from cold to warm at rates of 500ml/min. It needs to be primed and
should be thought of early during the resuscitation process. Be aware
that there is a possible risk of air embolism when using this device.<br><br>


REMEMBER: RAPID INFUSION DOES NOT STOP
THE BLEEDING.<br><br>
GIVE BLOOD EARLY IN ELDERLY
PATIENTS.
<br><br>

RATES OF INFUSION
<br><br>

Hypovolaemia causes cardiovascular decompensation, reduced
oxygen delivery and the development of lactic acidosis. If oxygen
delivery is not restored quickly, irreversible cell damage results in
organ failure or death. Acute anaemia is better tolerated than
hypovolaemia, therefore, intravascular volume should be increased
first. This must be balanced against the risk that fluid resuscitation
may worsen outcome by disruption of thrombus, coagulopathy,
haemodilution and rebleeding.
<br><br>

ASSESSING HYPOVOLAEMIA
<br><br>

The ATLS® / EMST classification of haemorrhage is well established.
However, the physiological responses to injury and haemorrhage are
not as consistent as is commonly believed. Heart rate and blood
pressure may be poor measures of hypovolaemia and haemodynamic
stability, particularly in young and fit patients. The effects of numerous
cardiovascular drugs used by trauma patients with pre-existing
disorders adds to these difficulties of assessment.
<br><br>

RATE OF FLUID ADMINISTRATION
<br><br>

The concept of permissive hypotension was derived from studies
demonstrating that aggressive fluid resuscitation in penetrating
trauma patients increased blood pressure, but also reversed
vasoconstriction, dislodged early thrombus and increased blood loss.
Survival was improved by allowing blood pressure to remain low until
haemorrhage was controlled. Care should be taken in extrapolating
this concept to all trauma patients, particularly those with severe
brain injury. When there is profound initial blood loss or when there is
likely to be a delay until the patient can get to an operating theatre,
significant hypovolaemia and hypoperfusion will develop. The risk of
organ ischaemia may outweigh the risk of provoking more bleeding
with fluid resuscitation and the best approach may be judicious fluid
Rule number one in fluid management for trauma
patients is: STOP THE BLEEDING.

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SECTION 3
infusion while expediting surgical haemostasis (i.e. controlled
resuscitation for uncontrolled haemorrhagic shock). The challenge
lies in tolerating hypotension before haemorrhage is controlled, whilst
watching closely for indicators of severe ischaemia. Attempts at
fluid replacement should not delay surgical control of
bleeding.
<br><br>

FLUID BOLUS (WHEN AND HOW MUCH)
<br><br>

When faced with continued hypovolaemia in the trauma patient the
following general approach is suggested:
· Expedite surgical haemostasis.
· Initial crystalloid bolus (0.9% sodium chloride solution) of 1000ml
for adults (20 ml/kg for children).
· Re-evaluate.
· Second bolus of 1000ml crystalloid or colloid - gelatin solution (20
ml/kg for children).
· Re-evaluate.
· Give blood Group O Rh-ve or O Rh +ve.
· Clear evidence of exsanguination is an indication to administer
blood earlier.<br><br>


Once haemorrhage is controlled, normovolaemia should be restored
and fluid resuscitation targeted against conventional endpoints. In
practice, fluid resuscitation for major trauma will include a mixture of
blood, colloid and crystalloid solutions.
<br><br>

REMEMBER: To stop bleeding, surgery or
embolisation is required. This decision-making
must involve the Trauma Surgeon.