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CDHB

Early Care of Trauma

For a more comprehensive manual on trauma management at CDHB, including Trauma Call Activation Criteria and Trauma Team composition and responsibilities, see the CDHB Trauma Guidelines (search for "trauma guidelines" on the CDHB intranet).

• The principles of the Emergency Management of Severe Trauma course form the basis for evaluation and treatment guidelines.
• Care of injured patients requires a process of rapid assessment and resuscitation followed by thorough examination and appropriate definitive therapy (or transfer). The sequence of evaluation and treatment is therefore:
  • Primary Survey: a rapid assessment.
  • Resuscitation: immediate therapy for life-threatening injuries and physiological abnormalities detected in the Primary Survey.
  • Secondary Survey: a thorough 'top to toe and front to back' examination of the patient, including any specialized investigations that are needed.
  • Definitive Care: the treatment to 'fix' the injury.

Primary Survey (ABCDE)

Airway (with C-spine control)

1. Assess the airway.
2. Create or maintain an airway by:
   • Suction.
   • Chin lift or jaw thrust (with C-spine control).
   • Oro/nasopharyngeal airway.
   • Oro/nasotracheal intubation.
   • Cricothyroidotomy.
3. Recognize the potential for cervical spine injury and maintain the spine in a safe neutral position until clinical examination and radiological findings exclude injury.

Breathing

1. Assess the chest clinically.
2. Administer high flow oxygen.
3. Consider chest decompression or drain where appropriate.

Circulation

1. Assess circulation.
2. Arrest external haemorrhage by local pressure.
3. Insert 2 large bore IV cannulae. If no IV access, consider alternatives - intraosseous, external jugular vein, central venous access, or cutdown depending on the situation and the clinical skills of the operator. Take blood for CBC+diff, cross match, Na, K, creatinine, glucose, coagulation profile and ethanol.
4. Begin infusion with crystalloid resuscitation fluid. This should be warmed if possible. Patients with exsanguinating haemorrhage should be resuscitated with blood as soon as it is available (see Collection of Blood from Blood Bank). Activate the Massive Transfusion Protocol.
5. Monitor the patient with an ECG and BP monitor and a pulse oximeter.

Disability

1. Determine the level of consciousness - AVPU or GCS.

   Is the patient:

   • Awake?
   • Responding to Verbal stimuli?
   • Responding to Painful stimuli?
   • Unresponsive?
2. Assess the pupillary size and response.

Exposure/Environmental Control

1. Expose the patient so that an adequate complete examination can be performed.
2. However, prevent the patient becoming hypothermic.

Resuscitation and Monitoring

Ongoing resuscitation of physiological abnormalities detected in the Primary Survey is very important.

Monitoring the progress of resuscitation requires consideration of the following:

1. Respiratory rate.
2. Pulse (ECG monitor).
3. Perfusion.
4. Blood pressure.
5. Oxygen saturation (ABGs, pulse oximetry).
6. Urine output. A urethral catheter should be inserted if there are no contraindications.

Radiology

Note: Unstable patients should never leave the Emergency Department for radiological investigation.

In general, only 3 X-rays are appropriate in the resuscitation room:

1. Chest X-ray: This is the only X-ray justified in an unresuscitated patient. If a pneumothorax is obviously present it is not necessary to wait for a chest X-ray. Have confidence in the clinical assessment. Insert a chest drain, and X-ray later.
2. Pelvic X-ray: A pelvic fracture not clinically obvious can be the site of unexplained blood loss. A dislocated hip can be missed in a patient with multiple injuries, especially if unconscious.
3. Lateral cervical spine: This should be done on any patient with any history of loss of consciousness, injury above the clavicle, or signs or symptoms of spinal injury. In these patients a spinal injury should be assumed to be present. A lateral C-spine X-ray may allow an injury to be confirmed early in the assessment process but exclusion requires a 3 view series.

Cases where C-spine X-rays are not routinely needed:

• Nearly all multisystem trauma patients require CT imaging. Many patients require a "trauma CT scan" from head to pelvis inclusive. If this CT is done, lateral cervical spine X-rays can be omitted, as CT is more sensitive for detecting injury than plain films.
• C-spine X-ray may also be omitted if the patient requires a CT head (do a CT head and neck), or if it is clear that they will require a CT regardless of the X-ray result (in which case proceed straight to the CT).
• In some patients it is possible to clinically clear the neck using the "NEXUS" (see www.mdcalc.com/nexus-criteria-for-c-spine-imaging) or "Canadian C-spine" rules (see www.mdcalc.com/canadian-c-spine-rule), in which case no X-ray is needed.

Focused Assessment by Sonography in Trauma (FAST)

FAST may be performed in trauma patients who show signs of abdominal injury. This should be performed only by clinicians trained in the technique. Remember the core purpose of a FAST scan is to rule out life-threatening intra-abdominal bleed as a site for major blood loss in the haemodynamically unstable patient to aid immediate disposition and treatment. A normal FAST scan does not rule out all abdominal injuries in every patient, and should not be used to do this.

Secondary Survey

This assessment is a complete examination of the patient from 'top to toe and front to back'. Take a thorough history from the patient, bystanders, or ambulance staff, so that you have as clear an idea as possible of what happened to the patient. This will allow you to prioritize your suspicions and examine the patient with a clear view of what the most likely injuries are. Where possible this is also an appropriate time to record the other aspects of an AMPLE history.

• A Allergies.
• M Medications (cardiovascular medications and anticoagulants are particularly important).
• P Previous medical / surgical history. Pregnancy.
• L Time of Last meal.
• E Events/Environment surrounding the injury.

Examination of the Patient

• Head and face
  • Inspect the whole head and face and palpate the region with gloved fingers.
  • Check the pupils again.
  • If the patient is cooperative, obtain a rough assessment of visual acuity, and look at the tympanic membranes.
• Neck
  • Maintain in-line immobilization of the cervical spine and remove the front of the semi-rigid collar. Inspect the neck and palpate posteriorly.
  • If not already performed, and clinically indicated, ask for a cross-table lateral cervical spine X-ray (see above). Regardless of the result, keep the collar on.
• Chest
  • Re-evaluate the chest as in the Primary Survey.
  • Ask for a CXR if not already done. This should be supine in the first instance unless there is no likelihood of any spinal injury.
• Abdomen
  • Inspect, palpate, percuss and auscultate the abdomen as you would in any other assessment of an acute abdomen.
  • A urinary catheter should only be inserted if there is no blood at the urethral meatus, no perineal bruising, and the rectal examination is normal.
  • If the patient has an abnormal level of consciousness he or she may need a CT abdomen as clinical examination is unreliable.
• Back
  • With 4 assistants it is possible to safely log roll the patient and examine the back. Inspection and palpation are the crucial aspects and it may be possible to perform rectal examination at this time.
• Extremities
  • Carefully inspect and palpate each limb for tenderness, crepitation, or abnormal movement. If the patient is cooperative ask him or her to move the limbs in response to command in preference to passive movement in the first instance. Assess neurovascular status of each limb.
  • Adequately splint any injuries.
• Neurological examination
  • Assess the Glasgow Coma Scale.
  • Look for any localizing signs.
  • Re-evaluate the pupils.
  • Assess the neurological level of injury (myotomes and dermatomes) as appropriate.

Glasgow Coma Scale

Topic Code: 3807