Mx of the major trauma patient

see also:

• trauma
• Vic Trauma Guidelines - Early Trauma Care
• Vic Trauma Guidelines - trauma in the older patient

• the following are general Mx processes for patients who fit criteria for a ED major trauma call

• call a ED major trauma call to ensure the trauma team is in attendance and a team leader and various team roles are assigned
• senior experienced leaders are generally need to ensure risk - benefit of interventions are appropriate, and that timely and appropriate Mx which minimises patient risk is attended without unnecessary extremes of Mx
• secondary (delayed) neural injury in patients with moderate to severe brain trauma can be reduced by:
  • maintenance of airway and ventilation through early intubation and strict avoidance of hypoxia
  • maintenance of cerebral perfusion pressure through maintenance of systolic BP > 100mmHg and perhaps elevation of head by 30deg to reduce intracranial pressures

• this is aimed at:
  • providing spinal protections
  • institution of life saving measures such as:
    • Airway - securing an airway
      • consider early rapid sequence induction (RSI) for emergency intubation
    • Breathing - maintain ventilation
      • place intercostal catheter if any pneumothorax and intubation is required
    • Circulation:
      • minimise ongoing blood loss
        • local compression
        • consider hypotensive resuscitation - allow lower BP target as excessive fluid loading risks further blood loss, coagulopathy, etc.
        • consider tranexamic acid (Cyclokapron)
      • large bore iv access
      • send bloods such as FBE, U&E, coagulation profile, cross match
      • maintaining the circulation
        • iv fluids +/- blood transfusion for hypovolaemic shock
          • consider activating massive transfusion protocols
        • relieve any tension pneumothorax by digital decompression rather than needle decompression
        • cardiogenic shock may be due to:
          • myocardial contusion, cardiac tamponade (which may require resuscitative thoracotomy if in a trauma centre)
        • neurogenic shock from spinal injury:
          • characterised by bradycardia
    • Disability:
      • brief assessment of neurologic state - GCS, gross focal neurology
      • identify other immediate life threatening problems
    • Exposure:
      • remove clothes to allow inspection of injuries and access for plumbing
      • maintain body temperature
  • assume the worst and institute measures as appropriate such as:
    • insert indwelling catheter if patient has been intubated and no C/I to IDC insertion (eg. urethral trauma)

• a head to toe examination looking for specific injuries
• log roll to assess back and spine as well as anal tone
• signs of possible spinal cord injury in an unconscious trauma patient include:
  • paradoxical breathing in absence of major airway obstruction or large flail chest
  • priapism
  • preserved facial grimace in absence of pain response in limbs
  • lower limb flaccidity with normal upper limb tone
  • observed upper limb movement in absence of lower limb movement
  • bradycardia with hypotension despite fluid challenge
  • flaccid anal tone
• baseline radiology plus specific radiology of urgent injuries suspected from survey
  • as a minimum:
    • CXR
    • pelvis Xray
    • cervical spine imaging (usually CT scan) unless can be cleared clinically
    • brain CT scan if indication for CT brain in adults
  • FAST ultrasound scan if available
  • consider chest/abdo/pelvis CT scan

• as per Victorian State Trauma Committee 2010

• deterioration of neurologic status (eg. drop of GCS of 2 points or more, seizure, increasing headache, new CNS signs)
• confusion (eg. GCS < 13) or other neurological disturbance > 2 hours
• persisting headache and vomiting 2 hours post-injury
• GCS < 9 after resuscitation

• skull fracture with confusion, decreased level of consciousness, seizure, focal neurological signs, or any other neurological signs or symptoms
• compound skull fracture or penetrating injury - known or suspected
• depressed skull fracture
• suspected base of skull fracture (eg. blood &/or clear fluid from nose or ear; periorbital haematoma, mastoid bruising)

• intracranial haematoma
• cerebral oedema
• aerocele
• midline shift

• NB. compliance with the following is being audited via VSTORM

• high risk mechanism of injury (MOI):
  • ejected from vehicle
  • motorcyclist or cyclist impact > 30kph
  • fall from height > 3m
  • struck on head by falling object > 3m
  • explosion
  • high speed MCA > 60kph
  • pedestrian impact
  • prolonged extrication > 30 minutes
• high risk trauma patients:
  • age > 55yrs
  • pregnancy
  • significant underlying medical condition
• high risk abnormal vital signs (adult values):
  • RR < 12 or >24/min
  • BP < 90mmHg
  • HR > 124/min
  • GCS < 13
  • SaO2 < 90%
• high risk injuries:
  • penetrating injury to head, neck, chest, abdomen, pelvis, axilla or groin
  • significant blunt injury to head, chest, abdomen, axilla or groin
  • two or more of the above body regions injured
  • limb threatening injuries
  • amputated limb
  • suspected spinal cord injury
  • burns > 20% or suspected to involve the respiratory tract
  • serious crush injury
  • major compound fracture
  • open dislocation
  • fracture to two or more of femur, tibia, or humerus
  • fractured pelvis