INITIAL MANAGEMENT OF PATIENTS IN TRAUMA AND SHOCK
Mohammad Said Maani Takrouri MB. CHB. FFARCS(I)
Department of Anesthesia ,
COLLEGE OF MEDICINE, KING SAUD UNIVERSITY
King Khalid university Hospital (KKUH)
* Based on a lecture delivered at the 1st Pan Arab Congress on Emergency Medicine Tunis, Tunisia 1996.
Also appeared in abstract form in Newsletter of Saudi Anaesthetic association vol. 6, (1):1-3,1995.
Running title: Emergency medicine, management, CPR.
Address for correspondence:
Dr. M.S.M. Takrouri MB.ChB. FFARCS(I)
Professor of Anesthesia
Department of Anesthesia , King Khalid university Hospital (KKUH)
Riyadh 11461 P.O. Box 2925
Tel 009661 4671595
E-mail : firstname.lastname@example.org
Trauma is a major health problem in the world today 1-4. In industrialised countries, trauma is the leading cause of death in persons younger than 38 years. In term of overall cause of death, trauma ranks third. Trauma cases are more amenable to treatment than cancer, stroke and some heart diseases, still less interest or funding is spent to research or support trauma victims. Even in developing country trauma is the prime killer of the most productive earners, car accident taking the heaviest toll .
Two major developments in that aspect are in practice within the hospital regarding management of trauma victims, the creation of trauma team in specialised centres, and setting trauma management protocols in general purpose hospital on one hand and the development of educational courses and certification in advanced trauma life support. The outcome of trauma and fitting to improve it come from understanding mortality. A. EARLY MORTALITY: Major neurological insult: (50%); head injury and cervical vertebral fracture. Massive blood loss due to major vessels injuries pelvic fracture and long bone fracture. Hypoxia due to obstruction of the airway, aspiration to the respiratory system, pneumothorax, and hemothorax. B. LATE MORTALITY: Multiorgan system failure, and sepsis.
GENERAL PLAN OF MANAGEMENT includes: Improvement of pre-hospital care of trauma victims. and establishment of trauma centres.
The following objectives should be addressed: Initiation of basic and advanced life support at the scene of the accident. This should reduce early fatalities and prevent the "second accident" which the defenceless victim may be subjected to. The items of the management are: Airway maintenance, cervical immobilisation, fluid resuscitation and rapid transport.
KEY WORDS: TRAUMA, EMERGENCY MEDICINE, CPR, MANAGEMENT, and PROTOCOL, SCORE. MORTALITY.
INTRODUCTION In modern medical practice, more patients suffering from major trauma or multiple injuries are coming under the anaesthesiologist’s care. These injuries are the result of modern style of living and modern trend in social developments. It is overwhelming to imagine the extend of stress and loss they produce on human and financial resources. The appearance of such patients in the casualty department initiate a chain of calls and consultations which engage the time and effort of substantial number of medical staff. In-spite of these efforts, patients still suffer from unnecessary damage and secondary injuries or even death under the nose of the treating team. Effort to combat this inadequacy is spend without despair. Two major developments in that aspect are in practice within the hospital, the creation of trauma team in specialized centers, and setting trauma management protocols in general purpose hospital on one hand and the development of educational courses and certification in advanced trauma life support. The costly setting of trauma team made it imperative to closely investigating the feasibility of calling it for action only for the cases were the benefit would be documented, for example is their need to call the team for every closed abdominal blunt injuries, or for isolated long bone injuries, or isolated head injury.
THE PROBLEM Trauma is a major health problem in the world today 1-4. In industrialized countries, trauma is the leading cause of death in persons younger than 38 years. In term of overall cause of death, trauma ranks third. Trauma cases are more amenable to treatment than cancer, stroke and some heart diseases, still less interest or funding is spent to research or support trauma victims. Even in developing country trauma is the prime killer of the most productive earners, car accident taking the heaviest toll 3,5.
CAUSES OF MORTALITY AFTER INJURIES
The mortality from injuries can be broadly classified as early and late. Although severe trauma may have an obvious screaming injury, and concealed pathology. The obvious injury is an open wound, a compound fracture etc. and the concealed pathology is a ruptured spleen or slowly expanding extradural hematoma or similar potentially lethal injuries. So while the attention is taken by the screaming out injury the concealed pathology progresses, so at the end of the simple operation the patient is unsalvageable.
A. EARLY MORTALITY
Major neurological insult: (50%)
Cervical vertebral fracture.
Massive blood loss:
Major vessel injuries
Long bone fracture
Obstruction of the airway
Aspiration to the respiratory system
B. LATE MORTALITY
Multiorgan system failure
GENERAL PLAN OF MANAGEMENT
1. Improvement of pre-hospital care of trauma victims.
2. Establishment of trauma centers.
The following objectives are addressed:
1. Initiation of basic and advanced life support at the scene of the accident. This
Should reduce early fatalities and prevent the "second accident" which the defenseless victim may be subjected to. The items of the management are:
1. Airway maintenance
2. Cervical immobilization
3. Fluid resuscitation
4. Rapid transport
2. Adoption of trauma team concept in the hospital setting.
In trauma center, trauma team may take care of the victim from the time of admission to the time of full return to community. The staff has a full time commitment to the work. The facilities of the hospital are geared for that purpose where the patient is treated in adequately spaced rooms, fully equipped by all necessary tested and ready for use equipment, and staffed by the following members which are included either as single or multiple numbers, in order to take the necessary steps simultaneously: anesthesiologist (s), surgeon (s), nurses, radiographer.
In general hospital, at least the arrival to the emergency department of trauma victim should call for organized team approach. The initial resuscitation, evaluation and stabilization should occur simultaneously. Anesthesiologist's role in this initial management differs from hospital to hospital, but generally his early involvement is necessary for obvious reasons, namely: The nature of the potentially lethal injuries or effects: respiratory, circulatory and neurological which need his skills.
CATEGORISATION OF TRAUMA
The use of the trauma score (TS) by medical and paramedical personnel in quantifying the severity of injuries, encourages organized and periodic assessment of the patient and allows brief and concise means of communication between the trauma management members involved in the treatment. Champion et al.6 described a widely acceptable and used trauma score. The original issue depend on assessing five vital functions: Respiratory system (4 points), Respiratory effort (1 point), Systolic blood pressure (4 points), Capillary refill (2 points), and Glasgow coma score (5 point). The assessor gives points according to clinical findings adding the final score of all functions. The highest score possible is 16, as the score goes low the severity of injury is major. A revised version omitted capillary refill and respiratory effort, and is termed revised trauma score (RTS) so the total possible score possible is 13.7
INJURY SEVERITY SCORE
Injury severity score (ISS), was developed by Baker et al.  It is the sum of the squares of the scores of each of the most severely injured area in the body, i.e. anatomical classification. The use of the ISS produces a good correlation with mortality. A score of 1 means relatively small injury, 6 unsurvivable, while in between are intermediate injuries. The maximum score is 75.
REVISED TRAUMA SCORE-INJURY SEVERITY SCORE CURVE
After calculation of both score they may be plotted against each other on a graph. On that graph the mortality line of 50% is marked, this allows to see which patient had high chance of survival and died and vice versa. Also it allows comparing notes with other centers.
TRAUMA STATUS CLASSIFICATION
This classification classify victims into three classes, according to the severity of effect of injury on five parameters:
Circulation, Respiration, Urine output, Central nervous system and the amount of blood loss. In any way it is related in all to the amount of the blood loss and reflects its degree. We expect modified response in elderly patients and with those who have pre-existing diseases 9. Other newer methods which are tried in America are expert human and automated abbreviated injury scale and International Classification of Diseases, (ICD9-CM) 9TH Revision of the Abbreviated Injury Scale (1990) (AIS-90) Injury Coding 3-5.
TRAUMA MANAGEMENT PROTOCOLS
Using a set of protocol of management of injured victims helps in following a comprehensive approach to management. One of these protocols is the Pan-Arab anaesthesia and intensive care scientific Committee’s protocol. Its title is A protocol for emergency management of polytraumatized patient 10,11. This protocol is staged into three phases:
1. First phase is concerned with saving life.
2. Second phase is concerned with initial assessment and evaluation.
3. Third phase is concerned with definite surgical intervention.
This is with full accord with similar European and American trauma protocols.
In the first phase assuring the preservation and saving life is by taking the following essential steps:
1. AIRWAY: Maintaining a free airway by using the systematic cleaning of the mouth
From blood false teeth and other foreign materials, by preventing the tongue from falling backward leading to airway obstruction, and by inserting an artificial airway or intubating the trachea.
2. BREACHING: High percentage of oxygen should be delivered and artificial ventilation using Ambu bag or similar devices should insure effective breathing. Also draining tension pneumothorax or haemo-pneumothorax to an under water seal bottle.
CIRCULATION: Cardiac massage if pulse was not felt, defibrillation and electrocardiograph should be used in this state. Intravenous infusion should start through wide gauge cannulae infusing plasma expander, Ringer’s lactate solutions and blood group O transfusion in life threatening bleeding. Cardiac stimulants and Inotropes can support temporarily the circulation. Calcium chloride (0.5-2 g) over 20 minutes, rapid digitalization in reduced contractility states and adrenergic agents like isoprenaline and dopamine for example 5-20 Micro.g-1.min-1 are widely used for that purpose}. Arresting the bleeding by direct pressure on the wound or the pathway of major artery, or the clamping a visible bleeding artery or the application of tourniquet to the limb may save the day.
In the second phase the evaluation of the extent of the trauma is by examining the naked body of the victim thoroughly. At this initial stage to know the state of the following components is essential:
The degree of alertness, size of the pupils and its reaction.
Measurement of the pulse, arterial blood pressure, temperature and respiratory rate.
Obtaining blood for blood investigations like blood tests, cross matching, blood gases, urea and electrolytes.
Insertion of the central venous catheter.
Measuring the urine output after catheterization.
Administration of the analgesics for example: Morphine or its derivatives in small divided doses, and avoiding it in head injuries. Ketamine 0.05-0.1 mg.kg-1 body weight.
Fixation of fractures.
Bandaging the wounds.
Radiographic and other investigation if the state of the patient permits.
Supportive measures like anti-tetanus serum or steroids.
Transfer to the intensive care unit.
In the third phase the step is to be taking in order to start a definitive surgery, like setting the fractures, relieving intracranial pressure, or cardiac tamponade. Stopping major bleeding from major vessels or abdominal organs.
This can set a comprehensive path to follow. Eventually it may need revision from time to time. Enlarging its sphere to include other aspect of trauma like burn, thoracic injuries. Conditions which may need immediate surgical intervention prior or on the same time as evaluation and investigations may also be described.
The improvement in pre-hospital management at the scene of the accident and better transport to hospital affected favorably the outcome of the injuries. This also allowed to transfer the critically ill traumatized patients to the hospital for further treatment.
Patients who are critically ill due to major trauma, need urgent management as soon as they arrive to the emergency room in the hospital. The speed and efficiency of the initial interference govern the outcome of the injuries.
The anesthesiologist play a major role using his skills in supporting the circulation and preserving the airway and ventilation. His role in monitoring and conducting analgesia or anaesthesia for further management made him an active member of any team involved in trauma services. His role should extend to the aggressive approach of circulatory resuscitation using transfusions and inotropics min order to preserve the vital organs. Trauma team in specialized trauma centers, and the comprehensive team approach to trauma victim in general purpose hospital my reduce fatality and morbidity. The popularization of trauma scores and trauma management protocol, help in more understanding among various discipline of medicine in the hospital, and allow common language of communication to revise and compare notes with other hospitals.
Education in Advanced trauma life support and further certification improved the outcome of treatment of trauma victims both in developed and developing countries 11.
Abrams K.J.: Preanesthetic assessment of the multiple trauma victim. Anesthesiology clinics of North America 8:4,811-27,1990
Trunkey D.D.: Organisation of trauma care in Bruke J.F., Boyd R.J., McCabe C.J.,(eds). Trauma management: early management of visceral. Nervous system, and Musculo-skelital injuries. Chicago, Year book p 1-10, 1988.
Joy S.A., Lichtig L.K., Knauf R.A., et al .: Identification and categorisation of and cost for care of trauma patients: a study of 12 trauma centres and 43,219 state-wide patients. J.Trauma 37:2,303-13, 1994.
Long W.B., Sacco W.J., Copes W.S., et al.: An evaluation of expert human and automated abbreviated injury scale and ICD-9-CM injury coding. J Trauma 36:4,499-503, 1994.
Karsteadt L.L., Larsen C.L., Farmer P.D. Analysis of as rural trauma program using the TRISS methodology: A three years retrospective study. J Trauma 36:3,395-400, 1994.
Champion H.R., Sacco W.J., Cormazzo A.J., et al.: Trauma score. Critical Care Medicine 9:673, 1981.
Champion H.R., Sacco W.J., Copes W.S. et al.: A revision of the trauma score. J. Trauma 29:623, 1989.
Baker S.P., O’Neill B., Haddon W. and Long W.B.: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14:187-196, 1974.
Raj P.P., Montgomery S.J., Bradley V.H.: Agents and techniques in Anaesthesia for the surgery of trauma. Chapter 6, Giescke A.H.(ed). Philadelphia, Davis, 1962.
PPAIC Scientific committee.: A protocol for emergency management of polytraumatized patient. Cairo, 1987.
Takrouri M.S.M.: A protocol for emergency management of polytraumatized patient. Anaesthesia: Essays and Researches 3: 1-2, 114-116, 1988.
Ali J., Adam A., Stedman M.,et al Cognitive and attitudinal impact of the advanced trauma life support program in developing country. J Trauma 36:5,695-702, 1994.
TAKROURI M.S.M. Management of trauma cases