Management
in hospital
Reception
in hospital
Accident departments dealing with the injured must have purpose-built
and well-equipped resuscitation rooms. Medical staff should ideally be trained
in a trauma system — ATLS provides an ideal framework within which to work and
certification will soon be compulsory in the UK. Certification is already
compulsory in North America. Nursing and other professional staff should also be
trained within the system. Another advantage of a structured approach relates to
equipment and layout. Working within a system removes debate concerning
intravenous fluid type and amounts, techniques and investigations to be
performed, and the summoning of appropriate specialists. Agreement in these
areas is laid down in advance and allows medical teams to work within a common
language and sequence.
The
trauma team
While a suitably trained doctor can successfully assess and resuscitate
an injured patient while working to a system, it is obvious that a team approach
is more efficient and is quicker. This is the vertical (alone) versus the
horizontal (team) argument. Dr Peter Driscoll in Salford has shown clearly the
benefits of a team in improving outcome. The team should initially comprise four
doctors, five nurses and a radiographer. Roles should be paired and tasks
allocated on a preagreed basis. To avoid chaos, there should be no more than
six people physically attending to the patient at any one time. Others should
stand back until called to perform specific tasks such as vascular access,
radiographic assessment or assisting in log rolling. The team should have a
leader responsible for co-ordination and at least one member should be a trained
general surgeon. Injury is a surgical disease and surgical consultation is
required throughout.
Controversy
once surrounded the mobilisation of the trauma team, with accusations of
inappropriate call-out resulting in time wasted from clinics and operating
lists. This has now been resolved by widespread acceptance of trauma
• penetrating injury to the chest, abdomen, head, neck or groin;
• two or more proximal long bone fractures;
• flail chest and pulmonary contusion;
• evidence of high-energy impact:
—
falls of 2 m (6 feet) or more;
—
changes in velocity in an road traffic accident of 32 km/hour (20
miles/hour) or more estimated from outward deformity of car;
—
rearward displacement of front axle;
—
sideward intrusion of 35 cm or more on the patient’s side of the car;
—
ejection of the patient;
—
rollover;
—
death of another person in the same car;
—
pedestrian hit at more than 32 km/hour.
Initial
assessment and resuscitation
The objectives in this phase are to seek and manage immediately
life-threatening conditions. In ATLS language this is the ‘primary survey and
resuscitation’, following an ABCDE sequence in every circumstance. The
description that follows holds good for vertical (alone) or horizontal (team)
management. The only radiographs permitted during this phase are:
• cross-table lateral cervical spine;
• antero-posterior supine chest X-ray;
• antero-posterior plain pelvic film.
A
— Airway management and
cervical spine control
Injury to the cervical spine is assumed in the presence of injury above
the clavicle, loss or alteration of conscious level, involvement in high-speed
collisions or where there is a history of neck pain. Airway assessment and
management is performed with the cervical spine immobilised in the neutral
position by manual in-line immobilisation or by a well-fitting neck brace,
sandbags and forehead tape. Many injured patients arrive in the accident
department with neck protection already in situ. In a conscious
patient, speaking in a normal voice, the airway is patent and the brain is being
adequately perfused. If the patient does not reply to a simple question, the
airway is opened and dealt with as described for prehospital personnel. If there
is any doubt concerning the integrity of the airway, skilled anaesthetic help
should be summoned if not already present as part of an attending trauma team.
All injured patients require supplemental oxygen at 15 litres/minute via a mask
with a rebreathing bag.
B
— Breathing and
ventilation
The neck and chest are exposed. Examination involves inspection,
palpation, percussion and auscultation. The examination starts in the neck with
inspection for wounds, condition of neck veins, wounds and evidence of tracheal
injury. The respiratory rate is counted and recorded, with the time noted. Chest
symmetry and respiratory effort are assessed. Wounds and bruising are noted.
Palpation, particularly to include the sides and back (without spinal movement),
is performed gently followed by percussion and auscultation. A dull percussion
note and absent breath sounds over a hemithorax in the presence of shock are
indicative of massive haemothorax (see Box 18.6). The objective is to hunt out
and treat the six life threatening thoracic conditions listed below
Immediately
life-threatening thoracic conditions
• Airway obstruction (dealt with under ‘A)
• Tension pneumothorax
• Massive pneumothorax (> 1500 ml blood in a hemithorax)
• Open pneumothorax (sucking wound’)
• Flail segment with pulmonary contusion
• Cardiac tamponade (almost always penetrating injury)
Tension
pneumothorax requires immediate needle thoracocentesis in the second
intercostal space in the midclavicular line on the affected side, followed by
tube thoracostomy through the fifth intercostal space just anterior to
the midaxillary line. Massive haemothorax is a combined breathing (B) and
circulation (C) problem with death likely from hypovolaemic shock and impaired
ventilation. Management is therefore by vigorous support of the circulation
followed by tube thoracostomy. Open pneumothorax is managed by sealing the wound
with a dressing secured on three sides followed by tube thoracostomy. Following
insertion of the tube, the dressing is sealed on the fourth side. Flail segment
with underlying contusion (always present) requires consultation with
anaesthetic colleagues as endotracheal intubation and mechanical ventilation may
be required to maintain adequate arterial oxygen saturation. Diagnosis of
cardiac tamponade requires a high index of suspicion, particularly if a
penetrating wound is noted medial to the nipples anteriorly or medial to the
scapulae posteriorly. Needle pericardiocentesis may be life-saving in the
short term; thoracotomy and repair are required for definitive management.
C
— Circulation and
haemorrhage control
This begins with assessment for signs of shock (see Chapter 4).
Tachycardia in a cold patient indicates shock. Equally, shock associated with
injury is hypovolaemic until ruled out. Causes of shock are listed below.
Causes
of shock following injury
• Hypovolaemic — haemorrhagic (most common)
• Cardiogenic or pump failure (cardiac tamponade, tension
pneumothorax or myocardial contusion)
• Neurogenic (often combined with
hypovolaemic shock and masked)
• Septic (a late event > 24 hours and associated with missed
faecal spillage)
An
early attempt should be made to assess the degree of blood loss. Table 18.1
lists four classes based on volume loss expressed as actual amounts and
percentages (to be used for adults only).
Blood
loss may be external and obvious, or internal and covert, or combinations of
both. External bleeding sites are dealt with by direct pressure at this stage. A
hunt must be undertaken for signs of covert bleeding. Bleeding in the chest will
have been noted already. The abdomen and pelvis must be rapidly assessed for
signs of injury. A good aidemémoire is ‘blood on the floor and four more’:
• blood on floor or enviornment , including clothing.
• blood inthe chest (dull percussion note);
• abdomen (wounds, abrasions, tenderness but may be silent);
• pelvis (usually associated with obvious pelvic disruption);
• limbs (should be obvious).
The
presence of shock demands the presence of a surgeon, appropriate to the region
injured if this is obvious. Whereas intravenous fluid administration has a vital
role, the emphasis must be on stopping the bleeding by surgical means. Vascular
access for resuscitation is by cannulation of peripheral veins
— if this fails, venous cut-down at the ankle or elbow is recommended.
Once a cannula is in position, 20 ml of blood should be withdrawn for group,
type or full cross-match depending on the degree of urgency. Central access will
be required later for monitoring but is not a good route for initial
resuscitation owing to slow flow rates, technical difficulty and uncertainty
concerning position of the catheter
tip. There is revival of interest in interosseous access for adults. It
is too early to comment on its utility for general use. Its place is well
established for children under the age of 6 years and should be resorted to
without hesitation if peripheral access fails on two attempts. Special
paediatric interosseous needles are available commercially.
In
adults, 1—2 litres of warmed Hartmann’s (Ringer’s) solution is recommended
as an initial fluid challenge. The initial volume in children is calculated
according to weight and is by convention 20 mI/kg body weight. This bolus may be
repeated once.
The
patient should now be reassessed. The three responses that may be seen are given
below.
• Immediate and sustained return to
normal vital signs
• Transient response with later deterioration
• No improvement
Immediate
responders are likely to have less than 20 per cent blood loss and bleeding will
have ceased spontaneously or by direct pressure — an open fracture of tibia,
for example. Transient responders may have intra-abdominal or thoracic bleeding,
and surgical intervention will be required. Non-responders are bleeding
actively, usually in a body cavity, or shock is nonhaemorrhagic in nature.
Hypovolaemic patients have lost over 40 per cent of their blood volume,
demanding immediate surgical intervention. Continuing intravenous fluid
administration may actually be detrimental.
D
— Dysfunction of the
central nervous system
The AVPU and pupillary assessment carried out by prehospital personnel
is repeated (see Box 18.5). In addition, a rapid assessment of motor and
sensory function is performed looking only for gross and obvious signs. A more
detailed assessment will be carried out during the secondary survey (see later).
E
— Exposure and environment
Any remaining clothing should now be removed. The environment must be
considered. If too cold, hypothermia will ensue. Blankets or air heaters should
be used if available.
Critical
decisions
The response of the injured patient to the primary survey and
resuscitation phase will influence decision making. A patient in whom no
life-threatening condition was found, or one whose condition responded well and
in a sustained way, is now fit for a full secondary assessment which may be
carried out in the resuscitation room or in a ward area following admission.
Some patients will have failed to respond and
Secondary
survey
This phase comprises a head-to-toe examination of the undressed and
stable patient. It is lengthy and includes a detailed history if this is
feasible. The examination may be conducted in any order. The description here
starts with the head and works distally. At this time check that vital signs
monitoring devices are in situ. These should include a pulse oximeter and
an oesophageal or a rectal thermometer. During this phase detailed radiographic
procedures including computerised tomography (CT) and dye studies may be
performed. Patients should be stable and can therefore travel safely for CT,
ultrasound or even magnetic resonance imaging (MRI) investigations if these are
indicated.
Head
and Glasgow Coma Scale (GCS)
A thorough check is undertaken for signs of external injury such as
bruising, laceration or bony deformity. Depressed skull fractures may or may not
he palpable.
At
this stage, the patient’s conscious level is determined by applying the GCS,
which measures eye opening, best verbal response and best motor response. The
coding for each is given in Table 18.2.
The
use of this coding system is detailed fully in Chapter 35 on ‘Cranium and head
injury’. Neurological deterioration may indicate a haemorrhagic
space-occupying lesion or rising intracranial pressure, or it may be due to
hypoxia and hypoperfusion. Hypercarbia and hypoxia are the commonest causes of
the preventable ‘second injury’ in head-injured patients. Hypotension in a
head-injured adult should lead to a further search for evidence of blood loss
elsewhere.
The
nostrils and external auditory meatus are examined for rhinorrhoea or otorrhoea.
Cerebrospinal fluid from these orifices mixed with blood produces a double
ring if dropped on a hospital sheet or pillowcase.
Face
Maxillofacial injuries are discussed in Chapter 38. In summary, the
eyes are checked for foreign bodies, perforation, subconjunctival haemorrhage,
visual acuity, and pupillary and corneal reflexes. The mandible is checked for
fracture and stability. Maxillary stability is also assessed — fractures of
the middle third of the face may be displaced with risk to the airway, either
immediately or late as a result of expanding haematoma. The mouth is checked
again for broken teeth, loose dentures and foreign bodies. Check also for
retropharnygeal haematoma. This may be associated with previously undetected
cervical spine injury.
Neck
Look for subcutaneous emphysema. Palpate (gently) the cervical spine. A
lateral radiograph showing all seven cervical vertebrae and the upper border of
the first thoracic is essential in all multisystem injury patients. Particular
care should be taken not to miss lesions at Cl, C2 and C7 levels
— fractures and dislocations at these levels are notoriously unstable.
Downward traction on the arms while the film is being taken will enhance the
demonstration of the lower cervical and Ti vertebrae. In some cases a
‘swimmer~ s view may be necessary — see also Chapter 33 on the spine.
Thorax
Start by repeating the steps on thoracic assessment performed in the
primary survey. The search is now for potentially life-threatening and less
serious injuries. These are listed below. Remember, penetrating and blunt injury
below the nipples (male patient) raises the likelihood of injury to intra-abdominal
structures, in particular the liver, spleen, stomach and transverse colon.
Simple haemothorax and pneumothorax may be picked up on an anteroposterior (AP)
supine chest radiograph. Tube thoracostomy will suffice in most instances. Check
also for the integrity of diaphragm, particularly on the left.
Secondary
survey — potentially life-threatening injuries
• Pulmonary contusion
• Myocardial contusion
• Aortic tear
• Diaphragmatic tear
• Oesophageal tear
• Tracheobronchial tear
The secondary survey is the phase of ‘fingers and tubes’ in every
orifice. This particularly applies to the abdomen. Nasogastric and urinary
catheters are inserted for diagnostic and assessment purposes. The abdomen is
now fully examined in the usual way. A rectal examination and inspection of the
perineum is mandatory. At this time please read the relevant sections on
specific injuries in Chapters 50—61 inclusive. Wounds should be covered with
sterile dressings or towels. Eviscerated bowel should be covered in warm wet
packs and must not be returned to the peritoneum at this stage. Assessment of
the abdomen in cases of penetrating trauma is relatively easy. In most instances
the abdomen will need to he explored. In some large centres, protocols may
permit local exploration of stab wounds in stable patients. Difficulty arises in
cases of blunt injury, all the more when multiple injuries are present or where
the conscious level is altered. Diagnostic peritoneal lavage, ultrasound
examination or, in some specialist centres, laparoscopy may be required to
detect covert intra-abdominal injury. The retroperitoneum is notoriously silent.
All of the foregoing remarks refer to stable patients. Any deterioration should
lead to consideration of rapid surgical exploration.
Pelvis
The pelvis is gently compressed and distracted manually to check for
pain enhancement and pelvic stability. If not already to hand, an AP radiograph
of the pelvic ring should be obtained. Blood at the urinary meatus may indicate
urethral injury. If injury is suspected, get expert help. If not available, do
not catheterise; instead, place a suprapubic catheter. Please also read the
sections on specific injuries in Chapters 63—68 inclusive.
Spinal
in juries
Please read the relevant sections in Chapter 33. Tests are made for
peripheral sensory and motor defects. In spinal injuries with unstable
fractures, further neurological damage can be caused by moving the patient
inappropriately. Full examination will require the patient to be log rolled when
sufficient personnel are present. At least five people are needed. The team
leader should control the neck and coordinate. Three others are needed to
effect rolling the torso and limbs, and a doctor to examine the back and
perineum. A rectal examination is performed if not done before. In large urban
centres, severely injured patients may he transported to hospital on a long
spine board. Removal from the board on to a hospital trolley requires the same
care as for a log roll.
Extremities
The limbs should be fully assessed for evidence of injury. This should
include a complete neurovascular examination. Appropriate radiographs may be
obtained at this stage. Readers are also referred to Chapters 21—23 for more
detailed discussions on specific injuries.
Drug
administration
As part of the early management of the injured patient, consideration
should be given to administration of analgesics. Opiates are best, given in
small intravenous increments. Antibiotics and tetanus prophylaxis may also be
appropriate.
Definitive
care plan
A position should now have been reached where a daily management and
definitive plan is initiated. Patients with multiple injuries may require the
attention of a number of specialists. A decision on ‘ownership’ must be made
but with arrangements for all involved to have access. The patient should not
‘fall between two stools’, without anyone in overall charge. The most
appropriate person to take primary responsibility in such cases is usually the
general or orthopaedic surgeon.