Initial Management of Severe Trauma - Standard Treatment Guidelines
There is an increasing incidence of accidents and crimes in India with increasing urbanization and attendant emergency admission of trauma victims. A comprehensive trauma care is lacking in majority of places. As this malady affects predominantly young patients it is a heavy burden to the exchequer. Improving organized trauma care with easy accessibility is an urgent need in our country.
Ministry of Health and Family Welfare has come out with the Standard Treatment Guidelines for Initial Management of Severe Trauma. Following are its major recommendations.
The American Trauma Society defines trauma as an injury caused by a physical force. More often, trauma is the consequence of motor vehicle crashes, falls, drowning, gunshots, fires and burns, stabbings, or blunt assaults.
Lot of emphasis has been placed on aggressive initial management of trauma. The concept of prehospital car is highlighted by the Golden Hour, which may be defined as the period during which all efforts are made to save a life before irreversible pathological changes can occur thereby reducing or preventing death in the second and third phase. This period may range from the time of injury to definitive treatment in a hospital. The first platinum 10 minutes becomes important to make this golden hour effective and should be distributed as follows to make it fruitful.
Time lines : Assessment of the victim & primary survey- 1-minute, Resuscitation & stabilization – 5 min, Immobilization & transport to nearby hospitals 4 minutes.
Incidence of the condition in our country
India contributes to 10% of world trauma with vehicular accident every 3 min & death every 10 min. Road traffic injuries are a major cause of mortality responsible for 22.8% of death related to injuries.The lower and middle-income group countries, including India contribute about 90% of the global burden of injury mortality. Uncontrolled bleeding is a leading cause of death in trauma. In fact, death in trauma follows a trimodal distribution of death. First peak occurs immediately after an accident. Second peak occurs 1-4 hours later and the third peak occurs 1-5 weeks later.
The initial management is usually done by paramedics, and an adequately trained team with skills in maintenance of airway, control of external bleeding and shock, immobilization of the patient and transportation. This has to be tied to early arrival of trauma ambulance and a system of triaging and notifying the receiving hospital with a central coordination.
In Polytrauma, the assessment of the extent of injuries is very important. A head to toe examination facilitates identifications of brain & cervical spine trauma, thoracic or abdominal or major skeletal trauma. If shock persists after resuscitation, patient must be evaluated for any other covert internal injuries. All patients with head injury should be assumed to have a cervical spine injury as well unless proved otherwise clinically or radiologically.
Prevention & Counseling
Road safety & pedestrian safety are two important issues. Most of the trauma victims are either pedestrians or bicyclists. Strict implementation of traffic rules and measures like wearing helmets, lane driving and implementing speed limits are important issues that need to be uniformly applied across India. A robust prehospital ambulance system manned by qualified emergency medical technicians will help in improving survival significantly.
Trauma victims are generally young and bread winners for their families. Any such death or disability is associated with significant financial and psychological trauma to the victim and his family. Adequate counseling and support is required for the trauma patients and their families.
Optimal diagnostic criteria, investigations, treatment & referral criteria
*Situation 1: At Secondary Hospital/ Non-Metro situation: Op
1. Medical Personnel with basic training in airway management and resuscitation
2. Basic Airway management equipment
3. Cervical collar
4. Spine Board
5. Scoop stretcher
6. Basic Volume resuscitation items like i.v fluids and i.v cannulas
7. Continuous oxygen supply and suction
8. Chest tube drainage system
9. Fracture stabilization material
10. Surgical sutures and hemostatic forceps.
11. X-ray & ultrasound facilities
12. Abdominal paracentesis equipment
13. Access to Blood Bank
14. Routine hematology, biochemistry, coagulation testing facility
15. Transport to higher center.
Clinical diagnosis : This remains the mainstay of diagnosis.
Investigations: Facilities like CT scan/MRI etc. are not available. Simple x-ray & Ultrasound should be available. Basic investigations like hematology, biochemistry, coagulation parameters should be available
Treatment: Quick identification and assessment of the extent of external injuries should be made. Basic care like intravenous access, fluid or blood resuscitation should be done. Splinting & bandaging of injured extremity or scalp should be done. Airway, breathing & circulation should get priority. Internal injuries and head injuries cannot be managed and should be referred to higher centres. These centers should have a clear policy on transfer of trauma patients and all patients who cannot be managed there should be shifted after initial treatment and resuscitation.
At Super Specialty Facility in Metro location where higher-end technology is available
1. Trauma Team with an on call rota and quick response time. The team should consist of a trauma surgeon or a general surgeon, intensive care or emergency medicine physician, Neurosurgical team, cardiothoracic team, orthopedician& anaesthesiologist.
2. The trauma team should be adequately supported by trained nurses and paramedical staff
3. Focussed abdominal ultrasound in trauma (FAST)
4. Portable X-ray facility
5. CT scan& MRI
6. Transport ventilator
7. Spine board
8. Scoop stretcher
9. Cervical immobilization devices
10. Difficult airway management equipment
11. Thoracotomy equipment
12. Portable echocardiogram
13. On site blood bank
14. Intravenous fluid warmed
15. Rapid i.v. infusion system
16. Central lines
17. Round the clock OT facility
18. Pericardiocentesis equipment
19. Trauma protocol to guide management
The principles followed in clinical diagnosis, investigations & treatment are same as above. However a more organized approach is used, which is described below.
1. TRIAGE : Triage is a process of determining the priority of patients’ treatment based on the severity of their condition and the resources available to provide that treatment. . In multiple casualty incidents, the number of patients and the severity of their injuries do not exceed the ability of the trauma care facility. The patients with life-threatening injuries are treated first. In mass casualty incidents, the number of patients and the severity of their injuries exceed the capacity of the trauma care facility. Here, the patients with the greatest chance of survival are treated first.
2. Primary Survey and Resuscitation: Primary survey involves rapid early assessment of the patient. The life threatening conditions are identified and treatment priorities are established based on their injuries, vital signs and injury mechanisms. During the primary survey, the following aspects are assessed and rapid corrective measures taken.
a) Airway maintenance with C-Spine Control
b) Breathing and Ventilation
c) Circulation and /hemorrhage Control
d) Disability/ Neurological Status
e) Exposure/ Environmental Control
Airway with C-spine control
The patency of the airway should be assessed with special attention to foreign body or maxillofacial fractures that may result in airway obstruction. Chin-lift or Jaw-thrust maneuver may be used to achieve airway patency simultaneously protecting the cervical spine. A definitive airway is warranted in a patient with an altered level of consciousness or a Glasgow Coma Score of 8 or less. It is critical to protect the spine. Spinal injury should be assumed in any patient of trauma unless specifically excluded.
Breathing and Ventilation
The patient’s chest should be exposed to adequately assess chest wall excursion. Auscultation to detect adequate air entry, percussion to exclude air or blood in chest and visual inspection and palpation to detect injuries to chest wall should be carried out. Specific life threatening problems such as tension pneumothorax, massive hemorrhage, flail chest and cardiac tamponade should be identified immediately and addressed during the primary survey.
Circulation with Hemorrhage Control
Hemorrhage is the primary cause of shock in trauma patients. Rapid and accurate assessment of the patient’s hemodynamic status and identification of the site of hemorrhage is therefore essential. It is critical to establish adequate intravenous access in a trauma patient. While the primary survey is going on, two intravenous lines should be established with short broad gauge cannula, preferably in the upper extremities, and resuscitation started with crystalloids.
Disability / Neurological Status
A rapid neurological evaluation is carried out at the end of primary survey after the resuscitation and before rapid sequence intubation. This assesses the patient’s level of consciousness, papillary size and reaction and focal neurological deficit. The level of consciousness may be described in terms of Glasgow Coma Scale (GCS)
Exposure / Environmental Control
The patient should be completely undressed to facilitate thorough examination and assessment. At the same time care should be taken to prevent hypothermia to the patient.
Adjuncts to Primary Survey and Resuscitation
a) ECG Monitoring: The appearance of dysrhythmias may indicate blunt cardiac injury. Pulseless electrical activity, the presence of cardiac rhythm without peripheral pulse may indicate cardiac tamponade, tension pneumothorax or profound hypovolemia.
b) Urinary Catheter: Urine Output is a sensitive indicator of the volume status of the patient and reflects renal perfusion. All trauma victims should be catheterized to enable monitoring of the urine output and plan intravenous fluid therapy. Transurethral catheterization is contraindicated in patients urethral transaction is suspected.
c) Gastric Catheter: A gastric tube is indicated to reduce stomach distension and decrease the risk of aspiration. It should be passed via the orogastric route in patients with head injury and suspected base skull fracture.
d) X-rays and Diagnostic Studies: The chest and pelvis x-ray help in the assessment of a trauma patient. Any trauma patient entering the red area of the emergency should undergo blood sampling. The blood should be sent for cross-match and arranging for packed cells, and important diagnostic parameters such as hemoglobin, renal parameters, ABG should be checked. Pulse oximetry is a valuable adjunct for monitoring oxygenation in injured patients.
e) FAST: Focused Assessment by Sonography in Trauma is a rapid non- invasive tool used to assess free fluid in the abdomen, blunt abdominal injury and cardiac tamponade.
f) CT scan & MRI: For brain, spinal cord trauma and in injury to internal organs.
Once the primary survey is accomplished, life- threatening conditions are managed and resuscitative efforts are underway, secondary survey is carried out. This is head to toe evaluation of trauma patient, which includes a complete history and physical examination and reassessment of all the vital signs. Each region of the body is completely examined. The care continues with regular re-evaluation of the patient for any deterioration and new findings, so that appropriate measures can be taken.
After the completion of the secondary survey, the patient should be reevaluated beginning with the ABCs and thorough physical examination and examined for any missed injury such as fractures. Constant monitoring of the severely injured patient is required and may necessitate rapid transfer to the surgical intensive care unit, operating room or to another centre having better specialized facilities. The transfer to another centre should not be delayed for the want of investigations.
|SITUATION||HUMAN RESOURCES FOR 4- 6 WEEKS||INVESTIGATIO N OF 4-6 WEEKS||DRUGS AND CONSUMABLES FOR 4-6 WEEKS||EQUIPMENT|
|1. At secondary hospital/ non-metro situation||One Each:|
1. Casualty Medical Officer (CMO)
2. X-ray Technician
One in each shift:
e. Blood grouping & cross matching
|a. Intravenous fluids Crustalloids Normal saline 50 , Ringer lactate 50|
b. Intravenous fluid Colloids Hemaccel, HES 5 bottles each
c. IV canula: 24,22,20,18,16 ,14 gauge ( 10 each)
d. IV drip sep- 25
e. Compression bags for fast fluid delivery (5)
f. Bandages (1-2 drums)
g. Dressing material (1-2 drums)
h. POP ( 100)
i. Blood set (10)
j. Leucoplast (5 rolls)
k. Dynaplast (5 rolls)
l. ICD tubes (10) different sizes
m. Underwater seal (5)
n. Nasopharyng eal & oropharyngea l airway (all sizes)
|a. X-ray machine (portable)|
b. Ultrasoun d machine
c. Orthopedi c splints
d. Spine board (1)
e. Scoop stretcher (1)
f. Ambu bag (2)
g. Bain circuit (2)
h. Oxygen cylinders (10)
i. Bllod staroage rfrigerato r 1
j. Dressing set (1)
k. Suturing set (1)
l. Cevical collar
m. Ambulanc e for transport
|2. At super specialty facility in metro location||As in situation 1|
a. Emergency Consultant-1
d. Nurses- 3 per shift in addition to Incharge
d. Ward boys 2
e. Housekeeping 2
f. Multiprofesio nal Trauma team as per the composition listed in the text.
|As in situation 1|
a. CT scan
d. Coagulatio n parameter s
e. Blood and other fluid cultures (Microbiol ogy)
|In addition to all items listed above:|
1. Arterial canulae (10)
2. Central venous lines (10)
3. Cardiac monitors
|As in situation 1 with|
1. Well equipped OT with C-arm
2. Airway & breathing equipmen t
3. Transport ventilator
4. ACLS ambulanc e with ventilator, monnitor, defibrillat or
- Patients should have basic control of airway, breathing and circulation, and surgery to stop bleeding if possible before contemplating transfer
- Need for specialized surgery: thoracic, cardiac surgery
- Need for advanced intensive care after initial stabilization
Guidelines by The Ministry of Health and Family Welfare :
Subhash Todi, Consultant Physician and Intensivist, AMRI Hospital, Kolkata