Management of major trauma





Abstract


Trauma is one of the leading cause of deaths in those <35 years old in the UK. It also has a significant morbidity burden with a subsequent economic impact. There is also a realisation that trauma is having an increasing impact in the elderly population. In the last two decades there have been changes in both the structure of trauma care across the UK, and also in clinical aspects from pre-hospital care to rehabilitation. This article will review the changes that have occurred, including the reasons, and give a broad overview of the immediate management of the critically ill trauma patient.




Learning objectives


After reading this article, you should be able to:




  • discuss key organisational changes that have taken place in trauma care in the UK



  • know the key priorities in the care of the major trauma patient



  • recognise the increasing impact of elderly trauma




Major trauma care has been transformed over the course of the past decades in the UK. This has been as a result of national reports that have examined the variation in care that has been delivered, together with clinical research and enhanced care that have been developed both in civilian and military medical practice. These changes have shown improvements in mortality.


Major trauma reports


Two national reports, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘ Trauma: Who Cares ?’, and the National Audit Office report ‘ Major trauma care in England’ highlighted that significant numbers of major trauma patients did not receive good practice care. They highlighted significant variations in care, and also that there had been a failure to act on previous shortcomings in trauma care. The recommendations resulted in the development of trauma networks, firstly in London in 2010 and then across the rest of England in 2012. Networks are now being established across the rest of the UK (Scotland, Wales and Northern Ireland).


In February 2016 the National Institute for Health and Care Excellence (NICE) published guidelines for the management of major trauma. These cover both recommendations for clinical management and for the organisations involved in running trauma services.


Organisation of major trauma services


National and regional trauma networks


The implementation of regional trauma networks, with a major trauma centre (MTC) at the hub, has been the mainstay of the changes. The MTCs are large specialist hospitals with appropriate services, and the intentions were that these were within 45 minute ambulance transfer of the majority of the population. One of the key concepts was bypassing smaller hospitals en route, so that severely injured patients were delivered to the MTC directly. The MTCs would be supported within the network by a number of trauma units (TUs) which would be able to perform lifesaving interventions, stabilisation, with rapid transfer for definitive care at the MTC, as well as deal with less severely injured patients. The growth in physician led pre-hospital services has also increased the number of interventions that are carried out in a pre-hospital environment. Within the UK there are various different MTC setups with regional variation for adults and children.


Within a major trauma centre


Hospitals receiving major trauma patients should have a consultant led trauma team available 24 hours a day. Consultant led teams make better initial management decisions compared to those led by more junior medical staff. Team roles should be allocated and rehearsed so that the trauma team leader (TTL) can remain ‘hands-off’, however maintaining overall control of the situation. Team members should feed information and receive decisions through the TTL. Contemporaneous recording of clinical signs and interventions given should be recorded by a dedicated scribe.


Whole body CT scanning is recommended for adult major trauma patients. The decision for CT scanning in unstable patients is difficult one and immediate haemorrhage control surgery may be required prior to CT scan. In children the decision to use CT scanning versus non-ionising radiation imaging will depend on physiological stability and local access to other imaging modalities.


Clinical aspects of initial management


Catastrophic haemorrhage


Massive catastrophic haemorrhage may result in death from exsanguination before the loss of airway results in death from hypoxia. In the military environment, over the last 20 years there has been a focus on tourniquets to arrest haemorrhage from extremity haemorrhage. This is less common in a civilian setting. In junctional areas, such as the groin and axillae, haemostatic dressings such as QuikClot Combat Gauze™ may be useful.


Airway and breathing


The traumatic airway is a difficult airway. The NECPOD report found that one in eight patients arrive at hospital with either a completely or partially obstructed airway and in 7% of the cases airway management was felt to be unsatisfactory. Therefore, it is advised that an experienced anaesthetist attends the trauma call.


If the airway has not been secured pre-hospital, then it is vital to assess this immediately. The NICE guidelines state a rapid sequence induction (RSI) should be performed as soon as possible. If this is not possible in the pre-hospital phase, the patient should be transferred to a major trauma centre if the journey time is an hour or less. Diversion to a trauma unit for RSI should only occur if a patients airway cannot be maintained or the transfer time is more than an hour to a major trauma centre. If there is no definitive airway or the RSI has failed, a supraglottic device should be used until a surgical airway or assisted tracheal placement can be performed. The use of a surgical airway needs to be considered if an airway cannot be maintained.


If C-spine immobilization is in process, then protection of the cervical spine should be continued with manual in line stabilization (MILS) during intubation. The collar must be undone during intubation. Induction of anaesthesia in the trauma patient is challenging and so the choice of drug remains with the anaesthetist. Consideration should be made for reduced doses of induction agents in hypovolaemic patients. An RSI checklist should be used prior to intubation, allowing definition of roles within the team, equipment checks and foreplaning of the ‘can’t intubate, can’t ventilate’ scenario. Once the airway is secure, mechanical ventilation should be commenced to free up team members and allow control of minute ventilation.


In patients with severe head and facial injuries, the tube should be left uncut to allow for facial swelling. The tube should be secured, either by ties or with tape, in those that are at risk of raised intra-cranial pressure.


Life-threatening injuries to the chest are tension/open pneumothorax and massive haemothorax. Immediate decompression of a tension pneumothorax should be performed prior to imaging if there is either haemodynamic instability or severe respiratory compromise. Chest decompression via open finger thoracostomy in the 5th intercostal space mid auxiliary space followed by an intercoastal chest drain insertion should be performed. ATLS recommend that a large bore tube (>28–30 Fr) should be inserted to allow drainage of haemothoraces. Chest drain insertion can cause complications and the complication rate can vary from 6% to 37%. Lethal complications may occur. Tube malposition is the most common complication and is more common in placement under suboptimal conditions. The use of the trocar also increases this risk compared to blunt dissection. Trocar use should be avoided in adult patients. Occult pneumothoraces (only detected on CT scanning) may be treated conservatively, even in ventilated patients if they are stable. Massive haemothoraces (>1500 ml blood immediately drained) may necessitate a resuscitative thoracotomy to control bleeding.


Ventilation of the major trauma patient can be complex. Initially mandatory ventilation is required but once stability is achieved it is necessary to individualize respiratory support. No specific optimal ventilatory mode has shown benefit apart from lung-protective ventilation. Ventilator-associated lung injury (VALI) can potentially induce acute lung injury (ALI) especially in the context of trauma where direct pulmonary/chest wall injury, massive transfusion, aspiration and haemorrhagic shock can occur. First aim is to achieve adequate oxygenation. Lung protection ventilation is necessary and a combination of reduced tidal volume (6 ml/kg), a level of FiO 2 as low as tolerated, and a plateau pressure limit below 30 cmH 2 O has been shown to improve outcome.


Circulation


<C>ABC is the approach used to assess major trauma patients with <C> being catastrophic haemorrhage. Massive haemorrhage from trauma is associated with poor tissue perfusion, multi-organ dysfunction and death. Exsanguination occurs rapidly with a median time of death of 2–3 hours after initial presentation and is an important cause of reversible trauma mortality.


There has been a paradigm shift in the last 20 years with the implementation of damage control resuscitation (DCR). Minimal crystalloid use (<1 L), permissive hypotension, balanced transfusion ratios and prevention of the lethal triad (hypothermia, coagulopathy, metabolic acidosis) ( Figure 1 ) are all major principles of DCR. Previous conventional use of crystalloid (1–2 L) with later transfusion of blood products often leads to adverse events such ARDS, MOF and dilutional coagulopathy. It is now recommended for simultaneous transfusion of FFP and PLTs with the first unit of RBC while minimizing crystalloid use. This resuscitation method reduces coagulopathies and reduces the complications associated with large volume crystalloid use. It is important to transfuse in a balanced method with early administration of PRC:FFP:Plts in a ratio of 1:1:1. Fibrinogen should be measured, and cryoprecipitate or fibrinogen concentrate used to correct a low value. Initially a fixed ratio resuscitation will be used but this should then be complemented by patient specific components, based on laboratory and near patient tests.


Aug 20, 2020 | Posted by in ANESTHESIA | Comments Off on Management of major trauma

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