Trauma care

ehospital trauma care

• Prehospital care of trauma patients is situation-dependent and centered on stabilization of the patient and prompt transport to a hospital.
• Nonmedical personnel trained in basic life support may provide life-saving interventions (see “Basic life support” in the learning card cardiopulmonary resuscitation).
• Emergency services personnel typically perform an abbreviated version of the primary survey (see ABCDE approach below)
• Low-threshold interventions that may be performed by emergency personnel prior to transport to a hospital include, but are not limited to:
  • Placement of a cervical collar (if cervical spinetrauma is suspected based on primary surveyor mechanism of injury)
  • Intubation or oxygen delivery via nasal cannula (if respiratory distress or altered mental status is suspected)
  • Administration of intravenous fluid (if hemorrhage or hypotension is suspected)
  • Administration of analgesia
  • Placement of tourniquets or pressure bandages for control of bleeding

References:[1]

Primary survey (Advanced Trauma Life Support)

The management of trauma patients begins with the primary survey (also commonly referred to as Advanced Trauma Life Support, or ATLS). The primary survey consists of 5 steps (ABCDE approach) that are performed in order.

1. Airway assessment (and cervical spinestabilization)
   • If appropriately answering questions, patient has a patent airway (at least for the moment)
   • Observe patient for signs of respiratory distress 
   • Inspect mouth and larynx for injury or obstruction 
   • Assume cervical spine injury in blunt traumapatients until proven otherwise 
   • If patient is unconscious (and therefore unable to protect their airway) or in respiratory distress, the threshold for intubation is very low.
     • Patients may be intubated or ventilated with the anterior portion of the cervical collar removed, or with their neck manually stabilized.
   • Patients with burn injuries and evidence of respiratory involvement  are often intubated out of precaution.
   • If orotracheal intubation is difficult, perform a cricothyrotomy. 
2. Breathing
   • Assess oxygenation status with pulse oximetry.
   • Inspect and auscultate chest wall for injuries. 
   • In unstable patients, do not delay treatment of tension pneumothorax or hemothorax in favor of imaging.
3. Circulation (and hemorrhage control)
   • Assess circulatory status by palpation of central  and peripheral  pulses
     • Blood pressure should be measured if it can be done expediently, but it can be skipped if it would delay the rest of the primary survey.
   • Place two large-bore intravenous lines (at least 16 gauge) for blood typing and crossmatch, and resuscitation (if needed).
     • If intravenous line placement is not possible or difficult, intraosseus line should be used instead.
   • Control on-going hemorrhage with manual pressure or tourniquets.
   • Emergency thoracotomy may be performed in patients with recent loss of pulses (especially in patients with stab wounds to the chest).
   • If patient is hypotensive, administer a bolus of intravenous saline.
     • If history of hemorrhage or on-goinghemorrhage, transfuse type O blood.
     • If significant hemorrhage and persistent hemodynamic instability, transfuse plasma, platelets and red blood cells at 1:1:1 ratio. 
   • Focused Assessment with Sonography for Trauma (FAST) exam is usually performed, especially for hemodynamically unstable patients
     • May be performed during the secondary survey in hemodynamically stable patients
   • Some patients may require emergent reversal of anticoagulation
   • Remember hypovolemic shock due to hemorrhage requires loss of ∼ 1.5 L of blood. Keep in mind the compartments where large amounts of blood may go:
     • Outside (external hemorrhage)
     • Thoracic cavity
     • Pelvic cavity
     • Abdominal cavity
     • Thighs (e.g., multiple femur fractures)
     • See Shock LC
4. Disability (and neurological evaluation)
   • Assess patient's Glasgow Coma Scale score
     • See Glasgow Coma Scale (GCS)
     • A GCS score < 8 is an indication for intubation
   • Assess pupillary size
   • If patient is interactive, assess motor function and light touch sensation.
5. Exposure (and environmental control)
   • Undress patient completely.
   • Examine body for signs of occult injury, including patient's back.
   • If patient is hypothermic, cover with warm blankets and warm intravenous fluids.
   • Palpate for vertebral tenderness and rectal tone.