Initial management of trauma victims

Primary survey and resuscitation

The purpose of this step is to very quickly evaluate for any life-threatening emergency and deal with it right away. Often an obvious external trauma such as fracture femur diverts the attention of the caregivers but a life-threatening injury is missed. This should be performed in the following order: A, B and C - A stands for airway with cervical spine control, B stands for breathing and C for circulation with haemorrhage control. The order of examination is important. Each step is assessed and the system optimised as necessary before proceeding to the next step.

Step 1: 10 s survey - A very quick way of evaluating airway, breathing and circulation is to address the patient and talk to him (For e.g., Ask the patient's name). If he replies appropriately, it is evident that his airway is patent, he is breathing and circulation to his brain is reasonable. Assess response to call and if no response, give a painful stimulus. The response can be quickly graded as AVPU, where A = Alert, V = Responds to verbal commands, P = Responds to pain and U = Unresponsive.

Step 2: Check airway. All patients sustaining trauma must be assumed to have cervical spine injury until proved otherwise. The mechanism of injury would provide a clue to the possibility of cervical trauma. Any trauma patient who is unconscious must be presumed to have cervical spine injury until further evaluation excludes it. The neck must be immobilised in a rigid cervical collar as early as possible.

If the airway is not patent or the patient's ability to maintain his airway is questionable, the airway must be secured. Signs of compromised airway include snoring, stridor, agitation (hypoxia), active accessory muscles of ventilation/paradoxical chest movements and cyanosis.

Open the airway first with a jaw thrust, oral airway or a nasopharyngeal airway. An oral airway is preferred if the patient is unconscious and may have sustained a base of the skull fracture. A nasopharyngeal airway is chosen if the gag reflex is intact and the patient is semiconscious. Insertion of a nasopharyngeal airway in a patient with base of skull fracture carries the danger of passing it into the brain. Provide oxygen using face mask and ventilate as necessary.

Indications for endotracheal intubation or tracheostomy for securing the airway include obstructed airway, apnoea, hypoxia, severe head injury, maxillofacial injury, penetrating neck trauma with expanding haematoma and chest trauma.

Endotracheal intubation is the most definitive airway. It is required in patients who are unconscious, not able to maintain their own airway, who have sustained extensive faciomaxillary injuries or airway burns. A rapid sequence induction and intubation is preferred. The cervical collar limits not only neck movements but also limits mouth opening. This makes securing airway more difficult. So, when securing the airway, it is recommended that the cervical collar is removed and manual immobilisation of the neck given. The collar is reapplied after airway is secured (Figure 1).

The level of sedation required for intubation would depend on the level of consciousness and haemodynamic stability. Generally, midazolam or etomidate is used for induction or sedation and succinyl choline as the muscle relaxant for intubation.

If endotracheal intubation is difficult, airway can be maintained using airway adjuncts such as laryngeal mask airway, laryngeal tube. If these are inadequate, a cricothyrotomy may need to be performed. This should be followed by a regular tracheostomy. Cricothyrotomy image, image showing in figure is for thoracostomy and pericardiocentesis. Cricothyrotomy is advocated as the initial choice as it can be done very quickly. Time is of essence in a hypoxic emergency.

Step 3: Breathing - Look, listen and feel: Inspect (look) at the chest for the respiratory rate, depth and pattern. If the patient's breathing is inadequate as evidenced clinically (rate and depth) or if the patient is cyanosed/oxygen saturation is low (< 93%), breathing must be assisted and oxygen supplementation given as required. Look for presence of flail chest, open chest wounds and use of accessory muscles of respirations.

Palpate (feel) for tracheal shift, broken ribs and subcutaneous emphysema. Percuss for diagnosis of haemothorax and pneumothorax. Auscultate both sides of the chest for equality of breath sounds and for any added sounds. Rule out endobronchial intubation, if an endotracheal tube is already in place.

If breath sounds are unequal, inspect the neck for any distended veins, tracheal position and percuss the chest. If neck veins are distended, trachea is deviated and the chest is resonant to percuss on the side of reduced air entry, suspect tension pneumothorax. The patient may require needle thoracostomy (Figure 2). A large bore (16-18 G cannula) is inserted in the second intercostal space in the midclavicular line. If air hisses out, decompression of chest would have been achieved. Chest tube insertion can follow later during secondary survey.

Step 4: Check circulation. Feel the radial pulse for its rate, rhythm, quality (strong, feeble and thready) and equality with opposite side. Check blood pressure. The commonest cause of shock in trauma is hypovolaemia. Neurogenic shock is a possibility in cases of spinal injury. Obstructive shock can occur in tension pneumothorax and cardiac tamponade. Septic shock is unlikely but not impossible in trauma.

If feeble, irregular or hypotensive, rule out the possibility of a pericardial tamponade by looking at neck veins. If the neck veins are distended, radial pulse is not felt, heart sounds are faint and needle thoracostomy has not treated the condition, perform a pericardiocentesis (Figure 2). Ultrasound of the heart is very useful to confirm the diagnosis and guide the protcedure. If ultrasound is not available, it is reasonable to proceed with landmark-guided drainage of the pericardium.

Look very quickly for any obvious bleeding from any part of the body. If present, apply pressure and stop the bleeding. Application of a tourniquet is not advisable unless absolutely necessary. If applied, it should be removed as early as possible to avoid injury to tissues.

Check the abdomen and pelvis. Abdominal trauma can be penetrating or nonpenetrating. Inspect and then palpate the abdomen for any distension, abrasion or contusion. Spring the pelvis to rule out pelvic instability due to fracture. Perform a focused abdominal sonography in trauma (FAST) to rule out liver and splenic injuries. If any abdominal injury with haemorrhage is suspected, the patient will need an urgent life-saving laparotomy.

‘Damage control laparotomy’ should be done as soon as possible in patients with evidence of abdominal trauma and maintaining a systolic BP at 80–90 mm Hg with fluid resuscitation is unsuccessful. The aim of this laparotomy is to stop the bleeding, often only packing, after which the mid-line incision is temporarily closed within 30 minutes with towel clamps. This laparotomy is described as not a surgery, but a resuscitative procedure.

An intravenous line should be securedand intravenous fluids, preferably at 40-42°C (crystalloids – saline, ringer lactate or plasmalyte) infused very quickly to restore volume. Dextrose containing solutions are not recommended. One or two large peripheral lines are preferred for the initial resuscitation. Insertion of central lines is not recommended (unless done by skilled personnel) as it takes much longer to insert, requires expertise and can be associated with complications. If a peripheral intravenous access is not available, intraosseous needle can be inserted and fluids infused into the bone marrow. All infusions that can be given intravenously can also be given intraosseously. External jugular venous access is another option for quick transfusion of large amounts of fluids and blood products.

The American College of Surgeons Classification of haemorrhagic shock (Table 1) can be used as a quick guide to gauge the amount of blood lost. If the patient is tachycardic (heart rate > 120/min) and hypotensive (systolic blood pressure is < 90 mmHg), the patient has Class III shock or higher where the patient has lost > 30-40% blood volume. Such patients will also require transfusion of blood products (packed cells and fresh frozen plasma). It may be necessary to activate massive transfusion protocol (when available at the hospital – Table 2) if the patient is bleeding profusely. Replacing the lost volume along with haemorrhage control is important to restore perfusion and prevent tissue damage.

In cases where the haemostasis is insecure or not definitive, volumes should be controlled to maintain systolic BP at 80–90 mm Hg till the bleeding can be stopped. This is called ‘hypotensive fluid resuscitation’ or ‘permissive hypotension’. All through the resuscitation, it is important to maintain the patient warm. Hypothermia impairs coagulation, increases bleeding, depresses respiration and circulation as well as increases chances of infection.

The pelvis should be examined by springing the pelvis. This should be done only once and if any instability is noted, the pelvis should be immobilised by application of pelvic binder and later on with an external fixator to stop bleeding.