Mini-symposium: Basic science of trauma(i) Initial resuscitation of the trauma victim
Introduction
Resuscitation of the trauma victim has evolved as new knowledge has become available over the years. Many of these advances in trauma management occur during times of war and the recent conflicts in Iraq and Afghanistan have resulted in significant changes in the treatment of trauma away from the war zone. There is increased focus on the physiology of the trauma patient, attempting to identify problems at the earliest stage in order to prevent the development of derangement rather than reacting to its emergence. This has included changes in the timing and type of surgery in an attempt to limit additional physiological insults that can be attributed to the surgery.
This review focuses on the management of the severely injured trauma victim, looking at the changes that have occurred in pre-hospital management, the major changes in haemorrhage control techniques, the concept of damage control resuscitation and the timing of surgery for the trauma victim.
Section snippets
Pre-hospital care of the trauma victim
The management of the trauma victim at the scene has a major impact on the overall care of the patient. The focus of pre-hospital care of the trauma patient should be on a rapid primary assessment whilst maintaining a patent airway, immediate control of massive external haemorrhage, immobilization of the patient and rapid transfer to an appropriate trauma centre. All the above measures should be performed in such a way as to reduce the overall time spent at the scene of the injury so that the
Tourniquets
Tourniquets are regularly used during transport from the scene of injury to the care facility in the military setting. In situations where haemorrhage control cannot be obtained with direct pressure, the application of a proximal tourniquet can be an effective method of haemorrhage control. The aim of tourniquet use in the pre-hospital setting is to control haemorrhage until the bleeding can be controlled in hospital, usually by surgical intervention. In the military setting, tourniquets are
Initial assessment of the patient
On arrival in the emergency department, patients are assessed and treated based upon their priorities using the ATLS protocol.2 This involves a rapid primary survey with simultaneous resuscitation, followed by a more detailed secondary survey to identify all injuries and plan for definitive treatment. In certain situations the whole assessment may occur in the emergency department. In others, haemorrhage control may require emergency surgery, and transfer to the operating theatre will be part
Haemorrhage control
In trauma victims there are two key goals for haemorrhage control: identify the source(s) of bleeding and then stop it (them). Recently, there have been developments in both areas that have improved the management of trauma victims.
Damage control resuscitation
Damage control resuscitation is a concept that has been developed during times of war in order to address the challenges of military trauma. The main thrust of damage control resuscitation involves two strategies; permissive hypotension and haemostatic resuscitation, and is subsequently followed by damage control surgery. The aim of damage control resuscitation is to correct the three components of the “lethal triad” that occur in trauma victims.11 The concept of damage control resuscitation is
Massive transfusion protocols
The concept of massive transfusion protocols links into damage control resuscitation. The practice has been developed over recent years and has gained popularity. A survey conducted in 25 countries found that 45% used a massive transfusion protocol, 34% did not use a massive transfusion protocol and 19% reported inconsistent use of a protocol.19 The concept behind massive transfusion protocols is simple: lost whole blood should be replaced with whole blood. Red blood cells, plasma and platelets
Young versus old red blood cells
The age and length of storage of red blood cells have been shown to affect the outcome of trauma patients. A review by Vandromme et al22 discusses the mechanisms by which red blood cells are altered by storage. After storage of whole blood for 14 days, there is an accumulation of glycolytic metabolism byproducts, which results in functional and structural changes to red blood cells such that they are less pliable and therefore less able to reach end-organ capillary beds, leading to decreased
Timing of surgery
The timing of surgery in patients who have sustained multiple injuries has changed in practice over the years. Prior to the 1950s stabilization of long-bone fractures was not performed because it was considered that the patient was unable to tolerate the physiological insult of a long surgical procedure.29 The patient was considered “too sick for surgery”. The disadvantages of delayed fixation of fractures are numerous. It results in prolonged bed rest with increased risk of decubitus ulcers,
Damage control orthopaedics
Damage control orthopaedics evolved from damage control surgery to improve the care of the severely injured, unstable trauma victim. It involves initial temporary stabilization of fractures with control of haemorrhage and decompressive surgery if required, followed by transfer to the intensive care setting for continued resuscitation. Once physiologically normal, the patient would then be taken to theatre for definitive stabilization of their injuries.29 The premise of damage control
Staging patients in polytrauma
When managing trauma patients, it is often a complex decision as to whether to manage the patient by early total care or proceed with damage control surgery. A review by Pape et al30 categorized polytrauma patients into four groups; stable, borderline, unstable and in extremis. These categories were delineated by the use of four main parameters (shock, coagulation, temperature and soft tissue injuries) and the degree of physiological abnormality and injury within these criteria and are shown in
Summary
The management of the trauma victim has evolved, and continues to evolve with time. Recent changes take effect in the pre-hospital setting, emergency department and operating theatre. Important changes within the pre-hospital setting include the use of hypotensive resuscitation, using the radial pulse as a guide, the use of pelvic binders, tourniquets and the development of trauma centres. In the emergency department itself, the development of damage control resuscitation with increasing
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Cited by (4)
Efficacy of prehospital application of tourniquets and hemostatic dressings to control traumatic external hemorrhage
2014, Prehospital Control of Traumatic External Hemorrhage: Literature Review and Evidence Analysis of Tourniquets and Hemostatic DressingsPrinciples of Trauma Care
2014, Orthopaedic and Trauma Nursing: An Evidence-based Approach to Musculoskeletal CareIsolated abdominal trauma: Diagnosis and clinical management considerations
2014, Current Opinion in Critical Care