Surgical emergencies: multiply injured patients

Ashok Handa, Kevin Turner, and Adam Jones explain the principles of advanced trauma care

A call to casualty to attend to a multiply injured patient causes anxiety in most doctors and sets their pulse racing. Fortunately, most hospitals now have a trauma team, and as a house officer in surgery you will be called to help your registrar or senior house officer rather than to deal with patients on your own. In general, most accident and emergency departments will have some warning from the ambulance service and will call you to the resuscitation room to prepare for the arrival of the patient(s).

Multiple trauma, mostly from road traffic accidents, is the leading cause of death among people aged up to 40 years. It is the third highest cause of death in all age groups. In the United Kingdom this is equivalent to 14 airline crashes per year and costs around £600000 per patient. In 1988, the Royal College of Surgeons of England adopted the course in advanced trauma life support (ATLS) from the American College of Surgeons¹ after the report by its working party showed a cause for concern in the management of multiply injured patients in Britain. Now ATLS training forms the basis for the management of multiply injured patients in most hospitals.

In order to perform their role effectively, new house officers should understand the process of ATLS and the principles of care. There is little time for teaching during the management of a multiply injured patient. The purpose of this article is to outline management principles, so that you can understand what is going on. Detailed aspects of management can be learned later.

Paramedics loading an injured man into an ambulance with a splint and neck brace (MAURO FERMARIELLO/SPL)

The chain of care

The outcome in a multiply injured patient depends on a number of people and agencies working together towards the same goals. The first link is the prehospital care provided by the paramedical service and the information the team provides to the trauma team on the mechanism of injury, initial condition, and subsequent changes in the patient. The second link is the reception, resuscitation, and initial assessment in casualty. The third link is the emergency investigation, surgery, and intensive care. The final link is the definitive care in the initial hospital or after transfer for specialist care.

There is a tri-modal distribution of death.

• Death within minutes - usually lethal injuries resulting in death at the scene of the accident
• Death in the first hour - life threatening injuries requiring urgent attention
• Death in days/weeks - resulting from the complications of initial injuries sustained

Emergency management is aimed at reducing death from life threatening injuries.

Trauma teams - who should be present?

The ideal trauma team consists of a minimum of four doctors and two nurses. The members should include the following.

• Surgical registrar/senior house officer/house officer
• Orthopaedic registrar/senior house officer
• Anaesthetist
• Accident and emergency registrar/senior house officer
• Two accident and emergency nurses

A team leader should be chosen in the preparation phase, although most hospitals have a protocol of one of the registrars being the team leader. Other members of the team with vital roles are the following.

• Radiographer
• Laboratory staff
• Porters
• Specialist surgeons
• Paramedics/ambulance crew

Initial assessment

Although the assessment is outlined as a longitudinal progression, many of these activities occur simultaneously. The initial assessment consists of the following.

• Primary survey
• Resuscitation
• Detailed secondary survey
• Initiation of definitive care

The primary survey and resuscitation run concurrently with intervention for problems as they are encountered. With the full team present, several problems can be addressed at once.

Primary survey

This is a logical sequential assessment of the patient's vital functions with identification and treatment of life threatening conditions. This constitutes the ABC of trauma care.

• A: Airway maintenance with cervical spine control
• B: Breathing and ventilation
• C: Circulation
• D: Disability (neurological status)
• E: Exposure

A: Airway maintenance with cervical spine control
This will normally be undertaken by the anaesthetist. The principles are to establish an airway while maintaining control of the cervical spine. Patients should be laid flat and neck extension avoided. Stabilise the neck by fitting a rigid collar and tape the forehead to the sides of the trolley.

Remember: all multiple injuries have a cervical spine injury until proved otherwise.

B: Breathing and ventilation
A patent airway does not ensure adequate ventilation. The patient's chest should be exposed to assess breathing movements. Briefly examine the chest, looking for any injuries to the chest wall that may compromise ventilation. Check for good bilateral air entry. Some injuries should be identified and treated immediately before moving on. These are tension pneumothorax, massive haemo- thorax, flail chest, and open chest wounds. A useful mnemonic for airway/chest injuries is ATLS-FC (Box 1). Give 100% oxygen through a mask or intubate if necessary.

C: Circulation with haemorrhage control
Assess blood volume and cardiac output from clinical examination. Cerebral circulation may be impaired resulting in altered level of consciousness. In a multiply injured patient blood loss is the commonest cause of diminished conscious level. The skin colour is a good indicator of circulating volume, and pale, ashen skin indicates at least a 30% loss in blood volume. The pulse (carotid or femoral) is a good indicator of blood loss, and rapid, thready pulses are early signs of hypovolaemia. External, severe haemorrhage should be identified and controlled by direct manual pressure on the wound.

Pulse, blood pressure, and respiratory rate can give you some idea of the amount of blood loss. Remembering how a game of tennis is scored can help (Table)!!

How much blood has my patient lost? It's a game of tennis
	0-15%	15-30%	30-40%	>40% (game over)
Pulse	<100	>100	>120	>140
Blood pressure	Normal	Normal	Decreased	Decreased
Respiratory rate	14-20	20-30	30-40	>35
Note that you may see a drop in blood pressure only after significant blood loss. Young patients maintain their blood pressure better than old people. Don't be reassured by a normal pressure in a young patient--they may have lost a lot of blood.

D: Disability (neurological status)
A rapid assessment of the neurological state can be made by seeing if the patient is speaking to you, by looking at the pupils and assessing the level of consciousness. A simple mnemonic is AVPU (Box 2).

The Glasgow coma score (GCS) is more comprehensive but is often left until the secondary survey. The GCS was described in detail in last month's article on head injury.

E: Exposure
FULLY undress the patient to allow a thorough examination, but keep him or her warm by then covering with blankets.

Resuscitation

Your patient should be resuscitated while the primary survey is being conducted. The aim of resuscitation is to achieve good tissue perfusion. This includes establishing that the airway, ventilation, oxygenation, and circulation are all adequate. You need to be vigorous with shock treatment and to manage any life threatening injuries as they are discovered. The following is the minimum management in most cases.

• Oxygenate with 100% oxygen
• Insert two cannulas (14 gauge) in the antecubital fossae, crossmatch blood
• Infuse 2 litres of Hartmann's solution rapidly
• Send blood samples for full blood count, urea and electrolytes, glucose
• Record vital signs (temperature, pulse, respiration, and blood pressure)
• Pulse oximetry
• Electrocardiogram monitor
• Urinary catheter--unless contraindicated
• Nasogastric tube--unless contraindicated
• Arrange x ray films: lateral cervical spine, chest, anterior-posterior pelvis

Secondary survey

This is a detailed head to toe examination of the patient undertaken after the patient has been resuscitated and stabilised. It may be interspersed with x rays and other procedures such as catheterisation. It should be undertaken by an experienced doctor and needs attention to detail. The secondary survey has been summarised as "tubes and fingers in every orifice." Remember this may be the only FULL examination the patient gets throughout his or her inpatient stay and thus should be very detailed. It is not unheard of for a patient not to thank you for saving his or her life but to sue you for missing a mallet finger deformity.

A full history should also be obtained from the patient if possible or from the ambulance crew or relatives. The mnemonic AMPLE is a good way to remember what you should ask about (Box 3).

Definitive care phase

During this phase the comprehensive care of the patient is planned and includes fracture stabilisation, operative intervention, and the transfer of the patient to a referral centre for specialist attention if required. The patient should only be transferred if stable and with appropriate medical escort, usually an anaesthetist.

Documentation

The team leader must ensure that this is clear and concise. Documentation should be detailed, chronological, and must include time of arrival and names of those present. Medical record keeping is an essential part of good medical practice.

Re-evaluate

Vital signs can change rapidly. Throughout the assessment of a trauma patient remember to re-evaluate your findings. You may discover something that you had initially missed. Impaired consciousness is the most common cause of a diagnosis being missed.

Conclusion

Managing multiply injured patients can be a scary experience. The advent of trauma teams and use of the ATLS process provides a framework and results in effective, rapid management of these patients (Box 4). As part of a trauma team you will quickly learn to assess and resuscitate trauma patients and have an impact on their outcome.

Ashok Handa, clinical lecturer, Nuffield Department of Surgery, John Radcliffe Hospital, Oxford

Kevin Turner, research fellow in urology, Molecular Oncology Group, Institute of Molecular Medicine, John Radcliffe Hospital, Oxford

Adam Jones, specialist registrar in urology, Churchill Hospital, Oxford


studentBMJ 2000;08:175-216 June ISSN 0966-6494

1. American College of Surgeons. Advanced trauma life support course manual. Chicago: American College of Surgeons, 1997.
2. Skinner D, ed. ABC of major trauma. London: BMJ Books, 2000.
3. Royal College of Surgeons of England. Report of the working party on the management of patients with major injury. London: Royal College of Surgeons of England, 1988.

   

           

Self test questions - Answers

1. The ABC of trauma:
   A: Airway and spine control
   B: Breathing and ventilation
   C: Circulation
   D: Disability (neurological status)
   E: Exposure
2. At least 30%. Hypotension is a relatively late sign of shock from blood loss and needs aggressive treatment.
3. Tension pneumothorax, massive haemothorax, open pneumothorax, flail segment, and cardiac tamponade.
4. Airway and cervical spine control.
5. A secondary survey is essential for all patients after the patient has been resuscitated and stabilised. It entails a detailed head to toe examination to identify all injuries and may be the only FULL examination the patient has hroughout his or her inpatient stay.