Trauma:

·       Is defined as a tissue injury that occurs more or less suddenly due to violence or accident and is accountable for initiating

·       Can be

-hypothalami –pituitary –adrenal axis

-immunologic and

-metabolic responses that are responsible for restoring homeostasis.

-Penetrating trauma

-Blunt trauma

-Deceleration trauma

Organized approach to be used in clinical diagnosis, investigations & treatment as described below:

1.      Triage:

·       Triage is a process of determining the priority of patients’ treatment based on the severity of their condition and the resources available to provide that treatment.

·       In multiple casualty incidents, the number of patients and the severity of their injuries do not exceed the ability of the trauma care facility. The patients with life-threatening injuries are treated first.

·       In mass casualty incidents, the number of patients and the severity of their injuries exceed the capacity of the trauma care facility. Here, the patients with the greatest chance of survival are treated first.

2.      Primary Survey and Resuscitation:

Primary survey involves rapid early assessment of the patient. The life- threatening conditions are identified and treatment priorities are established based on their injuries, vital signs and injury mechanisms. During the primary survey, the following aspects are assessed and rapid corrective measures taken.

a)    Airway maintenance with C-Spine Control

b)    Breathing and Ventilation

c)     Circulation and /haemorrhage Control

d)    Disability/ Neurological Status

e)    Exposure/ Environmental Control

3.      Airway with C-spine control-

·       The patency of the airway should be assessed with special attention to foreign body or maxillo- facial fractures that may result in airway obstruction.

·       Chin-lift or Jaw-thrust manoeuvre may be used to achieve airway patency simultaneously protecting the cervical spine.

·       A definitive airway (endotracheal intubation) is warranted in a patient with an altered level of consciousness or a Glasgow Coma Score of 8 or less.

·       It is critical to protect the spine. Spinal injury should be assumed in any patient of trauma unless specifically excluded.

4.      Breathing and Ventilation-

·       The patient’s chest should be exposed to adequately assess chest wall excursion.

·       Auscultation to detect adequate air entry, percussion to exclude air or blood in chest and visual inspection and palpation to detect injuries to chest wall should be carried out.

·       Specific life-threatening problems such as tension pneumothorax, massive haemorrhage, flail chest and cardiac tamponade should be identified immediately and addressed during the primary survey.

5.      Circulation with Haemorrhage Control-

·       Haemorrhage is the primary cause of shock in trauma patients. Rapid and accurate assessment of the patient’s hemodynamic status and identification of the site of haemorrhage is therefore essential.

·       It is critical to establish adequate intravenous access in a trauma patient. While the primary survey is going on, two intravenous lines should be established with short broad gauge cannula, preferably in the upper extremities, and resuscitation started with crystalloids.

·       Central venous catheter insertion in case of haemodynamic instability requiring vasopressor support, inadequate peripheral IV access, and if there is need for hyperosmolar agent (mannitol)

6.      Disability / Neurological Status-

·       A rapid neurological evaluation is carried out at the end of primary survey after the resuscitation and before rapid sequence intubation.

·       This assesses the patient’s level of consciousness, papillary size and reaction and focal neurological deficit.

·       The level of consciousness may be described in terms of Glasgow Coma Scale (GCS)

·       GCS of 8 or less indicates a need for endotracheal intubation

7.      Exposure / Environmental Control-

·       The patient should be completely undressed to facilitate thorough examination and assessment

·       At the same time care should be taken to prevent hypothermia to the patient

Adjuncts to Primary Survey and Resuscitation: -

a)     ECG Monitoring:

 ·       The appearance of dysrhythmias may indicate blunt cardiac injury.

·       Pulseless electrical activity, the presence of cardiac rhythm without peripheral pulse may indicate cardiac tamponade, tension pneumothorax or profound hypovolemia.

b)    Urinary Catheter:

·       Urine Output is a sensitive indicator of the volume status of the patient and reflects renal perfusion.

·       All trauma victims should be catheterized to enable monitoring of the urine output and plan intravenous fluid therapy.

·       Transurethral catheterization is contraindicated in patients urethral transaction is suspected.

c)    Gastric Catheter:

·       A gastric tube is indicated to reduce stomach distension and decrease the risk of aspiration.

·       It should be passed via the orogastric route in patients with head injury and suspected base skull fracture.

d)    X-rays and Diagnostic Studies:

·       The chest and pelvis x-ray help in the assessment of a trauma patient.

·       Any trauma patient entering the red area of the emergency should undergo blood sampling. The blood should be sent for cross-match and arranging for packed cells, and important diagnostic parameters such as haemoglobin, renal parameters, ABG should be checked.

·       Pulse oximetry is a valuable adjunct for monitoring oxygenation in injured patients.

e)    FAST:

·       Focused Assessment by ultra-sonography in Trauma is a rapid non- invasive tool used to assess free fluid in the abdomen, blunt abdominal injury and cardiac tamponade.

f)     CT scan & MRI:

·       For brain, spinal cord trauma and in injury to internal organs.

Secondary Survey: -

·       Once the primary survey is accomplished, life- threatening conditions are managed and resuscitative efforts are underway, secondary survey is carried out.

·       This is head to toe evaluation of trauma patient, which includes a complete history and physical examination and reassessment of all the vital signs.

·       Each region of the body is completely examined. The care continues with regular re-evaluation of the patient for any deterioration and new findings, so that appropriate measures can be taken.

Re-evaluation: -

·       After the completion of the secondary survey, the patient should be re-evaluated beginning with the ABCs and thorough physical examination and examined for any missed injury such as fractures.

·       Constant monitoring of the severely injured patient is required and

·     May necessitate rapid transfer to the surgical intensive care unit, operating room or to another centre having better specialized facilities. The transfer to another centre should not be delayed for want of investigations.

Referral Criteria: -

·       Patients should have basic control of airway, breathing and circulation, and bleeding to be stopped before contemplating transfer

·       Referral if there is need for specialized surgery

·       Referral if there is need for advanced intensive care after initial stabilization