Cardiac arrest associated with trauma: Survival rates of 0-3.7% are reported for victims of traumatic cardiac arrest. Consider if there are reversible causes of cardiac arrest and treat which include hypoxia, hypovolemia, diminished cardiac output secondary to pneumothorax or pericardial tamponade and hypothermia

BLS modifications- A jaw thrust should be used instead of a head tilt-chin lift to patient airway. Stop any visible hemorrhage using direct compression and appropriate dressings.

If the patient is completely unresponsive despite rescue breathing, provide standard CPR and defibrillation as indicated

Management: Pre hospital care

1.     Airway management

2.     Chest trauma- clinically assess for presence of pneumothorax for the purpose of triage or intervention.

3.     Hemorrhage - Use simple dressings with direct pressure to control external hemorrhage. In patients with major limb trauma use a torniquet or bandage roll, rubber tubing, crepe bandage, if direct pressure has failed to control life-threatening hemorrhage. Inj. Tranexamic 1g IV over 10 min followed by 1 g IV over 8 hours as soon as possible with major trauma and active or suspected active bleeding

4.     Analgesic for pain

5.     Spine trauma-Carry out full in-line spinal immobilization by placing two blocks on either side of the head. IV fluid bottles can also be used to prevent movement

6.    Fractures- Do not irrigate open fracture of the long bones, hindfoot or midfoot. Use saline soaked dressing covered with an occlusive layer.

HOSPITAL CARE: -

Airway management- Quickly assess by clinical examination of the thorax and respiratory function and observe for following: on inspection, palpation and percussion of the thorax together with pulse oximetry and in ventilated patients. Airway assessment reveals one of three clinical scenarios:

a)    Patient is conscious, alert, talking- give high flow oxygen via face mask

b)    Patient has a reduced conscious level but airway control and gag reflex present-there is no need for immediate intervention. Endotracheal intubation maybe done later, depending on the clinical condition

c)    Patient has a reduced conscious level, gag reflex absent-

d)    Secure airway with endotracheal intubation. Patients with multiple injuries must be preoxygenated before anesthesia. If intubation failed for more than 3 attempts, consider alternative methods like emergency cricothyroidoctomy or surgical airway for ventilation

e)    For anesthesia Inj. Ketamine 1-2 mg/Kg

f)      Monitor and control ventilation by frequent ABG analysis

Assessment of Chest Injuries:

a)   Decompress immediately in case of tension pneumothorax with acute severe respiratory distress. Use open thoracostomy instead of needle compression, if experts are available.

b)   Observe the patients after chest decompression for signs of recurrence of the tension pneumothorax

c)    In case of open pneumothorax, cover it with a simple occlusive dressing and observe for the development of a tension pneumothorax

d)   In case of perforating chest injuries, remove embedded foreign bodies during surgery only under controlled conditions after opening up the chest and immediate exploratory thoracotomy

e)   Immediate chest Xray as part of the primary survey to assess chest trauma with severe respiratory compromise. CT also advisable

f) Manage hemorrhage and shock

SPINAL TRAUMA

Assessment for spinal injury: -

·       On arrival at the hospital, use a prioritizing sequence to assess people with suspected trauma

·       History and thorough clinical examination for spinal injury including the functions associated with it must be carried out

·       The spine is suspected to be stable, unless any of the following 5 criteria are present: impaired consciousness, neurologic deficit, spinal pain, intoxication, trauma in the extremities

·       Assume the presence of spinal injury in unconscious patients until evidence to the contrary is found brain injury or if this assessment cannot be done

·       Procedure for spinal immobilization: Let the patient find a position where they are comfortable with manual in-line spinal immobilization.

·       Manually stabilize the head with the spine in-line using the following stepwise approach:

·       Fit an appropriately sized semi-rigid collar unless contraindicated by a compromised airway, known spinal deformities

·       Reassess the airway after applying the collar

·       Place and secure the person on a stretcher

Radiological investigations: -

· Cervical spine Xray if CT is not available

· MRI if after CT there is a neurological abnormality which could be attributable to spinal cord injury

· Perform an x-ray as the first-line investigation for people with suspected regions. Perform CT if the x-ray is abnormal or there are clinical signs and symptoms of a spinal column injury without abnormal neurological signs or symptoms in the thoracic or lumbosacral spinal column injury.

· Do not use the following medications, aimed at providing neuroprotection and prevention of secondary deterioration, in the acute stage after acute traumatic spinal cord injury: methylprednisolone, nimodipine, naloxone. Do not use medications in the acute stage after traumatic spinal cord injury to prevent neuropathic pain from developing in the chronic stage

HEAD INJURY

· The management of head injury patients should be guided by clinical assessments and protocols based on the Glasgow Coma Scale (GCS)

· Symptoms and signs of severe forms may appear immediately as in concussion or contusion or may appear after a few minutes to hours as in acute subdural hematoma.

· Patients with history of unconsciousness at any time since injury, amnesia for the incident or subsequent events, severe and persistent headache, nausea, vomiting, bleeding from nose/ear, seizures or presence of black eye, suspected fracture of skull and hematoma of scalp indicate severe form of head injury and require hospitalization.

Severe Head Injury (GCS <8 or less): - Patients with suspected open or depressed skull fracture, haemotympanum, panda eyes, CSF leakage from ear or nose, battles sign, persistent confusion, behavioral change, post-traumatic seizures, coma, focal neurological signs and features of raised intracranial pressure require immediate attention and should be admitted to the hospital. A CT should be done in all cases and treated as follows:

Check and maintain airway and breathing

·    Check and maintain airway and breathing

·    Check circulation by pulse, volume, rate and BP

·    Establish IV access

·    IV fluids according to volume loss: NS/ crystalloids are a fluid of choice

·    Check for and stabilize extracranial injuries

·    A head injury maybe accompanied by a cervical injury. If spinal injuries are excluded, then transfer the patient in a side position with head down, to a tertiary care centre where neurosurgical interventions are available

·    If spinal injury is suspected then transfer the patient on a hard board, place two sand bags on either side of the head

·    In case of raised intracranial pressure with signs of transtentorial herniation (pupil widening, decerabrate rigidity, extensor reaction to painful stimuli, progressive clouded consciousness), give IV Mannitol 20% 0.25-1g IV over 30- 60 minutes every 3-4 hourly

·    Do not administer glucocorticoids in traumatic brain injury