Author: Charlotte Davies / Editor: Nikki Abela / Codes: CMP3, HMP3 / Published: 31/07/2018
“I’m an Emergency Doctor”
“Cool, what’s the best trauma you’ve seen”
“Come quickly, this man has jumped off a bridge”
When you tell people you work in the ED, they invariably ask you for your great stories but they also ask you for help and advice when needed. Most of the time, you can confidently say “it’s not life threatening, go and speak to your GP”. But what if it is? You know how to treat cardiac arrestanaphylaxisbut ED is likely to be your first exposure to trauma. So when your neighbour falls down the stairs, you need to remember a systematic approach so that you can confidently manage trauma whilst you wait for equipment, and specialists to arrive. If you’re in the department, the principles remain the same!
If you ask most people to think up a “trauma” scenario, it is likely to involve multiple injuries, high velocity injuries (cars, planes, entrapment) and an unwell patient. In reality, trauma is less dramatic falling down the stairs, falling off the monkey bars or maybe falling off a push bike. Whether it is major trauma, “silver trauma“, or minor trauma, the same logical process should be used. In some circumstances it takes a long time to finish assessing the airway. Sometimes, the whole process can be followed very quickly. This blog post isn’t going to turn you into a trauma expert, but it will remind you of the basics – and often doing the basics well is what saves lives.
Scene safety always seems obvious, but is frequently overlooked. Think about the danger to yourself, then bystanders, and then the patient. Consider whether you are dressed appropriately, and fit to proceed. Think about other traffic; cars, bikes and other “helpful” bystanders. Think about broken glass, debris, falling walls. If it’s not safe, or youre not sure, don’t put yourself in danger.
If you’re in the department, your safety should be assured. What if the person who stabbed your trauma patient is following them in? More realistically, is it safe for you to manage this patient solo or do you need to ask for help? Trauma call?
Mechanism of Injury
As you approach any trauma patient, think about what forces are involved. If their car is very smashed, there will be lots of energy involved and the patient must go to hospital as soon as possible. If they’ve fallen from the monkey bars, the forces are lower. Elderly people need really low levels of energy to sustain significant injuries, falling down the stairs is likely to break lots of bones. Falling against a wall could break a rib. Be suspicious and have a read of the London elderly trauma guidelines or the HECTOR handbook or our RCEM silver trauma blog to make you think.
Children are very good at bouncing but often appear well until suddenly they’re not. Observe carefully, and read our post on paediatric anatomy to make you think of some of the differences.
Is there any haemorrhage that is going to kill the patient if it’s not dealt with immediately? Are they pumping all of their circulation out of an amputation or a significant wound? If so, put pressure immediately on the wound. If you don’t have appropriate personal protective equipment, ask the patient to apply the pressure! A tourniquet might be useful here. In mass casualty situations, tourniquets are recommended. Why not look at the citizen aid app to remind yourself about what steps to take.
Most patients we see will have a patent airway, but you still need to assess it as part of your primary survey. If the patient needs their airway opening make sure they are in resus and your seniors are aware! We normally use a head tilt and chin lift, but if trauma is involved, we should use a jaw thrust. Check out this module for a reminder of basic airway manoeuveres.
An open airway is the most important thing for everyone, so although a head tilt chin lift would move the c-spine, an open airway gives your patient the greatest chance of survival, so if a jaw thrust isn’t working and help isn’t there yet it’s better than doing nothing.
If you are worried the patient has damaged their c-spine, now is the time to start quickly manually immobilising it. Put your hands around their head to keep it still. Unless there’s lots of help available, don’t faff around with collars at this point. There are still life threatening injuries you need to look for and the benefit of collars is controversial. Manually immobilise until help has arrived!
You need to make sure your patient is breathing. If they’re not start CPR. Assuming they are, check their respiratory rate. Check the saturations if available and put on high flow oxygen what ever the result and your seniors can remove it later. Look at the chest for any open “sucking” chest wounds. These may suck more air in and cause a tension pneumothorax. Cover them up with a gauze dressing. Then have a quick look to check both sides of the chest are moving, if one side isn’t moving and you’re pre-hospital, make sure your ambulance is on the way.
If you’re in hospital, think “could this be a tension pneumothorax?”. If it could be (hyperresonant to percussion, absent breath sounds), perform a needle decompression. If you don’t think it could be, make sure you have urgent senior help and arrange a chest x-ray.
Think “could this be a massive haemothorax” (dull to percussion, likely shocked patient). Make sure senior help is arriving, move on to circulation, and prepare for chest drain insertion.
There are six life threatening chest injuries traditionally taught. We’ve moved on from the traditional “ATOM FC” to “TOM CAT”.
Have a look for any bleeding. If you can see any obvious bleeding, apply pressure to stop the bleeding as you would normally.
Check a pulse rate.
Traditionally, there can be bleeding in five places; the floor (external haemorrhage), and four more, chest, abdomen, pelvis, and long bones. Bleeding in the chest has been (hopefully) identified in your B assessment. Inspect the abdomen for bruising and palpate for any guarding. This will guide you towards intra-abdominal bleeding. The pelvis can bleed a lot. If you think the patient may have a pelvic injury, figure a way to splint the pelvis and close the book to stop the bleeding. In hospital, this will be application of a pelvic splint. Pre-hospital you may need to tie your bed sheets around the patients pelvis or tie their legs together which helps. Don’t rock the pelvis to check its stability. If you want to touch something, feel the greater trochanters to see if there is any pain.
If you think the patient has broken their femur the patient is likely to have lots of bleeding. Splinting the leg can help with this.
Gain IV access the biggest cannula you can in both antecubital fossae. Take bloods: FBC, U&E, LFT, Amylase, pregnancy test, group and save, clotting, lactate, venous blood gas. Your seniors will decide if these are all really needed, you can always throw the blood away before it hits the lab!
Don’t rush to give any IV fluids until your senior is present, as IV fluids can dilute clotting factors and make things worse. Blood is often best!
This is another chance to assess how awake the patient is. Assess their consciousness level using AVPU. Have a quick chat with them – are they confused? Do they know where they are?
Have a look for any head injuries.
Get a pain score and give some analgesia. Running IV paracetamol through is often a quick and easy way of improving pain and it’s in before the CD keys have even been found (yes I know its apparently no more effective than oral). Remember that reassuring patients is a very effective way of relieving pain.
Exposure has a few components. The most important part of this is to make sure your patient isn’t cold; if you’re cold, your blood doesn’t clot as quickly. This is *really* important. You loose a lot of heat just by lying on a cold floor, try it. Pre-hospitally, cover the patient above and below. In hospital, we often strip the patient off to examine them, but why not be the one that covers them up to prevent loss of dignity, as well as loss of heat?
The next part of this is to think about doing a secondary survey and looking for further injuries. To do this properly, you need to get down to skin, expose a bit at a time and re-cover it up when you’ve done. It’s not often practical to do this pre-hospitally, and even in hospital you often need imaging and time before this can be properly performed.
Packaging and Transport
If your patient is unconscious, you need to decide what position to put them in. In most of our patients we use the recovery position as a nice safe position. This moves the c-spine quite a lot. If there are enough of you, consider log rolling the patient instead, to minimise spinal movement.
If you’re pre-hospital, you then need to plan how your patient is going to get to definitive care and where they’re going to go. This decision is best made by the pre-hospital practitioners who fully understand all the nuances.
Helicopter Transport: if you think the patient needs helicopter transport to hospital, you should have already dialled 999 and the operators make that decision.
Emergency Ambulance: an emergency ambulance is needed if the patient needs treatment en route to hospital, or wouldn’t manage to get in to a car.
Own Transport: If the patient doesn’t need an ambulance, they can make their own way to hospital for assessment. They do not need to arrive in the Emergency Department in an ambulance to get seen. It doesn’t get you assessed any quicker. If you think the patient has broken their arm, they don’t need an ambulance to get to hospital. If they have wounds that need suturing, they don’t need an ambulance to get to hospital. Chances are, your patient will be waiting over an hour for an ambulance by which time, they could have already made their way to the emergency department, been booked in and triaged.
If you’re in hospital, your seniors will help you decide whether the patient needs transporting elsewhere or not. Trauma care has all been centralised. Trauma units are local hospitals that can deal with most things and stabilise patients. Major Trauma Centres are bigger units that have all trauma specialities on site and can often provide more unified care for the multiply injured patient. Some patients will need transferring from your trauma unit to your major trauma centre. In London, our MTCs are centrally based which is great if you live inside the M25, but if you get transferred from Hastings to Kings, your journey home is quite long!
Normally for trauma we have used kit and equipment. We would now need to re-stock and clean any equipment used, don’t rely on anyone else doing it. We also need to think about whether we are still physically and emotionally prepared to continue at work, we may need a quick debrief.
If this has whet your appetite for more trauma care, have a look at all our trauma resources on RCEMLearning. We have podcasts, blogs, and e-learning. Your hospital is likely to run trauma simulation courses. ATLS is a great starter course for anyone wanting to learn trauma systems. Although much complained about, it still provides a basic, core common language for anyone involved in trauma care.