Severe trauma
Definition
• Multiple trauma: injury of at least two
organ systems, of which at least one is
life-threatening.
• Severe trauma is defined by an Injury
Severity Score (ISS) >15
Injury severity score
• Evaluation based on anatomical injury
• Anatomical regions:
– Head or neck- including cervical spine
– Face - including the facial skeleton, nose, mouth,
eyes and ears
– Chest - thoracic spine and diaphragm
– Abdomen or pelvic contents - abdominal organs and
lumbar spine
– Extremities or pelvic girdle - pelvic skeleton
– External
• Severity: none, minor, moderate, serious,
severe, critical
• Calculation: ISS = A2 + B2 + C2
Mechanisms of injury
• Blunt
• Penetrating
• Thermal (burns and cold injury)
• Blast
Epidemiology
• 250 per million population per year
• More in urban areas in countries such as
South Africa and North American cities
• The challenge is to centralise trauma care
The team approach
• Team leader (intensivist, surgeon…)
• Trauma surgeon, general surgeon
• Intensivist, anesthesist
• Radiologist
• Optional:
– Neurosurgeon, neurologist, urologist, neck-,
face surgeon, urologist…
Generic approach to trauma care
• Detection and treatment of life-threatening injuries
during a primary assessment and intervention
phase.
• Detection of all the other injuries during a secondary
assessment when a more detailed clinical
examination is combined with investigations such as
imaging. Definitive care plans are then made.
• Detection of missed injuries and early sequelae or
complications (i.e. compartment syndrome after
tibial fracture) in a tertiary assessment, performed
within the next 24 hours.
Primary assessment
-pre-hospital
• Airway with C-spine control: look, listen (stridor/wheeze),
feel
• Breathing: look (symmetry, paradoxical movement),
listen (symmetry), feel (symmetry, subcutaneous
emphysema)
• Circulation: pulse (rate and pressure), peripheral
perfusion, jugular venous distension, signs of external or
internal bleeding
• Disability: Glasgow Coma Scale score, pupillary
reactions and any suspicion of paralysis
• Exposure: in preparation for the head-to-toe examination
that follows in the secondary assessment
Exposure
• Falls >2 metres
• Pedestrian or cyclist hit by a car at speed >30 km/hr (18
miles/hr)
• Death or severe injury of another occupant in the same
vehicle/accident
• Ejection from a vehicle
• Major deformity of the vehicle or intrusion into the
passenger space, especially bent columns around the
front doors
• Extrication time >20 minutes
• Vehicle roll-over
• Penetrating injury to the head or trunk
Secondary assessment- ED
• Clinical examination
– Head to toe
– Front and back
– Surface–orifice–cavity–skeleton
• Imaging
– plain radiographs
– ultrasonography of the chest and abdomen
– CT
– angiography
• Laboratory tests
– Haematology
– Biochemistry
– toxicology
Beware of the patient whose clinical
presentation is not as expected (e.g. little
pain with obvious injury or bradycardia
with obvious pain or extensive blood loss),
as these may be signs of severe
underlying injuries.
CASE
A 50-year-old driver (restrained with a seat belt
in a head-on collision) presented with mild head
injury (GCS of 13: eye opening 3, verbal
response 4, motor response 6) and fractures of
his zygomatic arch, causing an impressive
haematoma around his left eye. On examining
him you note a fracture-dislocation of his left
forearm, a nitroglycerin patch on his chest, and
atrial fibrillation with a heart rate of 60/min.
Interpret these findings and make a differential
diagnosis.
Tertiary assessment- ICU
• Review the anatomical injuries and physiological
disturbances as part of the handover process
and review their management.
• Re-examine the patient for missed injuries and
new complications, e.g. compartment syndrome
of the limbs or abdomen.
• Review the imaging.
• Perform a more detailed physiological
assessment, with clinical evaluation
supplemented by intensive care monitoring.
Physiological assessment
• Respiration
• Circulation
• Nervous system
• Metabolism
• Host defence
TASK
• auscultate the chest
• tightly control glycaemia
• assign tasks to team members
• give oxygen by face mask
• reposition a dislocated ankle fracture
• control the C-spine
• infuse 20 ml/kg Ringer's lactate
• give antibiotics
• perform neurologic assessment
• examine the prostate.
A- Airway problem
• fiO2 need
• Airway patency–
Obstruction
– coma
• Spontaneous ventilatory
activity
• Airway obstruction signs:
– Stridor
– Ineffective breathing
attempts
• Causes of obstruction
– Foreign body
– Trauma to the neck
– Burns- inhalation trauma
B- Breathing conditions
• Pneumothorax
• Haemothorax
• Flail chest
• Lung contusion
Treating breathing problems
• Oxygen
• Intubation, mechanical ventilation
• Chest tubes
• Analgesia
C- Circulatory conditions
• Types of shock: ??????
– Hypovolemic
– Obstructive
– Cardiogenic
– Distributive
• Haemorrhagic shock
• Cardiac tamponade, tension pneumothorax
• Cardiac contusion- resembles AMI
• Later- SIRS
QUESTION
• What are possible causes of PEA in trauma
victims? Are there differences as compared to
non-trauma victims of PEA?
• 6 'H'
– Hypovolaemia, hypoxia, H + ions (acidosis), hypoand
hyperkalaemia, hypothermia, and hypoglycaemia
• 6 'T'
– Toxic ingestions, tamponade (cardiac), tension
pneumothorax, thrombosis (coronary),
thromboembolism (pulmonary), trauma
Treating circulation
• Two large peripheral intravenous lines
• Fluid resuscitation aliquots of 20 ml/kg
body weigh
• Beware of over-resuscitation
• Accept a lower pressure target
• Haemotherapy
– Haemodynamics
– Heamoglobin
– Haemostasis
QUESTION
• What is the goal for blood pressure in a
young victim of a bicycle accident with
multiple fractures of his extremities?
• What is the goal for blood pressure in an
old patient (>70 yrs.), with cardiovascular
comorbidities, victim of the same
accident?
• Blood flow, with satisfactory signs of tissue
oxygenation, is more important than blood
pressure.
D - Nervous system
• TBI
• Spinal cord injury:
– respiratory arrest- Q: why?
• Interruption of the the phrenic nerve supply
– neurogenic shock:
• hypotension but with warm extremities- Q: why?
– loss of sympathetic (vasoconstrictor) tone
• Bradycardia- Q: why?
– Loss of the sympathetic nerve supply to the myocardium
Imaging
• Plain radiograph- chest X-ray
• Ultrasonography- focused assessment by
sonography in trauma (FAST):
– liver, spleen, kidneys, pouch of Douglas,
paracolic gutters, pelvic gutter, pericardium,
pleural cavities
• CT
Traumatic brain injury
hypothermia
Heamostasis disorders treatment
• Damage control
• Treat:
– Shock
– Acidosis
– Hypothermia
• Substitution of thrombocytes and
heamocoagulation factors
• Antifibrinolytics
Damage control
• Addresses bleeding and contamination
promptly
• Objective: interrupt the downward spiral of
acidosis, coagulopathy and hypothermia
• Involves rapid surgery to stop bleeding
and decontaminate wounds, deliberately
postponing definitive repair until
physiological stability has been re-
established
The phases of damage control
• Initial assessment and stabilisation in the
Emergency Department
• Immediate, limited surgical intervention:
haemorrhage and contamination are controlled using
temporary methods- closure and stabilisation of pelvic
ring disruptions, packing, embolisation and local
haemostatic measures.
• Continuing stabilisation on the ICU: physiological
system control, monitoring for wound complications (e.g.
abdominal compartment syndrome, if the abdomen has
been closed) and continual vigilance for missed injuries.
• Re-operation: definitive repair can now take place. If the
original wound was left open at the initial operation,
wound closure and definitive repair may be possible
now.
Management of Coagulopathy of
trauma
• Coagulation monitoring and measures to support coagulation should be
implemented as early as possible following traumatic injury and used to
guide haemostatic therapy.
• A damage control approach to surgical procedures should guide patient
management, including closure and stabilisation of pelvic ring disruptions,
packing, embolisation and local haemostatic measures.
• Use appropriate physiological targets and use and dosing of fluids, blood
products and pharmacological agents in the bleeding trauma patient.
• The growing number of older patients requires special attention to
appropriately manage the inherent thromboembolic risk profiles and
possible pre-treatment with antiplatelet agents and/or oral anticoagulants.
• A multidisciplinary approach to the management of the traumatically injured
patient remains the cornerstone of optimal patient care, and each institution
needs to develop, implement and adhere to an evidence-based
management protocol that has been adapted to local circumstances.
Continuing acute care in the ICU
• Respiratory control
• Circulatory control
• Nervous system control
• Metabolic control
• Host defence
Haemodynamics
• Ongoing bleeding
• Cardiac tamponade
• Cardiac contusion
• Traumatic rupture of the heart valves
• Neurogenic shock – spinal cord injury
• Brain stem compromise
• Septic shock (unlikely at early stage)
• Over- sedation
• Allergy to administered drugs or fluids
Haemoglobin
• Before bleeding has been controlled
haemoglobin level can be allowed to drop
to 100 g/l
• Once bleeding is controlled, a target
haemoglobin level of 70-80 g/l is
appropriate in most patients.
Take-home messages
• Centralization of trauma care
• Generic approach
• Damage control
• Deliberate under-resuscitation, under-
repair
• Correction of haemostasis
• Weight risk vs. benefit