Trauma Program Procedure

TRAUMA RESUSCITATION and PREPARATION for TRANSPORT:

Guidelines for Trauma Resuscitation:

TThe basic principles of trauma resuscitation including airway, breathing and circulation (A, B, Cs) apply to every trauma case.

  1. Airway/Breathing: Early endotracheal intubation is indicated in all trauma patients if there are concerns about (a) airway compromise (facial trauma, inhalation injury); (b) inadequate oxygenation or ventilation; (c) severe brain injury with a Glasgow coma Scale of < or = 8, or if there are concerns with the patient's ability to protect their airway in transport.
  2. Circulation/Resuscitation: Maintaining adequate organ perfusion is a basic component of trauma resuscitation. In the adult patient, use warmed normal saline with up to two litres in the initial resuscitative phase of the hypotensive patient. If the patient remains hypotensive, transfuse packed red blood cells. In the pediatric patient use warmed normal saline at 20 cc/kg & a second bolus may be given. If the patient remains hypotensive, transfuse 10 cc/kg of PR packed red blood cells and repeat, as needed including repeated boluses of saline at 20 cc/kg. Avoid hypothermia. If less than 6 years of age consider intraosseous access if venous access impossible.
  3. Do only necessary imaging/laboratory studies before transport. If the decision has been made to transport a major trauma patient early in resuscitation, the only essential imaging modality recommended is a chest x-ray. Optional x-rays include a cervical spine lateral x-ray and AP of the pelvis & a laboratory hemoglobin value. In a critically ill trauma patient CT scanning should only be performed if the therapeutic interventions needed to treat that patient as a result of the CT scan are available locally. Extremity radiographs play no immediate role in the resuscitation of the unstable major trauma patient prior to transport.

General Interventions in the Major Trauma patient Prior to Transport:

  1. Early endotracheal intubation and maintenance of adequate oxygenation/ventilation.
  2. Inserting chest tubes in patients with pneumothorax /or hemothorax.
  3. Secure 2 large bore IV lines and use warmed normal saline whenever possible.
  4. Application of direct pressure to all sites of external bleeding.
  5. Immobilize spine with rigid cervical collar and spinal board.
  6. Immobilize suspected extremity fractures and check pulses.
  7. Stabilize suspected unstable pelvic fractures with a bed sheet tightly wrapped around the pelvis (Pelvic MAST component can be used).
  8. Apply dry dressings to burns and not wet dressings.
  9. Insert a Foley catheter and gastric tube (especially in children) in all severely injured patients without contraindications.
  10. Rapidly suture and control bleeding from scalp lacerations.

Common Pitfalls in Major Trauma Patients:

  1. Delaying patient transfer to obtain diagnostic studies that will not alter immediate patient management.
  2. Failure to perform early and controlled endotracheal intubation.
  3. Failure to recognize, and aggressively treat, hemorrhagic shock.
  4. ailure to insert chest tube in patients with significant pneumothorax and/or hemothorax prior to transport.
  5. Failure to control active bleeding sites, especially in the scalp.
  6. Failure to recognize, stabilize and rapidly transport patients with unstable pelvic fractures.
  7. Failure to anticipate, recognize and treat hypothermia in the trauma patient.
  8. Failure to sedate patients receiving paralytic agents and failure to give analgesia (fentanyl - 0.5 - 1.0 mg/kg) in the trauma patient.

Specific Head Injury Guidelines:

Within the province of Nova Scotia, advanced, tertiary-based neurosurgical care is available only in Halifax and thus the early transfer of seriously head-injured patients is of paramount importance after initial resuscitation. The following guidelines and criteria are meant to assist in this process.

  1. Hypoxemia and hypotension independently double mortality in head injury.
  2. Always protect/immobilize c-spine in trauma patients.
  3. Use Glasgow Coma Scale to classify head injury and to assist in clinical decisions.
  4. Mild head injury: GCS: 13-15.
  5. Moderate head injury: GCS: 9-12.
  6. Major head injury: GCS: 3-8
  7. Use pupillary response, gross sensory/motor function and reflexes to assess neurostatus after GCS.
  8. Moderate and Major head injuries are best treated in a tertiary care neurosurgical setting.
  9. Never ascribe an altered level of consciousness solely to ethanol in a traumatized patient with a head injury.
  10. Mannitol, hyperventilation and steroids (for spinal cord injury) should be used only after consultation with the provincial trauma team leader and/or receiving neurosurgeon.
  11. The decision to CT a trauma patient's head at a facility without neurosurgical interventions should be rare; the CT scanner is a poor place for an unstable trauma patient and information gained will often delay transfer to tertiary care. Stable patients with mild head injury (GCS 13 to 15) may be imaged (CT) to assist in clinical decision making.