+ Table of Contents

  1. Contributors
  2. Objectives
  3. Chapter 1: The importance of initial trauma management
  4. Chapter 2: Patient and staff safety
  5. Chapter 3: Introduction to the Trauma Team
  6. Chapter 4: Initial assessment of a trauma patient
  7. Chapter 5: Trauma resuscitation and management
    1. (H) Haemorrhage: Life-threatening external haemorrhage
    2. (A) Airway: Management of an unconscious trauma patient (airway management and spinal immobilization)
    3. (B) Breathing: Management of a trauma patient in Respiratory Distress (tension pneumothorax, haemothorax and open pneumothorax)
    4. (C) Circulation: Management of a trauma patient in Shock (recognising shock, haemorrhage control, IV fluid resuscitation)

Chapter 1: The importance of initial trauma management

Trauma (physical injury) has contributed significantly to the rise of 21st Century non-communicable disease.

By 2030 the leading disease burdens worldwide are predicted to be unipolar depressive disorders, ischemic heart disease, trauma and cerebrovascular disease1. All of these conditions are characterized by sudden and unpredictable healthcare demands. All require immediately accessible, systemized and multi-disciplinary approaches to care for improved outcomes.

Severe trauma is life-threatening and life-disrupting. Individual physical capacity, relationships, education and employment are all endangered. Unsurprisingly effective trauma care that results in reduced mortality and improved functional outcome is a current global imperative.

The World Health Organization (WHO) Essential Trauma Care project advocates a spectrum of activities to decrease trauma morbidity and mortality2. These comprise surveillance, basic research, prevention programs and effective trauma management. Understandably much weight has been placed on preventive strategies (e.g. speed limits, seatbelts, alcohol breath-testing and weapons control). There are also major gains to be made by improving trauma management - particularly the initial reception and resuscitation on arrival at hospital.

The overall impact of trauma is exaggerated by the lack of integrated emergency healthcare3. There is commonly minimal pre-hospital medical intervention and long delays to hospital arrival. There is often no pre-arrival hospital notification of trauma patients. Triage may be ineffectual and expert medical and nursing attendance to a trauma patient is often delayed. In many hospitals there is no Trauma Team or activation system in place - and no interdisciplinary approach to trauma reception. Unsurprisingly 55-91% of reported errors that contribute to preventable trauma deaths occur during the initial trauma reception and resuscitation in the Emergency Department4.

Although trauma reception and resuscitation has improved dramatically over the last three decades, even in the best centres there is an ongoing rate of errors contributing to adverse outcomes5.

This is because, trauma reception and resuscitation - for the seriously injured patient requires recognition that the patient has an immediately life-threatening problem, activation of both an appropriate medical and nursing response and numerous, correctly determined management decisions in a short span of time.

Errors occur because of time pressure, inexperience, reliance on memory, multitasking, and failures in trauma team coordination, especially during the initial minutes of patient reception and resuscitation6,7. In particular, failure to immediately correct airway, ventilation and circulatory compromise has devastating consequences.

There are several programs that teach early trauma care in an attempt to address these priorities. However, are few education programs that involve both medical and nursing staff working as a team to ensure standardization of trauma response including immediate deployment of life-saving interventions and a reduction in errors of omission.

This program – ‘Trauma Resuscitation – the Initial Approach’ has been developed to provide this foundation for initial care of the severely injured for all hospitals staffs involved in the care of the severely injured. It concentrates on the immediate management of patients with three commonly presenting scenarios - airway compromise, threats to breathing and severe blood loss.

The program has been successfully delivered to medial and nursing staff in China, India and the Philippines and has been adapted for The Alfred- King Saud Medical City International Trauma Program.



References

  1. World Health Organisation (WHO) 2004 Burden of Disease Update (2008). http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
  2. WHO Essential Trauma Care. “Guidelines for essential trauma care.” 2005. Available at: http://whqlibdoc.who.int/publications/2004/9241546409.pdf
  3. Sharma, BR. Road Traffic Injuries: A Major Global Public Health Crisis. Public Health 2008; 122:1399-1406. Epub 2008 Oct 31.
  4. Fitzgerald, M, Dewan Y, O’ReillyG, Matthew J, McKenna C. India and the Management of Road Crashes: Towards a National Trauma System. Indian J Surg 2006; 68: 237-43.
  5. McDermott FT, Cordner SM, Tremayne AB. A ‘before and after’ assessment of the influence of the new Victorian trauma care system (1997–1998 vs. 2001–2003) on the emergency and clinical management of road traffic fatalities in Victoria. Report of the Consultative Committee on Road Traffic Fatalities in Victoria 31st December 2003. Melbourne: Transport Accident Commission, 2003.
  6. Clarke JR, Spejewski B, Gertner AS, et al. An objective analysis of process errors in trauma resuscitations.Acad Emerg Med. 2000;7(11):1303- 1310.
  7. Ivatury RR, Guilford K, Malhotra AK, Duane T, Aboutanos M, Martin N. Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma. 2008;64(2):265-270, discussion 270-272.