+ 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 5: Trauma resuscitation and management

(H) Life Threatening External Haemorrhage »

  • Recognition of external haemorrhage is an immediate priority in trauma resuscitation
  • The initial aim is to control external haemorrhage with local pressure and pressure dressings. Haemostatic dressings and proximal tourniquet application may assist
  • Occasionally more proximal control is required with direct pressure, open surgical control or endovascular balloon occlusion.

(A) Airway Management & Spinal Immobilization »

Management of an unconscious trauma patient (airway management and spinal immobilization)

Recognition of airway compromise or obstruction is a key priority in the first few minutes of trauma reception. The aims for airway assessment are:

  1. Identify and/or predict the impaired or obstructed airway
  2. Secure a patent airway
  3. Maintain a patent airway
  4. Maintain in-line spinal immobilization

Assessment

Look for:

  • Agitation or reduced conscious state
  • Cyanosis
  • See-saw respiration
  • Use of accessory muscles of respiration
  • Foreign body, blood or vomitus in airway
  • Fracture or laceration to the face larynx, neck or maxillofacial region
  • Evidence of airway burns

Listen for:

  • Noisy breathing
  • Hoarse voice
  • No sounds of air movement
  • Stridor
  • Inability to talk in sentences

Feel for:

  • Facial instability
  • Crepitus of neck
  • Movement of air


Management

Airway opening manoeuvres:

  • Jaw thrust / Chin lift / roll patient onto side if required
  • Suction

Airway adjuncts

  • Nasal airway
  • Oral airway
  • Endotracheal tube
  • Laryngeal mask airway

Surgical airway

  • Cricothyroidotomy

Provide high-flow oxygen

  • Start pre-oxygenation early, add nasal cannula for apnoeic oxygenation during intubation


Airway Adjuncts

Table 4. Airway adjuncts (Trauma nursing from resuscitation through rehabilitation, McQuillan, Makic & Whalen)

(B) Breathing & Ventilation »

Management of a trauma patient in Respiratory Distress (tension pneumothorax, haemothorax and open pneumothorax)

Compromised ventilation may rapidly kill the patient. The aims for ventilation assessment are:

  1. Ensure adequate oxygenation and ventilation
  2. Monitor ongoing status of airway patency and ventilator status
  3. Identify and treat any life-threatening injuries

Assessment

Look for:

  • Patient’s chest wall integrity
  • Fractures, laceration and bruising
  • Paradoxical chest movements
  • Asymmetry of chest wall movement
  • Posterior chest wall

Respiratory effort:

  • Agitation or reduced conscious state
  • Cyanosis
  • Reduced chest wall movement
  • Use of accessory and/or abdominal muscles
  • Tachypnoea or abnormal respiration rate

Listen for:

  • Absent or decreased breath sounds and unequal air entry
  • “Sucking” through an open chest wound
  • Stridor

Feel for:

  • Subcutaneous air
  • Chest wall instability and crepitus
  • Position of trachea
  • Dullness or hyper resonance

Management of life threatening injuries

Tension pneumothorax

Signs and symptoms:

  • Dyspnoea, laboured respirations
  • Decreased or absent breath sounds on affected side
  • Unilateral chest rise and fall
  • Tracheal deviation from affected side
  • Cyanosis
  • Jugular venous distension
  • Tachycardia and hypotension
  • History of chest trauma or mechanical ventilation
  • Chest pain
  • Decreased oxygen saturation

Interventions

  • Requires immediate intervention without radiological confirmation!
  • Provide high-flow oxygen (100%)
  • Perform rapid digital decompression followed by tube thoracostomy on affected side

Figure 4. R Tension Pneumothorax



Haemothorax

Signs and symptoms

  • Dyspnoea, laboured respirations
  • Decreased or absent breath sounds on affected side
  • May have unilateral chest rise and fall
  • May have visible wound to chest or back
  • History of chest trauma (often penetrating)
  • Tachycardia
  • Bruising or lacerations on chest
  • Pain
  • Decreased oxygen saturation

Interventions

  • Provide high-flow oxygen (100%)
  • Digital decompression followed by tube thoracostomy on affected side

Figure 5. Massive Right Sided Haemothorax Case courtesy of Dr Andrew Dixon, Radiopaedia.org. From the case rID: 31573



Open Pneumothorax

Signs and symptoms

  • Dyspnoea, laboured respirations
  • Decreased or absent breath sounds on affected side
  • Visible, sucking wound to chest or back
  • Chest pain
  • May have decreased saturations

Interventions

  • Provide high-flow oxygen (100%)
  • Cover wound with occlusive dressing and secure on three sides with tape
  • Watch for signs of tension pneumothorax and remove dressing during exhalation if they are noted
  • Place chest tube on affected side

Figure 6. Open left pneumothorax secondary to gunshot wound

(C) Circulation & Shock »

Management of a trauma patient in Shock (recognising shock, haemorrhage control, IV fluid resuscitation)

Haemorrhage is the principal cause of preventable death after traumatic injury. It is essential that all hypotension is considered hypovolemic until proven otherwise.

The aims of circulation and haemorrhage control are to:

  1. Identify signs and sources or haemorrhage
  2. Assess mental status
  3. Assess pulses
  4. Asses skin colour, temperature and moisture



Assessment

Look for:

  • Obvious signs of external bleeding
  • Skin colour for pallor or cyanosis
  • Level of consciousness
  • Neck veins (collapsed or distended)
  • Abnormalities underneath the hard collar

Listen for

  • Muffled heart sounds that indicate pericardial tamponade

Feel for

  • Assess skin for moisture and temperature
  • Palpate pulses for presence, quality, rate and rhythm



Management

External haemorrhage control is a priority (see 1. Life-threatening external haemorrhage)

Signs and symptoms

  • Obvious bleeding site

Interventions once controlled

  • Elevation where able
  • Direct pressure applied to stop bleeding
  • Splint long bones and pelvic fractures



Shock

Causes of shock

  • Haemorrhagic (internal and external)
  • Tension pneumothorax
  • Cardiac tamponade
  • Spinal cord injury

Types of shock

  • Hypovolemic (most common in trauma patients)
  • Neurogenic
  • Cardiogenic
  • Distributive

Signs and symptoms

  • Tachycardia
  • Weak, thready pulse
  • Cool, pale, clammy skin
  • Tachypnoea
  • Altered mental state
  • Delayed capillary refill
  • Decreased urine output

Interventions

  • Provide high-flow oxygen (100%)
  • Treat cause of shock (control bleeding)
  • Place two large-bore IV cannula and infuse with isotonic crystalloid solution
  • Administer fluid bolus (1L in adults or 20 ml/kg in children)
  • Prepare to administer blood
  • Chest and pelvic X-rays
  • Ultrasound
  • +/- laparotomy or thoracotomy



Pericardial tamponade

Signs and symptoms

  • Tachycardia
  • Muffled heart sounds
  • Distended neck veins
  • Hypotension
  • ECG showing electromechanical dissociation
  • Signs of hypovolemic shock

Interventions

  • Pericardial decompression