Emergency management of trauma practically begins prior to arrival of the patient to emergency room (ER). The emergency medical service (EMS) providers inform the emergency department about the mechanism of trauma, and update them regarding the vital sign values, suspected injuries and first aid treatments provided to the patient. The emergency team is activated and the concerned specialities involved in the management of poly trauma patients are informed beforehand.
Trauma care should be guided by the following concepts of
- Rapid assessment
- Serial reassessment
- Diagnosis and therapeutic intervention
To facilitate an organised approach to trauma patients, the examination is divided into primary and secondary survey. The goal of primary survey is to identify and immediately treat life threatening conditions. In order to achieve efficiency auniversal acronym ABCDE is followed which helps the clinician to examine patients. This includes Airway, Breathing, Circulation, Disability and Exposure(to completely expose the patient so occult injuries are not missed). In primary survey, life-threatening issues are identified and quickly addressed by intervention. Subsequently, secondary survey is carried out by doing head to toe examination of the patient and then proceeded further with specific diagnostic tests and appropriate therapeutic interventions.
Trauma code is further activated after the patient arrives at the emergency department. Trauma code mainly consists of team of specialists from various departments like Emergency, Anaesthesia, Gastro physicians, Gastro Surgeons, General Surgeons, Neurosurgeons and Orthopaedicians. The medical team also receive extended support from Interventional radiologists, blood bank, laboratory services, operation theatre, catheter laboratory and critical care units who will be intimated for the trauma code.
Primary Survey ensures initial airway and neck spine stabilisation. Airway management includes assessing for clearing and protecting the airway and performing endotracheal intubation for patients with depressed level of consciousness.
The airway procedures are followed, if there is significant bleeding for obstruction and also to permit air to pass freely to and from the lungs in order to ventilate the lungs. Management of breathing involves ventilating the patient with 100% oxygen, monitoring oxygen saturation level, inspecting for open chest wounds and abnormal chest wall motions. If there is any abnormality detected in the patient, the team adopts immediate intervention like needle thoracostomy and tube thoracostomy for life threatening conditions like tension pneumothorax and hemothorax.
Circulation -This domain involves assessing blood volume loss and monitoring vitals like pulse rate, blood pressure and placing large bore Intravenous peripheral cannula for facilitation of beginning rapid infusion of intravenous fluids (crystalloid solution) andsubsequently arranging for blood transfusion in the eventuality of severe blood loss.
Also, basic approach of applying direct external pressure on bleeding sites should be given a priority, if the situation arises.
Disability – In this domain, the patient’s assessment involves screening neurological and mental status, to look for any limb weakness and assessing the level of consciousness (Coma scale). They also keep track of the blood glucose levels of the patient to avoid hypoglycaemia.
Exposure involves completely exposing the patient and inspecting for injuries with log rolling the patient to inspect for any spine, back and flank injuries.
Subsequent to the primary survey, the secondary survey involves head to toe examination for rapid identification of the injuries or potential instability.
Secondary survey is performed for reassessing the unstable patient. They go through various scans such as sonography to detect any further complications.
Once the primary and secondary assessments are completed the reports are reviewed by the respective specialists such as Neurosurgeons, Gastro surgeons for intra-abdominal bleeding,Orthopaedic assessment for bony injuries including shattered pelvis. Based on the type of injury, patient will be channelized to respective specialties then transferred to intensive care unit, critical care unit, operation theatre or catheter laboratory ensuring right care for patient at right time.
While the medical force are occupied in handling emergency patient care, the managers in emergency medicine play a significant role by liaising with patient’s family members, ensuring admission process, medico legal aspects are handled efficiently in a professional manner.
(Writer is Dr Srimushnam Narasimachar, Senior consultant – Emergency & Trauma Medicine, BGS Gleneagles global Hospitals. Views expressed are personal opinion.)