Multiple life-threatening trauma
By Antika Jacqueline Klein – Psychiatrist Bangkok Hospital Samui
Multiple trauma represents less than 0.2% of attendances at Accident and Emergency (A&E) departments in the UK. However, trauma is the commonest cause of death in patients up to 45 years and is responsible for 61% of deaths in the 15-24 year age group. In developed countries, road traffic accidents (RTAs) causing blunt injury are the greatest source of multiple trauma patients.
The management of multiple trauma patients requires a coordinated team response, with rapid assessment, resuscitation and the development of an investigation and management plan. This will commonly involve a range of specialists, in particular specialists in A&E medicine, anaesthetists, intensivists, surgeons (general, cardiothoracic, orthopaedic and vascular) and radiologists. The ultimate aim is to stabilise the patient, prevent secondary organ injury, investigate appropriately and deliver the patient quickly to the point of definitive care
What you should do?
Systems of care for the trauma patient. Good outcomes for multiply-injured patients depend on effective resuscitation as soon as possible after the initial trauma. This time period is often termed 'the golden hour' and starts at the scene of the event (pre-hospital care) and extends into the hospital environment
1.1 Pre-hospital care - paramedics/medical teams
From various analyses of avoidable trauma deaths (39% of the total) it is clear that interventions to correct hypoxia, restore blood volume and prevent hemorrhage have a major beneficial effect. It appears logical, therefore, to supply trained ambulance crews, in particular paramedics, to achieve these goals. Where there is likely to be a delay in transfer to hospital, or the patient has major airway or ventilatory problems, then a suitably trained and experienced Pre-hospital Medical
Team may be called to the scene, or to rendezvous with an incoming ambulance. The aims of such a team are to:
1. ensure the safety of patients and team members at the scene
2. liaise with other emergency personnel to coordinate the rescue
3. secure the airway and support ventilation and circulation using appropriate resuscitation techniques
4. deliver intravenous opioid analgesia to facilitate extrication
5. extricate the casualty safely and swiftly with due protection of the spine
6. stabilise fractures
7. ensure the safe transfer of the patient to hospital
8. alert the appropriate specialists or activate the Trauma Team prior to arriving.
It is important to avoid inappropriate interventions 'in the field' which may delay the arrival of the patient at the point of definitive care. It is the responsibility of the medical team leader to balance the 'scoop and run' with the 'stay and play' approach.
1.2 The hospital phase
The ambulance service or medical team will usually give advance notice by radio of the imminent arrival of a patient with multiple or life-threatening injuries. On receipt of such an alert, the hospital will respond by mobilising a team to the resuscitation room in the A&E department. The composition of this team will vary between different hospitals. Some larger A&E departments operate their own resuscitation team; others rely on a hospital Trauma Team.
The adoption of a trauma team approach has reduced mortality as demonstrated by studies in the USA. In the UK, audit has shown that time in the resuscitation room is reduced from an average of 122 to 56 minutes, with a significant reduction in time to definitive care.
The exact composition and experience level of the team will vary between hospitals.
A Trauma Team usually comprises the following staff:
1. the team leader (usually an A&E Consultant)
2. A&E medical staff
3. an experienced anaesthetist
4. a general surgeon
5. an orthopaedic surgeon
6. experienced A&E nursing staff (with Trauma Nursing Core Course training)
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