The make-up of this team varies between hospitals depending upon the resources and the time of the day. The trauma team should consist of:
Trained medical personnel
Supportive trained paramedical personnel
A team leader who should assign specific tasks to each person.
The trauma reception team undertakes the following tasks:
Team Leader
Coordinates the tasks assigned to the team members Questions ambulance personnel
Assimilates clinical findings
Determines investigations in order of priority
Liaises with relatives and provide information to trauma team Liaises with specialists who are called.
Team Members
Manage the airway
Clear the secretions and intubate if necessary Manage circulation
Establish infusion line quickly Takes blood for investigations Supportive measures
Connect to monitors Urinary catheterization
27 CHAPTER 6 POL YTRA UMA
Receiving the Patient
Receiving and transferring the patient (Fig. 6.1) is very crucial and requires five people to do the job, which should be a well practiced procedure in order to protect the spinal cord if it is intact, and to prevent further injury if it is already compromised. During the transfer, the patient’s head and neck are stabilized by one member of the team, three others lift from the side and the fifth member replaces the ambulance trolley with the resuscitation trolley.
Primary Survey and Resuscitation
The activities listed below are carried out simultaneously if there are enough personnel, if not should be done in alphabetical order (ABCDE).
Airway and cervical spine control Breathing
Circulation and hemorrhage control Disability
Exposure.
Airway and Cervical Spine Control
A cervical spine injury should be assumed if the patient has been the victim of significant blunt trauma or if the mechanism of injury indicates that the cervical region may have been damaged. One member of the team needs manually to immobilize the cervical spine while talking to the patient which also assesses the airway.
28
SECTION IV
TRA
UMA
If the patient is able to give a logical answer in a normal voice, the airway is assumed to be patent and the
brain adequately perfused.
If the patient gives an impaired or fails to reply, the airway could be obstructed, and immediate measures
should be taken:
A simple chin lift will help in relieving the obstructing soft tissue usually the tongue Saliva, blood, vomitus, tooth or other foreign bodies should be removed
Suction through rigid suction tube is necessary to remove secretions
In patients who vomit and regurgitate, head end of the bed should be dropped 20 degrees, allowing the secretions to drip down and facilitate removal by suction
A nasogastric tube may be inserted to aspirate the stomach contents and prevent further vomiting. When it is established that the airway is clear and patent, 100 percent oxygen is provided via mask or by endotracheal intubation. Pulse oxymeter is connected to maintain good SaO2, if needed with ventilatory support.
The neck should be examined for the following five signs which could indicate the presence of immediately life-threatening thoracic conditions (Table 6.1).
When below given signs in Table 6.1 are checked, the neck may be immobilized with appropriate collar if the patient is not restless, in a restless patient, semi-rigid collar is accepted.
All the multiple injured patients, particularly those who have injuries above the clavicle or a change in level of consciousness, should be treated as though they have a cervical spine injury, until it is ruled out.
Breathing
The clinical examination of chest consists of:
Inspection
Marks and wounds Respiratory rate Inspiratory effort
Symmetry of chest movements
Table 6.1: Signs of life-threatening thoracic conditions
Signs Conditions
1. Swellings and wounds Vascular and airway injury
2. Distended neck veins Cardiac tamponade, tension pneumothorax
3. Tracheal deviation Tension pneumothorax
4. Subcutaneous emphysema Pneumomediastinum
29 CHAPTER 6 POL YTRA UMA Percussion
Assess ventilation at the periphery
Auscultation
Assess defects in air movement.
The respiratory rate and effort are sensitive indicators of underlying lung pathology, and requires to be monitored and recorded at frequent intervals.
Circulation and Hemorrhage Control
Bleeding can result due to:
Fractures of long bones Vascular injuries Soft tissue injuries
Application of pressure is the best way of management of hemorrhage, as tourniquets increase intraluminal pressure of the vessels, distal ischemia and tissue necrosis. Application of tourniquet is undertaken in select situations, and when used the time of application of tourniquet has to be noted so that neighboring soft tissue is not jeopardized.
Recognition and Assessment of Hypovolemia
The assessment of hypovolemia has to be done in a systematic manner:
Skin – color, clamminess and capillary refilling
Vital signs – heart rate, blood pressure and pulse volume Consciousness level
Isolated determinations of above parameters is unreliable as various organs try compensate at early stages, especially at extremes of age.
Common sites of occult bleeding are:
Chest
Abdomen and retroperitoneum Pelvis
Long bone fractures
30 SECTION IV TRA UMA Fluid Resuscitation
Once any overt bleeding is controlled, it is necessary to maintain the circulatory volume. This is done by administering a warm crystalloid followed by blood transfusions, maintaining the radial pulse and blood pressure. This administration of fluids is done by peripheral venous cannulation, and when not possible done through central venous catheterization.
• Vital signs return to normal after less than 2 liters of fluid are administered, when the lost blood is less than 20
percent of the blood volume
• Transient responders who are actively bleeding or recommence bleeding during the resuscitation, and the
improved vital signs deteriorate indicating loss of over 30 percent of the blood volume
• Little or no response indicates that the loss is more than 40 percent or no hypovolemia.
Disability
Disabilities when occur in a patient with trauma shows seriousness. It can occur in:
Hypoxia Hypovolemia Hypoglycemia
Increased intracranial pressure.
Exposure
The patient’s clothes have to be removed by cutting through the seams so that there is minimal patient movement. All clothes are removed only after adequate intravenous access is established, as a rapid removal of tight trousers can precipitate sudden hypotension due to the loss of the tamponade effect in a hypovolemic patient.
Once stripped, trauma victims should be kept warm with blankets when not being examined. Now the patient is rolled on and the spine examined from base of skull to the coccyx, with a rectal examination.
What to look for during rectal examination in a trauma victim:
Is the sphincter tone present? Is the rectal wall breached?
Is the prostate in a normal position? Is there blood on the examiner’s finger?