Caring for Trauma Patients

There has been great improvement in the last 20 years in trauma care, especially from enhancements in trauma systems, assessment, triage, resuscitation, and offering emergency care.

Trauma care involves the provision of appropriate care at any medical establishment to road crash victims or victims of any type of accident who have major and minor injuries. A trauma care system has to be an organized and coordinated effort within a demarcated geographic area to deliver the full spectrum of care to any injured patient. It starts from the time of the injury through transport to arrival at any acute care facility and transfers to rehabilitative care if needed.¹

A trauma care system typically consists of three main providers, which are:

• Prehospital
• Acute trauma care
• Rehabilitation

When all these three providers are closely integrated, it ensures that a continuum of care is there.

Minor injuries are sometimes treated by the patients themselves, a general practitioner, or the emergency department. Correct treatment of injuries like neck and head trauma combined with adequate follow-up care is important to limit the pain and also prevent any adverse consequences.

In case of major injuries, a trauma care system has to be put in place by every hospital that is receiving patients with major trauma.

In any trauma system, the integration of prehospital, acute care, and rehabilitation providers are usually administered by a public agency that provides leadership, coordinated service delivery, put in place minimum standards of care, designate the trauma centers, and also ensure system evaluation and refinement from time to time. Trauma care systems need to be endowed with the following clinical or operational components:²

• Medical direction
• Prevention
• Communication
• Training
• Triage
• Prehospital care
• Transportation
• Hospital care
• Rehabilitation
• Medical evaluation

Trauma is one of the leading causes of mortality in the world.³ Globally, road traffic injuries are the major cause of death in people between the age of 18 to and 29 years. In the United States, trauma is the leading cause of death in young adults and accounts for nearly ten percent of all deaths in men and women.⁴

Over 45 million people globally sustain some type of moderate to severe disability every year due to trauma. In fact, in the US alone, over 50 million patients receive some type of trauma-related medical care every year, and trauma accounts for nearly 30 percent of all intensive care unit (ICU) admissions.⁵

Of the millions of ways people get injured due to trauma, most injuries are categorized as penetrating or blunt. Blunt injury involves having a forceful impact, for example, a blow, kick, motor vehicle crash, blast, or being struck with an object. Penetrating injuries in trauma usually involves a breach of the skin by an object, such as broken glass or a knife, or by a projectile, such as shrapnel from an explosion or a bullet.

Other types of trauma injuries may include chemical and thermal burns, toxic inhalations, radiation injury, or ingestions.

All types of injuries can cause direct damage to your tissues. The exact nature of the injuries and the extent depends on the location of the injury, mechanism, and intensity of the trauma. Severe direct damage tissue damage to any critical organs, including the heart, brain, or the spinal cord, is responsible for the majority of the immediate trauma deaths.

Furthermore, patients surviving the initial trauma may end up developing other indirect injury effects. This can include disruption of blood vessels that can cause bleeding, which either might be internal or external. The bleeding can either be confined inside an organ like a hematoma or a contusion, or it can be free hemorrhage into any body cavity, such as the thorax or the peritoneal cavity.^6,7

Minor amounts of blood loss are typically tolerated well by most patients, but a larger amount of blood loss can cause a progressive decline in blood pressure and lead to shock, organ failure, and even death. Hemorrhagic brain injury and shock are responsible for most short-term deaths, and multiple organ failures due to prolonged shock are usually responsible for many near-term deaths. Sometimes, near-term deaths can also be a result of infection following the injury.⁸

The most seriously injured patients after trauma have to be identified in the field itself and then safely transported to the designated trauma center where the appropriate care is made available immediately.

Trauma triage is used to prioritize patients for treatment and transport according to the severity of their injury. Primary triage is carried out at the scene of the accident, while secondary triage is carried out once the patient reaches the hospital.

The A, B, C, D, E of trauma triage is discussed in the following sections.

While conducting triage, priority is given to patients who are most likely to deteriorate clinically by the time they reach the hospital. However, triage is a dynamic process, and it focuses on assessing patients frequently.

Trauma care primarily takes place in the emergency department, along with some type of emergency care delivered at the accident site. Evaluation and treatment in trauma cases have to be done simultaneously, beginning with injuries that post the most immediate threat to life. Attending to the less deadly injuries before moving on to immediate life-threatening injuries can prove to be a fatal mistake in trauma cases.⁹

The most commonly mnemonic used in trauma care triage is A, B, C, D, E, which stands for:

• Airway
• Breathing
• Circulation
• Disability
• Exposure or Environmental Control

The body systems have to be rapidly examined for any form of serious abnormalities (known as a primary survey), and a more detailed examination (known as a secondary survey) is carried out later once the patient is stable.¹⁰

Here is an overview of how emergency teams and doctors care for trauma patients.

1. Airway

The opening of your airway after trauma is threatened by foreign bodies, blood clots, or teeth in the oropharynx; soft tissue laxity, and posterior retraction of the tongue caused by head injury, shock, or intoxication. Hematoma or edema due to direct trauma to the neck can also compromise the airway. These obstructions are usually visible on direct first inspection of the neck or mouth. Having the patient speak can also rapidly confirm whether there is any immediate danger to the airway or not.¹¹

Foreign material and blood from the airway can be removed either manually or by suction. Obtunded patients whose ventilation, airway patency, and oxygenation is in doubt, and patients with severe oropharyngeal injury need to be cared for with endotracheal intubation. To achieve this, drugs are usually given to induce paralysis or unconsciousness before intubating.¹²

There are multiple tools that help doctors take care of airway issues in trauma patients, including airway bougie, video laryngoscopy, and extraglottic devices. A capnography can also help confirm the proper endotracheal tube placement.¹³

2. Breathing

Assuring adequate ventilation to a patient after trauma is an important step. Ventilation can be threatened by a decreased central respiratory drive due to intoxication, head injury, or a fatal shock, or even by chest injury like a pneumothorax or hemothorax, multiple rib fractures, or pulmonary contusion.¹⁴

In taking care of a trauma patient, one needs to have the chest wall fully exposed to look for external signs of trauma, paradoxical wall motion, and chest wall expansion. All these can be indicative of a flail chest. The chest wall needs to be palpated to check for any rib fractures and to check for the presence of subcutaneous air.¹⁵

Usually, whether the patient is getting enough air or not becomes apparent as soon as the patient is examined. Conditions like tension pneumothorax, hemothorax, or a simple pneumothorax can all be responsible for decreased breath sounds on the impacted side. If you determine that the patient has a pneumothorax, bedside ultrasonography or chest X-ray should be done before proceeding further.¹⁶

3. Circulation

Significant external bleeding can happen from any major blood vessel, but it is usually always apparent. However, internal bleeding can become life-threatening if left undetected. However, a large amount of internal hemorrhage usually occurs in only a few body cavities, including the chest, abdomen, soft tissues of the thigh or the pelvis, and/or the retroperitoneum.

Blood pressure and pulse have to be assessed, and any signs of shock are noted. These include:

• Diaphoresis
• Tachypnea
• Dusky color
• Altered mental state
• Poor capillary refill

In cases of internal bleeding, there is also abdominal enlargement and tenderness, thigh deformity, and pelvis instability.¹⁷

External bleeding is brought under control by applying direct pressure to the area.

Over the years, various protocols have been developed for patients who need large volumes of blood products.¹⁸

4. Disability or neurological dysfunction

Neurological functioning in trauma patients has to be evaluated for any severe deficits that may involve the spinal cord and the brain. In such cases, the Glasgow Coma Scale and pupillary response to light are the primary protocols that are used to assess the level of severity of the intracranial injury and consciousness.^19,20

Sensation in the extremities and gross motor movements are looked at to determine any serious injury to the spinal cord. The cervical spine will be palpated to check for any deformity and tenderness and then stabilized with a rigid collar until any injury can be ruled out.

In most countries, trauma patients arriving by ambulance are already immobilized on a long and rigid board that keeps them as stable as possible before they can be checked out.

5. Exposure or environmental control

To make sure that any injuries are not missed, trauma patients are undressed completely (clothes are usually cut off), and the entire body surface is checked for any signs of trauma. The patient is given heated blankets and warmed IV fluids to keep them warm and prevent hypothermia.

In every country, there are different protocols in place for the management of trauma care systems and for taking care of trauma patients. Evidence of the effectiveness of trauma services is carried out periodically from various panel reviews of preventable deaths, hospital trauma registry studies, and other population-based studies carried out by the governments.

Studies done in the United States have found that the effect of the trauma care systems is that there has been a significantly lower risk of death when patient care is provided at a trauma center instead of a non-trauma center. There has been an eight percent reduction in overall trauma mortality, including deaths on the scene, due to the system improvements. Trauma registry studies have, in fact, shown a 15 to 20 percent reduction in mortality as a result of the improvements brought about in the trauma care system in the US.^{21,22,23,24,25}

The outcome of patients after major trauma has improved all over the world after the implementation of various comprehensive trauma care systems. Critical components of a trauma system have to include a coordinated approach to both prehospital care as well as hospital care and to provide proper training to physicians in both these areas.

Paramedics and medical staff are both equally responsible for caring for patients after a trauma, and they have to be provided with a clear and objective framework to assess patients, establish and engage the required treatment protocol, follow triage guidelines, engage in transportation and communication protocols, and also implement ongoing performance improvement programs.

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