Major Trauma Management Guideline in a 2- A level Hospital Emergency Service Approaching and trea
BACKGROUND
There are different ways to classify hospitals, the most commonly accepted is 1st level or local hospitals, a 1st level trauma centre does not require an in-hospital general/trauma surgeon 24-hours a day but a surgeon must be on-call and able to come into the hospital within 30 minutes of being called. Anaesthesia and OR staff are also not required to be in the hospital 24-hours a day but must also be available within 30 minutes. These centres must have transfer arrangements so that trauma patients requiring services not available at the hospital. [1]
A 2nd level hospital has the ability to manage the most complex trauma patients with a spectrum of surgical specialists including orthopaedic surgery obstetric & gynaecologic surgery, ophthalmology, otolaryngology, and urology. In addition, they must have a spectrum of medical specialists including cardiology, internal medicine, gastroenterology, infectious disease, pulmonary medicine. The 2nd level A hospitals don’t have neurosurgery, cardiac surgery, thoracic surgery, vascular surgery, hand surgery, microvascular surgery, plastic surgery, urology and nephrology but 2nd level B hospitals do have theses specialities, and there is no need to refer vascular or neurosurgical patient.
3rd level of central hospitals with all the specialities, high grade of specialization PCI, burn unit, trauma surgeon 24-hours a day but a surgeon. Anaesthesia and trauma team 24 hours vascular surgery, interventionist radiology in addition to the rest of the services mentioned in the previous hospitals.
A lot of protocols have been done for small hospitals which need to refer most of the critical patients and for highly specialised trauma centres, but there are few protocols of managing a severe trauma in an intermediate level of hospitals, such as 2A level hospitals.
ROLL DISTRIBUTION AND PATIENT SELECTION
A 2-A level hospital’s ED is divided triage room, rooms dedicated to the treatment of patients with mild pathologies, central area with boxes and the chance of monitoring moderate and severe pathologies and the central box or boxes, for critical patients with ALS support equipment.
Patients with severe trauma are treated in the central box (ALS box) If the number of victims is more than two, they should be placed in individual boxes as well and the mentioned central boxes other central, trying to leave a free central box as soon as possible.
In case of exceeding the capacity of the emergency department, intensive care or/and anaesthesia services will be asked to cooperate in triage and delivering patients to other hospitals, once they have started the stabilization, starting with the catastrophe protocol, we would start with the level 1, and during this action the Head of Service must be informed.
Patients suffering severe trauma will be evaluated and treated by senior doctors from the Emergency Department who will assume the leadership of managing the emergency and will require the presence of the intensivist physician, the general surgeon, the orthopaedist and anaesthetist (depending on situation), as well as be in charge of requiring image diagnosis and starting the patient stabilization in the emergency service. Although the emergency care will involve multiple emergency senior doctors, only one of them will keep the leadership and responsibility of patient care. This must be identified from the start. The action on every patient with severe trauma will involve two nurses and one nurse assistant.
Acting prior to patient arrival Trauma patient care begins when the hospital is informed from the EMS (emergency medical service) of the existence and imminent arrival of the patient. [2] A senior doctor of emergency service will talk to the medical coordinator of the EMS, who will inform the clinical situation of the patient and the approximate time for his or her arrival. Depending on the number of victims and the situation of these, staff will be mobilize, the necessary facilities will be prepared, universal blood be asked, if required, and talk to radiology to reserve the tomography or prepare for the echographer in emergencies, according the clinical situation described by the EMS coordinator; in all of these situations to the radiology and blood bank will be pre-alerted. The I.C.U. will also be alerted and informed of the number of victims to prepare their further admission if necessary.
And in situations in which the surgery is needed, anaesthetist and the surgeon on call will be informed. Selection of the patient to whom the protocol of severe trauma will be applied Patients transferred by a EMS under "severe trauma protocol" (PPT) [3]
- Patients who have had cardiac or respiratory arrest.
- Patient who have required by the EMS or another hospital ABCDE approach (orotracheal tube, placement of chest tube, central line, transfusion of more than one litter or more infusion of saline serum to keep tensions ...)
- Head injury with loss of consciousness and initial Glasgow C.S. under 13. - Head injury with Glasgow Coma Scale declining.
- Facial trauma that may endanger the permeability of the airway.
- Patient traumatized in state of psychomotor agitation. - Patients who present respiratory distress in the context of trauma.
- Patients who present symptoms or signs of shock.
- Patient having large external bleeding (explained later in the C approach).
- Patients with penetrating wounds to the chest and / or abdomen. - Patients exposed to explosions.
- Patients bullet wounded.
- Burn extensive or suspected inhalation injury.
- All patients who by accident mechanism exploratory data may have injuries that can endanger their life. (Mechanism injured high energy, precipitated more than three meters, collision in a car in a speed more than 70 km / h motorcycle more than 35 km / h, outrage with the car going faster than 35 km / h, deformity of the cabin, prolonged extrication > 20 minutes, death of another affected in the same vehicle, ejection of the passenger from the vehicle, rollover of the car of the victim)
Distribution of the rolls during the process of care to traumatized patients [4]
·DOCTOR 1: He or she is the responsible for managing the process and all care decisions taken during the performance. It is in charge of receiving the patient when arrival and putting him/her in charge of the intensive care physician or anaesthetist at the end of emergency care. This doctor will be in charge of the patient during all the process. He or she is also responsible of completing the medical report and giving the final information to the family.
• DOCTOR 2 (may be a resident) helps physician 1. Gives continued support, he or she is also responsible of collecting clinical information, to perform resuscitative manoeuvres or techniques that assigned by doctor 1. He/she will handle the request for further tests and establish relationship with other specialists under the supervision of doctor 1.
• NURSE 1: handles canalization peripheral lines, obtaining blood for tests. This is responsible for measuring and recording vital signs. Help with central line placement. It is responsible for preparing and administering medication. It is responsible for nursing sheet. He/she will be responsible for clinical standards are followed during patient transfers
·NURSE 2: monitors the patient upon arrival, she is responsible for the material for the management of airway, ensures that the capnograph is ready at the time of intubation, the O2 mask, the material for chest drainage, material pericardial drainage, placing nasogastric or orogastric tube, placing the urinary catheter. She/he can help the nurse 1 with medication.
• NURSING ASSISTANT: cuts the patient's clothing and performs the functions requested by doctors and nurses. They will give rings and personal objects to security personnel of hospital.
•STRETCHER-BEARER: help in all mobilizations and patient transfers. Transfers of patients suffering severe trauma will always be a priority. They have to know the procedures for transfers.
·ADMINISTRATIVES: Must be responsible for data affiliation of the patient and ensure that the families have been notified, placing them in the waiting room, informing the doctor 1 of this.
INITIAL PERFORMANCE IN EMERGENCIES ON PATIENT WITH SEVERE TRAUMA:
A, B, C, D, E approach standardized by the American College of Surgeons shall always be followed. [5] Always remember, universal measures of self-protection measures. There are two main rules to follow:
• Once a problem is detected, this problem must be solved; do not continue before doing so.
• After having solved the problem, start again from the A
. A: Airway.
The first manoeuvre to perform in a traumatic patient is the release of the airway. Open the mouth looking for foreign bodies. With control of the cervical spine immobilization always trying to keep it aligned. Place or maintain cervical collar. The best method to ensure a patent airway is protected and isolation of this is the orotracheal intubation (OTI). We will perform IOT in the following cases:
- Patient with decreased consciousness with GCS <9.
- Respiratory insufficiency once discarded and solved the compressive problem. - State of uncontrollable agitation.
- Extensive burns on face with suspected inhalation injury.
- Stage III or IV hypovolemic shock - Respiratory insufficiency.
- Acidosis (respiratory or metabolic)
- Severe maxillofacial trauma.
- High Spinal Cord Injury with ventilatory impairment. If for intubation we have to remove the cervical collar, in case the patient needs Sellick manoeuvre for difficulty in visualizing the vocal cords, short neck, cervical trauma etc. While a physician is performing the OTI, the other physician will keep the neck aligned maintaining continuous traction on the axial axis. In addition to the auscultation, we will verify correct intubation by capnography.
Doctor 1 with the help of nurse 2 will open and assure the airway with cervical control.
Meanwhile nurse 1 will monitor the patient and doctor 2 will get the history of the trauma from the paramedics and share with doctor 1, AMPLE history, and inform the anaesthetist if there is any need or complex management of airway or intubation
B: Ventilation / breath
Once secured airway will assess the patient has a good gas exchange in his/her lungs. We will auscultate and measure respiratory rate and O2 saturation with pulse oximeter. Both hemithorax must be checked, looking for thoracoabdominal incoordination or asymmetries in the thoracic expansion.
In case of respiratory failure at high flow O2 supply we apply and will consider the possibility of tension pneumothorax. If any, tension will be released by placing 14G catheters, placed in 2nd or 3rd intercostal space, mid-clavicular line.
After this emergency action, a thick chest tube in 5th intercostal space mid-axillary line will be placed.
If we have well solved discarded the pneumothorax, we will administer high flow O2, if respiratory failure persists proceed to tracheal intubation by rapid sequence and subsequent mechanical ventilation.
If required OTI will keep the usual ventilator settings according to the characteristics of the patient, trying to keep the pCO2 at 38-42 mmHg.
Doctor 2 should inform the surgeon or/and the thoracic surgeon while the decompression of a hemo or pneumothorax is being perform, ask for a portable chest X ray previous and after the decompression if possible
C: Circulation
It is essential in the care of severe trauma early identification and treatment of shock. We must look for signs of poor tissue perfusion, coldness, elongated capillary refill, tachycardia and hypotension. We always evaluate four hemodynamic parameters: heart rate (HR), blood pressure (BP), Capillary refill (RC) and the existence of jugular venous distension (IY).
In addition, we measure the rectal temperature as the fight against hypothermia form part of the treatment of shock. The most common shock in the trauma patient is hypovolemic. It is not always easy to identify this type of shock because there can coexist several types at once. We will initially administer 500cc isotonic saline isothermal serum (36 ° C) in 5 minutes and according to the response boluses we will continue with 250cc to 2000cc complete or stabilize the patient.
While looking for causes of the shock, if there is not obvious bleeding chest, long bones, pelvic instability. Check for abdominal causes, perform E FAST
If signs of compression appear (shock persists and appears jugular venous distension), we must assess the possibility of tension pneumothorax as the most likely diagnosis, and pericardial tamponade and breaking of the diaphragm as alternative diagnoses. If after the administration 2000cc of warm saline serum (36 ° C) the patient is in shock, there are no signs of tamponade and no tachycardia we must think of the possibility of neurogenic shock. Especially if there are data of low cervical spinal cord injury clinical or high chest injury.
In case of patients in coma, the suspect of spinal injury is more complex and we have to look at data as priapism, piloerection or loss of anal sphincter tone. In case of suspecting neurogenic shock, it will treat it with warm isotonic saline serum and norepinephrine or alpha dose dopamine.
The use of steroids has been an option until now, in the last protocol ERC questioned its usefulness, we can use of them, but it’s not clear their usefulness.
Clinical signs that can make us suspect the shock can be difficult to appreciate in the early stages due to compensatory mechanisms. Poor perfusion, high lactate levels and the bases excess can be used as indicators. It is essential to arterial blood gasometry as soon as possible (without delaying the stabilization of A, B, C, D, E) to properly assess tissue perfusion. Then we can use the laboratory test as a parameter of good resuscitation, it has prognostic value.
While Doctor 1 is evaluating, Nurse 1 will be monitoring, canulating the veins, administering medication, tranexanemic acid if needed, fluids. Doctor 2 will be in charge of calling surgeon, anaesthetist, intensivist, radiology department, activate massive blood protocol. Nurse 2 will send the blood samples and come back to the resuscitation area or central box for patient following up.
D. disability.
GCS, pupils, and glucose level.
Alarm signs:
GCS less than 9.
Decrease in the level of consciousness and one of the following clinical signs:
- Anisocoria
–Default engine central neurological origin
–Bradycardia and hypertension
While doctor 1 is doing the evaluation doctor 2 will contact the radiology department if not done yet, nurse 1 will be in charge of the medication and nurse 2 in charge of the monitor and ventilator connections. If the patient needs to be moved to radiology doctor 1 will be in charge of the airway and orotracheal tube during the mobilization of the patient and doctor 2 in charge of the parameters of ventilation. Nurse 2 in charge of the connections and nurse 1 in charge of the monitoring and the medications and fluids.
E exposure and environmental control.
Check if there are any life threatening injuries. Temperature measure and control.
Do log roll manoeuvre to exam the back of the patient in the first survey only if there is an external bleeding and we can’t see the wound.
MOST FREQUENT SYDROMES IN TRAUMATIC PATIENTS
APPROACHING AND STABILIZATION IN HYPOVOLEMIC SHOCK [6]
Once presence of other types of shock is discarded or treated, if a situation of hemodynamic instability persists, we must suspect the presence of hypovolemic shock.
Typical sings and symptoms of hypovolemic shock:
• Agitation or stupor, tachycardia, poor tissue perfusion with increased capillary refill time, hypotension, cold skin and hypothermia.
• In the early stages these signs can not so clear, and quick way to confirm the poor tissue perfusion it is to assess excess bases that will be negative and elevated lactate levels.
Possible points of blood loss:
• External bleedings: compression of external bleeding sites is a priority, if possible will be done at the same time stabilizes the A. If major bleedings occur, due to amputations or damage of large vessels of a limb the patient will need urgent surgery. .
• Thoracic bleeding: large thoracic vessels lesions (which in many cases cause immediate death), sometimes blood can be in the pleural space (haemothorax) in case of massive blood flow while placing the tube (over 1000cc) is necessary clamping the tube calling immediately to the thoracic surgeon. If massive compression of the lung occurs again, we must re-open the tube and let the blood pass to the Pleur-Evac®.
• Abdominopelvic traumatism: It is the most common cause of hypovolemic shock. The priority will be the location of the bleeding point and closing it. While trying status shock, we will try to prevent the subsequent coagulopathy, acidosis and hypothermia, try early diagnosis. .If the patient is in a critical situation and cannot be moved from the central box a FAST echography and portable chest and pelvic radiography must be performed. If free intraabdominal liquid is found, an urgent laparotomy may be necessary. At the slightest suspicion of pelvic fracture a stabilizer belt must be placed the and after radiographic confirmation and call the orthopaedist.
Treatment of hypovolemia:
• We must catheterize two peripheral lines of large calibre (14G), preferably in antecubital fossa. If not possible we will place short and large-calibre central lines which will allow greater volume replacement.
· Hot serum at 36 °C in bolus of not more than 250-500cc must be administered to the patient in order to stabilize him/her.
• If the patient is young without associated head trauma we will start hypotensive resuscitation, our target will be systolic blood pressures around 90 mmHg or presence of radial pulse.
· If the patient suffers severe hypovolemia, in stage III or IV shock when arrival, or have required CPR or remains in shock after administration of bolus of crystalloid send request to the blood bank to start "critical Trauma" protocol, telephoning them to send us immediately the necessary blood products: concentrated hematies, platelets (1pool) and plasma (500cc) and call the hematologist, as established in massive transfusion protocol, which will be activated from the central box.
· If the patient is anticoagulated it will be essential to start as soon as possible administrating clotting factors and if the victim is being treated with antithrombotic treatment, platelet transfusion from the platelet pool will be necessary. It is important to treat with plasma and platelets as soon as possible in patients suffering severe hypovolemia. It is vital to avoid the appearance of coagulopathy, which increases overall mortality We must avoid by all means hypothermia. Cover the patient with thermal blanket and we will administer the patient hot iv fluids. We will measure the core temperature.
· Monitoring lactic acidosis will let us follow the evolution of shock. Approaching the hypovolemic shock
· Isolation of airway performing rapid sequence intubation and mechanical ventilation (Class I evidence) ensuring good gas exchange, to avoid aspiration. The must use low tidal volumes, which will increase cardiac preload improving the shock suffering patient’s situation.
· Discard other causes of shock: Compressive: Tension pneumothorax, cardiac tamponade, diaphragmatic rupture. Neurogenic shock. Cardiogenic: myocardial contusion.
·Quick diagnosis aimed to stop the blood losses. The bleeding must be stopped. · Catheterizing 2 peripheral lines for high flow fluid reposition. Antecubital placement 14- 16G
· Volemic reposition.
1. Initial administration of 20-30 ml / kg of crystalloid (isotonic saline isothermal (36°C) serum) is indicated. Class II evidence. We will re-evaluate the patient after having administered each 250-500ml.
2. Hypotensive resuscitation: replacement must not be aggressive until the bleeding is controlled. Try to keep SBP around 90 mmHg (presence of radial pulse) It is not indicated in elderly hypotensive resuscitation, or severe head injury.
3. It is indicated blood transfusion with O type (without knowing haemoglobin level): massive transfusion protocol will be activated. In the following cases: (Class II evidence.) - Exsanguinating lesions loss of > 40% of blood volume. - Patient who remain hypotensive after the bolus of crystalloid. - Stage IV shock (American College of Surgeons) - Patient who have suffered cardiac arrest and hypovolemic shock.
4. While catheterizing the two lines, blood samples will be taken, a routine biochemistry test, an hemogram, coagulation test and blood type, so that the 0 group transfusion can be stopped and the transfusion of blood with patient’s blood type can be started as soon as possible
· Prevention of hypothermia: Cover with thermal blanket to the patient, environmental temperature control in the central box (24 °C), serums and blood must be administered at 36 ° C blood products heater must be used for blood transfusions. Core temperature must be measured.
· Prevention of coagulopathy: Using plasma, platelets and coagulation factors as required. The blood bank will be notified telephonically to inform them of the need for urgent blood products, following the "critical trauma" protocol. The blood bank will start the massive transfusion protocol.
· Avoiding acidosis: The onset of acidosis is a true reflection of poor tissue permission and its increase is a poor prognosis. The base excess and lactate must be monitored as parameters good Resuscitation.
· In addition to avoiding the lethal triad (Hypothermia - Coagulopathy - Acidosis), we must not forget the hypotensive resuscitation in some cases and surgical concept of "damage control”
PROCEDURE IN EMERGENCY DEPARTMENTIN CASE OF HYPOVOLEMIC SHOCK DUE TO AN ABDOMINOPELVIC TRAUMA [7]
Phase I: Initial assessment and stabilization of A and B
· Airway management open the airway, tracheal intubation if required. Rapid intubation sequence must be used
· Tension pneumothorax must be diagnosed and treated
. · Ensure good oxygenation. Minimum Tidal volumes must be used without causing hypoxemia or hypercapnia.
· Cathetering two peripheral lines and obtaining blood samples for laboratory tests. Phase 2: Assessment of A and B and simultaneous start of the initial treatment of C · Restore blood loss with a maximum of physiological hot serum of 2000cc with 500cc repeated bolus.
· Discard other causes of shock.
· The goal is to reach a SBP around 90 mmHg except in arteriosclerotic patients or suspected intracranial hypertension in those cases aimed blood pressure must be higher.
· Avoid hypothermia.
· Blood transfusion, firstly universal type of blood, after lab. tests patient’s blood type
· Ask for urgent platelet and plasma transfusion in severe hypovolemic patient. · Administrate clotting factors in anticoagulated patients or in patients in treatment with antiplatelet agents if they are bleeding
· Use the stabilizer pelvis belt to the slightest suspicion of fracture.
· Patients with penetrating wounds and shock need urgent laparothomy.
Phase 3: Diagnosis and simultaneous treatment of C
· Consider cranial and cervical tomography, another tomography involving thorax, abdomen and pelvis, both must be performed, without contrast, followed by abdominopelvic tomography in arterial phase and portal phase if there is a hematoma. · If the patient is very unstable to perform a tomography, a chest radiography and FAST echography must be performed in the central (CPR) box.
Phase 4: acting according to findings and clinical situation
· Unstable pelvic fracture: first step is to put a pelvic stabilizer belt in the central box (if it had not been placed before) and subsequent external fixation in the operating room by orthopaedic surgeon.
· Findings requiring laparotomy: Patient must be delivered to the operating Room (damage control strategy).
· Patients with penetrating abdominal trauma and shock need an urgent laparothomy. Don’t remove any foreign body if it’s nestled.
INFORM THE REST OF THE SPECIALIST AS SOON AS THEIR NEED IS SUSPECTED Radiologist – Orthopaedic surgeon – General surgeon - Anaesthetist - Arteriographist – Intensivist
SEVERE CRANEOENCEPHALIC TRAUMA [8]
· Severe traumatic brain injury is the leading cause of death and disability in injured patients. It is the most common cause of death in the general population less than 45 years.
· Mortality increases significantly if the initial cares aimed at reducing the secondary damage are not performed properly or if the diagnosis and treatment of the primary lesion is not precocious.
· Sequential protocolised performance by emergency services have been shown to increase survival and decrease the aftermath of severe cranioencephalic trauma.
· Our aims should be:
1. Prevention of secondary damage by optimization of A, B, C.
2. Specific measures to patients with signs of trans tectorial herniate
on.
3. Conduct an early diagnosis of space-occupying lesions that may require urgent neurosurgical treatment. Definition of severe craneoencephalic trauma CET: It is considered a serious CET every patient with at least one of the following clinical and / or radiological elements:
1- Glasgow Coma Scale less than 9 points
2- Decrease in the level of consciousness and one of the following clinical signs:
- Anisocoria
–Default engine central neurological origin
–Bradycardia and hypertension
3- Prolonged posttraumatic seizures or status epilepticus.
4- Penetrating cranial trauma with Glasgow below 13 Asses of A, B, C.
A: Airway
· Asses the airway by OTI while protecting of cervical spine.
· The rapid sequence intubation reduces the deleterious effects they have on ICP laryngoscope and intubation.
· The indicated drug for induction in the rapid intubation sequence in trauma patients is etomidate though midazolam can also be used. Midazolam will be used to maintain sedation.
· As miorelaxants succinylcholine or rocuronium can be used. B: Ventilation • Normal ventilation should be maintained, with O2 saturations above 95% in the Oximeter and CO2 and 35-40 mm Hg in the capnograph. The parameters on the ventilator must be adjusted to get these values.
• Moderate hyperventilation is only indicated if there is a clinical suspicion of transtectorial herniation.
• The possibility of pneumothorax must be considered, treating it if suspected.
C: circulation
· Hemodynamic stabilization is a priority from the point of view of neurological evolution and immediate treatment of shock. Hypotension increases morbidity and mortality due to brain damage in severe head injury by reducing cerebral perfusion. CPP = MAP –ICP (cerebral perfusion pressure=mean systemic arterial pressure – intracranial pressure)
· Lower systolic blood pressure than 100 mm Hg must be avoided. It is not indicated hypotensive resuscitation on the patient with associated severe brain trauma.
· Resuscitation must be performed using physiological saline serum. In case of hypovolemia associated to signs of intracranial hypertension hypertonic saline can be used. 250ml at 7.5% concentration in 15 minutes in a single dose. 5.3 Treatment of intracranial hypertension.
· Avoid hypoxia: Establish adequate ventilatory support and continuous monitoring O2 Sat and capnography for: pO2 = 100 mmHg must be between 35-40 mmHg pCO2.
· Avoid arterial hypotension
· Put the patient in anti-Trendeemburg position between 15-30 ° degrees this measure is contraindicated in shock
· Analgesia and sedation: pain, agitation, not being adapted to the ventilator... increase the ICP, that’s why sedation-analgesia is essential in the management of these patients. Fentanyl is recommended for analgesia and midazolam for sedation, both continuous infusion is. If there is no a good adaptation to the ventilator muscle relaxant (rocuronium) is recommended.
· Administration hypertonic saline serum: It is preferable to mannitol in patients with hemodynamic instability. In emergencies we pass 250ml single dose of 7.5% in 15 minutes.
· Mannitol administration: we will use it if transtectorial intracranial hypertension with herniation is clinically suspected and the patient is hemodynamic stabile. The recommended dose is 0.5 to 1 mg / kg, in a serum 250cc, 20% concentration in 15 minutes.
· Moderate hyperventilation (pCO2 30-35 mmHg) must only be used in patients with clinical suspect of brain herniation that have not improved after all the above mentioned measures. ** An isolated convulsion does not require treatment. If status epilepticus the best choice are benzodiazepines (Midazolam 5 mg) if no response, we can repeat dose in five minutes, if there is no response with this two doses, Valproic acid, levetirazetam or Phenytoin 5.4 Findings on tomography in severe brain trauma and contacting neurosurgery (in hospitals where this specialist is not available, phone the neurosurgeon on call in the hospital of reference.)
· Subdural hematoma: The most common surgical intracranial lesion, approximately 20-40% of patients with severe injuries. It is a blood collection in the subdural space (in the potential space between the dural anarachnoid) due to rupture of veins. A surface bridging vessel can be torn because the brain parenchyma moves during a violent head motion. Its mortality is 30-70%. Urgent surgical treatment is required except in laminar if <5 mm hematomas. It requires radiological assessment (to have access to our images) from neurosurgery and transfer to the reference hospital if applicable. Meanwhile the patient must remain in the central box.
·Epidural hematoma: (1% of the admissions) blood collection in the extradural space. Epidural hematomas most commonly (85%) result for bleeding in middle meningeal artery. Epidural hematomas, however may occur in other locations, may develop from bleeding from diploic vessels injured by overlying skull fracture, it can also be due to a venous bleeding. The morbidity and mortality depends on the precocity of surgical treatment. (Mortality of 10-30%). Neurosurgery specialist must be called immediately and the patient transferred to the reference hospital. The patient will remain in the central box
· Diffuse axonal injury: This type of injury commonly results from traumatic rotation of the head, with mechanical forces that act in long axon, leading to axonal structural failure. This causes micro intracerebral hemorrhages in the cocorticosubcortical union. The prognosis is poor when the patient is in coma. The neurosurgeon will be phoned, as well as the intensivist on call to assess transfer of the patient to the center of reference. · Cerebral Edema: Obliteration of basal cisterns and ventricular system. The guidelines of cerebral edema protocol must be followed. The neurosurgeon and the ICU must be contacted.
· Cerebral contusion and intraventricular hemorrhage: Conrp injuries (contusions) are caused by direct transmission of impact energy through the skull into the underlying brain and occur directly below the site of injury, Intraventricular blood is an indicator of more severe head trauma. Intraventricular blood also predisposes the patient to posttraumatic hydrocephalus. Contusions may not need surgical treatment if intraventricular hematoma is bigger than of 25ml. Mass effect will be produced. This will require contact the neurosurgeon remaining the patient in the central box while he/she is transferred to neurosurgery or ICU.
· Ttraumatic subarachnoid hemorrhage: It is a prognostic factor in head injury severity. It does not require initial surgical treatment but can cause hydrocephalus. Contact neurosurgeon and UCI.
· Depressed skull fractures: can be locked in the brain parenchyma and injure cortical vessels. Require immediate surgical treatment. Contact the neurosurgeon the patient will remain in the central box while waiting to be transferred. NOTE: in any case the neurosurgical assessment should delay the urgent stabilization the A, B, C, approach, or the surgery or angiography to treat a bleeding lesion. Remember that the more severe hypovolemia is, if it is associates with a severe brain damage, the mortality will increase dramatically in a trauma patient.
SPINE TRAUMA AND SPINAL CORD INJURY [9]
· The spinal cord injuries (SCI) are rare, around 30 cases per year per million inhabitants. Up to about 50% related to multiple traumas. The most commonly affected area is C6 to D1. The SCI leave important permanent disability.
· The existence of other trauma, the existence of vital risk and decreased level of consciousness often difficult to diagnose this disease. In almost one third of patients the diagnosis of spinal cord injury is delayed more than 48 hours.
· Our initial approach in SCI (spinal Cord Injury) must be:
1. Stabilization of ABC
2. Do not increase the existing damage, acting as if there is injury until it is completely dismissed.
3. Prevent secondary spinal cord injury.
4. Early diagnosis. Patients at high risk of having a spinal cord injury
• Impaired consciousness recovered or not.
• Intoxication with alcohol or drugs.
• Abnormalities on neurologic examination
• Neck pain
• High energy traumas
• Injuries due to diving or jump
• Direct cervical trauma
• Rigid spine (Ankylosing Spondylitis ...) Stabilization of A, B, C in spinal cord injury When all patients in which spinal cord injury is suspected, the spine must be kept fully aligned using spinal board and cervical collar.
A: Airway:
· The spinal injuries with associated respiratory problems. The C1 and C2 can cause respiratory arrest by complete paralysis of all respiratory muscles, requiring immediate mechanical ventilation.
· OTI will be performed by rapid intubation sequence. The drugs are the same as for other severe trauma, considering that there may be hemodynamic instability.
· The intubation has to be made with special care, always keeping the spine aligned. We removed the collar as a partner performs continuous traction in the axial axis. A good alternative is the use of AirTrack® or fiberscope. B: Breath:
· The level C3 to C5 spine cord injuries often associate diaphragmatic paralysis. The patient continues breathing accessory muscles, but they usually fatigue soon. They also it require OTI and immediate mechanical ventilation to prevent complications. · Injuries below C5 can cause paralysis of intercostal and abdominal muscles, which may cause some respiratory failure on which we will act according to the severity of it. Injuries below D5 rarely cause respiratory failure.
· Acute pulmonary oedema secondary to spinal cord injury is rare in the first hour but can occur C: Circulation:
· Patients with spinal cord injury above D5 may suffer spinal shock or neurogenic shock.
· It is a distributive shock causes hypotension, bradycardia and normally warm skin.
· Hypotension must be initially treated with a bolus of saline serum of 1000cc and the coexistence of hypovolemia due to bleeding must be discarded.
· If BP does not normalize the use of Dopamine at high dose (alpha) can be required.
· If bradycardia is intense atropine can improve the frequency and cardiac output. If severe bradycardia is unresponsive to treatment the use of external pacemaker may be necessary.
· Manoeuvres or pharyngeal and tracheal secretions aspiration may increase bradycardia and even cardiac arrest. When performing tracheal intubation is advised to prepare atropine in case it is needed. Specific treatment of traumatic spinal cord injury · It is essential for the good prognosis of SCI the correct perfusion and oxygenation of the damaged tissue, that’s why hypoxia and shock must be treated.
· Although discussed, today is still accepted the early use of corticosteroids IV. An initial bolus of methylprednisolone, 30 mg / kg in 15 minutes. After a pause of45 minutes, start an infusion of the same drug to 5,4mg / kg / hour.
· After imaging tests we will contact neurosurgery or orthopaedic surgery according to the affected area. Diagnosis of spinal cord injury
· Radiographs in different projections remain the first recommended image test in the initial diagnosis of spinal injuries. However given the number of SCI not visualized in radiographies will often be necessary spine tomography.
• An urgent spine tomography will be required in the following patients: + Comatose trauma patients require CT cervical spine. + Patients intoxicated with cervical trauma and / or head and neck pain. + Patients with impaired neurological examination compatible with spinal cord injury. + Patients diagnosed or suspected by plain radiography of cervical fracture. + Patients with high clinical suspicion of cervical spine fracture or even if they have normal neurological examination and simple Rx. + Severe trauma patients by high-energy mechanism require a full TAC, including the entire column.
• MRI will be performed in certain cases, after assessment by neurosurgery and if it can lead to a change in the urgent therapeutic approach. In most cases it will not be required urgently
SEVERE CHEST TRAUMA [10]
· Severe chest trauma is associated with up to 80% with multiple traumas. The vast majority are secondary to traffic accidents.
· Causes of death are due to chest injuries also have a trimodal distribution. In the first minutes patients die due to heart failure, tracheal rupture or breakage of large vessels. In the early hours, tension pneumothorax, pulmonary laceration, diaphragmatic rupture or uncontrolled bleeding are the main causes of death. The following days die because of sepsis or multiple organ failure. The guideline of diagnosis and treatment of severe thoracic trauma is all traumatized patient is A, B, C, D approach. Approach in emergencies to severe chest trauma
· Asses the need for isolation of the airway, according to the needs described in previous sections.
· Ensure providing a good gas exchange O2 at high flows and if necessary after performing mechanical ventilation OTI.
· Early diagnose of tension pneumothorax as a cause of respiratory failure and we must monitor the evolution of small pneumothorax in mechanically ventilated patients.
· Cover the existing wounds to contact with Asherman pleura patch to prevent tension pneumothorax.
· Never remove foreign bodies if they are stuck in the chest.
· Chest trauma can cause all types of shock - There may be hypovolemic shock due to rupture of large thoracic vessels, or secondary haemothorax due to the breaking intercostal vessels. - There can also be a compressive shock due to tension pneumothorax as pericardial tamponade as diaphragmatic rupture. - We can also find neurogenic shock spinal thoracic high injuries, and even cardiogenic shock of because of myocardial contusions or injury of the anterior descending artery. Specific chest injuries Pneumothorax:
· It is present in 70% of penetrating injuries and 40% of non-penetrating trauma. 65% of pneumothorax associate haemothorax of greater or lesser extent.
· The diagnosis of tension pneumothorax must be clinical (severe dyspnoea with respiratory work, hypotension, sweating, poor perfusion, jugular venous distension and decreased murmur in) and must be treated immediately (first catheters nº16 in the 2nd intercostal space midclavicular line to relieve pressure and then thick drainage tube in 5th intercostal space midaxillary line).
· Open pneumothorax (with contact with the outside wound) we must place an Asherman patch and perform thoracic drainage. Closed non tension pneumothorax must also be drained with a thick tube unless they are very small. The tube will join a water seal, initially without suction.
Haemothorax:
· The presence of fluid in the pleural space after trauma is usually due to bleeding. If hemorrhage is due to lung injury (unless there is involvement of the hilar vessels) bleeding is usually small and slow. Hemorrhages from injury of systemic vessels (parietal, mediastinal or diaphragmatic) quickly cause significant hemothorax.
· Its clinical suspicion is based on the presence of hypoventilation predominantly in dependent areas and dullness to percussion, with or without hemodynamic deterioration and with or without respiratory failure.
· In chest radiography can be seen a homogeneous veiling all hemothorax when the blood quantity exceeds 200 ml, or a disappearance of the diaphragmatic silhouette when hemothorax exceeds 500cc or white lung large bleedings. Tomography is the imaging test of choice.
· Its treatment is the placement of a chest thick drain connected to a PleurEvac®. Previously check it with a fine needle the liquid contains blood and not digestive rests (diaphragmatic rupture which will need surgical treatment) or whitish liquid (quilotórax conservative treatment).
· Exploratory thoracotomy is indicated if the amount of blood in the initial drainage exceeds 1000cc or in the first hour after draining a debit of 400cc or 200cc over time is obtained for 3 hours straight. Bone fractures:
• Rib fractures: Rib fractures are very common in the chest trauma. Many of them are unnoticed. The fractures of the first three ribs mean high energy trauma and require searching other internal injuries by CT. The presence of low costal fractures often associates intra-abdominal solid organ injuries and also require study.
· Rib Volet: It is due to fracture of more than three consecutive ribs in more than one point each of them. This results in a paradoxical breathing (the area sinks with inspiration). If it produces severe respiratory failure, recommended treatment is mechanical ventilation. Sometimes require surgical fixation.
· .Sternum fracture: It is associated with high-energy trauma. The patient requires observation even when apparently there are no other injuries.
· Scapular fracture: up to 50% remain unnoticed in the chest radiograph. It involves high energy trauma. The scapulothoracic dislocation is a rare injury but frequently associated with both major vascular lesions and injuries in brachial plexus. Pulmonary contusion:
· it’s frequent and associates high mortality.
· Damage occurs by different mechanisms that damage the alveolar-capillary membrane, parabronchial oedema, haemorrhage and atelectasis area hypoventilation and shunt effect.
· Its diagnosis is radiological, being CT the gold standard test. Sometimes injuries do not appear until 6 hours later. The initially visible lesions indicate high energy and worse prognosis.
· Initial treatment must be aimed at reducing breathing effort by analgesia, oxygenation and treatment with mechanical ventilation in severe cases. Pulmonary laceration:
· It’s defined as pulmonary tears commonly secondary to penetrating trauma.
· Normally they do not require surgical treatment
. · They are usually associated with haemothorax and / or pneumothorax that require drainage.
• If severe respiratory failure is associated it may require mechanical ventilation as well as drainage
DEFINITIVE TREATMENT, ADMISION OR REFERRAL
ADMISION
Patients who can be managed in a A 2 lvel hospital do not need to be referred. There are two different situations for a patient which should be admitted in a A 2 level hospital. [11]
1. A person who doesn’t need urgent surgery, that person will be admitted in ICU
2. A person who needs urgent surgery. That person will go to theatre, after a surgeon and anaesthetist assessment.
Patients who don’t need urgent surgery. [12]
Thoracic concussion, normally with multiple rib fractures
Haemothorax, drained
Pneumothorax, drained
Patients who need urgent surgery
Abdominal trauma with a liver or spleen laceration
Pelvic instable fracture
Long bone fracture, such as femur
People with abdominal trauma, fluid in E FAST to instable to go to a CT.
Penetrating wounds both thoracic and abdominal
Doctor 2 will ask the surgeon or orthopaedic surgeon to go to ED the resus area, anesthesist or/and intensive care specialist. Doctor 1 will inform about the situation, background, suspected diagnosis, tests made to the patient and treatment administered. Doctor 2 will fill a form with all this information. Nurse 1 will give a form with the medication, times and fluids including at what time they had been administered to the specialist. Meanwhile the Nurse 2 will be in charge of checking the vitals and the correct monitoring of the patient while he/she is being transferred to the specialist.
REFERRAL
Criteria for referral to a 3rd level hospital
Any patient who can’t be managed in a A 2 level hospital should be referred to a 3rd level hospital.
This includes
- Need of neurosurgery
- Burns more than 20% of the corporal surface or with affection or face, neck and hands.
- Need of vascular surgery
- Need or paediatric ICU
- Spinal injury
HOW TO REFER A PATIENT TO A 3RD LEVEL HOSPITAL
PATIENT TREATMENT
The airway should be open or isolated with an endotracheal tube [13]
Ventilation (correct parameters depending on the pathology, allways trying to give a protective ventilation, avoid barotrauma)
Thoracic drainages placed, if needed.
Blood and tranexamid acid administered amines if needed to keep the patient stable.
Correctly inmovilised.
REFERRAL PROCEDURE
Doctor 1 will phone the interhospital coordination centre of emergency services.
Explain situation, background, diagnosis, applied treatment and test made to the patient. And reason for referral.
Doctor 2 will ask for the radiology forms and finish the treatment form to be referred.
Nurse 1 will fill a form with all the drugs and fluids administered to the patient
Nurse 2 will take care of monitoring and make sure that there is no change in the VS of the patient, if there is any change inform doctor 1.
The inter hospital centre will inform which the receptor hospital will be and will send an advanced life support unit to the hospital.
Doctor 1 will summarize the situation and changes in the patient since the last phone call to the coordinator centre to the doctor in charge of the ALS unit, nurse 1 will inform about the medications and fluids given to the patient.
All the team must do a debriefing of the situation once the procedure has finished in order to reassess all the procedures that have been correctly done and correct situations which can produce errors in the future. [14]
REFERENCES
1. https://www.mscbs.gob.es/estadEstudios/estadisticas/docs/CMBD/CLASIFICACIONHOSPITALESCLUSTER.pdf
3. Cruz Roja Sinaloa, Mecanismos de lesion. ... Lesiones Penetrantes Baja Velocidad Alta Velocidad / Media Energía Alta Velocidad / Alta Energía; 40.
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