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Chapter 1
Initial Assessment and Management: Primary Survey and Resuscitation
David V. Skinner1 and Peter A. Driscoll2
1John Radcliffe Hospital, Oxford, UK
2Hope Hospital, Salford, UK
OVERVIEW
- Initial management of trauma victims requires a team approach in which each member carries out a specific task. Collectively, the team should aim to treat all the immediately life-threatening conditions and identify the need for surgery early.
- The ABC (airway, breathing, circulation) approach provides an optimal system whereby urgent, potentially life-threatening conditions are dealt with first.
- The critically injured patient requires a calm rapid response to his/her injuries, in the field, resuscitation room and operating theatre. If prehospital personnel, the resuscitation room team and its leader, as well as the appropriate surgeons can deliver this, then lives will be saved and unnecessary deaths avoided. Any deaths that do occur will have been unavoidable. The team should also be aware of this and suitably debriefed.
Morbidity and mortality in seriously injured patients, managed in UK hospitals, remain higher than necessary. Recognition of this problem over the last 25 years has seen a variety of initiatives designed to improve the situation, including the introduction of Advanced Trauma Life Support (ATLS) to clinical practice, the widespread use of the auditing tool TARN (Trauma Audit and Research Network), and the deployment of multidisciplinary trauma teams to manage trauma victims in emergency department (ED) resuscitation rooms. Increasingly, consultant-delivered services, where available, will further enhance care.
For each individual patient, however, survival and reduction of long-term disability depend on the rapid deployment of skilled prehospital clinicians (paramedics and/or doctors), the skills and experience of the receiving clinicians (trauma team) and the human and other resources available round the clock to deal with patient injuries in a timely and effective fashion.
Most seriously injured patients seen in UK EDs have suffered blunt trauma. This, by its very nature, presents its own unique set of difficulties for the clinician, not least because serious life-threatening injuries may be initially covert, especially in the young. Prehospital clinicians may not recognise potential problems; this may be further compounded by a failure of recognition by the receiving hospital, leading to inappropriate triage. Lone junior doctors may then find themselves assessing a deteriorating trauma patient in an unmonitored area of the ED, leading to potential catastrophe.
All ED doctors should therefore be ATLS trained and encouraged to have a very low threshold for âupgradingâ such patients without delay to the resuscitation room for a team response. Such upgrade should include not only the deteriorating patient, but also those in whom the mechanism of injury suggests the possibility of serious problems. In the authors' experience, most problems arise from a failure to understand, or take note of, the mechanism's injurious potential, rather than poor management of an overtly seriously injured patient.
Comprehensive management protocols (usually ATLS) must be followed to the letter. Short cuts expose patients to risk which will lead some into difficulty. The âexperiencedâ clinician's personal opinion must be outweighed every time by the multitude of experienced clinicians who devised the protocol. Such protocols are frequently driven by the need to avoid the errors of the past.
The introduction of trauma centres will hopefully produce a further improvement in trauma care but in the end, individual clinicians, either working alone or as trauma team leaders, bear the responsibility for ensuring optimum care.
Effective ED care depends on the following.
- Safe, accurate receipt of prehospital information regarding the trauma victim or victims.
- Assembly of a competent trauma team, competently led, and dressed in protective clothing.
- The team's ability to identify immediately life-threatening problems and begin their correction.
- Limiting investigations and interventions to those crucial to addressing life-threatening problems.
- Ready availability of all investigation modalities, and a suitably urgent response by labs, radiology, intensive therapy units (ITU) and theatres.
- The additional ability to sensibly allocate resources when a multivictim response is needed.
Trauma centre âfeeder unitsâ will not have the resources and manpower to provide a full trauma team response 24 hours a day, 7 days a week. In spite of this and given the difficulty of complete triage accuracy in the prehospital field, seriously injured patients will continue to arrive at such feeder centres. It is crucial therefore that such patients are managed in a logical way, based on ATLS, before possible onward transfer to a trauma centre. The main difference will be that the resuscitation phase will take longer given the reduced numbers in the trauma team.
Where a trauma team can be made available round the clock then it is in the patient's interests that it should be deployed. The following text suggests one way in which such a team should be developed and deployed. Individual centres will decide on the exact composition of such teams and comparative national data will identify the optimum team size and composition.
The trauma team
Personnel
The trauma team (Figure 1.1) should initially comprise four doctors, five nurses and a radiographer. The medical team consists of a team leader, an âairwayâ doctor and two âcirculationâ doctors. The nursing team comprises a team leader, an âairwayâ nurse, two âcirculationâ nurses and a ârelativesâ nurse.
Team members' roles
Examples of paired roles and tasks are given below but assignments may vary among units depending on the resources available. To avoid chaos, no more than six people should be touching the patient. The other team members must keep well back. The objectives of the trauma team are shown in Box 1.1.
Box 1.1 Objectives of the trauma team
- Identify and correct life-threatening injuries.
- Commence resuscitation.
- Determine the nature and extent of other injuries.
- Prioritise investigation/treatment needs.
- Prepare and transport the patient to a place of continuing care.
Before the patient arrives
All EDs should be warned by the ambulance service of the impending arrival of a seriously injured patient. This communication system can also provide the trauma team with helpful information about the patient's condition and the paramedics' prehospital interventions.
After the warning, the team should assemble in the resuscitation room (Figure 1.2) and put on protective clothing. A safe minimum would be rubber latex gloves, plastic aprons and eye protection because all blood and body fluids should be assumed to carry HIV and hepatitis viruses. Ideally, full protective clothing should be worn by each member of the team, and all must have been immunised against tetanus and the hepatitis B virus. Trauma patients often have sharp objects such as glass and other debris in their clothing and hair and on their skin, and therefore suitable precautions must be taken by all team members.
While protective clothing is being put on, the team leader should brief the team, allocating roles and responsibilities. A final check of the equipment by the appropriate team members can then be made. As the resuscitation room must be kept fully stocked and ready for use at any time, only minimum preparation should be necessary.
Roles of trauma team members
Medical and other staff
Team leader
- Co-ordinates the activities of the whole team.
- Performs a rapid initial primary survey to identify any immediately life-threatening problems.
- Ensures that airway and circulation team members are managing their roles rapidly.
- Allocates a suitably skilled team member to any task necessary, e.g. chest drain.
- Constantly prioritises patient's needs and team's activities.
- Ensures all information from prehospital team is noted.
- Ensures that other specialist clinicians are urgently alerted as soon as their need is identified.
Airway doctor
- Clears and secures the airway while taking appropriate cervical spine precautions.
- Inserts central and arterial lines if required.
Circulation doctors
- Assist in the removal of the patient's clothes.
- Establish peripheral intravenous infusions and take blood samples for investigations.
- Carry out other procedures depending on their skill level.
Radiographer
- Takes three standard X-ray films on all patients subjected to blunt trauma: chest, pelvis and lateral cervical spine.
Nursing staff
Team leader
- Co-ordinates the nursing team and liaises with the medical team leader.
- Records clinical findings, laboratory results, intravenous fluid and drug infusion, and the vital signs as called out by the circulation nurse.
- Prepares sterile packs for procedures.
- Assists the circulation nurses and brings extra equipment as ...
