IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS
(See Figure 12–1.) The primary goal in providing care to the trauma patient is effective resuscitation while minimizing the time from injury to definitive care.
Assessment of the patient with multiple injuries. DPL, diagnostic peritoneal lavage; FAST, focused assessment with sonography for trauma. (please see changes to figure).
Trauma care begins at the scene of the incident. It is important for hospitals to have good working relationships with local fire departments and emergency medical services (EMSs) to ensure that proper care is provided early. Preparation efforts should be coordinated between the emergency departments and the local EMS systems including prehospital protocols related to the treatment and transport of trauma patients. Transport protocols should incorporate decision-making guidelines including information regarding transporting patients to the most appropriate facility and the proper use of air medical transport. Prehospital providers should be trained to detect specific injuries and know the mechanism of forces that could predict the possibility of severe injury (Table 12–1). Prehospital personnel should provide early notification to the emergency department for all major trauma patients to allow emergency department preparedness.
Table 12–1.Definitions of major trauma. ||Download (.pdf) Table 12–1. Definitions of major trauma.
|Mechanism of Injury ||Clinical Information |
|Falls >20 ft ||Systolic blood pressure <90 mm Hg |
Rollover motor vehicle collision
Crash speed >40 mph
|Respiratory rate <10/min or >29/min |
|Auto-pedestrian or auto-bicycle collision ||Glasgow Coma Scale score <10 |
|Ejection of patient ||Penetrating trauma other than distal extremity |
Occupant fatality same vehicle Major auto deformity (greater than 20 inches intrusion)
Combination of 2nd- or 3rd-degree burns over >15% of the body and multiple trauma
Trauma score <13
Revised trauma score <11
Pelvic fractures, paralysis
Injury-scoring systems, such as the Glasgow Coma Scale (GCS), Trauma Score, and Revised Trauma Score, may be used to help quantify the degree of injury (Figure 12–2).
Trauma scores used to quantify degree of injury. A. Determine total on Glasgow Coma Scale. B. Convert Glasgow Coma Scale total to Revised Trauma Score points and determine Revised Trauma Score total. (Modified with permission from Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale, Lancet. 1974 Jul 13;2(7872):81-84.)
Maintain a high index of suspicion with pediatric, geriatric, and obstetric patients. Their physiologic responses to major trauma differ from those of other patients, and their injuries are often missed or delayed in diagnosis. Early transfer to definitive care improves outcomes in these patient groups.
Emergency department response should include a stepwise notification system to alert local surgeons or trauma teams and ancillary services such as X-ray, ...