You are called to see a 65 year old male tourist who has been admitted to your emergency department after being hit by a car while attempting to cross a busy street. He is unconscious and has obvious chest and limb injuries.
(a) Please outline your initial management of this patient.
Organized approach is essential. ATLS/EMST approach should be used. Most emergency departments that receive trauma do so with facilities that support a trauma team concept. Initial management should be undertaken as part of the trauma team, with roles usually well delineated.
Initial management requires simultaneous primary survey, resuscitation and assessment of history, followed by a secondary survey then definitive care.
Primary survey involves assessment of adequacy of airway, breathing and circulation (with interventions at each point whenever identified), followed by assessment of neurological state (pupils, level of consciousness, localising signs) and adequate exposure to assess major injuries. Indications for endotracheal intubation should be clearly described (GCS < 9, hypoxia/respiratory distress etc.). Initial ventilatory management should be detailed (respiratory rate, tidal volume, blood gas goals etc). Fluid administration and goals of resuscitation should be discussed. Relevant history should be obtained from ambulance officers, family, witnesses etc. In particular details about the mechanism of injury and patient’s previous medical condition, medications and allergies etc.
Secondary survey involves a detailed head to toe examination to assess extent of injuries (including flanks, back and rectal examination), as well as a detailed neurological assessment.
Definitive care involves planning for surgery, other specialist involvement and transfer as appropriate.
A systematic approach to this answer would follow the normal ATLS pattern of the primary survey.
A) - Urgent assessment of the airway, and of the need for immediate intubation (with in-line spinal stabilisation). A very high spinal cord injury may have resulted in respiratory arrest.
The decreased level of consciousness suggests that intubation is required.
B) - Evaluation of respiratory function and chest injuries. This patient can potentially have a tension or non-tension pneumothorax or haemothorax, and this diagnosis needs to be made early in the primary survey. High FiO2 should be administered. One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury.
Features of hypovolemia (eg. cool peripheries, pallor) should be sought. Blood should be sampled for crossmatch, and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia. Large-bore IV access should be established.
Blood products should be preferentially used for resuscitation, with a 1:1:1 ratio of PRBCs, FFP and platelets. The MAP target for fluid resuscitation should be a MAP >50mmHg.
D) The level of consciousness should be assessed. Features of spinal cord injury should be pursued on examination. Pupils should be examined to assess for signs of herneation.
E) The patient needs to be rewarmed (presuming they are hypothermic) and a blood warmer should be connected to maintain normothermia in spite of massive resuscitation
After the completion of the primary survery, the following investigations must urgently take place:
- Pelvic XR
- FAST US of the abdomen chest and praecordium can rapidly differentiate between the abovementioned causes of shock.
- CT trauma series, if available
This pathway of investigation should be abandoned and urgent damage control surgery should take place if any of the above assessment methods make it abundantly clear that a catastrophic shock state due to abdominal or thoracic haemorrhage is developing.
Definitive transfer arrangements must be made if definitive care cannot be offered at the current facility.
ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma