By Mark Walker, M.D.
Trauma is a unique illness that presents several challenges in the early period after injury. Time is of the essence as vital functions must be restored quickly to minimize ongoing damage from shock, severe brain injury or multiple fractures across several anatomic compartments.
To complicate matters, trauma physicians are often working with an incomplete database. The patient may be unresponsive, and consequently there is limited information available about med-ications or prior medical history.
Advanced Trauma Life Support (ATLS)Protocols
An organized team familiar with advanced trauma life support – using the Airway, Breathing and Circulation (ABC) triage protocol – will meet the critically injured patient in the resuscitation bay. Emergency room physicians and general surgeons are critical members of the team. Specific tasks are assigned, and a rigorous search for acute life-threatening conditions is undertaken.
Airway obstruction, tension pneumothorax, cardiac tamponade and exsanguinating hemorrhage must be excluded during the primary survey.
Airway. The first priority is to secure the airway. Most often this will be accomplished with oro-tracheal intubation using c-spine precautions. A chest X-ray is then done to confirm the position of the tube.
Breathing. Tension pneumothorax is addressed with needle decompression followed by chest tube decompression. Cardiac tamponade will often require pericardiocentesis followed by opera-tive intervention to repair the damaged heart or great vessels.
Circulation. Exsanguinating hemorrhage is addressed with direct pressure combined with the use of a tourniquet if the bleeding is coming from an extremity. We have adopted this technique from lessons learned during military combat (1). We are always thinking about the underlying source of blood loss, and a rapid abdominal ultrasound can help to exclude an abdominal source. The chest and pelvic cavities are important sources of hemorrhage as well. Plain films of these areas will provide some clue regarding sequestered blood. CT imaging will also help to define sites of blood loss.
The importance of approximating whole blood resuscitation for patients with massive hemor-rhage is another principle garnered from military experience. It has been applied successfully in the civilian setting (2). Fresh frozen plasma (FFP) and packed red blood cells (PRBCs) are avail-able in the trauma bay and are used liberally when shock and massive blood loss is evident. Thromboelastography has emerged as a useful tool to guide blood product administration.
Rapid Operative Intervention. The hallmark of quality trauma care, rapid operative interven-tion must be part of any protocol to address ongoing shock. In 1994, Bickell and Mattox ques-tioned the efficacy of pre-hospital fluid resuscitation in the landmark paper “Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries” (3). Limiting crystalloids and tolerating a lower blood pressure until definitive control of vascular injuries has been achieved is a vital part of resuscitation in the current era. This is called permissive hypoten-sion and is reasonable if the patient is on the way to the operating room for definitive control of bleeding.
Staged Operative Interventions. We have also learned that staged operative interventions may be needed in the setting of shock, acidosis and coagulopathy. This vicious bloody cycle or triad can be interrupted if judicious surgical intervention focused on packing, rapid control of vascular injuries, limiting peritoneal contamination and temporary closure of the abdomen is implement-ed. This damage control approach should not be applied to every patient in shock but has a vital role to play in those with the most serious injuries. Combining damage control resuscitation (1:1:1 ratio of packed cells to fresh frozen plasma and platelets) with a damage control laparotomy re-sults in more rapid resolution of shock with clearing of elevated lactate levels and resolving aci-dosis (4). This in turn may have a positive impact on outcome as the speed of lactate clearance is correlated with mortality and morbidity (5).
Multi-Disciplinary Effort
Trauma resuscitation is a multi-disciplinary effort. The general surgeon with training or special interest in trauma serves as the team leader and helps to coordinate care. Close coordination with interventional radiology and orthopedics has improved the management of complex pelvic frac-tures with ongoing hemorrhage. Pelvic binders combined with angiographic embolization and the application of external fixators have been life-saving in several instances. Close coordination with neurosurgery and the use of intracranial pressure monitoring along with surgical decompression has improved outcomes in select patients with severe cerebral trauma. Close communication with vascular surgery and their use of an endovascular approach has made a significant difference in the outcome of patients with blunt aortic injury. Close communication with anesthesiology during operative interventions has improved intra-operative resuscitation.
Ongoing Resuscitation
Once the patient leaves the trauma bay or the operating room, our work to achieve adequate re-suscitation continues. We must correct hypothermia, as this can contribute to coagulopathy and platelet dysfunction. We must maintain oxygen delivery with judicious transfusions, and we must plan additional operative interventions as needed. This takes coordination and close com-munication with our specialists. All of this underscores the multi-disciplinary nature of trauma resuscitation.
Ongoing Resuscitation
1. Correct hypothermia
2. Maintain oxygen delivery
3. Optimize metabolic and coagulation function
4. Coordination and communication between consultants and hospital services
5. Serial imaging
Nutritional Support
Nutritional support is an important part of care and is usually addressed within 48 hours of the initial injury. We have learned from multiple studies that enteral nutrition is best. It preserves the gut barrier and minimizes infection risk.
Prevent, Monitor and Treat Infections
From this point forward, we are vigilant regarding the development of infection, and antibiotics are initiated based on culture data and the clinical course.
In summary, trauma resuscitation is very complex and predicated on attention to detail. ATLS protocols are rigidly adhered to, and rapid assessment, treatment, specialty and hospital service coordination is imperative to achieve the optimal outcome.
The airway must be secured, and shock must be diagnosed quickly and addressed definitively. Each phase of trauma care is focused on providing the patient the very best opportunity to recov-er from devastating injuries. Often, the care provided on the front end will determine the ultimate outcome.
References
- Ode G, Studnek J, Seymour R, Bosse MJ, Hsu JR Emergency tourniquets for civilians: Can military lessons in extremity hemorrhage be translated? J Trauma Acute Care Surg 2015; 79(4) 586-591
- Holcomb JB, Wade CE, Michalek JE, et. al. Increased Plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients Ann Surg. 2008;248(3):447-58
- Bickell WH, Wall MJ, PepePE, Martin RR, Ginger VF, Allen MK, Mattox KL Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries NEJM 1994 Oct 27;331(17):1105-9
- Cotton BA, Reddy N, Hatch QM, Lefebbvre E, et. al Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg, 2011;254(4):598-605
- Zachary DW, Dexman MD, Comer AC, Smith GS, Mayur N, Scalea TM, Hisrshon JM. Failure to clear elevated lactate predicts 24-hour mortality in trauma patients. J Trauma Acute Care Surg 2015; 79(4): 580-585
