Major Trauma

Question 1

A 23-year-old male cyclist is admitted to the emergency department following a road traffic collision with a car travelling at 50 mph on a dual carriageway.

How is major trauma defined?

Answer 1

• The Injury Severity Score (ISS) is used to define major trauma, with a score of more than 15 suggesting major trauma.
• To calculate the ISS, the body is divided into six regions, and injuries in each area are scored on a scale of 1 (minor injury) to 6 (not survivable).
• The three highest scores are squared and added together to give the fnal result.

Question 2

How would you approach this patient?

Answer 2

• A patient with major trauma is usually taken directly to a major trauma centre, where a trauma team should be assembled in the emergency department and briefed prior to the patient arriving, for rapid assessment and treatment.
• A “hands-of” handover to the trauma team should be done if the patient does not require any immediate life-saving treatment.
• A primary survey should be carried out by multiple medics on the team to identify any life-threatening injuries. This should be fed back to the trauma team leader.
• The priority is to reduce the time from the injury to definitive care, so only absolutely necessary interventions should be performed, such as securing the airway and gaining adequate intravenous access.
• If the patient is stable, a trauma CT (head to pelvis) should be performed to guide further management.
• The patient should be transferred to an appropriate location for definitive or supportive treatment e.g. theatres, intensive care unit, trauma ward.

Question 3

On examination, the patient has oxygen saturations of 90%, and paradoxical breathing is noted. He is tender to palpation on the right side of his chest, which is bruised. His arterial blood gas demonstrates a type 1 respiratory failure.

What are the potential causes for these findings?

Answer 3

Respiratory:
* Pneumothorax.
* Haemothorax.
* Pulmonary contusion.
* Diaphragmatic rupture.
* Tracheal/bronchial rupture.

Cardiovascular:
* Cardiac tamponade.
* Damage to the thoracic aorta.
* Cardiac contusion.

Musculoskeletal
* Flail chest.
* Sternal fracture.

Question 4

What are the strategies available for minimising blood loss in this patient?

Answer 4

• Stop the bleed following the haemostatic ladder: direct compression of the wound; application of a compression dressing; and packing with haemostatic agents. If the above measures fail, consider a tourniquet. Limb immobilisation and pelvic binding should be considered if internal bleeding is suspected. For cavity haemorrhage (e.g. abdominal bleeding), early damage control surgery may be necessary, aimed at controlling the bleeding rather than physiological restoration of function. If appropriate and available, consider interventional radiology.
• Replace the volume that has been lost: rapid blood transfusion using an appropriate device (e.g. Level 1 infuser or Belmont) through a suitable large bore intravenous line. Bedside clotting testing (e.g. TEG) should be used to guide further transfusion.
• Facilitate clotting: tranexamic acid, active warming and calcium.

Question 5

The arterial gas shows a blood glucose level of 14.9 mmol/L. Why might this be?

Answer 5

• The patient has undergone major trauma, leading to activation of the stress response.
• Increased plasma catecholamine and glucocorticoid levels secondary to the stress response facilitate gluconeogenesis and glycogenolysis, causing the plasma glucose levels to increase.

Question 6

The patient desaturates to 84% and his blood pressure drops to 65/43. There are no breath sounds on the right and his trachea is deviated to the left. How do you proceed?

Answer 6

• This is likely a tension pneumothorax, which is a life-threatening emergency.
• Alert the multidisciplinary trauma team immediately.
• The urgent treatment is a thoracostomy performed in the 4th or 5th intercostal space in the mid-axillary line. Following decompression, a
  chest drain will be required.
• Decompression of the pneumothorax will likely restore the patient’s
  normal physiology. However, if the patient deteriorates further, a c - areful plan is required prior to intubation and ventilation taking the following into account:
• The patient is currently haemodynamically unstable, and both induction and positive pressure ventilation may lead to a cardiac arrest.
• Surgical decompression can be done during induction, which requires appropriate preparation.
• Continuous reassessment of the patient is necessary. Intubation should be considered prior to a transfer to prevent a challenging emergency intubation during the transfer. However, it might be safer to continue resuscitative measures first to reduce further cardiovascular collapse on induction.