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23Initial management of the poly-trauma patientScandinavian Journal of Surgery 91: 2333, 2002

INITIAL MANAGEMENT OF THE POLY-TRAUMA PATIENT:

A PRACTICAL APPROACH IN AN AUSTRALIAN MAJORTRAUMA SERVICE

S. K. DAmours, M. Sugrue, S. A. Deane

Departments of Trauma and General Surgery, Liverpool Hospital, Sydney, AustraliaDepartment of Surgery, Southwestern Sydney Clinical School, UNSW, Sydney, Australia

ABSTRACT

The initial management of the poly-trauma patient is of vital importance to minimizingboth patient morbidity and mortality. We present a practical approach to the early man-agement of a severely injured patient as practiced at Liverpool Hospital in Sydney, Aus-tralia. Specific attention is paid to innovations in care and specific controversies in earlymanagement as w ell as local s olutions to challenging problems.

Key words: Trauma; resuscitation; trauma systems; quality assurance; Australia

INTRODUCTION

The initial assessment and management of a patientwith multiple injuries is critical toward decreasing

both morbidity and mortality and aiding recovery.Initial management includes care in both prehospi-tal and hospital environments. Prehospital care andorganized systems of trauma care will only be dis-cussed in this paper with reference to immediate pa-tient management issues. Both play a crucial role inthe delivery of optimal care to the injured patient(1, 2). Preparation for patient arrival in terms of sys-tems, designated trauma centres, training of person-nel and communications is as important as specificpatient interventions (3).

Institution of an organized approach to the injuredpatient such as that taught in the Advanced TraumaLife Support (ATLS) Course of the American College

of Surgeons improves trauma patient care and out-comes (48). A similar philosophy has been adaptedby prehospital care providers to optimize care of thepatient before delivery to a medical facility (1, 9, 10).

The initial management of trauma patients is car-ried out in all types of health care facilities from thesmall rural clinic to the major trauma centre. Al-

though the resources of these differing institutionsmay vary greatly, the way in which they deliver ini-tial care to the injured patient should be highly stand-ardized. Such is the way that courses such as ATLS

have defined an optimal means of assessing andtreating an injured patient or triaging and treatingmultiple patients (11). The simplicity of the overallapproach can be adapted to the available resourcesso that initial care and management can be optimizedfor any given patient with the tools at hand. ATLS

was introduced into Australia as EMST (Early Man-agement of Severe Trauma) by the Royal Australasi-an College of Surgeons (RACS) in 1988 and has sub-sequently become the national standard for initialcare of the injured patient (4).

Liverpool Hospital is the Major Trauma Service(MTS) in southwestern Sydney Australia, serving apopulation of > 750,000 people. This MTS designa-

tion was made by the New South Wales Health De-partment within a trauma plan for the city of Syd-ney (12). More than 4500 injured patients are admit-ted each year to one of six hospitals in the region (13).Liverpool Hospital, being the largest of these hospi-tals and the designated MTS, receives more patientsdirectly than any of the regional hospitals and alsoreceives transfers of the more seriously injured pa-tients after initial assessment at a regional centre (Ta- bles 1 and 2). Surgeons at Liverpool Hospital havehad a strong interest in trauma care in Australia es-pecially pertaining to development of trauma teams,trauma education, registry, and better practice guide-lines (1418).

Correspondence:Stephen A. Deane, M.D.Division of SurgeryLiverpool Hospital Locked Bag 7103Liverpool BC NSW 1871 AustraliaEmail: [email protected]

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24 S. K. DAmours, M. Sugrue, S. A. Deane

Using the ATLS approach as a platform, we willoutline and address some of the challenges faced andapproaches used in the initial management of poly-trauma patients in southwestern Sydney as well asdiscuss some of the most current initial assessmentand management strategies for these patients. Pre-senting this local viewpoint offers a practical tem-plate, and allows global comparisons.

PREPARATION

TRIAGE, TRAUMA CENTRE VERIFICATION AND TRAUMABYPASS

The triage process begins in the prehospital phase ofcare when transport decisions are made to take theseriously injured patient to the nearest, most appro-priate facility. No perfect triage system exists. How-ever, the American College of Surgeons Committeeon Trauma has set reasonable criteria for field triageinResources for Optimal Care of the Injured Patient. The

receiving facility ideally has some kind of designa-tion to receive seriously injured patients and the re-sources and expertise to adequately manage their in-juries (8). A verification process for facility designa-tion is an important step towards ensuring resources,personnel and a quality assurance programme are in

place for optimal care of injured patients (19) MajorTrauma Services were originally established in thestate of New South Wales with the implementationof a state trauma service plan in 1992 (20). A by-pass system was central to the plan and directedambulance crews to bypass the nearest hospital andtake injured patients with the highest risk to a MajorTrauma Service (12). More than 96 % of patients inour region that meet bypass criteria are correctly being transported to Liverpool Hospital instead ofthe nearest facility (13). Liverpool Hospital was re-cently the first MTS in Australia to be visited by theSite Survey Team of the RACS Trauma Committeeas part of a pilot verification project. This processidentified strengths and weaknesses in the initialmanagement of the poly-trauma patient and in theproposed verification process. The weaknesses iden-tified were the low seniority of some of the traumateam members and the lack of a formal admittingservice for trauma. The former is especially impor-tant in the initial management of trauma patients.

COMMUNICATION

Coordination and communication between prehos-pital and hospital care providers is the key to timelypreparation and mobilization of resources. LiverpoolHospital has established direct communication links,using a government radio network, between prehos-pital care providers and the resuscitation room, tofacilitate the transfer of information and to allow di-rected preparation of the trauma team response (21).This radio link is used to advise the trauma teamwhen a patient with haemodynamic instability is to be expected and to outline suspected injuries andtreatment initiated. The majority of our prehospital

transport times are less than 20 minutes (13), how-ever, when pre-hospital transport times are longthere may also be benefit to medical direction givenby the same communication link (22).

TRAUMA TEAM

Activation of a prepared trauma team results in bet-ter patient care and improved patient survival (23).The ability of prototype Australian trauma teams to

TABLE 1

Number of trauma admissions per year to each hospital in the SouthWestern Sydney Area Health Service (SWSAHS).

Hospital 1995 1996 1997 1998 1999 Total

Liverpool 1703 1848 1809 1959 1906 9225

Bankstown 1015 0817 1093 1005 1009 4939Campbelltown 0779 0916 0798 0860 0884 4237Fairfield 0526 0537 0558 0584 0528 2733Bowral 0300 0306 0356 0342 0352 1656Camden 0170 0139 0220 0191 0127 0847

Total 4493 4563 4834 4941 4806 236370

From: South Western Sydney Regional Trauma Registry Report19951999

Reprinted with permission: Trauma Department, Liverpool Hos-pital

TABLE 2

Mechanism of injury (grouped) annu ally for trauma admissions to hospitals in the South Western Sydney A rea Health Service (SW SA HS).

SWSAHS 1995 % 1996 % 1997 % 1998 % 1999 % Total %

Road vehicle 576 12.8 548 0.12 617 12.7 627 12.7 626 13.1 2995 12.7Pedestrian/Cyclists 216 04.8 253 05.5 278 05.7 281 05.7 286 05.9 1314 05.6Interpersonal Violence 291 06.5 356 07.8 367 07.6 364 07.4 336 0.7 1714 07.3Falls 19610 43.7 18180 39.8 20410 42.2 19890 40.3 18540 38.8 9663 40.9Industrial 474 10.6 438 09.6 411 08.5 385 07.8 309 06.5 2017 08.5Recreation 234 05.2 156 03.4 238 04.9 493 0.10 567 11.9 1688 07.2Burns 094 02.1 116 02.5 116 02.4 126 02.6 107 02.2 0559 02.4Other 646 14.4 878 19.2 766 15.8 676 13.7 688 14.4 3654 15.5

Total 44930 4563 48340 4941 48060 236370

From: South Western Sydney Regional Trauma Registry Report 19951999Reprinted with permission: Trauma Department, Liverpool Hospital

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25Initial management of the poly-trauma patient

respond and triage patients effectively was criticalprior to widespread development and implementa-tion of similar teams in other major Australian cen-tres (14, 15). Liverpool Hospital established a trau-ma team in 1989 and has previously published on itsperformance (16, 17).

Activation of the trauma team begins with identi-fication of specific triggering criteria (incorporatingassessments of injury mechanism, physiological sta-tus, evident injuries) and a group trauma call is putout by switchboard operators resulting in attendanceof registrars from Surgery, ICU, and the EmergencyDepartment (17). Additionally, the trauma fellow,trauma nurse coordinator, and radiographers receivecalls and attend. Three nurses from the EmergencyDepartment, a ward orderly and social worker alsoattend. The charge nurse in operating theatres alsoreceives a page so that if a theatre is urgently re-quired, maximal warning has been given. The trau-ma team is led by a registrar from the EmergencyDepartment or ICU. These two registrars alternatebetween team leading and a role as the airway doc-

tor on a fortnightly basis. The team leaders role is tolead the team at arms length and plan interventionsand treatment based on information produced by thebedside team. The surgical registrar takes the role ascirculation and procedure doctor as well as doctorperforming secondary survey. The team leader, inconsultation with the surgical registrar, then plansand prioritizes interventions and investigations. Thetrauma fellow plays both an advisory role to the teamleader and acts as an extra team member if needed.The active participation of a trauma fellow has beenpreviously shown to promote optimal patient careeven when not in the role of team leader (24). If re-quired by the instability of the patient or inexperi-

ence of the rostered team leader, the trauma fellowor emergency department consultant assumes therole of team leader. The consultant surgeon is auto-matically paged for any patient with prehospital hy-potension and as required for other injuries. If morethan one patient is expected, several teams are as-sembled using the emergency department consultantand trauma fellow to team lead. If several teams areneeded, the role of team leader can be assumed byeither the airway or procedure doctor in addition totheir regular role. The hospital disaster plan is acti-vated for the arrival of more than 5 or 6 unstable andseriously injured patients or at the discretion of theconsultant in the resuscitation room. The multidis-

ciplinary membership of the trauma team has beenpreviously identified as having a positive effect ontrauma team function (16). We have paid special at-tention to the role of the trauma team leader to avoida COCUP or Consortium Of Care for Urgent Pri-orities. This pitfall is an easy one to fall into with thepoly-trauma patient when there are many injuriesand subspecialist consultants involved. It results incare that is fragmented, poorly integrated, undulycomplex and therefore prone to errors (25).

All trauma team members arriving in the resusci-tation room prepare by putting on splash-resistantand lead gowns, eye protection and gloves. Airwayequipment, suction, monitors and IV cannula carts

are rechecked and warmed IV fluids are positionedand lines primed. Other preparation is based onavailable prehospital information and may includeopening of chest tube and thoracotomy trays if sig-nificant chest injury, penetrating chest wounds or vi-tal signs suggest an urgent need for intervention.

TRAUMA EDUCATION AND TRAININGThe role of a teaching hospital in preparing traumateam leaders and educating younger doctors is animportant one. It has been previously identified thaterrors occur in the early part of trauma resuscitationsand can contribute significantly to avoidable deaths(26, 27). Trauma team leaders with greater clinicalexperience yield more optimal resuscitations (24) andour teaching programmes, trauma audit meetings,performance improvement initiatives and quality as-surance filters are strategies to give our trauma teammembers the best clinical experience possible. Mostrecently we have established a new method of ori-enting and training new surgery, ICU and ED regis-

trars to the Liverpool Hospital trauma system bycombining classroom and interactive web-basedteaching modules (28). This has permitted both train-ing and assessment of new trauma team leadersprior to their assumption of the team leader role. Therole of the internet and reputable web sites in trau-ma education is just beginning to be realized and hasnot yet reached its full potential (29, 30). One mustseriously ask if it is acceptable to have a doctortreating trauma patients if only minimal standardsare adhered to in terms of trauma education andorientation.

PRIMARY SURVEY

Unlike many areas of medicine where all informa-tion is gathered, synthesized and a comprehensivetreatment plan is undertaken, trauma requires thatinjuries that may kill a patient in seconds or minutes be immediately addressed. The injuries most likelyto kill a patient quickly must be excluded beforemoving onto a more comprehensive examination.Frequent reassessment is required, since previouslyunrecognized or seemingly insignificant injuries maybecome more prominent mandating immediate treat-ment. The ABCDE of the primary survey is, in es-sence, a quick examination to exclude injuries that

are immediately life-threatening along with concur-rent treatment to permit resuscitation and furtherexamination. At Liverpool Hospital, the airway doc-tor in the trauma team undertakes the primary sur-vey and reports the findings to the team leader. De-cisions are made for immediate interventions as theprimary survey proceeds commencing with airway.

PATIENT ARRIVAL AND HAND-OVER

When the trauma team is activated by prehospitalcommunication, the trauma team arrives and isstanding by and prepared for patient arrival (Fig. 1).As the patient is transferred from ambulance to re-

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26 S. K. DAmours, M. Su grue, S. A . Deane

suscitation stretcher the ambulance officer gives ver- bal hand-over directly to the trauma team leaderloud enough for all other team members to hear. Theinformation transfer is succinct and follows theMIST format:

Mechanism of injury Injuries suspected Vital Signs Treatment en route to hospital

We have shown that this method of information

transfer is successful for most trauma patient arriv-als (31). The airway doctor begins the primary sur-vey as the patient is being transferred and connec-ted to monitoring equipment.

AIRWAY AND CERVICAL SPINE PROTECTION

Airway is the first priority in assessment and man-agement of the poly-trauma patient as without a pat-ent airway, ventilation and delivery of oxygen to al-ready-depleted cells will fail resulting in poor patientoutcome. Rapid assessment consists of quickly exam-ining the patient for signs of airway compromise. Thepatient is asked a simple question. Absence of re-

sponse, stridor, confusion or a hoarse reply may in-dicate airway compromise. Foreign bodies, blood,vomitus and a decreased level of consciousness aremost commonly responsible for airway obstruction.Facial or laryngotracheal fractures may also result inacute airway obstruction. Patients with facial burnsand inhalation injury may have compromised air-ways or be at risk of rapidly losing a marginally pat-ent airway. Early intubation of burn patients withstridor, carbonaceous sputum, oropharyngeal andmassive facial burns can prevent later loss of airwayand ability to ventilate.

During early assessment of the airway, we takecare to protect the cervical spinal cord by immobi-

lizing the cervical spinal column. Although treatmentof cervical spine injury is not part of the primary sur-vey it is important to realize that an existing injurycan be worsened (32). Exclusion of cervical spine injury is impossible in the early stages of examiningand treating the multiply injured blunt trauma pa-tient; therefore all patients are assumed to have cer-vical spine injury and only later is this excluded orinvestigated definitively. We do not make clinical orradiological clearance of the cervical spine a part ofthe primary survey in the poly-trauma patient. Thehead and neck are maintained in a neutral position by the airway doctor using in-line immobilizationuntil external immobilization is fitted. Immobiliza-tion of the cervical spine is effected by a semi-rigidcollar alone in most patients. This is effective in theshort term and can be easily removed with in-linestabilization when improved access to the head andneck is required (e.g. with intubation) (3335).

A patient with absent ventilatory effort is quicklyassessed for oropharyngeal foreign bodies, oropha-ryngeal secretions and vomitus are suctioned, and ajaw thrust is performed to relieve airway obstructionsecondary to decreased oropharyngeal muscle tone.Relief of airway obstruction by these simple manoeu-vres usually permits spontaneous ventilation. Anoropharyngeal (Guedel) airway helps if upper airwayobstruction is a result of decreased level of conscious-ness. Supplemental oxygen is given to all of our poly-trauma patients. Of the trauma patients admitted toLiverpool Hospital over the past 5 years, 75 % re-quired no airway intervention and just over 11 % re-quired endotracheal intubation (13). We intubate pa-tients for the following reasons:

Inadequate ventilation and oxygenation Impending or actual airway obstruction second-

ary to injury Brain injury with a Glasgow Coma Scale (GCS)

of less than 8

Fig. 1. Liverpool Hospital trauma teamtransferring a new patient.

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Inability to adequately protect the airway fromaspiration

We may intubate patients in the following settings:

Severe multi-system injury or haemodynamicinstability

Facial burns or inhalation injury

Inability to closely monitor during ongoing re-suscitation and investigation (e.g. angiographyand CT scanning)

Uncooperative or combative behaviour Infant or child unable to cooperate with inves-

tigations

Once the decision to intubate has been made, the des-ignated airway doctor (ICU or ED registrar) under-takes the procedure with the assistance of the airwaynurse. If the initial attempt fails then the patient isoxygenated with a bag-valve mask and the attemptis repeated. A second failure requires attendance ofthe in-house consultant or registrar in anaesthesia

before a third attempt. If the intubation is not emer-gent (still able to oxygenate patient in some way) anda difficult airway is anticipated (facial swelling, pos-sible laryngeal fracture or difficult anatomy) then in-tubation is performed by the in-house anaestheticregistrar or consultant.

Endotracheal intubation remains the gold stand-ard for control of the airway and ventilation/oxygen-ation of the unstable poly-trauma patient (36, 37).There may be a role for other techniques such as thelaryngeal mask airway and combitube (38) but theirrole in trauma is unclear (39) and we have not yetused them in our resuscitation room. All haemody-namically unstable poly-trauma patients are intuba-

ted using a rapid sequence induction technique em-ploying pre-oxygenation, cricoid pressure, thiopen-tone and succinyl choline. These drugs are chosen asthey have a rapid onset and short half-life along withminimal effect on blood pressure. The short half-lifeallows quick recovery should the attempted intuba-tion fail. A combination of narcotic (usually fentanyl)and midazolam is occasionally used in an otherwisestable patient if major haemorrhage is not presentand transient hypotension is of little or no conse-quence.

Attempts at endotracheal intubation or laryngo-scopy in a patient with unrecognized laryngeal frac-ture or partial upper airway transection can be cata-

strophic by precipitating complete obstruction or air-way transection. Although sometimes difficult to an-ticipate, it is important to have a high index of sus-picion for these types of injuries, based on mecha-nism of injury or subtle signs on physical examina-tion, and to be prepared to perform a rapid surgicalairway should complete obstruction be precipitated.The surgical registrar or trauma fellow is standingby with equipment readied to perform a cricothy-roidotomy should complete airway obstruction resultand ventilation become impossible.

Cricothyroidotomy is our emergency surgical air-way of choice in a hypoxic patient who cannot beventilated by other means (spontaneous or assisted)

and has failed two intubation attempts or has com-plete upper airway obstruction. Airway obstructionmay be due to disruption of the airway, fractures, tis-sue loss, burns or other maxillofacial injury. This life-saving procedure is actually required quite uncom-monly but when needed, any delays potentiallyworsen outcome. The surgical registrar or trauma fel-low performs the procedure with assistance from theairway doctor and nurse. Although we do have pre-packaged kits available, a scalpel and endotrachealtube alone are sufficient to accomplish the task. Only4 emergency surgical airways have been requiredover the past 5 years (~0.1 % of trauma admissions)at Liverpool Hospital. Over that same time periodthere were a total of 32 laryngotracheal injuries butthe majority of these patients airways were able tobe managed without surgical intervention (13). Thisreflects the advanced airway skills of ICU, emergencyand anaesthesia doctors and is one of the benefits ofa multi-disciplinary trauma team.

BREATHING AND VENTILATION

The assessment of breathing and ventilation natur-ally follows the securing of an airway. Providing ox-ygen to cells and eliminating carbon dioxide is thecentral aspect of this part of the treatment algorithm.Both blood circulation through the pulmonary ves-sels and gas circulation through the alveoli are re-quired.

During the primary survey we seek and treat anyimmediately life-threatening chest injuries that willprevent proper ventilation:

Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest

A tension pneumothorax will be immediately decom-pressed with a needle while the surgical registrar be-gins chest tube placement; an open pneumothoraxresults in simultaneous placement of a chest tube andocclusive dressing. Massive haemothorax is treatedwith one or more chest tubes. The blood drainedfrom the chest can be collected in chambers that per-mit autotransfusion although this is not without riskand can be cumbersome to use (40) especially whenneeded infrequently. At Liverpool Hospital we gen-erally opt for rapid transport of the patient to the

operating suite for thoracotomy and transfusionwhen acutely placed chest tubes drain >1500 ml or>150200 ml/hour. Massive flail chest can be veryproblematic. Ventilation is impaired by a malfunc-tioning chest wall and oxygen uptake impaired byan injured and edematous alveolar-capillary gas ex-change surface. The impact of this type of injury isoften initially underestimated (41). All of these pa-tients require careful fluid administration and anal-gesia and often need ventilatory support. Even withthis support, optimal oxygenation can be difficult toachieve. As a result, all patients with flail chests atLiverpool Hospital are managed in our intensive careor high dependency units.

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CIRCULATION AND BLEEDING

Urgent and early attention must be paid to any ex-ternal haemorrhage. While our trauma teams airwaydoctor is assessing and securing an airway, the sur-gical registrar and procedure nurse are assigned toapply pressure dressings on any obvious externalsites of bleeding. We give particular attention to the

following:1. Scalp lacerations can bleed extensively and result

in hypovolaemic shock even when no other inju-ries are present. If external pressure does not ar-rest bleeding immediately, we use a runninglocked suture to quickly control blood loss.

2. PASG (pneumatic anti-shock garment) trousers arenot used by us to arrest lower extremity bleedingor splint fractures. These devices can ultimatelyworsen patient outcome although they may tran-siently appear to decrease bleeding. Direct pres-sure, fracture reduction and other externalsplinting techniques are used instead. There is alsoevidence showing increased patient mortalitywhen the PASG is used in patients with penetrat-ing thoracic injury (42, 43).

3. Fractured long bones are reduced and traction-splinted to decrease ongoing blood loss and painas well as to prevent further local injury and restoreflow to potentially ischaemic distal extremities.

4. We do not attempt to blindly clamp vessels inbleeding wounds or use tourniquets as they oftenworsen ischaemia and damage adjacent/distalstructures. A pressure dressing is applied insteadand the patient taken to the operating room assoon as possible.

5. We use Foley catheters to tamponade bleedingfrom the nasopharynx when anterior nasal pack-

ing fails; a catheter is passed through the nares intothe nasopharynx, the balloon is inflated with 1015 mls of water or normal saline and gentle trac-tion is applied on the catheter to lodge the balloonin the nasopharynx and to tamponade bleeding.Bilateral catheters can be used if needed and ifhaemorrhage is resulting from non-reduced max-illary and cranial-base fractures (44). Angiographyand embolization can also be used if packing failsand some hospitals use this technique moreaggressively.

Hypotension in a trauma patient is always initiallyassumed to result from haemorrhage until this is ex-

cluded. Cardiogenic, septic and neurogenic shock areless common causes of hypotension in the traumapopulation. Patients at extremes of age, athletic pa-tients or pregnant patients may not manifest classi-cal signs and symptoms of hypovolaemia; these pa-tients may bleed extensively and lose a great deal oftheir intravascular volume without the usual objec-tive findings. In patients taking prescription or illicitdrugs, vital signs may not be reliable (tachycardia incocaine users and absence of tachycardia in patientstaking beta-blockers).

Adequate intravenous access is confirmed or es-tablished by the procedure doctor while airway and breathing are being assessed by the airway doctor.

Ideally, we place two large bore (14 or 16 gauge) IVcannulas in the upper extremities. Otherwise, a large bore femoral vein catheter or saphenous vein cut-down is utilized depending on the experience of thesurgical registrar. We avoid lower extremity cannu-las and femoral lines in patients where there is con-cern about possible iliac vein or IVC injury (majorpelvic fractures and abdominal trauma especiallywith a distended abdomen). Subclavian and internal jugular veins are only used if no other options areavailable. In children under the age of 6, intraosseousinfusion devices are utilized only in shocked patientswhen two peripheral access attempts have failed or90 seconds pass without successful placement of acannula. Regular cannulas are then inserted follow-ing adequate resuscitation and the intraosseous nee-dle is removed. A pump set is always included aspart of the IV tubing used for all trauma patients. Weprepare rapid-infusing devices for IV fluid adminis-tration whenever there is prehospital notification ofhypotension or massive blood loss. We avoid thelong double and triple lumen central venous cathe-

ters and opt for short 7.58.5 French catheters for ourfemoral lines to maximize infusion speed.

The optimal type of fluid to be administered totrauma patients continues to be debated (45). In Aus-tralasia gelatin-based colloids are available for usewhereas hetastarch-based solutions are not. Patientswho arrive to Liverpool Hospital without evidenceof massive haemorrhage or shock are usually com-menced on a crystalloid solution at a maintenancerate of ~100 ml/hour in the average adult. In ashocked patient or patient with suspected Class IIIor IV haemorrhage we use a gelatin-based colloid so-lution initially. It has been shown that fluid admin-istration without control of ongoing haemorrhage

can worsen outcomes in patients suffering penetrat-ing torso trauma (46) and in this situation we estab-lish at least two large bore cannulas but limit fluidresuscitation until the patient is taken to the operat-ing room and the haemorrhage is controlled. The endpoint of resuscitation in this preoperative situationis maintenance of vital organ perfusion (e.g. patientawake and able to converse) which usually requiresless than 500 ml of fluid. In all other shocked patientsinitial boluses of gelatin-based colloid are used as thereturn to normal haemodynamics may be fasterand with lower volumes than with crystalloid (45).

We give blood to patients with ongoing haemody-namic instability after initial fluid boluses exceed 2L

and occasionally earlier when transfusion is deemedto be inevitable (unstable patients with severe pelvicfractures, more than two long bone fractures, esti-mated total blood loss exceeding 40 % and for lesserinjuries when combined with a serious head injury).This is especially true in patients with concomitanthead injury where the overriding principle is to en-sure that the brain receives adequate perfusion andoxygen delivery to prevent secondary brain injury(4749). Patients are given cross-matched or type-spe-cific (ABO and Rh groups) blood if available but iftransfusion is required before matched blood is avail-able, we will give type O Rh negative blood to fe-males (of child-bearing years or younger) and all oth-

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ers will receive type O Rh positive blood. Rapid op-eration and prevention of further blood loss is themost important principle.

The specific role of hypertonic saline has not yet been fully determined although there is some evi-dence that it may have a role in the early manage-ment of patients with severe traumatic brain injury(50, 51). The smaller volumes infused allow rapid in-creases in mean arterial pressure without increasinginterstitial oedema and potentially increasing intra-cranial pressures. Some studies, however, have notshown any difference when compared to crystalloidresuscitation (52). We have not yet started treatingpatients with severe brain injuries at Liverpool Hos-pital using hypertonic saline although it is being con-sidered.

Cardiac injury as a cause of shock is consideredonly after hypovolaemic shock has been excluded ina patient who has risk factors for cardiac injury (flailchest, multiple rib fractures, sternal fracture withnew precordial murmur or ventricular arrhythmias,penetrating chest injury). Cardiac ultrasound is used

at Liverpool Hospital in all of these situations to as-sess the heart for evidence of injury. Cardiogenicshock can arise from contusion causing myocardialdyskinesia, acute valvular rupture leading to a de-creased ejection fraction or from the compressive ef-fects of a haemopericardium that greatly reduces car-diac filling, thereby decreasing cardiac output.

DISABILITY

At this point in the primary survey the airway doc-tor does a quick neurological assessment by deter-mining level of consciousness using GCS as well asexamining pupils for indirect evidence of massive

intracranial haemorrhage. GCS is used as a baselinedetermination of neurological function and frequentre-examination is necessary. A complete neurologi-cal exam is not appropriate at this time. We are care-ful to avoid the following pitfalls or errors that canresult in poorer patient outcomes:

Attributing any neurological changes to alcoholor illicit drug use without specifically exclud-ing injury.

Assuming that anisocoria is secondary to directeye trauma or previous eye (especially cataract)surgery.

Not recognizing a decreasing level of conscious-

ness in a patient with minimal initial evidenceof brain injury.

EXPOSURE/ENVIRONMENT

All patient clothing is removed for complete exami-nation. We avoid worsening patient hypothermia byremoving wet or blood-soaked bedding, giving IVfluids warmed to 39C and using blood warmers fortransfusing and external warming (warmed blanketswith all patients and forced, heated air or radiantwarmers as needed). Patients at both extremes of ageare less able to compensate for heat loss and we takespecial care with these patients to reduce heat loss.

ADJUNCTS TO PRIMARY SURVEY

MONITORING

Equipment for continuous monitoring of pulse, bloodpressure and respiratory rate is always put into placeas the primary survey begins. Temperature, pulseoximetry and end-tidal carbon dioxide monitoring

(in the intubated patient) are routine at LiverpoolHospital. We use arterial lines for blood pressuremonitoring in the resuscitation room for patientswith severe head injuries. We do not use central ve-nous pressure monitoring in the resuscitation room.

TUBES AND CATHETERS

We place a urinary catheter in all poly-trauma pa-tients following examination for evidence of a ure-thral injury (meatal blood, perineal/scrotal haemato-ma, high-riding prostate on digital rectal exam). Ifany evidence of injury is found, we perform a ure-throgram to exclude injury prior to placing an ind-

welling catheter. If the patient is stable this is donein the radiology suite but it can be performed in theresuscitation room if required. If the urethrogram ispositive, a urological consultation is obtained and acatheter is guided into the bladder after direct visu-alization using cystoscopy, or a suprapubic catheteris placed with delayed repair of the urethra. If thereis no evidence of injury, we pass a catheter into thebladder via the urethra so that urine output can bemonitored. Urine output is the method we use mostfrequently to determine adequacy of end-organ tis-sue perfusion.

We place a nasogastric tube (orogastric if any sus-picion of basal skull or cribriform plate fractures) in

all intubated trauma patients, patients with shock,spinal injury and severe head, chest or abdominalinjuries. Decreasing gastric distension lowers the riskof aspiration and the gastric access can be used toadminister a contrast agent for CT scanning. In chil-dren, gastric dilatation is common and decompres-sion assists resuscitation.

X-RAYS

Routine X-rays at Liverpool Hospital are done dur-ing the primary survey while the airway doctor isundertaking the primary survey. The radiographers

place film cassettes under the resuscitation stretcherprior to patient arrival to expedite the process. Allunstable patients will have an immediate chest andpelvic X-ray. Previous study in this hospital has de-termined a median time of less than 9 minutes tochest X-ray and 13 minutes to pelvic X-ray for trau-ma activations (17). In a stable patient with isolatedinjury and no pelvic tenderness we may not performthe pelvic X-ray or delay it until secondary survey iscompleted. These X-rays are performed to identifymajor hidden threats to airway and breathing (e.g.unrecognized tension pneumothorax, haemopneu-mothorax), hidden sources of substantial bleeding(massive haemothorax, major pelvic fracture) and

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radiological signs of other early threats to life (e.g.aortic arch injury). These findings can modify theplanning and urgency of subsequent investigationsand therapeutic manoeuvres. We still include the lat-eral cervical spine X-ray in the initial radiology se-ries but recognize that in the unstable poly-traumapatient with a possible head injury that we will notuse the information to determine immediate priori-ties or make decisions. An unstable spine injury isalways assumed at this point and appropriate pro-tection is undertaken until injury is later excluded(53). Ideally, all X-rays in the resuscitation roomshould now be digital. This allows for optimum pic-ture quality and immediate quality assurance andreview.

ULTRASOUND AND DPL

We do no other investigations until completion ofthe secondary survey. The only exception to this isthe need to rapidly exclude the abdomen as site ofmajor bleeding in a haemodynamically unstable pa-

tient suffering blunt trauma. Focused abdominalsonography (FAST) by an experienced individual(usually the trauma fellow or another accreditedperson) is appropriate at this point and if ultra-sound is not available, diagnostic peritoneal lavageis required. A rapid technique of lavage was devel-oped at Liverpool Hospital and continues to be usedsuccessfully here (54). An unstable patient with ev-idence of free intraperitoneal fluid on ultrasound ora grossly positive lavage will undergo immediatelaparotomy and control of haemorrhage. Rememberthat DPL in an unstable patient is looking only forfrank blood. If the DPL does not reveal gross blood,then the search must be continued for another site of

blood loss.

CONSIDERATION FOR INTERHOSPITALTRANSFER

Although all injuries may not have been diagnosedand resuscitation of the patient may be continuing,it is important to consider early the potential needfor transfer of the poly-trauma patient to an institu-tion where definitive care can be undertaken. Trans-fer must be considered early when the needs of thepatient exceed the capabilities and resources of thereferring institution (11). This requires well-devel-

oped working relationships between hospitals witha regionalized trauma care plan. It is also assisted bymutually agreed trauma patient transfer protocols.In the South Western Sydney Area Health Service(SWSAHS) a regional trauma care plan was devisedwith Liverpool Hospital designated as the MajorTrauma Service (12, 20). The SWSAHS administra-tion established a trauma committee including inputfrom all area hospitals, the New South Wales Am-bulance Service and the Medical Retrieval Unit; thiscommittee has devised locally appropriate protocolsand indications for trauma patient transfer. Im-proved methods of transfer of patient and informa-tion within SWSAHS have been developed and are

showing promise with respect to improving the saf-ety of transfer and shortening the time to definitivecare (55). Better Practice Guidelines have been recen-tly developed for trauma patient transfers withinSWSAHS and these detail the indications for bypassof other SWSAHS hospitals, indications for interhos-pital transfer, the transfer process itself and perform-ance indicators and audit filters (56).

The need for interhospital transfer can usually bedetermined early based on known injuries and pat-terns of injury. Patient retrieval and transfer oftentake time to organize and should therefore be com-menced as soon as the need is recognized. Once thetransfer process is activated complete patient exami-nation and resuscitation can continue. A haemody-namically unstable poly-trauma patient who has anindication for laparotomy should undergo immedi-ate operation if surgical services are available (dam-age control at minimum) even if early transfer is re-quired for further definitive care.

Once the Major Trauma Service at Liverpool Hos-pital is contacted regarding a need for possible trans-

fer of a trauma patient from another SWSAHS hos-pital, it immediately becomes our responsibility topromptly provide comprehensive assistance.

SECONDARY SURVEY

The surgical registrar undertakes the secondary sur-vey as soon as primary survey, interventions andadjuncts to the primary survey are completed. Al-though the examination is thorough, systematic, andstandardized, it is important to recognize patterns ofinjury and to examine carefully for injury combina-tions guided by both pattern and mechanisms of in-

jury (11).Complaints of pain by the patient can be a helpful

guide to examining for injury but often the multi-trauma patient will be intubated, sedated, or other-wise unable to assist or guide the examiner. Full pa-tient exposure and careful inspection, palpation, per-cussion and auscultation are the best approach. Spe-cifically, we take special care to examine body re-gions where injuries are easily missed or underesti-mated:

Back of head and scalp Neck beneath semi-rigid collar Back, buttocks and flanks Groin creases, perineum and genitalia

As with the primary survey, many things are donesimultaneously, especially when a well-staffed trau-ma team is available. For instance, identification of along bone fracture with deformity leads to reductionand splinting as the examination continues. Bleedingfrom a scalp laceration leads to a pressure dressingor suturing; identification of an open book pelvicfracture with haemodynamic instability will lead toattempts at decreasing pelvic volume (external fixa-tion or sheet tied around pelvis) or urgent angiogra-phy and embolization (5759).

Pain relief is important to achieve and we ensureadequate analgesia by administering IV morphine as

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needed. Manipulation of any fracture or joint dislo-cation requires analgesia prior to the procedure. Tet-anus and antibiotic prophylaxis should be givenwhen indicated.

During all phases of care it must be emphasizedthat frequent re-evaluation is required. We will spe-cifically re-examine known injuries for evidence ofexpanding haematomas, worsening perfusion oflimbs, developing compartment syndromes andevolving brain injury. Any patient who becomes un-stable or begins to develop new symptoms is reas-sessed starting with airway and continuing withbreathing and circulation as was undertaken duringthe primary survey.

TERTIARY SURVEY

At Liverpool Hospital we have incorporated a ter-tiary survey into the evaluation of all trauma pa-tients admitted after trauma team activation. A studydetermined that clinically significant injuries weremissed during the secondary survey in 14.5 % of ad-missions (30 of 206 patients) resulting in complica-tions in 5 % of admitted trauma patients and contrib-uting to death in 1 % of the same admissions (60).Tertiary survey consists of a repeat of the primaryand secondary survey examinations, reassessment ofthe functions of all tubes and catheters, and reviewof all X-rays. It is routinely performed on the morn-ing after the patients admission.

INVESTIGATIONS AND DEFINITIVE CARE

RADIOLOGY

Investigations following the secondary survey aredirected towards abnormalities identified during thesecondary survey, exclusion of injuries suspected bymechanism of injury and the planning of the defini-tive care of diagnosed injuries. These may include:

Plain radiographs CT scanning Contrast studies Angiography Ultrasound (including plain sonography,

echocardiography and colour-flow Doppler) Endoscopy

We do not commence these investigations until theprimary and secondary surveys are completed andimmediately life-threatening injuries are treated. Ide-ally the patient should be exhibiting haemodynamicand ventilatory stability although in the poly-trau-ma patient, stability must be defined with referenceto a given patient over a specific time frame and notarbitrary values such as systolic BP > 100 andpulse < 100.

The best way of investigating specific types of injury is beyond the scope of this paper. It is impor-tant to note that many investigations require mov-ing the patient from the resuscitation area to areaswhere there are often fewer personnel, less working

space and less equipment to manage potentially life-threatening complications. If the patient is haemody-namically stable then we will move the patient outof the resuscitation room to the radiology suite whereinvestigations can proceed. We will not move a pa-tient anywhere other than to an operating theatre ifongoing haemodynamic instability is present. Theone exception to this is the patient with an unstablepelvic fracture, no other known injuries and suspec-ted ongoing pelvic arterial bleeding where transferto the angiography suite for angioembolization isconsidered and supported for this selected subgroupof patients (59, 61, 62).

BLOOD TESTS

The drawing of venous blood for investigation usu-ally occurs with IV cannula placement but is other-wise completed by the end of the secondary survey.The most important tube of blood that we send is theone for cross-matching for transfusion. All otherblood tests are useful as baseline studies but are rar-

ely helpful for early management decisions involvingthe poly-trauma patient. New South Wales State lawalso requires blood alcohol testing for any person(driver, pedestrian, or cyclist) involved in road trau-ma. Serial arterial blood gas determinations are usedin the haemodynamically unstable trauma patient tomonitor resuscitation efforts in the injured patient byquantifying base deficit and acidemia which reflectthe adequacy of tissue perfusion (63, 64). At Liver-pool Hospital we do not have an arterial blood gasmachine in the resuscitation room although we canget results fairly quickly through the main hospitallaboratory.

DEFINITIVE CARE

Definitive care begins once the immediately life-threatening injuries are excluded or treated, the sec-ondary survey completed, a plan of action has beendecided upon and the prioritizing of investigationsand treatments has been determined. Resuscitationis a dynamic process that is partially determined bythe response of the patient. Although definitive careis the ultimate goal of trauma patient treatment, itcan only proceed once all of the above steps havebeen taken to increase chances of patient survival andto decrease patient morbidity. Occasionally traumaresuscitations are suspended in the primary survey

by an urgent need for operative intervention (e.g. apatient rapidly exsanguinating secondary to massivehaemothorax). In this situation, secondary surveymust be resumed after the immediately life-threat-ening injury is addressed.

JUDGEMENT AND DECISION-MAKING

Judgement and decision-making by caregivers playan important role in trauma patient care. Both havebeen shown to be important in trauma patient triage(15), the timely formulation of definitive care plans(24), and with respect to overall patient morbidityand mortality (26, 27, 65, 66). In South Western Syd-

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ney and at Liverpool Hospital we continue to workon improving our delivery of care, making better andmore rapid decisions, and reducing provider-relatederrors in judgement as informed by our audit andreview processes. Our trauma registry and data col-lection system has specific filters that flag patientsfor review when a specific point relating to patientcare is not met (13). These errors, omissions and de-lays are then corrected when possible or investiga-ted for further action. We are commencing a new in-itiative toward closing the loop and providingfeedback to our registrars and consultants when er-rors in care were made and specific audit filters wereflagged. Trauma patient deaths are immediately re-viewed with a de-briefing of involved care-giversand we also have a multi-disciplinary death auditprocess to review and examine all in-hospital trau-ma patient deaths for system and provider errors(67). Our quality assurance programme also includesa weekly multidisciplinary trauma audit meetingwhere specific trauma patients are reviewed andtheir resuscitation and investigations are critiqued.

This is also used for education of our ICU, emerg-ency and surgical registrars in aspects of judgementand decision-making during trauma resuscitation.Currently at Liverpool Hospital we use videotapesof specific aspects of trauma resuscitation and intra-operative management as teaching tools. Continuousvideo recordings of resuscitations have been used byother authors to determine errors in the process ofcare and to improve trauma care delivery (68, 69);this is a challenge that we hope to add to our arma-mentarium of processes which are designed to de-liver better trauma care to our patients.

SUMMARY AND FUTURE DIRECTIONS

Although there are always variations in the algo-rithms that are used to resuscitate and treat traumapatients, the ABC principles of immediate care ofthe poly-trauma patient have remained remarkablystatic. The concepts taught in courses such as ATLS

(Early Management of Severe Trauma in Australa-sia) provide a good structure by which the majorityof critically injured patients can be treated safely andquickly. With specific mechanisms and patterns ofinjury, there are alterations to these algorithms thatcan be made to better optimize patient care. We arebeginning at Liverpool Hospital to explore many ar-

eas that pertain to the initial care of the poly-traumapatient. These include hospital credentials and veri-fication of all hospitals accepting trauma patients andnot just the larger centres, the expansion of our web-site for trauma scenario teaching and team leader-ship skill development, as well as the use of videofor resuscitation audit and performance improve-ment. Local issues of injury demography, resourcesand logistics often lead to differences in the detailedimplementation of ATLS protocols and algorithmsand this paper has attempted to portray the ap-proaches used in the Major Trauma Service at Liver-pool Hospital in Sydneys Southwest.

Emerging concepts and research provide ideas that

may further enhance immediate trauma care andtreatment algorithms. Trauma care is a difficult areain which to conduct controlled research but what welearn from data gathered in large databases and ourown trauma registries can lead to improvements inpractice which will potentially increase our ability tominimize injury occurrence and better treat the inju-ries which continue to occur.

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Received: August 16, 2001

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