Polytraumatized Patient

Issues of Concern

Polytrauma management requires a well developed and standardized management system or protocol, the Advanced Trauma Life Support (ATLS). This is a universal management system that includes combined evaluation and management of injured patients. The ATLS protocol consists of a primary survey, adjunct measures, secondary survey, and tertiary survey.

The Primary Survey

The objectives of the primary survey are to identify and treat immediately life-threatening conditions. Using the ABCDE approach for each patient allows for patients to be assessed systematically, and if enough team members are present, tasks are performable simultaneously. The primary survey should take place promptly and quickly.[5][6]

Airway Management (including cervical spine protection)

Airway assessment and management is the first priority in the ATLS protocol. It should be cleared or secured before moving to the rest of the ABCDE assessment. An appropriate verbal response from a patient indicates a patent airway with adequate oxygen delivery to the lungs, and cerebral perfusion pressure to deliver blood to the brain. Simple maneuvers, including chin lift/jaw thrust, may assist airway patency. If there is evidence of neurological deficit, neck pain, or history of head injury or high-speed impact, then a cervical spine injury should be assumed. In patients who have had their cervical spine immobilized prehospital, this should be maintained until ruling out the injury. 

In patients who are apnoeic or who have a Glasgow coma scale (GCS) less than 8, the airway should be secured, most commonly with orotracheal intubation is indicated. Induction of general anesthesia using a rapid sequence induction (RSI) may be useful in patients requiring airway support.[7] The following steps are necessary for intubation: 

• Plan in advance, check equipment, prepare induction and maintenance anesthetic drugs needed, plan for failed intubation and surgical airway, allocate roles, and know where rescue equipment is stored.
• Prepare suction equipment and check equipment required to provide positive pressure ventilation.
• Preoxygenate the patient with 100% oxygen.
• Apply pressure over the cricoid cartilage.
• Administer induction, followed by muscle relaxant medications. 
• Intubate the trachea using an appropriately sized cuffed oral endotracheal tube (ET)
• Inflate the cuff and confirm tube placement through auscultation of the chest and end-tidal CO2 monitoring.
• Connect the ET to the ventilator.

If the trachea cannot be intubated, then alternative routes for delivering oxygen to the lungs must be sought. Patients with upper airway obstruction where an endotracheal tube cannot be passed through the vocal cords will require a surgical airway such as a cricothyroidotomy or tracheostomy.[8] With regards to trauma patients requiring an emergency surgical airway, cricothyroidotomy is preferable as it is technically easier to perform and takes less time.[9] Needle cricothyroidotomy is a short-term solution to providing patients with supplemental oxygen while a definitive airway is secured. It involves placing a wide-bore cannula (12 to 14 gauge in adults, 16 to 18 gauge in children) through the cricothyroid membrane and into the trachea. Connecting the patient to an oxygen source and manually ventilating using a ‘jet insufflation technique’ allows for 30 to 45 minutes of oxygenation.

Surgical cricothyroidotomy involves a skin incision over and through the cricothyroid membrane to directly visualize the trachea and insert an endotracheal tube. Both needle and surgical cricothyroidotomy should only be performed by users who are familiar with the technique required for their success.

Breathing and Ventilation 

Breathing and air entry are then assessed by auscultating the breathing sounds and observing chest movement. Several serious chest injuries, like hemothorax or pneumothorax, can be identified by this physical exam only. Other injuries may need further assessment or imaging. 

All clothes should be removed, and a note of the patient’s respiratory rate, work of breathing, tracheal placement, and chest symmetry should be noted. The chest and axillae should be examined for abrasions, bruising, open wounds, and evidence of penetrating trauma. Auscultation and percussion of the chest will indicate the symmetry of ventilation and resonance. If a tension pneumothorax is suspected, needle decompression should be employed by inserting a wide-bore needle into the second intercostal space in the midclavicular line on the affected side.[10] If a tension pneumothorax is suspected, do not delay treatment waiting for radiological confirmation. Hemothorax and pneumothorax both warrant the insertion of a wide-bore thoracostomy tube. Pulse oximetry will indicate arterial oxygenation, but supplemental oxygen may mask hypoventilation. Ultrasound of the chest may suggest the location of air pockets in the chest indicative of pneumothoraces.[11]

There are critical conditions that necessitate immediate management. If these conditions remain untreated, or if there is a significant delay in the treatment,  they will result in hypoxia, hypovolaemia, and reduced cardiac output and possible death. Thoracic conditions that are immediately life-threatening include:

• Tension pneumothorax
• Flail chest
• Massive hemothorax
• Open chest wound
• Cardiac tamponade

Circulation

Bleeding is a common and potentially severe consequence of polytrauma. The most likely cause of shock in trauma patients is a hypovolaemic shock due to bleeding. Clinical signs of hypovolaemic shock include tachycardia, prolonged capillary refill, cool peripheries, a drop in pulse pressure, increased respiratory rate, and a drop in conscious level. A decrease in systolic pressure in some patients may not become apparent before they have lost up to 30% of their blood volume. The clinical presentation of hypovolemic shock follows the four classes of shock ( Class I, II, III, and IV).

In patients presenting with hemorrhagic shock, access to the vascular system (usually venous access) must be obtained, and appropriate volume replacement initiated.  Following intravenous access, blood should be drawn for cross-matching and the necessary blood tests. Patients should be connected to continuous ECG monitoring, non-invasive blood pressure monitoring set to an appropriate interval, so that response to resuscitation is measurable. If the patient has had significant blood loss, non-invasive blood pressure measurement may not be recordable, in which case palpation of central pulses can help identify if there is any cardiac output.

Volume resuscitation usually starts with a bolus of crystalloid fluids. If the patient does not appropriately respond to this initial fluid replacement, or the patient has suffered major injuries, then blood should be urgently considered. Evidence suggests that a ratio of 1:1:1 for packed red cells, fresh frozen plasma, and platelets may provide the greatest survival advantage.[12] Pharmacological adjuncts such as tranexamic acid should merit consideration in trauma patients. Tranexamic acid inhibits both plasminogen and plasmin, thus acting as an antifibrinolytic and reducing clot breakdown. Administration of 1 g bolus within three hours of injury followed by a further 1 g over the following eight hours is a commonly observed regime.

Control the source of bleeding is essential. Efforts of identifying the bleeding source should be concomitant with the volume resuscitation. External bleeding sources are usually easier to identify and control. Scalp laceration and open long bone fractures are common causes of eternal fractures. Internal bleeding sources are more challenging to identify and control. The thorax, abdomen, or pelvis may all be sources of bleeding that the clinician cannot see. Appropriate examination and Imaging such as chest x-ray and focussed assessment with sonography (FAST) will assist in the diagnosis of hemorrhage. The clinical pelvic stability assessment may be performed once; further attempts may dislodge clot from an active bleeding point. A pelvic splint can be used to tamponade bleeding due to pelvic fractures. Definite treatment by an orthopedic surgeon should follow. Severe uncontrolled hemorrhage can drive the lethal triad in trauma patients of hypothermia, coagulopathy, and acidosis.[13]

Hemorrhage Control

External hemorrhage control requires pressure on the bleeding source.[14] Alternatively, proximal limb tourniquets are an option in uncontrolled bleeding. Tourniquets are designed to occlude arterial flow to a limb through compression and should be employed to control blood loss when methods such as compression, elevation, and topical hemostatics have failed. [15] They should only be used by practitioners trained in their use. They are usually applied 10 cm proximal to the injury, directly on top of the skin and not over a joint. They should be used for a maximum of two hours to reduce the chance of ischemic damage to the limb.

Disability

Proper and complete neurologic function assessment is an essential component of polytrauma patients. A normal initial exam is critical to document, so consequent deterioration can be identified and properly managed. The assessment of neurological function includes central and peripheral deficits or injuries. Glasgow coma scale, pupils' status/reaction, and the peripheral neurologic exam are parts of the assessment. In patients suspected of neurological injury, it is crucial that patients are not subjected to uncontrolled movement, and should be immobilized on a spinal board with appropriate cervical spine precautions.[16][17] Spinal surgeons should be involved early in the case of suspected spinal injuries.

Exposure/ Environment 

The patient should have had clothing removed to access the thorax and abdomen for assessment. Remaining clothing should be removed to allow for further examination. Patients should be actively warmed or covered with blankets to minimize heat loss to prevent hypothermia.[18] The team leader should ensure that all interventions have been completed at this point, if necessary, reassess the patient starting from the beginning of ABCDE. The patient may require transfer to the theater, radiology, or another hospital, and the team leader needs to make provision for transfer by suitably qualified personnel. Early involvement of the appropriate surgical team, if not part of the trauma team is vital in avoiding the delay of further treatment following the primary survey.

Key points

• Trauma teams are necessary for the successful management of trauma patients
• Trauma patients benefit from an interprofessional team approach
• The trauma team leader should organize the trauma team to perform the primary survey quickly and systematically
• Airway, Breathing, Circulation, Disability, and Exposure assessment should then be the next step. If the trauma team has sufficient organization, these can occur simultaneously rather than in sequence.
• Successful performance of the primary survey can quickly identify life-threatening injuries that need immediate management, and other injuries that may become life-threatening if not managed appropriately.

Enhancing Healthcare Team Outcomes

Polytrauma patients may present unexpectedly to any hospital, including non-trauma centers hospitals. It is therefore vital that these patients are managed systematically by an interprofessional team, with a view to further treatment and possible transfer once the patient is stable. Many hospitals have designated levels of trauma service according to the clinical and scholar capabilities of the hospital. Trauma bay of variable beds and all the necessary supplies are available in the emergency department of the trauma centers. Trauma teams are available to initiate trauma care once trauma codes are activated. Trauma teams consist of members from emergency departments, general surgery, neurosurgery, orthopedic surgery, intensive care, anesthesia, radiology department, nursing, and lab. Pharmacists may also have involvement depending on the medical needs of the individual patient and must be prepared to rapidly deploy medications in conjunction with the trauma or emergency room clinicians. This is why many facilities have a pharmacist on duty dedicated to the emergency department. Trauma nurses will also be on the front lines, collaborating directly with the trauma clinicians in providing the interventions needed, monitoring patient status, and collecting information from the patient (if possible) or other witnesses or family members. This type of interprofessional teamwork is essential in polytrauma emergencies. [Level 5]

Trauma activation commences upon the arrival of the injured patient. Occasionally, trauma activation may take place before the patient's arrival in critical injuries. Upon arrival, the patient enters the trauma bay, where the transfer from the prehospital team to the trauma team takes place. Effective handover is critical at all stages of the patient journey. Essential information that is required by the trauma team is:

• Mechanism of the injury
• Name (if available), age and sex of the patient
• The patient's injuries with most life-threatening mentioned first
• Airway, breathing, and circulation assessment and interventions
• Consciousness level and spinal status

Nursing, Allied Health, and Interprofessional Team Monitoring

Each member of the trauma team is vital in providing a high standard of care to the patient. The nursing role within this team is pivotal to a full perspective of the situation at hand. Familiarity with the environment means that nurses can be an invaluable resource to other team members. Usually, two nurses are a requirement in a trauma team.

If there is a hospital pre-alert received by the hospital, it is essential that the information given is clarified and any further questions asked before alerting the trauma team in the receiving unit. More information about expectations means that better preparation can take place; for example, advance notice of a suspected major hemorrhage could prove helpful in accessing blood products promptly.

Once the trauma alert has gone out, an appropriate area to receive the patient should be prepared and checked. A nurse should be ready to remove the patient's clothing upon arrival in the emergency department so that all possible injuries may be fully exposed. Clothing may need to be cut off. Initial monitoring should include non-invasive blood pressure cycling 3 to 5 minutes, electrocardiogram (three-lead), and pulse oximetry. Other monitoring, such as end-tidal CO2 or invasive blood pressure monitoring, may be requested by the team and should be available. A second nurse can take handover from the pre-hospital crew and document treatment given so far. Communication is vital, and once the initial monitoring and transfer have taken place, further treatment may necessary; the team leader should receive notification once other team members are free to complete other tasks.

A vital role of the nursing staff in the polytraumatized patient is to act as an advocate for the patient, where they can voice particular concerns to the team, with important regard given to the patient's pain level.

The trauma nurse is expected to have many skills and needs to be adaptable to the often rapidly changing clinical situation. To keep the trauma team progressing requires rapid switching from task to task. Communication with the patient, and possibly family, during this time, will help reduce anxiety.