Trauma month: what next

Advanced trauma team

Over the course of this month we have explored the trauma care offered to our patients and have covered how to utilise the East of England Trauma Pathway; what assistance is available to crews in the form of critical care; packaging a trauma patient; management of traumatic cardiac arrest; haemorrhage control and optimising your patient.

In this article we are going to look at how we can further support our patients once initially managed, packaged and transferred into an ambulance.

Patients with head injuries

A patient with a head injury can be a challenge to manage, and optimisation to prevent secondary brain injury is based around some key principles. When an enhanced care team (ECT) is available they may decide to perform a pre-hospital emergency anaesthetic (PHEA) to instigate neuro-protective strategies as described, in part, below. In the absence of an ECT, or whilst preparing for their arrival you can:

  • ensure any cervical collars are loosened
  • ensure any airway tie or tube holders are not too tight and not compressing the neck and underlying blood vessels (whilst maintaining a secure airway)
  • lifting the head of the trolley up to 30 degrees (with patient immobilised)
  • ensure oxygenation (high flow oxygen as appropriate)
  • aim for a systolic blood pressure of 120 or a MAP of 90mmHg (MAP is provided on both Zoll and Corpuls when NIBP is undertaken)
  • where a patient is being ventilated, attempt to achieve an EtCO2 of between 4.0kpa and 4.5kpa
  • maintain body temperature.

By instigating the above measures, you will be helping to optimise your patient. Clearly attention to basics and applying the principles from previous articles will go to support the care of this type of patient.

Traumatically injured and shocked patient

These patients can be even more challenging.  Most critical care provision (both in the pre-hospital and acute setting) applies the principles of damage control resuscitation.

In the context of EEAST, we should manage patients as per the National Clinical Practice Guidelines although also apply the Trauma East Manual of Procedures and Operations (TEMPO2) guidance.

Whilst we can be quick to administer intravenous fluids, the aim, in the context of a traumatically injured and shocked patient, is to achieve ‘adequate organ perfusion’. This can cause a dilemma; infusing too much fluid is going to risk exacerbation of bleeding and coagulopathy, whilst inadequate perfusion could cause damage to the brain and other organs.

In targeting fluid resuscitation we should aim for (adults):

  • traumatic brain injury – SBP >120mmHg
  • blunt-force trauma  - SBP >80mmHg
  • penetrating-force trauma – SPB >60mmHg.

The patient must also be managed with a view to preventing a worsening coagulopathy.

The balanced approach

Clearly, major trauma patients often present with both head injuries and blunt force trauma requiring fluid resuscitation.  Clinicians need to balance cerebral perfusion (which requires higher MAP or SBP) with permissive hypotension (recognising that lower MAP or SBP will prevent clot destruction and coagulopathy). Advice or guidance can be obtained through the Trust’s clinical advice line or support from the critical care desk clinician.

The future

As with everything in pre-hospital care, management strategies are continually changing and developed in accordance with the emergence of new evidence.  The Faculty of Pre-Hospital Care is currently consulting on a new consensus statement for haemorrhage control which may inform our future practice. Within the east of England there is a pre-hospital blood product trial which ECTs are participating in, although this is in its early stages.

It is important to recognise, as with any critically ill patient (medical and trauma), our treatment strategies must be based on sound assessment and interpretation of physiological or anatomical findings, then linked to best available evidence. By paying attention to detail we can ensure that we are making informed decisions about the care of our patient; not only providing initial intervention but also looking to optimise their condition en route to the receiving hospital.

Published 31st May 2015 

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