Early Management

Haemostatic resuscitation

Early administration of blood products in haemorrhagic shock is advised in order to reduce the lethal triad of coagulation, acidosis and hypothermia. Administration of packed red blood cells (PRBC) is advised if available. If greater than two units are required, specialist consultation, use of a balanced transfusion protocols (PRBC, plasma, platelets) and initiation of a trauma transfusion protocol is advised. Where massive transfusion is required (more than five units of blood in under four hours), blood product administration should be guided by the Critical bleeding massive transfusion guideline published by the National Blood Authority.¹⁵

Permissive hypotension

Maintenance of a circulating volume at a reduced level whilst maintain adequate perfusion until haemorrhage control is established. Applicable to the penetrating trauma patient pending emergency surgical intervention.¹⁶

Damage control surgery

Emergency temporizing surgery performed in order to gain haemostatic control prior to definitive intervention. Diversion to a RTS may be necessary where capability exists and where flight and landing logistics allow in order to access immediate haemostatic interventions.

Naso/orogastric tube (N/OGT)

All patients should be kept nil orally in the initial post-resuscitation phase of injury. A gastric tube should be inserted early in the resuscitation phase to relieve acute gastric dilation, remove gastric contents and decompress the stomach before performing a diagnostic peritoneal lavage (DPL). 

Urinalysis

Gross haematuria suggests serious renal injury and mandates further investigation. Microscopic haematuria (>25 RBCs per high power field), increases the likelihood of significant intra-abdominal injury.

Imaging

Further diagnostic imaging should be considered if available and indicated. Do not transport an unstable trauma patient to an imaging facility unless absolutely essential.
 
If FAST was not completed in the primary survey it should be done now. This is a non-invasive procedure, is quick to perform and can be completed in the ED.

FAST:

• Used to identify free fluid in the peritoneal cavity.
• Sensitivity approaching 96% in detecting >800mls blood.
• Involves directing the ultrasound probe in four main regions:

1. Subxiphoid: to determine fluid in the pericardial space and to assess cardiac filling and contractility.
2. Right upper quadrant: Liver, kidney, diaphragm (including Morrison’s pouch).
3. Left upper quadrant: Diaphragm, spleen, kidney.
4. Suprapubic view: Bladder.

Positive results from a FAST scan warrant further investigation and management in accordance with the patients’ clinical status.

CT abdo/pelvis

• Allows haemoperitoneum to be identified & allows specific injuries to be graded.
• Permits evaluation of retroperitoneal structures including the kidneys, major blood vessels & bony pelvis
• In the haemodynamically stable patient with suspected intra-abdominal injury the key decision is whether the patient requires CT scanning or a period of observation. CT is the diagnostic modality of choice in the stable patient.
• Contrast extravasation found on CT is a sign of active bleeding and is a strong predictor of failure of non-operative management.

Hollow viscus, diaphragmatic & pancreatic injuries are frequently missed on initial scanning. Isolated intraperitoneal fluid findings on CT should raise a high suspicion of hollow organ injury.

Blunt trauma

Patients who do not present with any predictive factors indicating intra-abdominal injury requiring urgent laparotomy or CT evaluation and have no other presenting problems may be observed with serial abdominal examinations and discharged if no reason for admission is found.

Penetrating wounds

In accordance with the inter-hospital major trauma criteria, all penetrating wounds except for isolated/superficial limb injuries should be transferred to a MTS for evaluation. A reliable approach to detecting significant injuries after penetrating wounds to the abdomen may be with serial physical examinations, so long as the patient has no other distracting injuries, is alert and orientated and not influenced by sedation. Ideally serial examinations should be performed by the same clinician. 

Laboratory tests

Routine laboratory tests are generally of limited value in the management of a trauma patient. Isolated results from single blood tests may be misleading and results should be considered in the context of the whole patient and trended results where available.
FBE: Haematocrit below 30% increases the likelihood of intra-abdominal injury in the setting of blunt abdominal trauma. Haemoglobin levels should be interpreted according to time since injury, amount of fluid administration and extent of haemorrhage.
UEC: and glucose should be routinely taken.
Serial blood gas assessment of pH and lactate levels provides good monitoring of tissue oxygenation, circulatory status and response to resuscitation.
Consider performing coagulation studies and group and cross-match if there is a high index of suspicion for haemorrhage.

Fluid resuscitation

Avoidance of hypovolaemia in trauma is a cornerstone of management. A balanced approach to fluid replacement is important, especially in establishing early treatment goals.
Resuscitation goals:¹⁷

• The main goal of fluid resuscitation in trauma is to preserve vital organ function until bleeding can be controlled.
• The assessment of hypovolaemic shock is difficult during the early phase of major trauma care. The clearest signs of end-organ hypo perfusion include decreased urine output, acidosis, altered conscious state and elevated lactate level.
• In immediate trauma care aim for a blood pressure greater than 90 mmHg systolic or a shock index less than 1 (HR/SBP).
• Blood pressure goals for penetrating trauma or uncontrollable haemorrhage are generally lower than for blunt trauma in the absence of a major head injury. (SBP values less than 90 mmHg may be acceptable if cerebral perfusion is maintained – that is, if conscious state is normal⁸. Early consultation about such patients is required.
• If possible, all blood/fluid administered to a major trauma patient should be warmed with a fluid warmer.

 

Crystalloid fluids

Initial treatment of hypovolaemia with crystalloid fluids (normal saline) is recommended, up to 20–30 mL/kg.

Colloids

Colloids are not generally recommended in the early treatment of major trauma.

Analgesia

Titrated narcotic analgesia is the initial approach to pain management in trauma. Intravenous administration is the most effective route. Administer as per local protocols and titrate to effect. Analgesia should be administered prior to any wound or fracture care as treatment and dressing of wounds or fractures can be particularly painful.
Consider prophylactic antiemetic administration, especially if transfer and retrieval is likely.

Prevent hypothermia

It is important to maintain normothermia. Ensure the patient does not lose excess heat due to exposure or wounds. Make sure all wounds are covered.
Use warmed IV fluids; cover the patient with extra warm blankets as well as keeping the room warm (a general guide is that if clinical staff are comfortable it’s likely to be too cold for a trauma patient). If available, the use of a forced air-warming machine is encouraged¹⁶. Re-assess the room temperature at regular intervals while awaiting the retrieval team.

Monitoring

Monitoring the heart rate, respiration rate, blood pressure and oxygen saturation should take place at 15-minute intervals or more frequently if indicated. Monitor continuously via electronic monitoring if facilities are available. All monitoring should be maintained until the retrieval team arrives.
A baseline ECG should be taken prior to transfer if time permits and facilities exist.

Glasgow Coma Scale

A focused neurological assessment using the Glasgow Coma Scale should be performed. This should include a description of the patient’s level of consciousness as well as assessments of pupillary size and reactivity, gross motor function and sensation. Document the findings and reassess at frequent intervals.

Tetanus immunisation

Tetanus immunisation should be updated in the case of significant or contaminated wounds. Tetanus immunoglobulin should be given to patients who have not received a complete primary immunisation.¹⁹

Antibiotics

Routine IV antibiotic administration is not recommended in major trauma, however, is indicated in patients with penetrating abdominal injury requiring surgical management.

Reassess

The importance of frequent reassessment cannot be overemphasised. Serial abdominal examinations should be performed at regular intervals as deterioration in a patient’s clinical condition can be swift. This will be evident in their vital signs and level of consciousness.
If in doubt, repeat ABCDE.