Trauma

Updated: 17th April 2018
In the UK major trauma is the leading cause of death in those under 40 years old [1]. In children, mortality from injury is greater than childhood mortality from all other causes combined [2].

HMP3– Major Trauma

EM Curriculum: (click to view)

Background

Major trauma is, however, a minor element of Emergency Department work equating to less than 0.2 per cent of total activity [3].

As a result those involved in the management of severely injured patients may not have regular or significant previous experience with such cases. Therefore it is important to have a good understanding of the principles behind the initial assessment and management of trauma patients.

The pattern of trauma deaths are classically described as having a Trimodal distribution comprising of immediate, early and late deaths. Immediate deaths are those due to massive injury that occur within seconds to minutes of the traumatic insult and are not preventable.

The early deaths that occur within minutes or hours after injury are largely due to bleeding. These deaths can be prevented and this group of patients are the focus of the ATLS protocol and those that good emergency department care can probably make the most difference to.

References:

  1. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Trauma: who cares? A report of the National Confidential Enquiry into Patient Outcome and Death (2007), November 2007

  2. Mace SE, Gerardi MJ, Dietrich AM, et al. Injury prevention and control in children. Ann Emerg Med 2001; 38:405–14.

  3. National Audit Office (NAO). National Audit Office (NAO). Major trauma care in England. Report by the Comptroller and Auditor General. HC 213 Session 2009-2010, 5 February 2010


LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Revise the immediate management of major trauma.

  • Assess and manage burns in the context of significant trauma with reference to the paediatric population.

  • Recall the anatomy of the spinal cord and how this relates to the spinal cord syndromes. 

    • Recognise that the patterns of spinal injury differ in children.

    • Define SCIWORA and explain the investigation and management required.

  • Revise the theory and steps for a Resuscitative Thoracotomy.

Learning Outcomes from Face-To-Face Teaching

  • Recognise the patterns of injury in paediatric trauma.

  • Be able to limit/control haemorrhage by the application of pelvic binders/pro-coagulants/tourniquets...

  • Understand the role of angiography.

  • Understand the indications and contraindications for emergency thoracotomy.

  • Describe how to perform an emergency thoracotomy in the ED.


TASKS

Complete the following before the face to face session:

TASK 1: APLS UPDATE (ST Emlyn's)

Duration: 16 mins

Listen to this padcast from St Emlyn's that summarises the 2015 APLS updates regarding the management of the Seriously Injured Child. You can also read the accompanying blog post here.

Task 2: Major Bleeding in Trauma

Duration: 40 mins

Although the first description of permissive hypotension was recorded by Army medics following the first world war, it has only really translated into recommendations for clinical practice within recent years. The podcast and editorial below provide two differing perspectives on this subject. A thorough summary of the evidence around this topic can be found in the article "Management of bleeding and coagulopathy following major trauma: an updated European guideline", this is in the additional resources folder for this module.

EMCRIT 30 – Haemorrhagic Shock Resuscitation

Anaesthesia Editorial – BP management in trauma

Task 3: Paediatric (Major) Burns

Duration: 45 mins

This article includes a systems approach to the effects of burns as well as the assessment and management of burns within the context of major trauma. It also includes revision of fluid calculations.

 

Task 4: Spinal Cord Syndromes

Duration: 25 mins

The Anatomy for Emergency Medicine videocasts summarise the spinal cord syndromes with particular reference to anatomy. It is well worth looking at the rest of the website for other work produced by Andy Neil.

Task 5: Resuscitative Thoracotomy

Duration: 35 mins

This article explains how to perform a resuscitative thoracotomy in the Emergency Department. 

Now watch the late John Hinds give what many regard as the definitive lecture on Resuscitative Thoracotomy.


#EM3 Content

Lightning Learning:

Simblog:


CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

A six year old boy was climbing a tree to get his football back, he has fallen 7 feet onto grass.
A 36 year old pedestrian was struck by a car traveling at approx 40mph.

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

Considerations in Pediatric Trauma

A summary article of how trauma differs in children.

An Approach to Paediatric Cervical Spine Injury

A fairly comprehensive review from "pemdatabase.org" of cervical spine injury in children including epidemiology, assessment clinically and radiologically, and how to immobilise a child with c-spine injury, although due to date of publication it still advocates the use of hard collars. It also contains some case examples.

Clearing the Paediatric C-spine (EMJ)

Objectives: To review the evidence available for clearance of the cervical spine in children under 16 years of age after trauma, and to provide guidance to enable this to be practised safely.

Methods: A comprehensive literature review was carried out, and combined with a review of standard texts and liaison with experts.

Bromley Case of the Week 41: Sweet Dreams

The practicalities of how to CT small children.

Bromley Case of the Week 62: A Clash of Heads in Football

A common enough presentation to the ED.

SONOGUIDE

A website about ultrasound for emergency medicine, it includes sections on physics and different uses of US, but in particular has information about FAST.

SKETCHY MEDICINE

Surface anatomy of the chest and sites for chest drains (note the latest guidelines for trauma suggest thoracostomy rather than needle decompression).

Management of Bleeding in Trauma

This European Guideline provides a detailed summary of the evidence regarding permissive hypotension as well as other principles of managing bleeding in trauma patients.

Angiography in pelvic trauma

Life in the Fast Lane blog entry on angiography and embolisation in pelvic trauma.

Angiography and embolisation for solid abdominal organ injury

Review article on current thinking regarding the role of angiography in abdominal trauma in adult patients.

Radiology masterclass

A great website with lots of images and tutorials in the interpretation of plain radiographs in trauma.

Anaesthesia UK

Another anaesthetic resource, this particular page provides a general overview of trauma as a whole. Key sections include:

  • Preparation both pre-hospital and in hospital.

  • Triage with adult and paediatric trauma scores.

  • Summary of primary/secondary surveys, what you are looking for, and outlining adjuncts.

  • Airway and ventilation management.

  • Shock: including classification and management.

  • Summaries of Chest, Abdo, Spine & Head trauma.

  • MSK injuries and thermal injuries.

  • Trauma in women and in pregnancy.


COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: