An introduction to the initial hospital management of acute trauma

Glasgow Coma Score

Best Eye Opening (E)	Best Verbal Response (V)	Best Motor Response (M)
4=Spontaneous 3=To voice 2=To pain 1=None	5=Normal conversation 4=Disoriented conversation 3=Words, but not coherent 2=No words......only sounds 1=None	6=Normal 5=Localizes to pain 4=Withdraws to pain 3=Decorticate posture 2=Decerebrate 1=None

Disability treatment options include:

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  O₂ administration
  
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  Intubation (to ensure normal p0₂ and pC0₂)
  
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  Inotropes / vasopressors (to ensure adequate cerebral perfusion)
  
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  Head up, ensure venous drainage
  
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  Emergency imaging of brain or spine
  
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  Neurosurgery
  

Exposure / environmental control

Fully undress the patient, allowing a thorough secondary survey. Avoid hypothermia which can have devastating consequences (coagulopathy, acidosis) by actively warming the patient. Check blood sugar.

Initial Investigations:
FBC, U+E, glucose, cross match, blood gas
Chest and pelvis plain radiographs
AP, Lateral and Odontoid peg view cervical spinal radiographs


Secondary survey

The secondary survey occurs after all life-threatening injuries from the primary survey have been identified and treated, and parallel initial investigations performed (see box). It aims to identify all the injuries sustained, involves a thorough head to toe examination including full neurological examination, examination of the spine, log rolling and performing a PR exam. Take a complete history from the patient, paramedics, police or relatives. Key questions stem from the mnemonic AMPLE “Allergies, Medication, Past medical history, Last meal (relevant for surgery), and Event and Environment related to injury”. As a result of the secondary survey further investigations may need to be taken.

Definitive care

Definitive care starts once the patient has been resuscitated and any life threatening injury dealt with. It includes further surgical intervention, antibiotics, tetanus immunisation and may involve transfer to a tertiary centre. Transferring a trauma patient is very risky and should involve the most appropriate doctor, trained in transfer. Ideally a tertiary survey should be performed the next day to ensure nothing has been missed in the initial surveys (eg small but functionally important digital injuries). Patients with certain injuries may sometimes need transfer before the secondary survey or even during the primary survey eg isolated head injury or polytrauma patients requiring cardiothoracic surgery.

Summary:

Trauma is a leading cause of death and disability especially amongst young people. A well rehearsed and systematic ‘ATLS’ approach to hospital resuscitation can save lives as well as limiting the consequences of the trauma. It should be remembered that the primary survey should be repeated whenever an intervention has been made and if changes in the patient’s clinical state occurs, to avoid the ‘triad of death’ (hypothermia, acidosis and coagulopathy) and to be aware of the golden first hour of trauma resuscitation: delays in treatment can kill.