Trauma is one of the leading causes of mortality, morbidity and disability worldwide. In developing countries, the magnitude of the problem has been increasing consuming more and more of the meager health resources of these nations. Moreover, trauma mostly affects people in their productive years of life, hence the high economic and social burden to society. The causes of trauma are various and their relative incidence varies in different populations.
Trauma is tissue damage, which occurs due to transfer of different forms of energy either intentionally or unintentionally.
Types of Trauma
Trauma can be classified according to the:
Cause: Homicidal injuries, Road traffic accident and falls, Industrial accidents, burn, etc.
- Blunt Injury: Caused by acceleration, deceleration, rotational or shearing force
- Penetrating Injury: Caused by a direct breach, by penetrating object E.g. Bullet injury, stab injury
Deaths due to trauma tend to occur in three patterns:
Immediate death (50%)
- Occur in the first few minutes after the accident
- Are due to extensive and lethal injuries to the brain, heart & major blood vessels
Early deaths (30%)
- Occur in the first few hours
- Are due to the collections and bleeding in the chest and abdomen, extensive fractures and increased intracranial pressure
- Early resuscitation, diagnosis and appropriate management can prevent these deaths.
Late deaths (20%)
- Occur days or weeks after the injury
- Are due to sepsis and organ failure
- May be decreased by early resuscitation and appropriate treatment
Management of trauma
Management of trauma requires adherence to an established order of priorities like the advanced trauma life support (ATLS) protocol developed by the American College of Surgeons. The ATLS generally consists of a primary survey and resuscitation followed by a secondary survey and definitive management.
The primary survey and resuscitation
This part of management comprises a quick evaluation of the patient to detect immediately life threatening situations and institution of measures to correct them. It has the following components:
Air way: Assess the patency of air way. In a trauma victim, it may be compromised by the back fallen tongue, broken tooth, vomits, blood etc. If the air way is compromised, use suctioning, jaw trust, positioning, oropharyngeal tube or endotracheal tube to open it, taking care of the cervical spine.
Breathing: Assess adequacy of breathing. It may be compromised by pneumothorax, hemothorax or multiple rib fractures causing flail chest.
Circulation: Assess the circulatory volume. Look for external hemorrhage and arrest it by pressure, bandaging or tourniquet if the other methods fail. Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound. Open a wide bore IV line, take blood sample for cross match and start resuscitation with Normal saline or Ringer’s lactate.
Do a quick neurologic examination to assess consciousness. Use the Glasgow coma scale (GCS) to determine the level. Look for any Neurological deficit or lateralizing sign.
Expose (undress) the patient fully for examination not to miss serious injuries.
Secondary survey and definitive management
This is done after the life threatening conditions have been evaluated and resuscitative measures are instituted. It includes the following aspects:
Take History: The informant may be the injured patient, relatives, police or ambulance personnel. The history should include:
- Time of injury,
- Mechanism of injury,
- Amount of bleeding,
- Loss of consciousness,
- Any intervention performed or drugs given should be asked for.
Do a proper and systematic examination of all body systems.
Make necessary investigations such as hematocrite, cross-match, urinalysis, X-ray, ultrasound, etc. However, never send a patient with unstable vital signs for investigation or referral before resuscitation.
Institute the appropriate specific treatment like laparotomy for possible abdominal organ injury, POP cast for tibio-fibular fracture.