Introduction

Major trauma is the term used to describe serious or multiple injuries associated with a significant possibility of death or disability. The term can be further subdivided into blunt or penetrating trauma. Blunt trauma describes injuries sustained from blunt force such as a road traffic collision or fall from height; penetrating trauma describes the injuries resulting from an object penetrating the body, commonly a knife or bullet. There are approximately 20,000 cases of major trauma in England each year, resulting in around 5400 deaths and many cases of permanent disability. The distribution and pattern of injury varies between countries, regions and over time. In the UK there has been a steady decrease in road traffic fatalities but an increase in penetrating trauma.

The resuscitation of trauma patients has, for many years, been heavily influenced by the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach derived mainly from the American College of Surgeons’ Advanced Trauma Life Support course. The course is taught in many countries to postgraduate physicians and other medical personnel but the main principles are embedded in standard undergraduate curricula. The approach taken is that in the initial management of trauma victims, the most lethal clinical problems are dealt with first. Thus, airway obstruction is dealt with before breathing problems, and breathing problems are dealt with before circulatory problems. This philosophy has been extrapolated in recent years to military practice where it was recognised that catastrophic haemorrhage from blast injuries may be more rapidly fatal than airway obstruction which has led to the term (C)ABC. This is rarely relevant to civilian practice. Priorities of care are the same wherever the patient is attended, that is in the pre-hospital environment, the district hospital or the trauma centre. Where the life-threatening problem cannot be immediately treated the patient needs to be rapidly transferred to a site where the problem can be addressed or a more advanced resource needs to be made available to attend the patient.

The concept of major trauma centres, which treat a large number of patients with the most severe injuries, is well established in the USA and some European countries including the UK. There is some evidence that centralisation of trauma care decreases mortality. Numerous reports have emphasised suboptimal trauma management in the UK and have provided the drive to develop trauma networks and trauma centres. Pre-hospital medical services are being developed throughout the UK, with the aim of providing interventions dictated by the immediate needs of patients without unnecessarily delaying their transfer to hospital.

Trauma patients require rapid assessment, triage and where appropriate, instigation of potentially life-saving interventions. The ABCDE approach to patient care provides a standardised framework that identifies the immediate needs of the patient whilst reducing potential for human error in a stressful situation by providing a basic structure for the personnel involved.

Airway management

Current practice

Prompt and effective airway assessment and management is essential for all trauma patients. Failure to maintain or secure an adequate airway and provide oxygenation in a timely fashion is a major cause of preventable death following significant injury (Box 17.1).

Box 17.1 Indications for early tracheal intubation

Airway obstruction
Hypoventilation
Severe hypoxaemia
Reduced level of consciousness
Cardiac arrest
Hypovolaemic shock

Simple airway manoeuvres such as a head-tilt and chin-lift, or a jaw thrust if cervical spine injury is anticipated, are used to open the patient’s airway. If the patient is breathing, apply oxygen to the open airway and continue the primary survey. If the patient is not breathing or seems to have an obstructed airway, the airway remains the focus of the assessment until it is secured. Airway adjuncts such as an oropharyngeal or nasopharyngeal airway can help to restore airway patency. Do not use an oropharyngeal airway in a conscious patient as it will not be tolerated and is likely to stimulate vomiting and possible aspiration. Nasopharyngeal airways are better tolerated but insertion can be uncomfortable.

Supraglottic airway devices (SAD) are increasingly used by prehospital personnel. The main benefit of these devices is ease of insertion. They enable either spontaneous breathing or assisted ventilation. Recommendations from the UK Joint Royal Colleges Ambulance Liaison Committee (JRCALC) are that paramedics are trained to insert SADs instead of tracheal intubation. However, tracheal intubation with a cuffed tube remains the standard of airway care for those highly skilled in the technique. The positioning of a cuffed tube below the vocal cords will reduce the risk of airway soiling with blood or vomit. Injuries sustained to the head and neck may make intubation more difficult because of anatomical distortion, bleeding and airway oedema. Several emergency airway algorithms exist to improve the chances of successful intubation.

Further considerations

Rapid sequence induction (RSI) is a technique used by doctors to facilitate tracheal intubation in an emergency. Only those who are trained and skilled in the technique should attempt it. Oxygen is applied to pre-oxygenate the patient and maximise time to desaturation of arterial blood once the patient has been anaesthetised. An intravenous anaesthetic and short-acting neuromuscular blocker are used to induce anaesthesia and optimise conditions for intubation. As the drugs are given, a trained assistant applies backwards upwards pressure to the cricoid cartilage in an attempt to occlude the oesophagus and prevent passage of gastric contents into the lungs. In a standard RSI, the patient’s lungs are not ventilated whilst the drugs take effect (usually 60–90 seconds) to further reduce the risk of aspiration; however, in the presence of significant lung injury, gentle lung inflation with oxygen will reduce the risk of hypoxaemia occuring during the procedure. Intubation is performed when the patient is fully anaesthetised and muscle relaxation has been achieved. Cricoid pressure is removed once the tracheal tube cuff has been inflated, correct positioning of the tube has been confirmed and ventilation has been established.

It is possible to establish ventilation in a non-breathing patient by accessing the trachea through the procedure of cricothyroidotomy. This technique is considered by most to be a last resort and is the final step in ‘Can’t Intubate, Can’t Ventilate’ guidelines. The procedure is best performed using a surgical technique, where a small horizontal incision is made, and a cuffed tube passed into the trachea. Needle cricothyroidotomy, in which a cannula is inserted through the cricothyroid membrane, is less successful.