AND
TRAUMA EMERGENCY CARE
This booklet has been produced to accompany the BBC Two series ‘An Hour To Save Your Life’. The series was produced in partnership with The Open University. This booklet describes different kinds of traumatic injuries, stroke and heart attacks and their treatment. In the centre spread you will find illustrations of some common types of conditions requiring emergency treatment. In addition to the information in this booklet, The Open University has a wealth of free online information and resources about health. To find out more visit: open.edu/openlearn/trauma
What is trauma? One definition is ‘a disease caused by physical injury’ and is not to be confused with emotional trauma. Major trauma, the subject of this book, means multiple, serious injuries that could result in death or serious disability. These might include serious head injuries, severe gunshot wounds or road traffic accidents. Fortunately these sorts of severe and complex injuries are quite rare. Taken in context, major trauma represents only 0.1% of total accident and emergency activity, with the average major trauma centre seeing about one case per day. In 2010, the National Audit Office estimated that there were about 20,000 cases of major trauma each year in England that resulted in 5,400 deaths (27%). According to NHS England, ‘many of these deaths could be prevented with systematic improvements to the delivery of major trauma care’. As major trauma is rare, it is not possible for all hospitals to have the equipment, onsite specialties and specialist doctors needed to treat it effectively. Therefore patients with multiple, complex and serious major trauma injuries are, or should be, taken directly to a major trauma centre, a hospital designed specifically for the care of seriously injured patients. The development of these centres has led to improved outcomes for
those who have been severely injured. Brain injury is the leading cause of death after trauma. Acute (short duration) haemorrhage is the next commonest, and the most likely cause of death in the first three hours after injury. Early diagnosis and intervention is essential to saving lives particularly in the first hour, defined by some as the ‘golden hour’. The concept of the golden hour comes from the United States’ military experience in wartime. It is widely believed that the victim’s chances of survival are greatest if he or she receives the proper care within the first hour. This is summarised by the three Rs rule as ‘getting the right patient to the right place at the right time’. Getting patients with trauma injuries to the right treatment in the shortest possible time remains the objective of pre-hospital care. It requires a rapid response by the emergency services, as short a time as possible at the scene and the swift delivery of the patient to a facility that possesses the expertise for treatment. The advances in protocols and equipment have as much to do with improved paramedical skills as with the skills of the accident and emergency physician, surgeon or anaesthetist. The emphasis in all cases is on minimal delay.
The Trauma Pathway
Pre-hospital care Ambulance services
Acute emergency care and surgery Trauma units
On-going care and reconstruction
Specialised or local rehabilitation
Local emergency hospitals
Rehabilitation providers
Acute / Early phase rehabilitation Adapted from figure 1 NHS England NHS standard contract for major trauma
Heart and Lungs The heart The heart is a four-chambered muscular organ located just to your left of the centre of your chest. It acts as a double pump, the right side serving your lungs and the left side serving the rest of your body. The first pump carries blood low in oxygen to the lungs, where it unloads carbon dioxide and picks up oxygen. After passing through the lungs, oxygen-rich blood is delivered back to the heart. The second, more powerful pump delivers blood carrying oxygen to the rest of the body. The cycle is then repeated as blood needing more oxygen is sent back to the heart. During your lifetime your heart works constantly without ever pausing to rest because heart (cardiac) muscles never tire. Their cells are highly interconnected allowing the heart to contract in a coordinated manner, controlled by specialised cells called the pacemaker. The blood supply to the heart comes from blood vessels (coronary arteries) that wrap around its outside.
Cardiac trauma The heart’s normal function can be impaired in a whole host of ways. Like any other organ in the body it relies on having a sufficient blood supply but after a heart attack, the blood supply is too inadequate for it to function properly. The heart’s pumping action can be affected by either direct injury or the build-up of blood in the chest or inside the sac that surrounds the heart. Injury can either be direct, as in a penetrating injury from a knife or broken rib, or can be blunt trauma injury caused by a massive shift of energy across the whole chest. This could occur in high-impact vehicle accidents when the body decelerates from, say, a speed of 100 kilometres per hour to zero in a few metres. Most blunt chest injuries are due to accidents involving cars but can also be caused by falls, work-related accidents, and sporting activities -- and also by resuscitation methods. Cardiac injury caused by blunt or penetrating chest trauma is common and often causes death. About a quarter of traumatic deaths are caused by cardiac-related injuries, most involving either damage to the heart or to the main cardiac blood vessels. Understanding the types and complications of these injuries and using new techniques to recognise them is important for correct
Pathway between atria Sinoatrial node or pacemaker
Left atrium Left ventricle
Atrioventricular node Right atrium Interventricular septum
Purkinje fibres Conduction pathway (bundle of His)
Right ventricle
The human heart (cross-section) showing the position of the atria, ventricles, major veins and arteries. The transmission of electrical activity (red arrows) is responsible for the coordination of the atria and ventricles.
diagnosis and treatment. The introduction of fast computed tomography (CT) for the initial evaluation of patients with blunt or penetrating chest trauma or blocked coronary arteries has led to more accurate identification and better survival rates. Injury to the heart can be worsened by the anaemia and low blood pressure that follows massive loss of blood volume (hypovolaemic shock), by raised intracranial pressure; and by hypoxia, a lack of oxygen in the blood, resulting from injury to the lungs (see next section). How an injury appears depends on the mechanism, location, wound size and degree of force.
Aorta Right coronary artery
Left coronary artery
Coronary blood vessels of a normal heart (a)
(b)
(c)
CT scan of the heart. (a) An image of the whole heart showing a blocked left coronary artery (indicated by white arrow) and (b) the same heart showing blood vessels only. (c) Image of normal blood vessels.
Heart attack A heart attack is the common name for acute heart failure. The severity can vary from an event that is virtually symptom or pain-free to something that is life-threatening or fatal. The most common cause of acute heart failure is a myocardial infarction, and both terms are often used instead of heart attack. A myocardial infarction is caused by blockage of a coronary artery, often by a blood clot (thrombus) and as heart muscle can only survive for a few minutes without its blood supply before permanent damage occurs, speed of diagnosis and treatment is critical to survival. Often during a heart attack the electrical conduction of the heart and the normal wave of electrical activity are altered so in the immediate aftermath of a suspected heart attack, the electrocardiogram (ECG) is particularly valuable in establishing whether the heart beat is normal or abnormal. Detailed examination of the ECG can reveal exactly what damage has occurred. A blood test is also useful as the presence of specific cardiac markers strongly indicates heart damage. The most useful marker is troponin-I, an enzyme that
is normally never found in the blood. It is released within one or two hours of heart damage. The ECG is now used routinely to assess patients before they get to hospital and blood troponin-I is currently under trial by some rural ambulance services. In the 1960s the treatment for a heart attack was aspirin and bed rest. In the 1970s clot-busting (thrombolysis) drugs were introduced and in the ’80s and ’90s the coronary angioplasty procedure was developed. Angioplasty is now the recommended procedure to treat blocked coronary arteries and this, combined with advances in implantable cylindrical mesh (stent) technology, has resulted in increased survival after a myocardial infarction. Coronary angioplasty is an invasive procedure used to stretch coronary arteries that have narrowed because of build-up of fatty deposits called plaque. The technique is usually carried out under local anaesthesia and sedation, and is intended to improve blood flow to the heart muscle. A small flexible tube (catheter) containing a guide wire and another catheter with an inflatable balloon at the end are placed into the artery and pushed along under X-ray guidance
until the narrowed coronary artery is reached. The guide wire is pushed through the restriction, and the balloon at the tip of the catheter is inflated for up to a minute, to widen the interior of the artery and eventually to allow the normal passage of blood through it and on to the heart muscle. During this period, the plaque deposit is flattened onto the wall of the artery, so that the coronary artery remains widened.
The lungs The lungs are located within the chest (thoracic) cavity. This space is formed by the chest wall of the ribcage, the breastbone (sternum), and the muscular diaphragm, which separates the thoracic cavity from the abdominal cavity. The lungs and the chest wall are elastic structures, which slide against one another as you breathe. This action is made possible by the pleura, thin membranes that cover the lungs and the inside of the chest wall. A thin layer of fluid fills the pleural cavity, the space between the lung pleura and the chest wall pleura. The lubricated membranes and the fluid layer allow the lung to move easily within the thoracic cavity, and prevent the collapse of the lung by maintaining the surface tension that holds it to the chest wall. Breathing in is an active process involving the diaphragm and the intercostal muscles, the external and internal muscles between the ribs. In its resting state, the diaphragm is domeshaped, arching upwards into the thoracic cavity. On contraction, the diaphragm flattens out and moves downwards, increasing the air intake capacity. Most rib movement during breathing is achieved by the external intercostal muscles. On breathing in, the ribs, which are attached to the spine and the breastbone, move upwards and outwards as the external intercostal muscles contract. Contraction of the diaphragm and the external intercostal muscles increases the volume within the ribcage, so there is a large area for the lungs to expand into. As the chest expands, the air pressure within the lungs decreases, air flows in through the windpipe (trachea) and thus forces the tiny alveolar air sacs in the lungs to expand and fill with air. However, if the air escapes from the lung or from the chest wall and into the chest or pleural cavity, the lung can collapse, a condition known
Oesophagus
Mouth
Trachea
Tongue
Right lung
Epiglottis Left lung Pleural cavity Bronchioles Intercostal muscles Ribs Heart
Diaphragm Abdominal cavity
Cross-section of the thorax (chest) showing the lungs and other structures involved in breathing.
as a pneumothorax. This can occur spontaneously from a weak spot of the lung or can be caused by a puncture of the lung, such as from a fractured rib or penetrating injury. Direct injuries are those caused by chemicals and trauma that directly affect the lungs, including the inhalation of vomit, salt water, smoke or fumes, and puncture wounds following a car accident or attack with a knife. An indirect lung injury could result from severe bleeding, a severe blow to the chest or from fat embolism, where fat blocks an artery following physical injury such as a broken bone. (In the lung this is called a pulmonary embolus.) When a lung injury results in a pneumothorax, it is a life-threatening condition and must be treated as quickly as possible. In some cases, the cause of the lung injury is obvious. In major trauma, time is of the essence. A pneumothorax, for example, may require removal of excess air through a syringe or needle, or by suction or chest tube.
The Brain A head injury may cause a wide range of symptoms depending on the seriousness of the injury. Symptoms of severe head injury or traumatic brain injury can range from a temporary loss of consciousness to severe brain damage and in the most serious cases, if the brain is injured, the results can be lifethreatening. Brain trauma can occur as a consequence of a blow to the head, by a sudden acceleration/deceleration within the skull or by a complex combination of movement and sudden impact or penetration by a projectile such as a bullet. In addition to the damage caused at the moment of injury, there can be secondary events that take place in the minutes and days following the injury. These processes may
include alterations in brain (cerebral) blood flow, and the pressure within the skull (intracranial or intra-cerebral pressure) contributes substantially to the damage from the initial injury. Under normal circumstances the brain is protected by the skull but with impact or sudden acceleration or deceleration, bruising or excessive bleeding can occur. If the brain swells as a result of head injury there is no room for the brain to expand, and the raised intracranial pressure can cause protrusion (herniation) of the brain out of the area where the spinal cord enters the base of the skull, a situation called ‘coning’. Without an urgent operation to relieve the pressure, significant brain damage or death can occur. Even with rapid intervention the outcome can range from complete recovery to permanent disability or death. Top of the risk list for head injury are males between the ages of 15 and 24 who drive or are passengers in a car, or ride bicycles, or play sports. The problems of brain injury can be divided into physical, emotional and cognitive. The physical signs include seizures, poor coordination, slowed reaction time, poor concentration, vomiting, a vacant stare, slurred speech, personality changes, weakness or paralysis, sensory impairment, fatigue, hormone imbalances and speech difficulties. The emotional changes include anxiety, mood swings, and apathy, anger and personality changes. Cognitive problems
can be associated with changes in memory, reduced attention and concentration, reduced empathy, language problems and difficulty recognising faces or objects. Traumatic brain injury is classified based on severity, mechanism (closed or penetrating head injury), or other features such as the location of the injury. When the brain is not exposed it is called a closed (non-penetrating or blunt) injury. A penetrating, or open head injury occurs when an object pierces the skull and breaches the outermost membrane that surrounds the brain. As the brain is organised into specific regions with unique functions, injury can lead to any combination of physical, emotional or cognitive changes depending on the region that is damaged. This concept applies equally to the effects of stroke or to spinal cord injury where the level of injury determines what function is lost (see the diagram of spinal cord injuries). In the example of a car crash, the result of rapid deceleration mechanisms can lead to rapidly developing bleeding between the brain and skull, which is not always associated with a skull fracture but requires immediate surgery to drill a hole through the skull and relieve the brain of increased intracranial pressure. Sometimes brain trauma can be much more subtle, as in the case of blast injuries that result from rapid acceleration of the skull and brain with little obvious damage to either structure. One type of injury, cerebral laceration, occurs when brain tissue is cut or torn. Such tearing is common in the front of the brain because of bony protrusions inside the skull above the eyes. The surgical removal of bone fragments or correction of the bony protrusion is essential. The rapid assessment of the potentially brain-damaged individual is critical. One assessment that needs to be made is the patient’s level of consciousness. For example, there are different levels of coma, ranging from very deep, where the patient shows no response or awareness at all, to shallower levels, where the patient responds to stimulation by movement or by opening their eyes. The assessment normally used is the Glasgow Coma Scale (GCS), a very simple, easy to administer technique, which assesses the patient’s ability to open their
Fractured skull Brain injury
Damaged membranes around the brain
Skull fracture
eyes, move and speak. The total score is calculated by adding up the scores from the different categories and ranges from a minimum of 3 to a maximum of 15. It is generally agreed that a GCS score of 13 or above is mild, 9–12 is moderate, and 8 or below is severe. Critical developments have recently been made in the diagnosis and treatment that has decreased death rates and improved outcome for patients with brain injury. Some of the current techniques used for diagnosis and treatment include CT scans and magnetic resonance imaging (MRI). Depending on the injury the treatment required may be minimal or may include interventions such as medications, emergency surgery or brain cooling. Rehabilitation may take several years. One development is decompressive craniectomy, where a section of skull is removed to allow the swelling brain room to expand without being squeezed onto the inner surface of the skull, thus relieving pressure on the brain. It is performed on victims of traumatic brain injury and stroke. It’s often used with a device that looks rather like a bolt through the top of the head, which measures the pressure of the fluid in the brain and spine. Not only can excessive pressure be relieved with this device but also measurement can be continued throughout recovery.
In instances of heart attacks due to myocardial infarctions or failure of the electrical conducting mechanism of the heart, the resulting loss of function is likely to deprive the brain of oxygen. This can also happen following head trauma or strokes. Although early re-establishment of normal heart rhythm following heart attack is of primary concern, the long term effects of oxygen starvation can be devastating on the brain. One solution currently recommended by the National Institute for Health and Care Excellence (NICE) is to use therapeutic hypothermia of the brain. This technique relies on evidence that indicates reducing the body’s core temperature (deep inside the body) or, more specifically, brain temperature, decreases metabolism and delays the process of cell death and thus limits permanent brain damage. The goal is to closely monitor the patient and reduce body temperature to below 35°C for up to 48 hours. Although hypothermia has been used in the treatment of head injuries for many years, encouraging results from small trials has led to renewed interest in its use. It is a strategy for protecting the injured brain that can reduce intracranial pressure and the effects of an inadequate blood supply. Evidence also suggests that cooling can prevent or reduce the many undesirable effects on the body’s metabolism that occur after acute injury. But it is not without its problems, including the possibility of pneumonia, bleeding and irregular heartbeat. Methods for inducing therapeutic hypothermia include rapid intravenous infusion of refrigerated 0.9% sodium chloride and intravascular cooling catheters. Another technique uses a coolant in a nasal spray (Rhinochill). As the coolant evaporates, it chills the blood under the skin in the nose, which passes into the circulation, cooling the brain and the rest of the body. Therapeutic hypothermia can also be achieved within the ambulance with chilled water blankets, torso vests and leg wraps. Some of these techniques, such as Rhinochill, require specialist medical training and specialised vehicles called ‘cool’ cars.
Spinal cord injuries
Vertebrae Cervical
Thoracic
Lumbar
Sacral
C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5
C4 injury (quadriplegia)
C6 injury (quadriplegia)
T6 injury (paraplegia)
L1 injury (paraplegia)
Coccygeal
Loss of sensory and motor function following injury at different levels of the spinal cord.
Stroke and Damage to the Nervous System Multiple traumatic injuries are often associated with motor vehicle accidents either as a passenger or a pedestrian. These multiple injuries are commonly termed ‘polytrauma’ and in many cases have life-threatening consequences. Polytrauma is the leading cause of death for people under 45 years and is exceeded only by cancer and diseases associated with hardening of the arteries (atherosclerosis) across all age groups. In many cases damage to the brain, spinal cord and peripheral nerves is a possibility. Major trauma involving the head and chest can lead to a patient becoming unstable and distressed. Some patients with head injury become confused, agitated or violent, making them hard to treat. Where the pre-hospital team includes a trauma doctor, one possibility is to stabilise a patient by anaesthetising them. This is a complex procedure that involves using the powerful anaesthetic ketamine, which in small doses sedates the distressed patient and in high doses is used as an anaesthetic.
Stroke patient being scanned in an MRI scanner
Pre-hospital anaesthesia is often used together with a muscle relaxant such as rocuronium and with rapid sequence intubation, an advanced medical procedure that maintains an open airway and prevents a patient sucking their stomach contents into their lungs. It also means that the person can be artificially ventilated. Muscle relaxation is achieved with rocuronium within 45 seconds and relaxation lasts about 45 minutes. This covers the critical time for transport to a trauma centre. For patients who need transportation to hospital by helicopter, about a quarter are intubated. Anaesthetising and intubating patients allows them to be rapidly transferred to a major trauma centre and into a CT scanner. Thus the stabilised, anaesthetised patient is far easier to manage. The traditional log-roll onto a spinal board is increasingly being replaced by minimal handling and ‘scoop’ stretchers that prevent the possibility of further damage to the spine and haemorrhage that can occur from dislodged blood clots from a fractured pelvis. The scoop stretcher has been designed to be placed under the body without the need for rolling or lifting so helping paramedics and doctors to work quickly and reduce the risk of further injury. These scoops can be used to secure patients and can accommodate various body sizes. One model can be used in a CT scanner (speeding up time to treatment). On admission to hospital any trauma patient should immediately undergo CT scan diagnosis of their cervical spine, chest and their pelvis, commonly known as a ‘trauma series’, to identify possible lifethreatening injuries, such as a
fractured cervical vertebra, a severely fractured pelvis, or blood in the thorax (haemothorax). Once the initial survey is complete, X-rays can be taken of the limbs to assess for other possible fractures. It is also quite common in severe trauma for patients to go straight from CT to the operating theatre if they require emergency treatment. Major trauma centre guidelines state that patients should ideally have a CT scan within 30 minutes of arrival. If the assessment at the scene of an accident suggests a CT scan is needed then booking the scanner should be made before the arrival of the patient at hospital. Such scans will take on average 6 minutes and the aim is to receive treatment within 60 minutes of an accident. All patients with significant trauma must be assumed to have an unstable spinal injury. The incidence is 2 in a 100 and increases up to a third in the unconscious patient. Almost half of spinal injuries occur at the level of the chest (thorax) or lower back (lumbar) with a fifth occurring at both sites. Although the recommendation in such cases is immobilisation with full spinal precautions, these restrictions create difficulties in intensive care units where pressure sores and lung complications may become common place. Immobilisation is therefore not recommended for more than 48 hours. Damage or disruption of the ligaments holding the neck in place, even without any noticeable bony injury, may also lead to instability. Wherever spinal injuries are suspected, modern CT scans can detect subtle abnormalities with a high degree of accuracy, something that was not possible in the past. As a consequence early detection and intervention has led to many more people surviving unstable neck (cervical) spine injuries. X-rays of the neck and upper thoracic spine are not as informative, and an MRI scan is only moderately useful for these areas and is also logistically very difficult for patients in intensive care units. A CT scan of the neck needs to be done routinely in all head-injured patients who have an altered level of consciousness. If a spinal injury is detected, neurological assessment must be made and repeated regularly before transferring the patient to an appropriate spinal injury facility. Trauma to the skeletal muscles and bone can often result in nerve injury. Nerve repair and complex nerve injuries,
particularly in and around the shoulder, are a specialist field. If nerve injury is present with an unstable fracture or dislocation (after life-saving interventions), the urgent priority is stabilisation of the skeleton. Nerves may be damaged during surgery and recognition and urgent treatment is essential. In all cases early repair gives the best possible outcome. Pain and gradual loss of sensation is the hallmark of acute loss of blood supply to an area. Early diagnosis must be followed by immediate surgical intervention as inaction may lead to paralysis.
Stroke Strokes are an example of non-traumatic brain injury and are caused by either blocked or burst blood vessels in the brain that vary in their severity according to the area of brain affected and the length of time blood flow is impaired. Strokes can kill or cause major disability, although full recovery is possible after a minor stroke. Strokes can cause cognitive or communication Examples of stroke Burst blood vessels
Blocked blood vessels
Blood leaks into brain tissue
Clot stops blood supply to an area of the brain
problems, depression, emotional changes, fatigue, physical disability, problems with vision, physical pain, incontinence and balance problems. The acronym ‘FAST’ is a quick method that helps to diagnose a stroke. FAST stands for face drooping, arm weakness, speech difficulty and time to call the emergency services, as the longer the stroke is left untreated the more of the brain function is lost. Face drooping is when a section of skin on the face is hanging down. Arm weakness is when the person is not able to raise their arm. Speech difficulty is about whether the person can speak clearly and understand speech. Time represents the need to get to a hospital (such as calling for help). In the United Kingdom roughly one person every five minutes has a stroke, a total each year of around 150,000 people. Strokes cause temporary or permanent brain damage and are the largest cause of adult disability. It is the third most common cause of death after heart disease and cancer. Strokes are a medical emergency with prompt treatment essential to reduce the damage that is likely to happen. People over 65 years of age are most at risk from having strokes, although a quarter of strokes occur in people who are under 65. There are two main types of
stroke; ischaemic (accounting for most cases) when something blocks an artery that carries blood to the brain as a consequence of a blood clot in an artery in the brain (cerebral artery), or a blood clot, air bubble or fat embolus that is carried to the brain from elsewhere. The second type of stroke is haemorrhagic which happens when a blood vessel bursts and bleeds into the brain (cerebral haemorrhage). Temporary symptoms may indicate a mini-stroke or transient ischaemic attack (TIA) and a person will have the symptoms of a stroke for a short time. A TIA is a sign that part of the brain is not getting enough blood, and there is a risk of a more serious stroke in future. As with major strokes, urgent medical attention is essential. The development of acute stroke units has improved the diagnosis and treatment of stroke patients. Assessments that determine the cause of the stroke and the treatment and care plan include an ECG (an irregular heartbeat may have caused the stroke) or blood tests that examine cholesterol and blood sugar level and check for the clotting mechanism of blood. It is recommended practice that an MRI brain scan is made within 24 hours of a stroke.
Skull fracture Damaged membranes around the brain
Broken skull
Damaged brain
Common Traumas CT scan of a fractured skull
Ruptured spleen Massive bleed
Vein Artery
Spleen ruptured during surgery, showing (black) in theblood abdomen Ultra blood sound scan showing from a ruptured spleen
Broken bone
Femur (thigh bone) Head (joint) Marrow containing fat cells. Fat cells can escape into bloodstream and cause blockages Shaft
X-ray showing a fractured femur
Ruptured blood vessel
Stroke Brain Damaged brain tissue Ruptured blood vessel
Blocked blood vessel Blocked blood vessel
CT scan of an area of stroke damage (orange) in the brain
Heart attack Coronary artery Heart muscle Blockage in artery Heart muscle damaged due to an interrupted blood flow
X-ray fluoroscopic image of a blocked coronary artery
Structure of skin
Skin Burn Epidermis
Hair Sweat gland Sebaceous gland
Dermis
Vein Nerve
Hypodermis
Artery Fat layer
First degree burn Superficial damage
Second degree burn Third degree burn Damage extends Damage extends to some of the dermis through all the layers to the tissues below
Burns Common causes of burns are exposure to thermal (heat), electrical, radiation or chemical sources. Thermal burns occur when hot metals, scalding liquids, steam or flames come in contact with the skin. Electrical current also causes burns and contact with caustic substances causes chemical burns. Perhaps the most common burns happen after prolonged exposure to ultraviolet rays from the sun or tanning booths. The first six hours following severe burn injury are critical and the patient should be transported to hospital as soon as possible. When diagnosing or classifying a burn, an evaluation of the depth and extent of the damage, the degree of pain, and the Rule of 9s Head and neck 9%
Trunk: Front 18% Back 18% Arm 9% (each) Genitalia 1%
Leg 18% (each)
amount of swelling are all included. Immediate emergency medical attention is required where burns cover a significant portion of the body, are associated with smoke inhalation or are from electrical injuries or where physical abuse is suspected. Death and disability rises with increasing burned surface area and with increasing age so that even small burns may be fatal in elderly people. The ‘Rule of Nines (9s)’ is commonly used to estimate the burned surface area in adults where the body is divided into anatomical regions that each represent 9% (or multiples or divisions of 9%) of the total body surface. For example, the outstretched palm and fingers is roughly 1% of the body surface area. The most serious burns are usually caused by scalding hot or flammable liquids, and fires. Nearly half of severe burn and scald accidents occur in children under five years and about half of these happen in the kitchen, with scalds from hot liquids being the most common. The patient with burns has the same priorities as all other trauma patients. The essential management is to stop the burning, make sure the patient can breathe, determine the area of burn using the Rule of 9s, and replace lost fluids intravenously (through a ‘drip’). Electrical burns can cause damage inside the body even if there is little evidence on the skin so the extent of the internal damage is difficult to determine. Burns can be divided into three main categories: superficial, partial thickness and full thickness, with a fourth, electrical burns, sometimes included (see centre spread). Superficial (firstdegree) burns affect the top layer of skin only. A good example is mild sunburn. The skin looks reddish and is mildly painful. The top layer of skin may peel a day or so after the burn, but the underlying skin is healthy. Usually with superficial burns there is no blister or scar although blisters sometimes occur in extreme cases. Partial thickness (second-degree) burns can cause deeper damage. The skin forms blisters, is continuously painful and usually has a red or mottled appearance. In this category some, if not all of the deeper layer of the skin (the dermis) is unharmed and this means the skin usually heals well, sometimes without scarring if the burn is not too extensive. The
usual cause of partial thickness burns is scalding by hot liquids at or below the boiling point of water. In full thickness (thirddegree) burns all layers of skin are damaged. These burns are often caused by fire or prolonged exposure to very hot liquids or objects. The skin is typically dry and white or charred black. As all the sensory endings and superficial nerves in the skin are damaged in the burn process the result is little or no pain felt by the subject. Full thickness burns nearly always require skin grafting. Occasionally there are further complications of definition as a burn from one accident may contain various types of burn within the affected area. For example, some areas of the burned skin may be superficial, some partial thickness and some full thickness. All cases of full thickness burn are considered to be serious. Serious burn cases requiring hospitalisation include: burns greater than 15% in an adult; greater than 10% in a child (for, example, a whole arm); any burn in the very young, the elderly or the infirm; any full thickness burn; burns of special regions including the face, hands, feet and genitalia; burns that continue all the way around a limb, chest or trunk; inhalation injury from hot fumes; associated trauma or where there is a pre-existing illness that compromised healing, such as diabetes. The Rule of 9s is used to determine the total percentage of area burned for each major section of the body. As an example, if the groin (1%) and both legs (18% x 2 = 36%) were burned, this would involve 37% of the body. In full thickness burns the dead skin has to be removed because without a blood supply it simply becomes a source of infection. The removal of dead skin (or small amounts of any tissue) is called debridement. It is followed by skin grafting, where a piece of skin is surgically sewn over the area of the burn after the dead tissue has been removed. The skin can be from another part of the person’s body, from a compatible donor, or from an animal (usually a pig) or could be artificial. Artificial skin is usually temporary to limit infection and to allow sections of the patient’s skin to be grown in culture for later use. Skin grafts from the person’s own body can be harvested from unburned areas and are permanent.
Tissue and Organ Damage High-impact injuries or crush injuries often result in damage to multiple sites on the body. Although the external damage can be obvious, such as broken limbs and severe bleeding from open wounds, these injuries can have life-threatening consequences due to ‘unseen’ injuries that, if not diagnosed and treated rapidly, can result in loss of life. The energy created, for example, in a vehicle accident is transferred through the whole body; limbs fracture and muscles and internal organs bruise or are forced onto rigid parts of the body such as the spine, ribs, pelvis or onto the unyielding road, railing, car or lorry. Under extreme conditions organs are ripped away from their blood supply or are lacerated. The resulting haemorrhagic shock is the leading cause of death following accidents. Uncontrolled bleeding accounts for death in a third of trauma patients who make it to hospital and in more than half of the people who die at the scene of an accident. Correcting the loss of blood is fundamental in understanding the body’s response and subsequent methods of treatment. This is a controversial area but some important lessons have been learned from Trauma Triad of Death Blood clotting problem (coagulopathy)
Decreased coagulation
Increased lactic acid in blood Severe blood loss
Low body temperature (hypothermia)
Decreased heart performance
Acidic blood (acidosis)
developments by the military. In recent years research has turned away from the type of infusion that replaces lost blood to prevention, early identification and treatment of the body’s response that bizarrely, increases the likelihood of death. This response is referred to as the ‘lethal triad’ or ‘triad of death’. The acidity of the blood increases (acidosis), the body temperature drops (hypothermia) and blood clotting is impaired. In an accident, massive haemorrhage leads to restricted blood flow to the body’s organs, resulting in low oxygen levels in the tissues. This triggers the accumulation of lactic acid and the start of the lethal triad. The body is unable to maintain its normal temperature, made worse by the environment, the older the age of the person and the possible infusion of cold, intravenous fluids by the emergency team to restore lost blood. Acidosis and hypothermia affect the third element of the triad, the function and production of natural substances that lead to the blood’s inability to form clots. The disastrous effects of major blood loss are therefore enhanced. Life-threatening bleeding in trauma patients is a combination of damage to blood vessels and lack of clotting ability, so treatment needs to address both factors; stop or limit blood loss and encourage blood to clot (see diagram of trauma cascade). At the scene of the accident, minimising catastrophic blood loss could be as simple as using a tourniquet, blood-stopping (haemostatic) gauze, pressure bandages and specialised seals. Care is taken not to disturb existing blood clots by handling the patient as little as possible, and using scoop stretchers. Broken limbs or pelvic fractures need to be stabilised with splints and pelvic binders. A binder acts as a giant tourniquet round the hips and reduces the risk of internal bleeding from fractured bones cutting into the major vessels in the pelvis. The prolonged use of a leg or arm tourniquet prevents oxygen reaching the tissues, and causes high levels of lactic acid, which hinders blood clotting, making the situation worse. If the limb has been crushed, muscle protein (myoglobin) may be released into the circulation. Most people with major traumatic injuries have some degree of myoglobin release and, of those who do, between a tenth and a half develop kidney failure. Six out
of 10 of those die, compared with 2 out of 10 of those with functioning kidneys. Nevertheless, most people who survive regain full kidney function. Crush injuries may cause damaged muscle cells to swell. The swelling may directly compress nearby tissue, further reducing blood supply to the area, or may result in uncontrollable bleeding and a condition called ‘disseminated intravascular coagulation’. Incisions are therefore made into the affected area, and left open until the swelling has reduced. Dead tissue is then removed if necessary and the incisions are closed. The release of high levels of potassium from damaged muscles may lead to potentially fatal disruptions in heart rhythm. The longer the crush or interruption of blood supply the greater the risk of complications, should normal blood flow be resumed. Preventing or counteracting the effects of haemorrhage is crucial to the survival of the trauma patient who has multiple injuries. New treatments based on a by-product of the shrimp
industry called chitosan have revolutionised the treatment of the most severe arterial bleeds. Examples include Celox bandages, gauzes and granules that allow blood to clot within 30 seconds, and work in low body temperatures and in people who are taking the anti-clotting drugs heparin or warfarin. Some types of absorbable gauzes can even be left in place inside the body after surgery. Not only have these products been perfected but also the blood-clotting ability of a patient can be determined within 20 seconds of taking a blood sample. Advances have also been made in developing drugs that reduce the risk of fatal bleeds in trauma patients. Tranexamic acid (TXA), a drug that blocks the action of an enzyme that dissolves blood clots, could potentially save 128,000 lives each year. This drug has traditionally been used to minimise blood loss during surgery, to control bleeding in people with haemophilia and to treat heavy menstruation (periods). The British military began using TXA for severely injured troops in
Trauma Cascade: Haemorrhage caused by major trauma can set off a cascade of events that disrupts the body’s normal metabolic processes, affecting blood clotting ability, body temperature and blood acidity.
Trauma
Clotting disease Medication
Haemorrhage
Tissue damage
Resuscitation
Inflammation
Blood dilution
Genetics
Shock
Acidic blood
Hypothermia (low body temperature)
Blood clotting problem (coagulopathy)
Lack of blood flow Disruption of blood clotting mechanism
Afghanistan, and found those who received it were twice as likely to survive severe physical trauma. Improvements in trauma therapy have not only been the result of developments of new technology or products but also of new protocols. If a patient has a major bleed and is unstable, and the severity of the situation necessitates calling the air ambulance, or Helicopter Emergency Medical Service (HEMS) then a Code RED call is made by the attending doctor and this is interpreted as a request for rapid access to blood products at the trauma centre. On arrival the patient receives packed red blood cells followed about 20 minutes later by thawed fresh frozen plasma. In London about 1 in 20 HEMS patients trigger Code RED. This decision is determined if the blood pressure is low, there is poor Patient assessment in a CT scanner
response to intravenous fluid and internal bleeding is suspected. As about a quarter of all major haemorrhage triggers blood clotting disorders, HEMS teams limit the use of intravenous saline drips. Early transfusion of blood and plasma helps restore clotting factors, improves the transport of oxygen to vital organs and increases overall blood volume during resuscitation. As hypothermia is one element in the lethal triad, all fluids must be warmed immediately before infusion. The Code RED approach has been shown to improve the survival of severely traumatised patients. It is, however, dependent on identifying and then controlling the causes of the bleeding. The goal of Code RED is to control blood loss and restore normal blood clotting. It buys time before transfer to the operating theatre. Once in theatre there are many options available to control the consequences of trauma. These include the new technique of interrupting the blood supply to the abdomen by inflating a tiny balloon in the main abdominal artery, via a tube inserted in the thigh. This is called REBOA (resuscitative endovascular balloon occlusion of the aorta) and maintains the blood supply to the heart and brain while investigations determine the source of the bleed. The decision on whether a patient with traumatic haemorrhage has open surgery or keyhole surgery, or a combination of the two, is made by the trauma team, which includes a radiologist who uses X-rays and dyes injected into the blood vessels to detect where bleeding is occurring. Almost any organ in the body can be damaged as a result of trauma. The most likely is the spleen, a delicate, fist-sized organ under the left ribs near the stomach. A ruptured spleen is a common occurrence following abdominal trauma and happens when the capsule-like covering over the spleen breaks and releases large volumes of blood into the abdomen. Surgical removal of the spleen is often the only solution. The spleen is involved in the body’s immune response to certain bacteria, and has a role in clearing old red blood cells. Patients therefore need to be monitored carefully and be vaccinated for common illnesses such as influenza for the rest of their lives.
Cutting Edge There have been rapid advances in trauma management in the past 40 years. Many have relied on changes in the way trauma is treated and on the development of new techniques and devices. Taken together these changes have led to increased survival from the most horrific injuries that would previously have been fatal. Almost all the changes have been due to a better understanding of how the body responds to traumatic injury, in particular in the battlefield. Here are some of the developments. AutoPulse is an automated, portable, chest compression device that is used on all patients with cardiac arrest. The device delivers consistent, uninterrupted, high-quality chest compressions. The AutoPulse is especially useful when patients are being transferred from the ground to the stretcher, from the stretcher into the helicopter, and during the flight to hospital. Blood flow can be continued throughout the rescue and rescuers freed up to focus on other potentially life-saving tasks. Blood transfusion on-scene is an innovation that has been made possible because of a refrigeration unit used by the British and American military. It allows blood transfusions to be administered at the scene of accidents, rather than later in hospitals. Blood transfusions can involve giving units of red blood cells, platelets and plasma (also known as fresh frozen plasma). London’s air ambulance became Britain’s first emergency service to carry blood whenever they’re called to an accident. Experience has shown that when soldiers have been seriously injured in battle, an immediate blood transfusion can increase their chances of survival. CABC protocol is a new procedure for treating trauma. CABC stands for catastrophic haemorrhage, airways, breathing, circulation, and has been used frequently by the US and UK military. It replaces the ABC (airways, breathing, circulation) protocol, which first-aiders may be familiar with. It has been suggested that major bleeding will kill a casualty before an airway obstruction and with the development of quick and easyto-apply agents, controlling blood loss should occur first.
Code RED protocol sends a patient straight to hospital without injecting any fluids in favour of rapid transfusion of blood products (usually red blood and plasma). Code RED is declared if blood pressure is low, there is a poor response to initial resuscitation and there is suspected internal bleeding. About 1 in 4 patients in this condition develop a blood-clotting disorder, triggered within minutes by major haemorrhage. Celox (a by-product of the shrimp industry) is one of the most effective blood-stopping (haemostatic) agents. It is used either as a clotting powder or impregnated into bandages or gauzes placed on open wounds, such as jugular vein injuries or following amputation of a limb. This product was originally developed by the military. It can be used where patients at increased risk of bleeding, for example, if they are on bloodthinning agents such as warfarin or heparin. CoaguChek XS is a portable unit that can be used to monitor the ability of blood to clot. It comprises a meter and special test strips that can quickly analyse a blood sample. Computed tomography (CT) scan, also known as a CAT scan, uses X-rays and a computer to create detailed images of the inside of the body. It is now becoming more routine to scan every major trauma patient. In a few cases they go straight from the ambulance to the scanner. Damage control surgery is a short-term, fast surgery to prevent massive blood loss. It is now thought to be better for trauma patients to receive short-term surgical fixes to prevent bleeding to death, than corrective surgery later. Damage control surgery is one of the major advances in surgical technique in the past 20 years. Surgeons around the world have been slow to accept it, as it goes against most standard surgical teaching practices -- that the best operation for a patient is one, definitive procedure. Patients with major bleeding-out (exsanguinating) injuries will not survive more complex operations, such as repair of the liver or removal of the pancreas and small intestine. Decompressive craniectomy is surgery in which part of the skull is removed to allow a swelling brain room to expand without
being compressed by the confines of the skull. It is performed on victims of traumatic brain injury and stroke. This is often used with central cerebrospinal fluid pressure measurement (the ‘brain bolt’). A defibrillator is a machine that gives electric shocks to the heart during a cardiac arrest. Although they have been around for some time it has been shown that for every minute that passes without defibrillation, the chances of survival decrease. Applying a controlled shock within 5 minutes of collapse gives the best possible chance of survival. ECG (electrocardiography) reads the electrical activity of the heart over a period of time, detected by electrodes attached to the surface of the skin and recorded by a device outside the body. Recording the electrical activity of the heart in someone with a suspected heart attack provides information that is used in the diagnosis. The earlier this information is available the greater the chance of survival. Emergency thoracotomy is an incision into the pleural space of the chest. The pleura is the layer between the inside of the chest wall and the outer part of the lungs. Emergency thoracotomy is performed by surgeons (or emergency physicians) who make holes through the chest wall to let out air in the pleural space. Helicopter paramedical staff are now being trained to perform these at the scene of accidents. FAST is an acronym used to help diagnose a stroke: face drooping, arm weakness, speech difficulty, time to call the emergency services. It is often used with ‘time is brain’, indicating that the longer the stroke is left untreated, the greater the possibility that brain function is partially lost. Face drooping is when a section of skin on the face is sagging. Arm weakness is if the person can’t raise their arm. Speech difficulty is whether the person can speak clearly and understand speech. Time represents the need to get to a hospital, in other words, calling for help. Fresh frozen plasma transfused into trauma patients as soon as possible stops them bleeding to death, as about 1 in 4
develop blood-clotting disorders. It is now a commonly used resuscitation technique that encourages blood clotting. The Glasgow Coma Score (GCS) provides a reliable, objective way of recording the conscious state of a person after trauma and during recovery. A patient’s responsiveness is scored by combining the results of tests on eye opening, verbal assessment and reflexes, giving the patient a score of between 3 (indicating deep unconsciousness) and 15 (fully conscious). GCS assessments now form an integrated part of the handover of information between clinicians. Golden hour boxes are used by some air ambulance teams for blood transfusion at the scene of the incident. They include a refrigeration unit similar to that used by the military, and 4 units of O rhesus negative blood. O negative blood is the universal donor as it can be transfused into a patient regardless of blood type. An implantable cardioverter defibrillator (ICD) is a small, battery-powered, electrical-impulse generator that is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation and ventricular tachycardia. The device is programmed to detect loss of normal heartbeat (arrhythmia) and correct the arrhythmia by delivering an electrical shock to the heart. The devices constantly monitor the rate and rhythm of the heart and only act when the heart rate exceeds a certain threshold. Interventional radiology refers to a range of techniques that rely on being guided by scans (X-ray fluoroscopy, ultrasound, CT or MRI) to target therapy precisely. It is used, for example, to control haemorrhage or to place mesh tubes (stents) for blood vessel repair including in severe pelvic injury. Intracranial pressure measuring devices that monitor pressure in the head and spinal fluid are essential in some patients with head trauma. If the pressure is too high, brain swelling (coning) or permanent damage to the brain can result. Intraosseous vascular access (IO) device. These are used to inject saline into bones after the collapse of veins following
a drop in blood pressure and major blood loss. This process increases blood pressure and relies on the myriad of intertwined blood vessels that are found in bone marrow. If access to veins is impossible (for example, in babies) this is the only way of boosting blood volume other than by surgery. IO devices are commonly carried on ambulances. A major trauma centre is a hospital designed for the specialist care of seriously injured patients. In some places such as London there are trauma centres that cater for trauma of specific areas, such as the head or other parts of the body. Octaplex is a drug that encourages the clotting mechanism. It is usually given when excessive bleeding happens in patients who are being treated with warfarin (which decreases the body’s natural blood-clotting ability). The Olaes army dressing is a new pressure-dressing developed for use on the battlefield. Its unique pressure cup allows the paramedic to focus pressure on top of the wound site instead of around it, as in a tourniquet. A pelvic binder is essentially a giant tourniquet that is placed around the pelvis in cases of pelvic crush injuries and fractures to prevent movement. Its main use is to reduce the risk of internal bleeding or haemorrhage from fractured bone and to stabilise the fractured end to stop it cutting into major veins and causing catastrophic blood loss. The Rhinochill intranasal cooling system machine cools the brain via tubes placed up the nose. This is currently in use in London to prevent further brain damage during resuscitation of patients after cardiac arrest or who have head injuries. Scoop stretchers can be split so that the two halves can be united beneath a patient, reducing unwanted movement. They are increasingly being used instead of spinal boards. There is even a type that the patient can remain on during X-rays and scans, saving transfer time. Telemedical devices are roving video-conference machines that allow doctors who are not in the hospital to consult with
patients and hospital teams. Images and sound are securely transmitted from one hospital to another. Therapeutic hypothermia (protective hypothermia) lowers a patient’s body temperature to delay death of tissues that are deprived of oxygen because of insufficient blood. Chilling is achieved with cold water blankets, torso vests, leg wraps or a Rhinochill machine. Insufficient blood flow occurs in, for example, cardiac arrest or when an artery is blocked, causing a stroke. Tracheal intubation or rapid sequence intubation is the placement of a flexible plastic tube into the windpipe to maintain an open airway and prevent patients inhaling their stomach contents into their lungs. Tranexamic acid (TXA) is a drug that is injected to improve the body’s clotting ability after blood loss, particularly if that ability is affected by major trauma. TXA inhibits the body’s ability to break down a substance called fibrin, which plays a key role in blood clotting, thus helping to stop bleeding.
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Acknowledgements Every effort has been made to contact copyright holders. If any have been inadvertently overlooked the publishers will be pleased to make the necessary arrangements at the first opportunity. Grateful acknowledgement is made to the following sources: Front cover: Surgical procedure © Press Association Images. Introduction: The Trauma Pathway: Adapted from Figure 1. The Trauma Pathway. © NHS Commissioning Board, 2013, now known as NHS England. Heart and lungs: CT scans of heart courtesy of Dr Richard Wellings, University Hospitals Coventry and Warwickshire NHS Trust Stroke and nervous system: Illustrations showing damage to brain: © Nucleus Medical Art Inc/ Alamy Act FAST image. © Public Health England, with kind permission Centre spread: Skull CT scan: © ZEPHYR/SCIENCE PHOTO LIBRARY Spleen surgery: A M ENGLISH,CUSTOM MEDICAL STOCK PHOTO/SCIENCE PHOTO LIBRARY X-ray of a leg compound fracture: © JOHN SMITH, CUSTOM MEDICAL STOCK PHOTO/SCIENCE PHOTO LIBRARY CT brain scan showing stroke: © ZEPHYR/SCIENCE PHOTO LIBRARY Coronary artery blockage: © CAVALLINI JAMES/SCIENCE PHOTO LIBRARY Burns: Young girl reaching for pan on cooker: © Angela Hampton Picture Library/Alamy All other photos and illustrations © The Open University
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Published in 2014 by The Open University, Walton Hall, Milton Keynes, MK7 6AA, to accompany the BBC/OU series An Hour To Save Your Life, produced by Boundless, part of FremantleMediaUK Ltd., first broadcast on BBC TWO in spring 2014. For Boundless Productions: Executive Producer: Fiona Caldwell Series Producer: Dov Freedman Broadcast Commissioner for the OU: Dr. Caroline Ogilvie Media Fellow for the OU: Dr. Janet Sumner Academic Consultants for the OU: Dr. Duncan Banks and Dr. Hilary MacQueen Broadcast Project Manager: Julia Burrows Open University Booklet: Trauma and Emergency Care Authors: Dr. Duncan Banks and Dr. Hilary MacQueen Graphic Designer: Peter Heatherington Graphic Artist: Sue Dobson Edited by: Anne Waddingham Broadcast Project Manager: Julia Burrows
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