NCEPOD: Trauma - Who Cares? - London Health Programmes

CHAPTER 5 - Hospital receptionIntroductionDeaths after major trauma can be grouped into immediate,early, and late deaths.Immediate deaths are caused by a fatal disruption of thegreat vessels, heart, lungs or a major disruption of bodycavities. Immediate death occurs at the scene of injury. Thisgroup of deaths is least likely to be infl uenced by measurestaken post injury. Injury prevention strategies and publichealth measures must remain the major strategy for reducingthis major source of mortality.Early deaths occur in the hours just after the injury. Thesepatients frequently arrive at a hospital prior to death whichusually occurs because of cardiovascular and/or pulmonarycollapse. Early trauma deaths result from failed oxygenationof the vital organs, massive central nervous system injury, orboth. The mechanisms of failed tissue oxygenation includeinadequate ventilation, impaired oxygenation, circulatorycollapse, and insuffi cient end-organ perfusion. Injuries thatcause early trauma mortality occur in predictable patternsbased on the mechanism of injury; the patient’s age, gender,and body habitus; or environmental conditions. Rapidresuscitation coupled with rapid defi nitive management ofinjuries and complications has the potential to reduce thesedeaths.Late deaths peak from days to weeks after the injury and aredue primarily to sepsis and multiple organ failure.Organised systems for trauma care are often thoughtto be focused on the salvage of a patient from earlytrauma mortality, while critical care is designed to managecomplications and avert late trauma mortality. However, itmust be noted that a good trauma process (early defi nitivecare and optimal resuscitation) will not only reduce earlymortality but also reduce the number of late deaths byminimising the number of patients who go on to developmultiple organ failure and require critical care. Importantlyfrom the perspective of survivors, a good trauma processmay also reduce morbidity.The recognition of these patterns led to the developmentof the advanced trauma life support (ATLS) approach bythe American College of Surgeons. ATLS is the basis oftrauma care and it is built around a standardised protocolfor patient evaluation. This protocol ensures that the mostimmediate life-threatening conditions are actively identifi edand addressed in the order of their risk potential.The objectives of the initial evaluation of the trauma patientare:1. to identify life-threatening injuries and to initiate adequatesupportive therapy;2. to effi ciently and rapidly organise either defi nitive therapyor transfer to a facility that provides defi nitive therapy.This chapter describes the initial reception of the severelyinjured patient and organisation of the trauma response.ResultsPre-alertsFrom the introduction above it can be appreciated thatone of the key steps in maximising outcome for theseverely injured patient is to ensure a rapid and appropriateemergency department response. One mechanism forensuring that this occurs is communication from theprehospital clinicians to the receiving emergency department,passing on details of the extent of the injuries and theresponse required in hospital. This communication is referredto as a pre-alert.50