NCEPOD: Trauma - Who Cares? - London Health Programmes

7Management of circulationways, CT scanning is the ideal non-invasive test as long asthe patient’s condition allows. As a result many injuries cannow be safely managed conservatively or non-operatively 40,41 .Advances in radiology have allowed a greater proportion ofbleeding patients to undergo successful angioembolisationof bleeding arterial vessels, especially for injuries that aretraditionally diffi cult to manage operatively or are associatedwith a high mortality 42,43 .Other important standards of care have now becomecommonplace for the exsanguinating trauma patientsubgroup. These approaches, which are almostcounterintuitive to classical surgical dogma, includehypotensive resuscitation and damage control surgery.These concepts place a much greater emphasis onpermissive blood pressure control at a subnormal butsurvivable level, followed by rapid, intraoperative control ofhaemorrhage in a staged fashion and less on diagnosticworkup and defi nitive treatment of injuries during the earlystages of treatment. Both concepts have been associatedwith higher survival rates for the exsanguinating subgroup ofinjured patients 44-46 .Despite the modern approach to the bleeding patient, thereis still one concept that has remained unchanged. Bloodis a precious commodity and early haemorrhage control,whether it occurs naturally or after iatrogenic interventionsuch as angioembolisation or intraoperatively by a surgeon,is still paramount in achieving good patient outcomes. Thus,effective and timely haemorrhage recognition and controlmay be the single most important step in the emergencymanagement of the severely injured patient.ResultsInitial haemodynamic assessmentThe casenotes available identifi ed that assessment ofpulse, blood pressure, capillary refi ll and temperature weremeasured on arrival at hospital in 95.4%, 95.7%, 31.6% and53.2% of cases respectively (Figure 24).Figure 24. Measurements in hospital800Number of patients7006005004003002001000Blood pressure Pulse Capillary refill Temperature FluidYesNot recorded71