Organization of trauma services

Triage

Triage is a confusing word. It was originally used to describe the process of sorting goods according to quality, but has been adopted into the vocabulary of warfare to describe the classification of patients according to medical need. In trauma services generally, triage retains its military connotation and is important at three levels:

• field triage;

• inter-hospital triage;

• mass casualty triage.

Triage decisions are crucial in determining individual patient survival and for this reason need to be made at the highest possible level of medical expertise.

Pre-hospital care

Active and appropriate pre-hospital care delivered by fully trained paramedical personnel improves survival during the vital first hour after injury. This means firstly that trained personnel have to arrive at the scene of the accident as rapidly as modern transport permits. They must be trained at the highest level in airway management with cervical spine control, securing intravenous access and initiating fluid resuscitation. Their prime duty is to stabilize the patient prior to rapid transport to a dedicated trauma centre.

 Hospital care

A suitable receiving hospital must have senior medical staff organized as a trauma team. Their first duty is further triage to ensure that medical resources are deployed to maximum overall benefit. Accepted resuscitation pro­cedure is in the following order of priority/

Primary survey

A: Airway and cervical spine control

An unconscious patient involved in a road traffic accident or fall has an approximately 10 per cent chance of having sustained a cervical spine injury. Witness statements, where they are able to describe the exact circumstances of the injury, are very important in assessment. Because of the potential catastrophic consequences of this type of injury the neck should be immobilized in a neutral position by a semirigid collar until damage has been excluded.

Early verbal response to a simple question 'Are you all right?' signifies not only that a satisfactory airway is present but also that cerebral function and by implication breathing and ventilation and circulation are adequate. The several techniques available to secure an unobstructed airway are integral to the manage­ment of all maxillofacial trauma whatever the degree of severity and are described in detail later.

B: Breathing and ventilation

An adequate airway is an obvious prerequisite for ventilation. Serious chest injuries such as pneumothorax, haemopneumothorax, flail seg­ments and rupture of the diaphragm prevent adequate ventilation and must be recognized early. Cardiac tamponade, which may also accompany serious chest injury, affects cardiac output rather than ventilation. Key signs alone or in combination are:

· deviated trachea

· absence of breath sounds

· dullness to percussion

· paradoxical movements

· hyper-resonance with a large pneumothorax

· muffled heart sounds.

A chest radiograph is essential and will demonstrate where present:

loss of lung markings deviation of the trachea raised hemi-diaphragm fluid levels fracture of ribs.

Emergency treatment will in the majority of cases require chest drainage. Open 'sucking' chest wounds are occluded by a sterile pad and unstable 'flail chest' injuries are managed by endotracheal intubation and intermittent positive-pressure ventilation. Needle decompression of the pericardium relieves cardiac lamponade.

Gastric dilation is a consequence of poly-trauma and constitutes an impediment to respiration and a risk to the airway if vomiting occurs. A wide-bore nasogastric tube is used to decompress and aspirate stomach contents.

C: Circulation

Circulatory deficiency leads to low blood pressure, increasing pulse rate and diminished capillary filling at the periphery.

Fluids for resuscitation

• Adequate venous access at two points is essential.

• Hypotension should always be assumed to be due to hypovolaemia.

• Resuscitation fluid can be crystalloid, colloid or blood.

• Recognizable surgical shock will require a blood transfusion, preferably with cross-matched blood or in emergency Group O negative.

• Urine output must be monitored as an indicator of cardiac output.

D: Neurological deficit

A rapid assessment of neurological disability is made by noting the patient's response on a four point scale:

· Responds Appropriately, is Aware

· Responds to Verbal stimuli

· Responds to Painful stimuli

· Does not respond, Unconscious

In the absence of direct damage to the eye, pupil response must be recorded.

E: Exposure

All trauma patients must be fully exposed, if necessary by cutting away clothing, and the environment accordingly must be warm and protected to ensure the patient suffers no further harm. At some point, unless indicated earlier, the patient must be turned in order that the back and other hidden areas can be properly examined.

Secondary survey

At some point after successful resuscitation of an injured patient a period of stability will be reached when the airway is secure with adequate circulation and vital tissue perfusion maintained. At this point a secondary and detailed survey of the whole body is carried out and repeated at regular intervals until the patient is fully stabilized. The objectives of the secondary survey are:

• accurate diagnosis of injuries;

• maintenance of a stable state;

• determining priorities in treatment;

• appropriate specialist referral.

The assessment of maxillofacial injuries will be part of the secondary survey although a maxillofacial surgeon may have become involved at an earlier stage if the airway has been compromised by direct facial trauma. The most important features of the secondary survey are a full assessment of:

• head injury;

• abdominal injury;

• injury to the extremities.

• Control of pain

• There is surprisingly little pain from maxillo-facial injuries but when present it is important to give adequate analgesia. It is, however, extremely important to avoid giving powerful analgesics, which depress the level of conscious­ness and respiration. The risk of respiratory obstruction is increased when drugs such as morphine and its derivatives are given to a patient with injuries of the maxillofacial region. Morphine also depresses the cough reflex and so encourages the aspiration of blood into the trachea. In addition it causes constriction of the pupil, which may mask an early sign of rise in intracranial pressure. It is, however, most important to minimize discomfort in the early stages after injury, as a patient is readily exhausted by efforts both to keep his airway clear and to obtain nourishment. Diclofenac, which can be administered rectally, is well tolerated and useful in maxillofacial trauma. Local toilet, support of mobile fractures, posture, availability of suction and administration of intravenous fluids are all of great importance in the early care of the patient.

• The majority of patients with mandibular fractures do not appear to suffer much pain, perhaps owing to the frequently associated neuro-praxia of the inferior dental nerve. Some mobile fractures of the body of the mandible are, however, extremely uncomfortable and a potent cause of restlessness in a cerebrally irritated patient. This situation is one of the rare indications for giving priority to immobilization of the mandible in the presence of other serious injury.

• Cerebral irritation is often considerable in patients with severe facial bone fractures as a consequence of associated head injury. They may be disorientated and intolerant of interference. In the past there was much debate about how such patients might be safely sedated in order to complete a detailed examination and take appropriate radiographs and impressions. Advances in anaesthesia and intensive care have made these considerations obsolete. It is important first and foremost to find out why the patient is disorientated, which means that after the baseline neurological status has been recorded the patient will need a CT scan. 'Sedation' is now achieved by intubation, anaesthesia and artificial ventilation, which in turn allows detailed examination of the facial region to be completed and CT or MRI scans to be carried out.

Ionizing (or ionising) radiation is radiation composed of particles that individually carry enough energy to liberate an electron from an atom or molecule, ionizing it. Ionizing radiation is generated through nuclear reactions, either artificial or natural, by very high temperature (e.g. the corona of the Sun), or via production of high energy particles in particle accelerators, or due to acceleration of charged particles by the electromagnetic fields produced by natural processes, from lightning to supernova explosions.

When ionizing radiation is emitted by or absorbed by an atom, it can liberate a particle (usually an electron, but sometimes an entire nucleus) from the atom. Such an event can alter chemical bonds and produce ions, usually in ion-pairs, that are especially chemically reactive. This greatly magnifies the chemical and biological damage per unit energy of radiation.

Ionizing radiation includes cosmic rays, alpha, beta and gamma rays, X-rays, and in general any charged particle moving at relativistic speeds. Neutrons are considered ionizing radiation at any speed. Ionizing radiation includes some portion of the ultraviolet spectrum, depending on context. Radiowaves, microwaves, infrared light, and visible light are normally considered non-ionizing radiation, although very high intensity beams of these radiations can produce sufficient heat to exhibit some similar properties to ionizing radiation, by altering chemical bonds and removing electrons from atoms.

Ionizing radiation is ubiquitous in the environment, and comes from naturally occurring radioactive materials and cosmic rays. Common artificial sources are artificially produced radioisotopes, X-ray tubes and particle accelerators. Ionizing radiation is invisible and not directly detectable by human senses, so instruments such as Geiger counters are usually required to detect its presence. In some cases it may lead to secondary emission of visible light upon interaction with matter, such as in Cherenkov radiation and radioluminescence. It has many practical uses in medicine, research, construction, and other areas, but presents a health hazard if used improperly. Exposure to ionizing radiation causes damage to living tissue, and can result in mutation, radiation sickness, cancer, and death.

Biological effects.

Ionizing radiation is generally harmful and potentially lethal to living things but can have health benefits in radiation therapy for the treatment of cancer and thyrotoxicosis. Its most common impact is the induction of cancer with a latent period of years or decades after exposure. High doses can cause visually dramatic radiation burns, and/or rapid fatality through acute radiation syndrome. Controlled doses are used for medical imaging and radiotherapy. Some scientists suspect that low doses may have a mild hormetic effect that can improve health.

Some effects of ionizing radiation on human health are stochastic, meaning that their probability of occurrence increases with dose, while the severity is independent of dose. Radiation-induced cancer, teratogenesis, cognitive decline, and heart disease are all examples of stochastic effects. Other conditions such as radiation burns, acute radiation syndrome, chronic radiation syndrome, and radiation-induced thyroiditis are deterministic, meaning they reliably occur above a threshold dose, and their severity increases with dose. Deterministic effects are not necessarily more or less serious than stochastic effects; either can ultimately lead to a temporary nuisance or a fatality.

Acute radiation syndrome (ARS), also known as radiation poisoning, radiation sickness or radiation toxicity, is a constellation of health effects which present within 24 hours of exposure to high amounts of ionizing radiation. They may last for several months. The terms refer to acute medical problems rather than ones that develop after a prolonged period.

The onset and type of symptoms depends on the radiation exposure. Relatively smaller doses result in gastrointestinal effects such as nausea and vomiting and symptoms related to falling blood counts such as infection and bleeding. Relatively larger doses can result in neurological effects and rapid death. Treatment of acute radiation syndrome is generally supportive with blood transfusions and antibiotics.

Similar symptoms may appear months to years after exposure as chronic radiation syndrome when the dose rate is too low to cause the acute form. Radiation exposure can also increase the probability of developing some other diseases, mainly different types of cancers. These diseases are sometimes referred to as radiation sickness, but they are never included in the term acute radiation syndrome.

Signs and symptoms

Classically acute radiation syndrome is divided into three main presentations: hematopoietic, gastrointestinal and neurological/vascular. These symptoms may or may not be preceded by a prodrome. The speed of onset of symptoms is related to radiation exposure, with greater doses resulting in a shorter delay in symptom onset. These presentations presume whole-body exposure and many of them are markers which are not valid if the entire body has not been exposed. Each syndrome requires that the tissue showing the syndrome itself be exposed. The hematopoetic syndrome requires exposure of the areas of bone marrow actively forming blood elements (i.e., the pelvis and sternum in adults). The neurovascular symptoms require exposure of the brain. The gastrointestinal syndrome is not seen if the stomach and intestines are not exposed to radiation.

1. Hematopoietic. This syndrome is marked by a drop in the number of blood cells, called aplastic anemia. This may result in infections due to low white blood cells, bleeding due to low platelets, and anemia due to low red blood cells.^[1] These changes can be detected by blood tests after receiving a whole-body acute dose as low as 0.25 Gy, though they might never be felt by the patient if the dose is below 1 Gy. Conventional trauma and burns resulting from a bomb blast are complicated by the poor wound healing caused by hematopoietic syndrome, increasing mortality.

2. Gastrointestinal. This syndrome often follows absorbed doses of 6–30 Gy (600–3000 rad). Nausea, vomiting, loss of appetite, and abdominal pain are usually seen within two hours. Vomiting in this time-frame is a marker for whole body exposures that are in the fatal range above 4 Gy. Without exotic treatment such as bone marrow transplant, death with this dose is common. The death is generally more due to infection than gastrointestinal dysfunction.

3. Neurovascular. This syndrome typically occurs at absorbed doses greater than 30 Gy (3000 rad), though it may occur at 10 Gy (1000 rad). It presents with neurological symptoms such as dizziness, headache, or decreased level of consciousness, occurring within minutes to a few hours, and with an absence of vomiting. It is invariably fatal.

The prodrome (early symptoms) of ARS typically includes nausea and vomiting, headaches, fatigue, fever and short period of skin reddening. These symptoms may occur at radiation doses as low as 35 rad (0.35 Gy). These symptoms are common to many illnesses and may not, by themselves, indicate acute radiation sickness.

Phase