Trauma

Systemic capillary leak is an early feature of the inflammatory response to localized injury, and is proportional to the severity of the inflammatory insult. Loss of local control of inflammation leads to an exaggerated systemic inflammatory response known as systemic inflammatory response syndrome (SIRS). SIRS is associated with multiple organ failure and death when there is failure to maintain homeostasis.

Whilst the application of molecular biology and recombinant techniques have produced major advances in our understanding of the mediation of the inflammatory response, there is no agent currently available which will prevent SIRS and reduce the incidence of post-traumatic multiple organ failure. In the meantime, a more practical approach to the avoidance of SIRS and its attendant capillary leak syndrome is to attempt to reduce the deleterious effects of interstitial oedema by tailoring treatment to the rapid changes in capillary permeability.

There is, as yet, no specific therapy available for post-traumatic brain damage; the treatment of head injury is therefore aimed at limitation of secondary damage at the cellular, whole organ and systemic level.

The purpose of monitoring the injured brain is twofold:

1. to obtain a better understanding of the mechanisms by which pathophysiological processes further damage the injured brain

2. to continuously detect potentially harmful influences and allow them to be reversed before damage is done.

In this review, we provide a general overview of mechanisms of brain damage due to high intracranial pressure (ICP) and discuss the following ‘brain specific’ haemodynamic monitoring techniques:

• ICP/CPP (cerebral perfusion pressure) monitoring;

• jugular vein saturation (SjO₂) monitoring;

• cerebral oxygen monitoring (PtiO₂) and near infra-red spectroscopy (NIRS);

• brain temperature monitoring;

• cerebral blood flow (CBF) monitoring; and

• transcranial Doppler.

We also discuss the role of functional techniques such as electroencephalogram (EEG) and evoked potential monitoring. This article gives an overview of the techniques currently available in a rapidly expanding field within neuro-intensive care, mainly for the interest of trauma surgeons, intensivists, and others with a practical need to understand the monitoring of the injured brain.

For many years there has been a debate about whether crystalloids or colloids should be used for resuscitation. Some years ago, albumin was the gold standard against which all other solutions were compared. This continues to be the case, despite the fact that other solutions are as effective for volume replacement. This paper stresses the need for a proper understanding of the properties of solutions that may influence the choice for volume replacement. Different classes of solutions are discussed in detail, with special reference to their effects on cardiovascular and oxygen transport parameters. Other important properties such as side-effects and effect on coagulation are also considered.

The critical decisions regarding thoracotomy for trauma occur soon after the injury, when decisions have to be made that may influence survival or have an impact on morbidity if operation is delayed. Roadside thoracotomy is impractical, and should not be considered; instead, patients should be taken rapidly to the nearest hospital. Endotracheal intubation prior to transport appears to be beneficial, but the application of MAST trousers and the infusion of large volumes of fluid for hypovolaemia before control of haemorrhage offers no advantage and may be hazardous. On the whole, resuscitative thoracotomy is associated with a low salvage rate, especially for the patient sustaining blunt trauma, but may be worthwhile in the patient with penetrating trauma. Urgent, as opposed to immediate thoracotomy, should be undertaken once the patient has been stabilized. This may occur in most patients with penetrating injuries of the heart who survive to reach hospital, those with continuing, significant haemorrhage through chest drains, and those with tracheal, oesophageal and diaphragmatic injuries. Extensive open chest wounds require considerable ingenuity in closure, often with plastic surgical help. Patients with blunt traumatic rupture of the aorta often have multiple injuries, which may also be life threatening. If bleeding into the abdomen is demonstrated, then laparotomy should precede thoracotomy: musculoskeletal injuries and neurological injuries can usually be dealt with after the aortic rupture has been repaired.

Hidden in the diagnosis of ‘the sprained wrist’ is the missed ligament tear. A resultant carpal instability pattern can cause persistent pain and late osteoarthritis. The carpal bones act as a link system of two rows between the forearm and hand, held together by both an intrinsic and an extrinsic ligament system. Two common patterns of carpal collapse occur, the first at the scapho-lunate joint, where a tear results in scaphoid flexion and lunate extension (dorsal intercalated segment instability - DISI). The second occurs at the luno-triquetral joint, and results in lunate flexion (volar flexed intercalated segment instability - VISI). Further instability patterns are now emerging; those at the triquetro-hamate joint producing ulnar-sided wrist pain and midcarpal laxity, and complex dislocations, with or without fracture. Careful clinical examination, plain X-rays, magnetic resonance imaging (MRI) scan and wrist arthroscopy can enable a clear diagnosis to be made for most instability patterns. Treatment consists of acute open repair, soft tissue stabilization procedures or limited intercarpal fusion, depending on the time from injury.

‘Mild’ head injury is increasingly recognized as a potential source of physical and psychological disability, but there is a lack of consistency about the definition and management of these patients. We discuss and define the terms ‘mild’ and ‘minor’, the assessment of post-traumatic amnesia, and the relevance of other signs and symptoms.

Previous guidelines and recent evidence that a ‘mild’ injury may be followed by an intracranial complication are reviewed as a basis for recommendations for investigation and management in accident and emergency departments, for in-patient observation and for discharge planning.

The key to successful trauma management is appropriate, timely and adequate surgery. However, infective complications do occur and it would therefore seem prudent to use antibiotics. They should be started within an hour or so of the injury, in adequate doses and with a view to the bacteria likely to be contaminating the wound. They should be stopped as soon as possible after surgery. If evidence of infection appears after surgery, all efforts must be made to identify the source and deal with it. Narrow spectrum antibiotics should be used where possible. Only in this way can the problems of bacterial resistance to antibiotics be obviated.

Accident and emergency departments are often the first point of contact for an abused older person. Elder abuse is common and can take many forms, including physical, psychological, financial and sexual abuse, or neglect. The stereotypical victim of abuse as a frail roleless female is probably not accurate, as there appears to be little correlation between the degree of physical and mental disability of the victim and subsequent physical abuse. Elder abuse is most often domestic violence that has graduated into old age.

Identifying physical abuse is not always easy - the key feature is the incongruity between the signs of injury and the account of the process that led to it. While accident and emergency departments have well-established mechanisms to deal with suspected cases of child abuse, very few have procedures for handling elder abuse. Raising the awareness of healthcare workers in this area is seen as a vital goal in tackling this problem.

Since its introduction to the UK in 1988, the Advanced Trauma Life Support (ATLS) course has become the accepted standard for the care of victims of trauma during the ‘golden hour’. Yet despite this success, ATLS has been criticized over the years for its philosophy, the course contents, the rigid regulations, cost to participants and lack of validation. The aim of this article is to explore these and other frequently voiced concerns in the light of evidence gathered over the 20 years since ATLS was first introduced in the USA.