Improving outcome in severe trauma: trauma systems and initial management—intubation, ventilation and resuscitation
- 1Dept Emergency Medicine, Royal London Hospital, London, UK
- 2Trauma Clinical Academic Unit, Royal London Hospital, London, UK
- 3Anaesthesia and Intensive Care North West Deanery, Pre-Hospital Care Registrar London HEMS, London, UK
- 4Dept Emergency Medicine, Leeds General Infirmary, Leeds, UK
- Correspondence to Dr Tim Harris, Royal London Hospital, London E11BB, UK;
Contributors The article was written by Tim Harris with contributions to the anaesthesia and ventilation sections by Tom Hurst, and the coagulopathy and trauma surgery sections by Ross Davenport. All authors then reviewed and refined the paper to its current form. The paper was then revised by a forth author, Dr. Jonathan Jones.
- Received 1 September 2008
- Accepted 18 September 2010
- Published Online First 1 November 2010
Severe trauma is an increasing global problem mainly affecting fit and healthy younger adults. Improvements in the entire pathway of trauma care have led to improvements in outcome. Development of a regional trauma system based around a trauma centre is associated with a 15–50% reduction in mortality. Trauma teams led by senior doctors provide better care. Although intuitively advantageous, the involvement of doctors in the pre-hospital care of trauma patients currently lacks clear evidence of benefit. Poor airway management is consistently identified as a cause of avoidable morbidity and mortality. Rapid sequence induction/intubation is frequently indicated but the ideal drugs have yet to be identified. The benefits of cricoid pressure are not clear cut. Dogmas in the management of pneumothoraces have been challenged: chest x-ray has a role in the diagnosis of tension pneumothoraces, needle aspiration may be ineffective, and small pneumothoraces can be managed conservatively. Identification of significant haemorrhage can be difficult and specific early resuscitation goals are not easily definable. A hypotensive approach may limit further bleeding but could worsen significant brain injury. The ideal initial resuscitation fluid remains controversial. In appropriately selected patients early aggressive blood product resuscitation is beneficial. Hypothermia can exacerbate bleeding and the benefit in traumatic brain injury is not adequately studied for firm recommendations.
- ‘injuries and wounds’
- ‘trauma centre’
- accident & emergency medicine
- adult intensive & critical care
- trauma management
- road traffic accident
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.