19. Assessing urgency of trauma – March 2015
Trauma is arguably the dramatic and exciting part of pre-hospital responding. It varies from a cut finger through to gruesome fatality. At one end minimally injured patients are usually obvious as are those at the other end who are in dire extremis. Many though are somewhere in between. Some require air retrieval, intensive care paramedics or transport to trauma centres. The last thing you want to do is miss something serious or underestimate the severity of any patient. And what happens when you have numbers of patients to assess? Enter time critical guidelines.
One way to recognise a sick trauma patient is to identify those who are already sick right now. That is, those who are in physiological distress. This includes the patient with severely compromised perfusion, in respiratory distress, or whose consciousness is significantly altered. You find this out when you take vital signs. Hence vital signs need to be established early, right after primary survey assessments for immediate life threats. Major trauma services typically provide criteria for which the ‘actually sick now’ patient can be identified.
Abnormal vital signs are usually more obvious though. Often patients will get sick over time from such things as bleeding. Pattern of injury is the next thing to look at. This is what happened to the patient’s body during the trauma. It is the forces applied and injures resulting. A blow to the head is blunt trauma, a knife to the belly penetrating. The head and the belly are body regions. Other serious injuries such as long bone fractures or large burns are also considered. These things are found in the secondary physical examination. They suggest the patient who is ‘emergent’. This patient isn’t physiological sick yet but likely soon will be. They also must be taken off to the trauma centre.
Finally, what about the patient who has got himself out of the high speed rollover, dusted himself off and said “wow, how lucky am I?” Putting aside the thought that rolling your car isn’t lucky, he has normal vital signs and no apparent injuries or pattern of injury. Can he still be potentially sick? This final category is what actually happened or the mechanism of injury. It is what you often observe as you arrive or get from history. It looks dramatic but is the least urgent of the criteria. Anyone involved in a major mechanism has potential to get sick. Young, fit and healthy adults mostly don’t without a pattern of injury. Just take them to the nearest for a ‘check up’. However those more vulnerable have much greater risk including pregnant women, older patients, children and those with co-morbidities. These are all potentially time critical off to the trauma centre.
Jeff Kenneally www.prehemt.com