Trauma

Most of us, deal with managing trauma in our residency. I remember the word “Trauma” – laterally means full of thrill, energy, and enthusiasm. To manage a trauma victim, we not only need to understand human anatomy, physiology & surgical skills but we should also understand soft skills to handle the emotional situations of a human being to console patients, family & friends. Understanding human psychology and behaviour is equally important, making you a real surgeon. So-called The Trauma Surgeon.

So, what is Trauma – “Any event which leads to serious grief or sadness.” Whenever it’s trauma – always associated with time boundedness management and psychological disturbances. That’s why the management of trauma is completely different from other surgical/medical treatments even non-traumatic surgical emergencies.

How traumatic emergencies are different from non-traumatic emergencies?

• The severity of trauma is always unpredictable for doctors & patients – until evaluated thoroughly.
• The line of treatment & Prognosis will remain unclear till proper investigation and emergency intervention.
• Radiological investigations, especially for abdomen & vascular trauma, are unreliable in acute trauma settings, here clinical knowledge and expertise play a crucial role in the definitive management of trauma victims.
• In the case of non-traumatic surgical emergencies – family members and patients are aware of past illnesses or symptoms, and most of the time good clinical history and examination reveal the diagnosis which helps us in managing patients.
• Always consider an emergency as a time-bounded situation, in a few cases in non-traumatic medical emergencies prior to optimization of the patient’s vitals, maintaining hydration, and Hemoglobin associated with a good outcome.
• Trauma can hit anyone but most of the victims have normal physiology prior to trauma – so any deterioration in physiology is directly proportional to injury. Co-morbidity is adding to poor prognosis.

Trauma management = Clinical expertise + Surgical Skills + Proactive behaviour + Soft Skills

Once trauma victims arrive in the Emergency department most important thing is to transfer the patient to the appropriate Zone or area in the Emergency. Every Emergency should have three areas – Red Area/ Yellow Area/ Green Area and Ideally separate Emergency ICU.

Trauma Emergency – Areas

Red Area

The red area is a highly alert and active area of the trauma centre and trauma emergency. The red area should be well equipped for resuscitations like functional laryngoscope, ventilators, and high-end monitors (EtCO2 monitoring, invasive Blood Pressure monitoring system). Dressing material for active haemorrhage control, tourniquet, and Defibrillators. Essential drugs for CPR, analgesics, antiarrhythmics, tetanus toxoids and antibiotics.

A good resident who oversees the red area – always ensures the functionality of the equipment, and the manpower available to help them as teams like nursing staff, colleagues, ward boys or attendants, security staff and sweepers. After taking handover – communicate with their team members, are more focused on new members and divide their work as per expertise. Never underestimate the value of non-medical manpower especially security guards and ward attendants. I always keep in the loop of communication – which helps me in handling the crowd and unwanted anger or emotional bursts out.

Closed-loop communication is the key to handling emergency situations, keeping informed and alert will be useful in multiple casualty or disaster settings.

The most ignored component in the red areas or emergency settings is unable to provide general care – medically or physically like maintaining temperature (especially the prevention of hypothermia) by proving blankets, warm saline, and patients’ clothing. In trauma patients’ hypothermia is part of the vicious cycle of death.

Yellow Area

The second most challenging zone to handle is the trauma centre. Triaging is a dynamic phenomenon – patients should be surveyed frequently till definitive management and can be re-triaged to red or green as per the patient’s condition. The yellow area holds moderately serious patients – at a given time patients can get serious or remain the same.

So, it is mandatory for trauma emergencies to keep a resuscitation trolley and essential resuscitation drugs to manage critically ill patients. 50% of beds in the emergency should be in the yellow area (15 out of 30 beds).

Green Area

The green area holds walking wounded patients. These patients are more alert and active which can create problems to manage your more serious emergencies. Here the role of non-medical manpower comes in. Use trauma consolers, and ward attendants to help people psychologically and physically. Emotional outbursts among patients and families are common in trauma scenarios. Green areas should have 15-20% beds of whole emergency beds. Good trauma centres always have a continuous monitoring system

Triaging System

Triage meaning – “to sort”

To be a good doctor it’s important to understand. why triaging is important for patient management in emergency scenarios. The main aim is to eliminate possibility of preventable death.

1. Triaging categorizes your patient into serious/less serious/Non-serious.
2. Triaging helps us to utilize our resources properly and timely – which is associated with good patient outcomes.
3. Triage help to utilize the clinical expertise – skilled staff should be in the red area and less skilled should be in the green area.
4. High-alert areas indirectly talk about the prognosis of the patients to their relatives – which is helpful in breaking bad news and explaining the prognosis.
5. Triaging is widely useful in multiple/mass causalities.

“Over-triaging is better than under-triaging to save a life.”

         Triage Protocols

If we truly sit and discuss triage criteria, more than a hundred criteria are defined theoretically. Here I am talking about practical useful criteria only –

 Simple Triage System (STS)

STS can be utilized for field triaging or in-hospital triaging.

1. Black – Dead
   1. Red – Alive with Gasp/ shock/ disoriented (GCS<15)
   1. Yellow – Unable to walk & oriented (GCS=15)
   1. Green – Wounded & walking

 START – Simple Triage and Rapid Treatment

Remember the fact – the whole purpose of learning facts, knowing laws or principles & understanding scores is focused to save patients. Sometimes patients will not fit into the system or principle – use your clinical skills and knowledge you learned.

“Saving a life is your goal, not following someone’s command or order”

Now you are ready to receive a critical trauma patient. But how will you approach ……

SALT triage (Sort, Assess, lifesaving intervention, Treatment/Transport)