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This edition deals with a common problem facing anaesthetists all over the Contents: No 6 world - Major Trauma. Patients who are injured need immediate, expert assessment to detect and Editorial treat life threatening injuries. Basic care given The Management of Major Trauma early following trauma may be life saving as many Atropine patients die within the first hour from complications Boyle’s machines of their injuries such as hypoxia and hypotension. Anaesthesia for Ophthalmic Surgery Spinal anaesthesia for Caesarean Section (Letters) How to rapidly assess and treat victims of major trauma is discussed in detail in this edition. Although there are differences in facilities from one centre to summarise the findings in a future issue of the another much can be achieved by careful attention journal. We would be grateful for as many people to a detailed clinical examination and then treatment as possible to reply to the questionnaire published with the facilities available. In the editors’ experience in the last edition. We are always delighted to many patients die from hypovolaemia following receive other letters or suggestions about the journal trauma, in many circumstances this is avoidable. and will publish a selection if they are likely to appeal to the readership. Many thanks to those who have answered the questionnaire contained in Update 5. We are unable Dr Iain Wilson to reply to everyone individually but will attempt to Dr Roger Eltringham THE MANAGEMENT OF MAJOR TRAUMA as great but has not been as extensively studied. Head injury was the commonest reason for admission to the Gareth Wrathall, Senior Registrar in Intensive Intensive Care Unit at the University Teaching Hospital Therapy; Ray Sinclair, Consultant in Anaesthesia in Lusaka over a ten year period from 1978-1988 and Intensive Therapy, Royal Cornwall Hospital, with between 90 and 123 cases per year (approx- Truro, UK imately 20% of all admissions). In the UK, there are approximately 15000 deaths annually attributable to Introduction accidents. One third of these are due to road traffic Accidental injury is probably the most serious of all accidents i.e. almost 100 people per week die in road the major health problems facing developed accidents. For every death, two people suffer countries. In the developing world the impact is just permanent disability. In the USA, injuries are the Editors: Drs Iain Wilson, Roger Eltringham Section Editors: Drs Bill Casey, Mr Mike Yeats Overseas Editors: Drs Daniel Amutike (Zambia), Henry Bukwirwa (Uganda) Distribution: Dr Ray Sinclair Designed by : Angela Brazier 1 2 Update in Anaesthesia leading cause of death up to the age of 44. Many Surgical sets should include equipment for the accidents are preventable and this is a major health following procedures: urinary catheterisation issue for planners in health economics. (including suprapubic), peritoneal lavage, pleural drainage (chest drains sets with underwater seal) Major Trauma and needle and surgical cricothyrotomy. Specific Patients suffering from multiple injuries are provision should be made for children with commonly known as major trauma victims. Such appropriate sizes of equipment to deal with all ages patients present tremendous demands at all levels and equipment for intraosseous fluid administration within hospitals particularly on those doctors, nurses (see Update 5). and clinical officers caring for the patient within the first hours of hospital admission. It is in this context Methods of Managing Trauma that systems for major trauma care have been A multidisciplinary approach is required in the developed. In this review we will set out a system management of major trauma and the same technique for the management of major trauma victims and for assessment and treatment of each patient should discuss the principals of anaesthesia for such patients. be followed. Most modern trauma systems therefore We will emphasise the importance of recognising have a fairly rigid protocol to follow, thus reducing mechanisms of injury and thereby identifying those the opportunity for misdiagnosis. at risk of life-threatening injury. The article will be illustrated by actual case studies. The most widely taught system is the Advanced Trauma Life Support (ATLS) Program for Physicians, Trauma Teams devised and disseminated by the American College Victims of major trauma are best treated by a well of Surgeons (ACS). This article follows many of organised and trained team made up of staff competent their recommendations. The management of major in assessing and treating the spectrum of life- trauma has also been reviewed in the ABC of Major threatening injuries commonly seen. An experienced Trauma published by the British Medical Journal, physician anaesthetist, possessing airway and Tavistock Sq. London, WC1H 2JR (ISBN 0-7279- resuscitation skills and confidence in dealing with 0291-1). unconscious patients, is a vital member of the team and in many UK hospitals is the team leader. The role Timing of Death Resulting from Trauma of the non-physician anaesthetist is similar using The mortality due to injury occurs during one of the airway skills under the direction of a surgical following time periods: colleague. w The first peak of death occurs at the time of the Whenever possible both a general surgeon and an injury. It may be instantaneous or within the first few orthopaedic surgeon should be members of the trauma minutes and is due to overwhelming primary injury team. Their presence can reduce delays in the accident to major organs or structures such as brain, heart or department, improve the early diagnosis of life great vessels. In most situations these injuries are threatening injuries and lead to earlier surgery when irrecoverable, although rapid treatment and transfer required. Having both specialists present prevents may salvage some patients. Primary prevention has one doctor becoming overwhelmed by complex a major role in reducing the incidence of these problems in an unstable patient. The team should injuries. include a radiographer when available. Adequate protection including gowns, gloves and eye protection w The second peak lasts from the end of this first should be worn by staff. It is often possible for the period to several hours after the injury has taken team to be given prior warning of a casualty arriving, place. It is during this time that many causes of thereby allowing time for preparation. Accident & morbidity and mortality are preventable by avoidance Emergency departments should have a resuscitation of a secondary injury due to hypoxia, haemorrhage area set aside to receive major trauma victims with or any process that leads to inadequate tissue anaesthetic airway equipment and drugs, intravenous perfusion. Reversible conditions may include fluids with blood giving sets and blood warmers. intracranial haematomas, major haemorrhage from Update in Anaesthesia 3 viscera, bones and vessels or pneumothoraces. Most w Disorders of the central nervous trauma care is directed at this period as skilled system assessment and treatment should reduce mortality w Exposure of the whole body and disability. Even with moderate facilities many lives can be saved by