Physical trauma



Editor-In-Chief: Niral Shah, M.D. [mailto:nashah@bidmc.harvard.edu]

Overview
Physical trauma refers to a physical injury. A trauma patient is someone who has suffered serious and life-threatening physical injury potentially resulting in secondary complications such as shock, respiratory failure and death.

Definition
Trauma patients require specialized care, including surgery and sometimes blood transfusion, within the so-called golden hour of emergency medicine, the first sixty minutes after trauma occurs. This is not a strict deadline, but recognizes that many deaths which could have been prevented by appropriate care occur a relatively short time after injury. In many places organized trauma referral systems have been set up to provide rapid care for injured people. Research has shown that deaths from physical trauma decline where there are organized trauma systems.

Techniques
In a prehospital setting, also called the "field", emergency medical technicians, paramedics, specialized nurses, and less trained providers known as 'first responders', use stabilization techniques to improve the chances of a trauma patient surviving the ambulance trip to the hospital. Professionals begin performing a primary survey, consisting of assessment of airway, breathing, and circulation (called the "ABC's"). The purpose of the primary survey is to identify life-threatening problems. Ensuring that the injured person is not disabled by unnecessary movement of the spine is paramount, so the neck and back are secured before moving the patient. Unless the victim is in imminent danger of death, first responders will usually "load and go" transporting the victim immediately to the nearest appropriate trauma-equipped hospital.

Upon completion of the primary survey, the secondary survey is begun. This may occur during transport or upon arrival at the hospital. The secondary survey consists of a systematic assessment of the abdominal, pelvic and thoracic viscera, complete inspection of the body surface to find all injuries, and neurological exam. The purpose of the secondary survey is to identify all injuries so that they may be treated. A missed injury is one which is not found during the initial assessment (for example, as a patient is brought into a hospital's Emergency Department), but rather manifests itself at a later point in time, sometimes with baleful consequences (i.e., a liver laceration is sometimes missed and a patient sent home, who will abruptly go into shock shortly thereafter.)

The appropriate first aid for a trauma patient is to immediately call for help using the emergency medical service, then treat for shock. Do not move the victim unless failure to do so would create a greater risk to their life (i.e. hazardous chemicals or a spreading fire). Also see wilderness first aid if immediate emergency help is unavailable.

In case of traumatic accidents, health care providers use the ABC of life (airway, breathing and circulation) as their primary survey in identifying and assessing the condition of the patient. Airway is considered as the most important factor to be assessed then the breathing and circulation. From this technique the appropriate intervention will be identified immediately and prioritization of action can be done according to the most important aspect to be assessed

Time
Generally, the earlier a trauma patient can get specialized care, the greater are the chances of survival and recovery. However, there have been exceptions from this generalization.

For example in the Falklands War the British military lost most of their helicopter support when the Atlantic Conveyor was sunk by an Argentine Exocet, resulting in no fast way to evacuate the wounded from the battlefield. Therefore any soldiers who suffered wounds lay where they fell in bitterly cold weather for hours with no blood transfusion, surgery or medication available. The opposite scenario was known from the Vietnam War in which wounded U.S. soldiers were usually quickly airlifted from the battlefield, kept warm and given aggressive medical treatment. The interesting statistic is that the casualty to fatality ratio in the Falklands War was still significantly lower than in the Vietnam War. Recently there has been some new research into how to treat physical trauma by comparing the different practices and experiences in these military conflicts. It might e.g. indicate that the environment is an important factor. For instance, in cold and barren areas, as around the Falkland Islands, the risk that wounds become infected is smaller compared with warm and humid environments, as in the rainforests of Vietnam.