Early involvement of surgical expertise is important in the care of the injured patient. A surgeon should be summoned as soon as it is known that a seriously injured patient is arriving. Early neurosurgical consultation is advised for patients with head injury.
General guidelines for field triage and interfacility transfer have used physiologic, anatomic, and high-risk mechanistic criteria to suggest triggers for triage and transfer. One may extrapolate that these parameters can be used to initiate involvement of a trauma surgeon as well. Some triggers are
suggested in Table 9-3 and Table 9-4.
Table 9-3: American Burn Association Criteria for Patient Transfer to a Burn Centera
Partial-thickness burns greater than 10% of total body surface area
Third-degree burns in any age group
Burns involving the face, hands, feet, genitalia, perineum, or major joints Patients at the extremes of age or those with significant comorbid disease Electric burns and chemical burns
Smoke-inhalation injury
Patients with combined trauma and significant burn injury
Children at hospitals with no expertise in caring for pediatric burn patients Burns suspected to be due to child or elder abuse
Burn patients with a delayed presentation or evidence of burn wound infection
aAdapted with permission from the American College of Surgeons.3 American College of Surgeons Committee on Trauma.
Guidelines for the operation of burn centers. In: Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2006:79-86.
Table 9-4: Indications for Field Triage and Interfacility Transfer
Physiologic Triggers
Glasgow Coma Scale score <14 Systolic blood pressure <90 mm Hg Respiratory rate <10/min or >29/min Anatomic/Injury Triggers
Penetrating injuries to head, neck, torso, and proximal extremities Deteriorating Glasgow Coma Scale score or lateralizing signs Paralysis, spinal cord injury
Major chest trauma, flail chest, pulmonary contusion Widened mediastinum or other signs of great vessel injury
Cardiac injury
Solid organ injury, open or unstable pelvic ring fracture
Fracture/dislocation with loss of distal pulse or open long bone fractures Crush injuries with limb ischemia
Major burns >20% total body surface area or associated with trauma Patient Triggers
Age <5 y or >55 y
Known cardiopulmonary or metabolic diseases Pregnancy
Immunosuppression Mechanism of Injury Triggers
Falls
– Adults: >20 fit (one story is equal to 10 ft)
– Children: >10 fit or 2-3 times the child’s height High-risk auto crash
– Intrusion: >12 inches occupant side; >18 inches any side
– Ejection (partial or complete) from auto
– Death in same passenger compartment
– Vehicle telemetry data consistent with high risk of injury
Auto vs. pedestrian/bicyclist: thrown, run over, or with significant (>20 mph) impact Motorcycle crash >20 mph
If appropriate surgical services are unavailable, early transfer to the closest trauma or burn center should be initiated. This should not be delayed for additional radiologic studies if surgical resources are unavailable, unless those studies are requested by the accepting physician. The trauma center should be contacted for advice and to discuss potential problems or concerns with transport
personnel.
Common pitfalls in the transfer of seriously ill patients include failure to intubate before transfer, failure to recognize the need for transfer to a higher level of care, and a general failure to stabilize the patient adequately before transport. Unrecognized ongoing hemorrhage, delayed onset of tension pneumothorax, and reversible/preventable causes of secondary brain injury must be considered.
Key Points
Basic Trauma and Burn Support
The first goal in trauma management is to identify and treat immediately life-threatening injuries by following the ABCDE sequence of priorities.
After blunt trauma, airway control should proceed on the assumption that an unstable cervical spine injury exists.
A diagnosis of tension pneumothorax should be based on clinical criteria and not on a chest radiograph.
Hemorrhage is the most likely cause of shock after injury, and initial empiric treatment consists of crystalloid infusion to normalize blood pressure, reverse tachycardia, and maintain adequate organ perfusion.
In general, blood should be added to resuscitation fluids when crystalloid infusion is >50 mL/kg.
Uncrossmatched, type-specific blood can be administered safely.
A secondary assessment includes a head-to-toe examination to identify and treat potentially life- threatening injuries.
Computed tomographic scanning is essential for the initial evaluation of head-injured patients with a depressed level of consciousness.
Burn resuscitation is proportional to the area sustaining second- and third-degree burns and is titrated to signs of perfusion, including urine output.
Closed-space smoke inhalation injury places the patient at high risk for upper airway and lung injury that may not be obvious at the initial presentation.
Surgical expertise should be secured early and transfer considered for those patients who require higher level of care.
Transfer to a specialized care setting should not be delayed for additional radiologic studies unless the accepting physician requests the studies.
Suggested Readings
1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors (ATLS). 8th ed. Chicago, IL: American College of Surgeons; 2008.
2. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors (ATLS): Student Course Manual. 8th ed. Chicago, IL: American College of Surgeons;
2008.
3. American College of Surgeons Committee on Trauma. Guidelines for the operation of burn centers. In: Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2006:79-86.
4. Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am. 2006;44:1-12.
5. Brain Trauma Foundation. Management and prognosis of severe traumatic brain injury. J Neurotrauma. 2007;24 (Suppl 1):i-S106.
6. Chan O, Wilson A, Walsh M. Major trauma. BMJ. 2005;330:1136-1138.
7. Cheatham ML, Malbrain ML, Kirkpatrick A, et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome, II:
Recommendations. Intensive Care Med. 2007;33:951-962.
8. Elliott DC. An evaluation of the end points of resuscitation. J Am Coll Surg. 1998;187:536-547.
9. Herndon DN, ed. Total Burn Care. 3rd ed. Philadelphia, PA: Saunders-Elsevier Inc; 2007.
10. Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001;51:261-271.
11. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: Directly addressing the early coagulopathy of trauma. J Trauma. 2007;62:307-310.
12. Moore EE, Feliciano DV, Mattox KL, eds. Trauma. 6th ed. New York, NY: McGraw-Hill; 2008.
13. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: Preliminary results of a randomized controlled trial. J Trauma.
2011;70:652-663.
14. Pryor JP, Braslow B, Reilly PM, et al. The evolving role of interventional radiology in trauma care. J Trauma. 2005;59:102-104.
15. Rhee P, Nunley MK, Demetriades D, et al. Tetanus and trauma: A review and recommendations.
J Trauma. 2005;58:1082-1088.
16. Rossaint R, Bouillon B, Cerny V, et al. Management of bleeding following major trauma: An updated European guideline. Crit Care. 2010;14(2):R52.
17. Sarrafzadeh AS, Peltonen EE, Kaisers U, et al. Secondary insults in severe head injury: Do multiply injured patients do worse? Crit Care Med. 2001;29:1116-1123.
18. Sheridan RL. Burns. Crit Care Med. 2002;30(suppl):S500-S514.
19. Society of Critical Care Medicine. Fundamental Disaster Management. 3rd ed. Mount Prospect, IL: Society of Critical Care Medicine; 2009.
20. Stengel D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Syst Rev. 2005;(2):CD004446. doi:
10.1002/14651858.CD004446.pub2.
Web Sites
1. American Burn Association. www.ameriburn.org
2. American Burn Association. Advanced Burn Life Support Course (ABLS). 2nd ed.
www.ameriburn.org/ablscoursedescriptions.php.
3. Burn Surgery. www.burnsurgery.org
4. American Association for the Surgery of Trauma. www.aast.org
5. Centers for Disease Control and Prevention – Data & Statistics. www.cdc.gov/injury/wisqars/
6. Eastern Association for the Surgery of Trauma. Resuscitation Endpoints.
www.east.org/research/treatment-guidelines/resuscitation-endpoints. Best site for evidence- based trauma care guidelines.
7. Trauma.org. http://www.trauma.org. Image bank and links.
8. World Society of the Abdominal Compartment Syndrome. http://www.wsacs.org. Consensus information on abdominal compartment syndrome.
9. Eastern Association for the Surgery of Trauma. Appropriate Triage of the Victim of Trauma.
http://www.east.org/research/treatment-guidelines/triage-of-the-victim-of-trauma
10. Centers for Disease Control. Injury Prevention and Control, Field Triage Decision Scheme.
http://www.cdc.gov/ncipc/dir/FLD_TRIAGE.doc
11. Interfacility Transfer of Injured Patients; Guidelines for Rural Communities.
http://www.facs.org/trauma/publications/ruralguidelines.pdf
Chapter 10