TRAUMA AND MILITARY ANAESTHESIA

Initial assessment and Learning objectives

management of trauma After reading this article, you should be able to:

encountered in the field C outline the different trauma scoring systems available and their
use
C describe the initial management of trauma patients specifically
Emma Coley relating to pelvic fractures, ballistic trauma and traumatic car-
Sarah Fadden diac arrest
C explain the initial management and resuscitation of patients
relating to burns and head injuries
Abstract C demonstrate the placement of the Combat Application Tourni-
This article covers the principles of trauma care relating to specific quet when clinically indicated
competencies within the military higher training module. The majority
of these principles relate to the pre-hospital assessment and manage-
ment of patients, introducing some of the nuances of military medicine
in comparison to civilian practice. platform for trauma data registries and widely used for trauma
Keywords Burns; cardiac arrest; forensic ballistics; head injury; research.1
military medicine; pelvis; thoracotomy; tourniquet; trauma severity Less frequently used anatomic systems include New Injury
indices; wounds and injuries Severity Score (NISS), ICD derived injury severity score (ICISS)
and Anatomic Profile (AP).
Royal College of Anaesthetists CPD Matrix: 3A10, 3A14, 2A02, 2F01, 1B04

Physiological scoring systems

Revised Trauma Score (RTS) has been widely used to predict
the prognosis of trauma patients and forms part of TRISS. It can
be used as a pre-hospital triage tool but requires complex cal-
culations. Triage RTS (T-RTS) is an adaptation that simplifies the
Trauma scoring systems triage method, using the parameters respiratory rate, systolic
Accurate and useful scoring in major trauma is a substantial blood pressure and Glasgow Coma Scale (GCS).
challenge, and there are multiple scoring systems. Most
concentrate on mortality outcomes rather than morbidity. New Trauma Score e Adaptations have been made to the RTS
Covered below are a few of the most widely recognized scoring system, changing the respiratory rate for saturations, altering
systems. blood pressure intervals and using actual GCS instead of a GCS
code. This has shown improved mortality prediction compared
Anatomic scoring systems with the RTS.2
Abbreviated Injury Score (AIS) developed in 1971, assesses the
severity of anatomical injury using a single score for each injury The Glasgow Coma Scale is familiar, internationally recognized
sustained. Scores range from 1 to 6 (minor injury to incompatible and a valuable physiological predictor and prognostic tool. It
with life). The AIS dictionary contains more than 2000 injuries.1 looks at the best scores for eye opening, verbal and motor re-
The difficulty with AIS lies in the assumption that patients with sponses. Its use has also been validated in assessment of TBI
the same AIS in different body regions would equate to similar patients.
odds of adjusted mortality. This further impacts on those scoring
systems which include AIS, such as ISS, NISS and TRISS. Combined scoring systems
Trauma Score e Injury Severity Score (TRISS) e Introduced in
Injury Severity Score (ISS) created in 1974, is a non-linear score 1981 combines age, the Revised Trauma Score, Injury Severity
derived from the AIS. It is defined as the sum of the square of Score and whether the injury was blunt or penetrating. Complex
each of the three highest AIS scores in six predetermined body to use, but useful for predicting the probability of survival. The
regions. The maximum score is 75. A patient with an AIS of 6 in probability of survival of each patient is calculated using age,
one body region is given an ISS of 75. ISS was developed as a gender, GCS and ISS.

Management of the traumatic pelvis

Emma Coley A/Lt Col MBChB FRCA RAMC is a Consultant Anaesthetist at
The Royal Infirmary of Edinburgh, Edinburgh, UK. Conflicts of Traumatic pelvic injuries
interest: none declared. Pelvic fractures are high-energy fractures rarely found in isola-
tion. The large pre-sacral venous plexus is the most common site
Sarah Fadden Major BA MB BChir FRCA DIMC RAMC is a Military
Consultant Anaesthetist based at Aintree University Hospital, of bleeding, followed by fracture surfaces and, more rarely,
Liverpool, UK, who also works at the East Anglian Air Ambulance, arterial injury. It is important not to underestimate the potential
Norwich, UK. Conflicts of interest: none declared. for retroperitoneal bleeding and large circulating blood volume

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Please cite this article as: Coley E, Fadden S, Initial assessment and management of trauma encountered in the field, Anaesthesia and intensive
care medicine, https://doi.org/10.1016/j.mpaic.2019.09.005
 TRAUMA AND MILITARY ANAESTHESIA

loss. Mortality rates for all types of pelvic fracture have laparotomy may cause decompression and re-expansion of the
improved, but they still range from 5e15%.3 retroperitoneal haematoma due to renewed venous bleeding.

Initial management and stabilization Operative anaesthetic considerations

A pelvic binder should be placed pre-hospitally if there is sus- These patients require robust multidisciplinary team work to
picion of a fracture. The binder can help reduce the fracture, ensure precise management. Good IV access, peripheral or cen-
temporarily stabilizing the pelvis and reducing pain. This also tral, is crucial. Arterial pressure monitoring may not have been
encourages clot formation and facilitates transport. It is impor- placed in the emergency department but is invaluable in an
tant that it is placed correctly over the greater trochanters to emergency theatre setting, allowing accurate blood pressure
provide support, also allowing access to the abdomen for lapa- measurement and intraoperative sampling.
rotomy without removal. These patients should be managed in a Patients are likely to be managed in a critical care environ-
major trauma centre with a consultant-led multidisciplinary ment postoperatively. Postoperative analgesia should take a
trauma team. multimodal approach. Although regional techniques are not
Resuscitation with blood products, initially allowing for appropriate for unstable patients, local anaesthetic wound infil-
permissive hypotension, should be initiated if there are con- tration by the surgeons can be used.
cerns about bleeding. This can be commenced pre-hospitally. If
there are no contraindications, patients should receive tra- Military anaesthesia for severe burns
nexamic acid. Resuscitation can be assisted by arterial blood gas
Burn injuries may occur in isolation, or in association with other
analysis and thromboelastography, if available. Dependent on
trauma. Burns can be classified broadly according to their type
stability for transfer to CT, adjunctive imaging in the emergency
and depth. The severity of burn may be further described by site,
department includes chest and pelvic X-rays and eFAST. eFAST
surface area and associated injuries/complications. The mainstay
scanning is not sensitive enough to reliably detect retroperito-
of burns management is supportive, with only a few specific
neal haematoma and cannot give information about solid organ
therapies that are relevant to the pre-hospital environment.
integrity. However, eFAST’s ability to show gross fluid collec-
Military Clinical Guidelines for Operations include protocols for
tions within the chest, abdomen and pelvis is useful in patients
management of burns. Significant burns cause systemic injuries
unsuitable for CT, helping the surgeons identify which body
and can be a heavy burden, both in terms of the medical re-
cavity to open first.4
sources required and long-term morbidity.5
Both pre-hospitally and in the emergency department it is
The pathophysiological sequelae of major burns are multi-
important to deliver adequate analgesia. This depends on asso-
system. A burn that is greater than 30% total body surface
ciated injuries and conscious level, but intravenous opiates can
area (TBSA) is more likely to cause substantial cytokine release,
be titrated, and ketamine provides a good adjunct with little
the effects of which may result in multiple systems organ failure
associated haemodynamic change.
and increased risk of mortality, particularly in patients at ex-
A trauma CT scan screens for injuries, with the addition of
tremes of age or with pre-existing comorbidities.
contrast allowing localization of bleeding to direct embolization
Knowledge of the history of the injury will help in the
if appropriate. Angiography and embolization has become the
assessment of a patient with burns, as well as anticipation of
most effective non-operative intervention for arterial bleeding.3
their clinical course:
For example, in cases of pelvic trauma with associated haemor-
! When, with what, at what temperature (or concentration),
rhagic splenic injuries, embolization can obviate the need for
and length of exposure?
laparotomy. In haemorrhagic splenic injuries associated with
! Did the burns occur in an enclosed or open space (the
pelvic trauma, embolization should be considered, potentially
former being more likely to cause inhalational injuries),
avoiding laparotomy.4 Fewer than 5% of patients suffer com-
and was there an associated explosion (resulting in other
plications post embolization, although these can be serious, such
injuries)?
as gluteal muscle necrosis.4
! What other injuries, if any, has the patient sustained?
Patients with isolated pelvic fractures may be managed in a
Hypovolaemia in the initial hours following injury is rarely
ward environment, ensuring a full secondary survey and referral
attributable to burns, so active bleeding secondary to other
to the pain team should analgesia be a concern.
trauma needs to be considered.
Surgical management Physical examination should incorporate a full primary sur-
Exploratory damage control laparotomy is required for severe vey, before assessment of the burn is undertaken.
haemodynamic instability associated with indistinguishable A burn is described according to the percentage TBSA that it
haemoperitoneum. There is debate about the best means of covers, estimated using tools such as the “rule of nines” for
pelvic stabilization.4 Pelvic binders are often left in situ. Place- adults or the Lund and Browder chart for paediatric patients
ment of a pelvic external fixation device may be beneficial prior under the age of 14 years old.6 The severity of a burn is also
to laparotomy.3 Surgical packing may be required, with pre- gauged by its depth and location (if a “special site”, such as the
peritoneal packing up to the bone. face).
Percutaneous pelvic fixation leads to definitive stabilization.
Anaesthesia for burns
This can be part of damage control surgery but may not be
Anaesthesia for a patient with burns may be required for a va-
appropriate in the initial surgical management. Exploratory
riety of reasons e to provide intubation and ventilation in the

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Please cite this article as: Coley E, Fadden S, Initial assessment and management of trauma encountered in the field, Anaesthesia and intensive
care medicine, https://doi.org/10.1016/j.mpaic.2019.09.005
 TRAUMA AND MILITARY ANAESTHESIA

situation of a compromised or at risk airway, where respiratory including the surrounding environment, type and amount of
complications have occurred secondary to inhalational injury; for explosive. Explosion causes rapid conversion of a substance to a
ongoing clinical care (such as wound debridement, skin grafting gas, substantially increasing the volume by more than a 1000-
or escharotomies); or for treatment of concomitant traumatic fold. Simultaneous increase in pressure causes the surrounding
injuries. Investigations include blood tests (full blood count, urea air to be compressed, forming a shock wave. This lasts only
and electrolytes, creatine kinase and arterial blood gas with milliseconds, but is followed by a longer lower pressure blast
carboxyhaemoglobin), electrocardiogram, chest X-ray, bron- wind.7
choscopy (for intubated patients) and urine analysis (output and Explosions have the potential to inflict multi-system life-
presence of haemoglobinuria or myoglobinuria). These in- threatening injuries, directly and indirectly, on multiple patients.
vestigations will help to assess the degree of physiological This is likely to create mass casualties, causing a major incident.
derangement caused, and to target the resuscitation strategy. The infrequency of these events creates challenges for local
Monitoring may be challenging in cases where there are burns emergency services, including triage and initial management.
overlying monitoring sites. Early placement of an arterial line Blast injuries have several sub-categories, representing
will provide both invasive blood pressure monitoring, for a pa- mechanisms of tissue injury. These all have implications for
tient who may be haemodynamically compromised and not able acute management and anaesthetic planning.
to tolerate a non-invasive cuff, and access for regular arterial ! Primary blast injuries e direct effect from the blast wave
blood gas analysis. Cross-matching the patient is judicious, as and over-pressurisation impulse. This is likely to cause
wound debridement can lead to rapid blood loss. injuries within hollow organs and gas-filled spaces
Ketamine is particularly useful for induction of patients with including middle ear, lung, and large bowel. It has also
cardiovascular instability (e.g., secondary to vasodilatation been implicated as a cause of traumatic brain injury (TBI)
caused by burn-induced systemic inflammatory response syn- and can affect the extremities.8
drome). It also causes bronchodilatation, which may be helpful if ! Secondary blast injuries e related to foreign objects and
inhalational injury has occurred. For muscle relaxation, sux- debris propelled by the blast wave becoming projectiles.
amethonium is contraindicated from 6 hours until 2 years after a ! Tertiary blast injuries e caused by blunt impact when the
major burn injury, owing to the risk of severe hyperkalaemia. casualty is displaced by the forces of the explosion.
Higher doses of non-depolarizing neuromuscular blocking drugs ! Quaternary blast injuries e indirect injuries occurring as
may be required due, in part, to the appearance of extra-junctional a consequence of the explosion, such as burns and smoke
acetylcholine receptors. Postoperative pain may be significant and inhalation.
should be addressed with prompt multimodal analgesia. The majority of blast injuries are found in a military envi-
Mechanical ventilation should employ a lung protective ronment, where there is a disproportionate representation of
strategy (e.g. tidal volumes of 6e8 ml/kg). Patients with inha- extremity injuries due to detonation on or under the ground.
lational injury will require regular pulmonary toilet and bron- Triage is extremely important for ensuring resources are directed
choscopic lavage. Carbon monoxide poisoning may necessitate appropriately to those with the most severe injuries, but also
ventilation with 100%, or even hyperbaric, oxygen. those with the greatest chance of survival.8 Initial scene assess-
Intravenous access, fluid resuscitation and electrolyte man- ment and triaging prioritizes immediate management of life-
agement can be challenging. The Parkland Formula (4ml/kg " % threatening injuries, such as tourniquet application for major
TBSA burn in adults) provides a useful estimate of the crystalloid extremity haemorrhage. An advanced trauma life support
volume required for resuscitation during the first twenty-four approach should be applied to those patients prioritized for
hours after a burn injury has occurred, with half given over the treatment. In the military setting, improved armouring and
first eight hours and half over the following sixteen hours. Fluid medical innovations, including haemostatic dressings and tour-
infusions are titrated against clinical response, measuring urine niquets, have reduced mortality.
output (aiming for > 0.5 ml/kg/hr in adults), intending to restore On arrival at a medical facility a rapid primary survey often
perfusion of the tissues and organs, whilst minimising oedema.5 leads to re-triaging. The focus is on damage control, allowing
Any electrolyte disturbances should be treated. time-limited surgical procedures to be carried out, such as rapid
Other anaesthetic considerations include measures to prevent initial wound debridement to reduce infection rates. This is fol-
hypothermia in patients whose inability to autoregulate while lowed by patient optimization in a critical care environment
anaesthetized is exacerbated by evaporation of fluid from their before definitive management.
wounds. This may be achieved by increasing the ambient tem-
perature, using warming blankets and infusing pre-warmed fluids. Ballistics
The anaesthetic management of a patient with severe burns Ballistics is the science of projectiles and firearms. Terminal
requires multi-system assessment and support. Depending on the ballistics is the study of how a projectile behaves when it hits a
circumstances, suspicion of other concurrent trauma injuries target and transfers its kinetic energy. If the target is biological,
must be explored and addressed. the term wound ballistics is applied.
Severity of any penetrating injury is related to the vicinity
Blast and ballistic injuries of the wound track to vital organs and large vessels. Dy-
namics of the projectile and local tissue reaction influence the
Blast injury nature of the gunshot wound. Energy transfer to the tissue is
Blast injury secondary to bombs and explosions can cause determined by the kinetic energy of the bullet (KE ¼ ½ mv2),
unique patterns of injury. Damage created depends on factors but also the specific tissue resistance to bullet penetration.

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Please cite this article as: Coley E, Fadden S, Initial assessment and management of trauma encountered in the field, Anaesthesia and intensive
care medicine, https://doi.org/10.1016/j.mpaic.2019.09.005
 TRAUMA AND MILITARY ANAESTHESIA

Where there is only an entry wound, all the bullet’s energy and reactivity, particularly pre- and post-administration of
has been distributed to the tissues. Where exit wounds exist, anaesthetic drugs.
they are commonly larger and more irregular due to bullet The anaesthetic management of a TBI patient may impact
tumbling.9 critically on their outcome. A rapid sequence induction is not
With high-velocity projectiles, cavitation is a process where without risk of complications, particularly in a group of patients
tissue displacement lags behind the bullet. A temporary larger whose already unstable physiology may be further compromised
cavity is formed, which then closes down to leave a permanent by anaesthetic drugs.11 Agents that are commonly used to induce
wound track. The vacuum created during this process can also anaesthesia rapidly in the pre-hospital environment are fentanyl,
entrain foreign material. This temporary track can vary in size, ketamine and rocuronium. A modified technique using intrave-
depending on energy deposition and bullet motion, but can have nous fentanyl, ketamine and rocuronium in a 3:2:1 (unit drug per
a devastating effect on susceptible organs.9 kilogram patient weight) ratio, or 1:1:1 ratio in more haemody-
namically compromised patients, achieves suitable intubating
Military anaesthesia for head injuries conditions. Concerns regarding the use of ketamine for TBI pa-
tients, in whom a high MAP could exacerbate a raised ICP, have
Primary traumatic brain injury (TBI) is the initial physical
largely been disproved.12 Careful laryngoscopy technique will
injury caused to brain parenchyma by mechanical forces. This
help to prevent excessive sympathetic stimulation. Rocuronium
results in activation of an inflammatory cascade, with further
is a useful muscle relaxant in trauma, because it has a rapid
tissue damage, oedema, and decreased cerebral perfusion
onset, long duration of action and can be reversed pharmaco-
pressure (CPP). Patients with apparent or suspected TBI are
logically if required.
vulnerable to secondary brain injury. Rapid management of TBI
Cervical spine problems should be suspected in trauma pa-
patients, including institution of neuroprotective strategies, is
tients where their injury involves a large transfer of energy or
essential for moderating the impact of this cause of morbidity
obvious injury to the neck. Stabilization of the cervical spine
and mortality.
(with manual in-line techniques during intubation) should be
Any reduction in conscious level will render the patient at risk
undertaken. Anaesthesia can be maintained safely using either
of airway obstruction and aspiration. Intubation and mechanical
inhalational or intravenous agents. Inhalational anaesthetics
ventilation may be indicated, both for airway protection and to
produce a dose-dependent increase in cerebral blood flow (CBF)
facilitate control of a patient’s physiological parameters. Opti-
that may lead to a rise in ICP, although this is less likely with a
mizing oxygenation (SaO2 $ 90%) and ventilation (PaCO2 35
minimum alveolar concentration of <1, but most inhalational
e40 mmHg) helps reduce intracerebral vasodilatation associated
agents also lower the cerebral metabolic rate (CMRO2). Nitrous
with hypoxemia and hypercarbia, counteracting any further rise
oxide should be avoided, because it increases CBF and CMRO2.
in intracranial pressure and consequent reduction in CPP (¼
All intravenous anaesthetics, apart from ketamine, decrease CBF
mean arterial pressure-intracranial pressure, MAP-ICP).10
and CMRO2, although evidence shows that ketamine does not
Although hyperventilation to lower PaCO2 may be used as a
cause a rise in ICP.12
temporizing measure for raised ICP, hypocarbia can cause a
Placement of an arterial line, for beat-to-beat monitoring of
vasoconstriction-associated decrease in cerebral oxygenation and
blood pressure and measurement of blood gas components, is
subsequent intracerebral ischaemia. Sedation will help to reduce
recommended. Unless a TBI patient requires either blood
cerebral metabolic requirements and seizure activity.
product resuscitation, or a dose of hyperosmolar therapy,
Neuroprotective management also includes maintenance of
isotonic solutions should be administered in favour of hypo-
an adequate blood pressure (systolic $100 mmHg) to maintain
tonic ones, because the latter more readily cross the blood brain
CPP.10 Brain Trauma Foundation (BTF) guidelines state that a
barrier and worsen cerebral oedema and raised ICP. Finally,
single pre-hospital episode of hypotension (defined as systolic
avoidance of hyperthermia, which increases cerebral metabolic
<90 mmHg) in a TBI patient is a statistically independent risk
rate, has been shown to be of benefit in TBI.
factor for a poor outcome. This becomes more challenging in the
Anaesthetic management of TBI patients is challenging,
context of multi-system trauma, when a balance must be struck
particularly in military austere and resource-limited environ-
with permissive hypotension, as part of damage control resus-
ments. However, careful monitoring and manipulation of phys-
citation for catastrophic haemorrhage.
iological parameters are crucial for preserving and protecting the
Other strategies to maintain CPP include taping, rather than
brain.
tying, the endotracheal tube and positioning the patient 30% head
up, to assist cerebral drainage and lower ICP. If there are clinical
Current concepts in the management of traumatic cardiac
signs of a raised ICP (e.g. a dilated pupil), administration of
arrest
intravenous hypertonic saline (3e5 ml/kg of 3%) can help to
reduce cerebral oedema by creating an osmotic gradient that Trauma may be a primary or secondary event in the situation of
mobilizes intracerebral fluid in to the systemic circulation cardiac arrest of a trauma patient. Differentiation is often
(thereby also augmenting blood pressure, without the subse- possible, based on the history of the patient and the circum-
quent potent diuresis and possible hypotension associated with stances of their arrest. It is crucial that a patient who has suffered
mannitol). Plasma sodium levels should be monitored. trauma as a result of a medical cardiac arrest is treated according
It is important to assess a TBI patient’s baseline neurological to the universal Advanced Life Support (ALS) algorithm. Initial
function, using the Alert, Voice, Pain, Unresponsive (AVPU) management of traumatic cardiac arrest (TCA) focuses on
scale or Glasgow Coma Scale (GCS), as well as their pupil size addressing potentially reversible causes simultaneously rather

ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 4 ! 2019 Published by Elsevier Ltd.

Please cite this article as: Coley E, Fadden S, Initial assessment and management of trauma encountered in the field, Anaesthesia and intensive
care medicine, https://doi.org/10.1016/j.mpaic.2019.09.005
 TRAUMA AND MILITARY ANAESTHESIA

EUROPEAN
RESUSCITATION Traumatic Cardiac Arrest
COUNCIL

Trauma patient

Cardiac arrest /
Periarrest situation?

Consider Universal ALS

non-traumatic cause LIKELY
algorithm

Hypoxia UNLIKELY
Tension pneumothorax
Simultaneously address reversible causes
Continue ALS
Start /
Tamponade
Hypovolaemia

1. Control catastrophic haemorrhage

2. Control airway and maximize oxygenation
Elapsed time
3. Bilateral chest decompression
< 10 min since
4. Relieve cardiac tamponade arrest?
5. Surgery for haemorrhage control
Expertise?
or proximal aortic compression?
Equipment?
6.
Environment?

Consider immediate
Consider termination Return of spontaneous
NO resuscitative
of CPR circulation?
thoracotomy

YES

Pre-hospital:
n Perform only life-saving interventions

n Immediate transport to appropriate hospital

In-hospital:
n Damage control resuscitation

www.erc.edu | info@erc.edu
Published October 2015 by European Resuscitation Council vzw, Emile Vanderveldelaan 35, 2845 Niel, Belgium
Copyright: © European Resuscitation Council vzw Product reference: Poster_SpecCircs_TraumaticCardiacArrest_Algorithm_ENG_20150930

Figure 1 European Resuscitation Council algorithm for the management of traumatic cardiac arrest 2015. (Reproduced with kind permission from:
Truhlar A, Deakin CD, Soar J et al. European Resuscitation Council Guidelines for Resuscitation 2015; 95:148e201.)

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Please cite this article as: Coley E, Fadden S, Initial assessment and management of trauma encountered in the field, Anaesthesia and intensive
care medicine, https://doi.org/10.1016/j.mpaic.2019.09.005
 TRAUMA AND MILITARY ANAESTHESIA

than on delivery of chest compressions, which are less likely to air that flows in during inspiration can become trapped in the
be successful under these circumstances (Figure 1). pleural space and cause a tension pneumothorax. This can lead
TCA is broadly categorized as blunt or penetrating but can be both to hypoxia and an increase in intrathoracic pressure that
managed according to the ‘HOT’ principles: Hypovolaemia, impedes venous return to the heart, which may result in cardiac
Oxygenation, Tension pneumothorax/cardiac Tamponade. arrest. In a patient in TCA, bilateral chest decompression is
achieved more reliably and effectively by open thoracostomies
Hypovolaemia than needle thoracocentesis. Siting thoracostomies is the first
Haemorrhage control e The majority of external or extremity step in performing a resuscitative thoracotomy (RT).15
bleeding can be controlled by compression, elevation and
splinting. Open wounds can be packed with haemostatic agents, Tamponade
such as CELOX-impregnated gauze. Suspected internal and non- Cardiac tamponade occurs when the pericardial sac is filled with
compressible haemorrhage can be controlled definitively by fluid under pressure, resulting in cardiac arrest secondary to
surgical intervention. The CRASH-2 trial shows that intravenous compromised cardiac function. Tamponade is more common
administration of the antifibrinolytic tranexamic acid is beneficial with penetrating trauma. TCA in penetrating trauma to the chest
when given within three hours of injury occurring.13 or epigastrium is one indication for immediate RT. Estimated
survival rates for RT are 15% for patients with penetrating chest
Damage control resuscitation (DCR) e This largely becomes wounds and 35% for those with penetrating cardiac wounds,
relevant if there is return of spontaneous circulation post-TCA, contrasting starkly with only 0e2% for patients with blunt chest
and comprises only necessary interventions to establish a sur- trauma. It is unclear whether blunt trauma patients should un-
vivable physiological status, before definitive injury repair is dergo RT in the pre-hospital environment. Ultrasonography may
undertaken. Damage control surgery (DCS), for control of hae- assist with diagnosis of the underlying cause of the TCA. It is
morrhage and treatment of contamination is undertaken difficult to determine the elapsed time threshold in a situation of
concurrently with DCR. DCR is synonymous with the concept of penetrating trauma, although the European Resuscitation Coun-
balanced resuscitation and consists of permissive hypotension cil Guidelines for Resuscitation 2015 advise that the time from
and haemostatic resuscitation. loss of vital signs to commencing a RT should not exceed ten
! Permissive hypotension (which does not apply during minutes.
TCA) involves maintaining a blood pressure that is low
enough to reduce haemorrhage but high enough to pre- Resuscitative thoracotomy15
serve end-organ perfusion. The overall purpose is to limit ! Position the patient in the supine position while other
significant increases in blood pressure (aiming for a sys- procedures (intubation, IV access) are undertaken.
tolic of 90 mmHg) until surgical control of bleeding has ! Apply skin antiseptic.
been achieved. Higher blood pressure thresholds are ! Perform bilateral thoracostomies in the fourth or fifth
advised for patients with traumatic brain injury, to main- intercostal space anterior to the mid-axillary line (using
tain cerebral perfusion pressure. A novel hybrid resusci- scalpel and Spencer Wells forceps).
tation strategy proposes limiting hypotensive resuscitation ! Join the thoracostomies with a deep scalpel skin incision.
to sixty minutes duration, to mitigate risks including poor ! Cut through the intercostal muscles and parietal pleura
oxygen delivery and significant metabolic acidosis.14 using medical shears, from the thoracostomies to either
! Haemostatic resuscitation (which applies throughout side of the sternum.
management of TCA) involves a balanced strategy advo- ! Perform a finger sweep under the sternum.
cating early use of blood products in ratios similar to whole ! Cut through the sternum, with medical shears or Gigli saw.
blood - red blood cells, plasma and platelets administered ! Open the ‘clamshell’, manually or using rib spreaders.
1:1:1. This aims to avoid complications associated with ! Identify the heart and ‘tent’ the pericardium with forceps
crystalloids, including dilution of red cell and coagulation before cutting a small hole with scissors, extending it
factor concentrations, worsening acidosis, exacerbation of vertically upwards and downwards.
hypothermia, oedema and immune system activation/ ! Evacuate any blood clots.
cellular injury. In a time-critical TCA situation, where ! If the heart makes no spontaneous movement, flicking it
hypovolaemia secondary to haemorrhage is a potentially may cause contractions to return. If not, perform internal
reversible cause of the arrest, early and aggressive fluid cardiac massage. Simultaneous compression of the aorta
resuscitation is required, even if only crystalloid is against the spinal column by an assistant may help to
available. maximize coronary and cerebral perfusion.
! Bleeding from myocardial wounds should be controlled
Oxygenation initially with a finger. Sutures may be required, placed to
To address hypoxia in TCA, airway management aims to estab- avoid occlusion of coronary arteries.
lish a definitive airway by means of intubation and mechanical ! IV volume should be given.
ventilation, thereby maximizing oxygenation. ! If return of spontaneous circulation (ROSC) is achieved
there may be significant internal mammary/intercostal
Tension pneumothorax vessel bleeding, which may need to be controlled with
Chest trauma can lead to disruption of the visceral pleura, pari- artery forceps.
etal pleura or tracheobronchial tree. If a one-way valve is formed, ! In the situation of ROSC the patient will require sedation.

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Please cite this article as: Coley E, Fadden S, Initial assessment and management of trauma encountered in the field, Anaesthesia and intensive
care medicine, https://doi.org/10.1016/j.mpaic.2019.09.005
 TRAUMA AND MILITARY ANAESTHESIA

have been sufficient to stem bleeding. NICE has recognized that

effective tourniquet application can prevent mortality, out-
weighing the potential adverse outcomes.
Military Clinical Guidelines for Operations (CGOs) advise
initial management of catastrophic haemorrhage. Where appro-
priate, a tourniquet should be placed early, 2e3 inches proximal
to the wound or limb amputation, on bare skin and tightly
enough to stop the bleeding. It is designed for self and ‘buddy’
application. Initially the main Velcro strap should be placed
around the limb tight enough that no more than two fingers can
fit under the strap. The tourniquet has a windlass rod system for
effective tightening. Once tight enough, the time band should be
fastened over the clip and time of application noted. If lower limb
bleeding is not controlled, a second tourniquet can be applied
Figure 2 Combat Application Tourniquet. (Reproduced with proximal to the first. It is important to check the tourniquet is
permission.) secure prior to patient transfer, and the wound should be
continuously reassessed for bleeding. Addition of other haemo-
static dressings may be required including Celox, which is useful
for junctional areas and has been shown to result in a statistically
significant improvement in survival.16 Celox contains chitosan,
which acts by ionic bonding, working independently of the
body’s clotting cascade. It should be packed tightly into a wound,
covered and compressed for approximately 5 minutes. It should
not be applied to open chest, abdominal or head wounds.
These are interim measures to stop bleeding, but it is impor-
tant to consider evacuation to an appropriate medical facility for
surgical management as early as possible.

Summary

Figure 3 Military emergency compression bandage. (Reproduced with This article provides a summary of the key management of a
permission.) number of military trauma scenarios, the principles of which can
be applied in the civilian setting. These include avoiding the triad
of hypothermia, acidosis and coagulopathy, which requires
Management of TCA is complex and time sensitive. There are careful resuscitation. In hospital, local major haemorrhage pro-
potentially life-saving interventions that can be made pre- tocols are activated to provide early hybrid resuscitation and
hospitally e which should be undertaken by highly trained cli- targeted blood product administration, directed by thromboe-
nicians using the right equipment, and should not delay defini- lastography where available. Cell salvage can be used, and rapid
tive care. infusion devices allow heated delivery of controlled volume
resuscitation. Along with temperature regulation, electrolytes
Combat application tourniquet (CAT) and haemorrhage should be monitored and replaced appropriately. Multidisci-
control compression dressing bandage plinary critical care management of major trauma patients is
paramount to optimizing their outcome. A
Ballistic trauma and battlefield deaths related to extremity injury
and major haemorrhage have been identified as the cause of
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care medicine, https://doi.org/10.1016/j.mpaic.2019.09.005