Learning objectives

1. To understand a simple system for examining the musculoskeletal system.

2. To learn the specific features to be sought in each area of the body.Musculoskeletal examination works on a simple system originally designed by Apley. It consists of four-letter words divided into threes.

The first stem is:

• look;
• feel;
• move.

The second stem branching off from each of these first two stems is:

• skin;
• soft (tissue);
• bone.

Finally, ‘move’ is divided into:

• active;
• passive;
• stability.

Look

You cannot look with your hands. Once you let your hands on to the patient, your ability to notice things with your eyes seems to be lost. While looking, it may be better to put your hands behind your back to remind you to look first, and to show the examiner what you are doing.

Make sure that you can see enough of the patient’s body. This means exposing at least one joint above and one below the area in question. It also means exposing the opposite side. It is said by some that the human body was made bilaterally symmetrical to help orthopaedic surgeons distinguish abnormal from normal. Do not spurn such ready-made help.

It is not always necessary to lay the patient down for an orthopaedic examination. It may be easier if the patient remains standing, provided that they are comfortable to do this. In this position it is easier to look at the patient’s back as well as their front. It is important to inspect all sides of the patient to make sure that no lesion is missed.

Skin

Look once at the skin for:

• bruising and wounds — evidence of recent injury;
• redness — signs of inflammation;
• scars — the archaeology of injury;
• sweating — loss of sweating may indicate nerve damage.

Soft tissues

Look a second time at the soft tissues. Now you are looking for:

• swelling — a cardinal sign of injury and inflammation;
• wasting — signs of disuse and nerve damage, the archae­ology of injury.

Bones

Look a third time at the bones (shape of the skeleton). Look for:

• deformity — unusual angles or joints held in unusual positions.

Summarise

You have now looked at three zones. Summarise these in your mind and make a record of what you have found.

Feel

Once again you will test in three zones: skin, soft tissue and bone.

Skin (temperature, sensation)

• Temperature — stroke the patient’s limbs with the back of your hand. It is more sensitive than the front. Use the patient’s other side for comparison. Warmth may indicate inflammation. A cold limb may indicate nerve or vascular damage.

• Sensation — if you ask the patient to shut their eyes and then test whether their feeling is normal, you are in danger of missing nerve damage. Patients do not always close their eyes when asked (especially if they are drunk). The question ‘Is that normal?’ is a closed question which invites the answer ‘Yes’. A better system is to leave the patient with their eyes open and then stroke first the normal limb then the other limb lightly. Ask if the touch on the two limbs feels the same. By comparing the two sides the patient should be able to detect any change in sensation, however slight.

Soft tissue (tenderness, lumps and circulation)

When you feel the soft tissues, you must be very careful to avoid hurting the patient. The best way to do this is to place your hands on the area under examination, then look up and watch the patient’s face as you palpate. This way you will be certain to spot immediately that you are causing discomfort or even pain. You will then be able to stop what you are doing immediately to prevent further suffering. If you fail to do this in an examination and then cause pain to a patient, the examiner will regard this as a serious transgression.

Feel for:

• tenderness — as you press with your fingers try to describe to yourself the actual anatomical structure that you are palpating: subcutaneous fat, bursae, muscle bodies, tendons, nerves, arteries and ligaments;
• lumps and effusions — each time you feel an abnormality under the skin you should be able to run through a checklist of features of a lump.
• distal circulation — feel for peripheral pulses and check capillary filling. When checking pulses, take the patient’s pulse elsewhere at the same time. This should ensure that it is the patient’s pulse you are feeling, not your own.

For capillary filling, simply press in on the tip of a digit and say under your breath ‘capillary filling’. If the blanching has not disappeared by then, there is diminished capillary filling. Before diagnosing local vascular damage, check whether the circulation is reduced generally (as it might be in shock).

Bone (bone outlines and joint margins)

Watch the patient’s face, feel the bone and joint margins gently for areas of tenderness, steps and lumps. Again, try to work out what anatomical structure your fingers are touching as you palpate.

Summary

Review your findings. Try to decide what structures are tender, what structures are swollen, wasted or displaced, and whether the circulation and sensation to the distal limb is normal. If not, where is the likely damage?

Move

Once again there are three phases of the examination, but this time they are active, passive and stability.

Active

The patient should move their own joints within the limits of pain. Use simple language to explain what you want them to do, and if necessary demonstrate the movement.

Passive

Don’t take the range of movement beyond the active range without watching the patient’s face.

Stability

There are two types of stability: dynamic and static. Dynamic stability is provided by muscle power; static stability by ligaments and intact joint surfaces.

Dynamic stability. Measure the force that the patient can develop by showing them the movement, then asking them to repeat it while you try to stop them. For each movement, try to work out which muscles are the drivers of that movement, which nerves supply them and the nerve root values.

Static stability. Static stability tests the integrity of the ligaments and the joint surface. The joint should be gently stressed in each direction controlled by a ligament, while watching the patient’s face to make sure that you don’t hurt the patient. You do not need to use any force. Indeed, the tests will not work if you do, as the patient’s muscles will go into spasm and hide the underlying static instability.

Mechanism of explosive blast injury

The explosive pressure that accompanies the bursting of bombs or shells ruptures their casing and imparts a high velocity to the resulting fragments. These fragments have the potential to cause even more devastating injury to the tissues than bullets. They are unstable in flight and may tear through tissue at high speed in a tumbling fashion. These statements are particularly true of old artillery shells and terrorist bombs where the casing fragments naturally into pieces of variable size. However, the trend in conventional war is towards carefully engineered weapons which carry preformed munitions, such as notched wire or ball bearings, or have their casing etched to allow predictable fragmentation patterns resulting in a multitude of small, relatively low-energy fragments. The aim is to incapacitate, not kill, by inflicting multiple low-energy transfer wounds to two or more body systems.

In addition, all explosives are accompanied by a complex blast wave. The two main components of this wave are a blast pressure wave (known as dynamic overpressure), with a positive and negative phase, and the mass movement of air (known as blast wind).

The positive pressure phase of the blast wave lasts for only a few milliseconds, but close to an explosion it may rise to over 7000 kN/m2. As the healthy tympanic membrane rup­tures at about 150 kN/m2, it is evident that the effects on the human body of such an explosion can be devastating, espe­cially in confined areas. Like sound waves, the blast pressure waves flow over and around an obstruction and affect anyone sheltering behind a wall or in a trench. The pressure affecting such a person is known as the incident pressure (defined as the pressure level at 900 to the direction of travel of the blast shock front). Also, any person standing in front of a wall or other vertical surface facing an explosion is subjected to the added effect of a reflected pressure.The negative effect of a pressure wave is of low amplitude, lasts longer than the positive wave and is of doubtful clinical significance.

A mass movement of air or dynamic pressure results from the rapidly expanding gases at the centre of the explosion which displaces air at supersonic (greater than the speed of sound in air) speed. This has been described by an eminent blast scientist as ‘fresh air moving very fast’. The mass movement of air results in what is colloquially known as blast wind and disrupts the environment, hurling debris and people. This phenomenon results in injury patterns ranging from traumatic amputation to total body disruption. The mass movement of air may disrupt buildings, causing entrapment and crush injuries.

Blast pressure waves travel at the speed of sound in the medium being traversed. In water, velocity and distance are greater and injuries tend to be more complex and severe. For example, blast pressure waves in air rarely affect the gastro­intestinal tract to any clinically significant extent in survivors; however, in water, the blast wave exerts a ‘water hammer’ effect with significant rates of gastrointestinal perforation.

When the body is impacted by a blast pressure wave, it couples into the body and sets up a series of stress waves which are capable of injury, particularly at air—fluid interfaces. Thus, injury to the ear, lungs, heart and, to a lesser extent, the gastrointestinal tract (see above) is notable. The exact mechanisms of injury at each specific tissue are still the subject of controversy but need not unduly worry readers as this topic is debated well by Cripps and Guy in Trauma and by Ryan et al. in Ballistic Trauma, as listed in the ‘Further reading’ section of this chapter.

General management of blast injuries

The structures injured by the primary blast wave, in order of prevalence, are the middle ear, the lungs and the bowel. How­ever, the most common urgent clinical problem in survivors is usually penetrating injury caused by blast-energised debris and fragments from the casing of the exploding device (see below). Many of those exposed will have blunt, blast and thermal injuries in addition to more obvious penetrating wounds (the clinical picture is usually referred to as combined injury). The deafness of the victims of blast, due to disruption of the tympanic membrane, makes communication with them difficult and may complicate early assessment and management. Here, the primary survey and resuscitation phases of a system such as ATLS are particularly apt. The management of penetrating wounds differs little from that of missile wounds referred to earlier. The soft-tissue wounds are usually heavily contaminat­ed with dirt, clothing and secondary missiles such as wood, masonry and other materials from the environment. Such contaminants may be driven deeply into adjacent tissue planes opened up by the force of the explosion. The propensity for wound infection in these cases is considerable and is often underestimated. Some cases are associated with multiple wounds of varying severity affecting a limb.

It may not always be practical to explore every wound at first surgery. The larger and deeper wounds should have priority of management due to the more serious consequences of infection. In many blast injuries one cannot be sure of complete wound excision and, therefore, it is imperative that all blast wounds should be left open at the end of the initial opera­tion and delayed primary closure performed 4—6 days later.

Regional management of blast injuries

Here one is particularly concerned with identifying specific injuries caused by the primary blast wave.

Auditory system

Blast damages the hearing in three ways. There may be rupture of the tympanic membrane, dislocation of the ossicles or widespread disruption of the inner ear. The latter is sometimes accompanied by permanent deafness. It should be remembered that the likelihood of ear damage depends on the angle between the incident blast wave and the external auditory meatus. Although deafness is a certain indicator of exposure to significant blast loading, its absence does not imply the absence of blast injury to other systems.

Respiratory system

Injury to the lung parenchyma is complex and the exact mechanisms are still the subject of debate. Undoubtedly, the impacting primary blast wave may cause a rapid inward movement of the chest wall and result in underlying pulmonary contusion, but this is not the principal mechanism in the severe and progressive acute lung injury picture seen in small numbers of survivors. In these casualties it is probable that the initial blast wave couples into the chest resulting in stress waves which spread out, reflect and reinforce at tissue interfaces. At air—fluid interfaces they may result in considerable disruption. This is particularly notable at the alveolar—capillary membrane and leads to capillary leakage resulting in a spreading haemorrhagic alveolar contamination.

An inflammatory cascade now ensues resulting in a post-blast respiratory insufficiency (PBRI), which is virtually indistinguishable from adult respiratory distress syndrome (ARDS) following generalised sepsis or fat embolism syndrome (FES), and posing a difficult clinical problem in criti­cal care units. PBRI varies from a mild and localised area of pulmonary contusion injury to a fulminating and rapidly fatal condition involving both lungs. This rapid and progressive condition is relatively rare, as casualties sufficiently close to suffer extreme blast loading to the chest wall are usually killed by multiple penetrating wounds or are dismembered by blast winds. In severe cases, respiratory insufficiency may be further precipitated by overtransfusion with electrolyte solutions. The clinical picture is typical — patients develop a cough with frothy blood-stained sputum, dyspnoea and a feeling of apprehension, bordering on a foreboding of impending doom — they are often right. A pulse oximeter will show a resistant low saturation, with values well below 90 per cent. Blood gas analysis confirms arterial hypoxia and a raised carbon dioxide partial pressure (PCO9.Chest radio-graphs in the initial stages may show localised contusion injury but, as the inflammatory cascade builds, radiographic evidence becomes generalised with bilateral fluffy infiltrates spreading out from the hilum of both lungs.

Specific clinical management of an established case remains controversial. There is still little hard evidence to guide clini­cians. However, most agree with the guidelines listed in below

Postblast respiratory insufficiency (PBRI) — clinical guidelines

• Work within the ABCDE system of the ATLS system

• Avoid overhydration while maintaining vital organ perfusion

• Administer high-flow oxygen (12 litres/minute) with mask and rebreathing bag

• Carry out arterial blood analysis to assess need for further measures

• Resort to mechanical ventilation early to ensure adequate oxygenation

• Use positive end-expiratory pressure (PEEP) carefully while avoiding excessive peak and plateau pressures

• Corticosteroids should be avoided

Gastrointestinal tract

Injury to gas-filled viscera is more common in underwater explosions than air blasts. Perforation of the stomach, small intestine and caecum is most common. The clinical presentation is one of increasing abdominal pain accompanied by signs of peritonism and often gas under the diaphragm. In the presence of clear physical signs urgent laparotomy is indicated. In cases where signs are few but the risks are high, ultrasonography, CT, diagnostic peritoneal lavage and laparoscopy should be considered. There is no single modality agreed by all. Serological assessment of gut-associated enzymes is still an experimental tool and no reliable serum marker of intestinal injury is available.

The eye

The eye should be examined in both the primary and sec­ondary surveys, yet injury is easily missed. Conjunctival haemorrhage following blast exposure may herald a more serious underlying problem of penetration of the globe by blast-energised debris or fragments. The pupil must be carefully examined and any abnormality, distortion of the iris or the presence of a hyphema, for example, should be inves­tigated by an ophthalmologist.

Other factors

Factors that increase the morbidity and mortality following bomb blast injuries are associated chemical and thermal burns, and the inhalation of toxic gases and smoke.

Introduction and epidemiology

Penetrating missile wounds, injuries from blast phenomena and burns are the typical features of modern conventional war. This chapter is concerned only with missile wounds and blast injury. Missile wounds are caused by bullets or by fragments from exploding shells, mines or bombs. Exposure to blast phenomena may result in unique and complex injury patterns, and these will be described.

There is a wealth of data on the cause and distribution of wounds in wars over the last 30 years. Care is needed in interpretation as the number of wounded varies greatly in each series. For example, Vietnam data cover over 17 000casualties. In contrast, Gulf war data are restricted to 63 casualties, Inclusion criteria are also very variable and many fail to record multiple injuries to different body systems in single casualties — the hallmark of modern war injury. While care is needed in interpreting the available data, some broad statements concerning war injury can be made. The most common wounding agent in surviving casualties is a fragment wound, not a bullet wound as many erroneously believe. Limb injuries predominate, pointing to the high lethality of hits to the trunk and head. The most startling revelation is the emerging incidence of multiple hits to mul­tiple body regions in survivors. This is a deliberate policy —the aim in modern war is to incapacitate, not kill. The reason is clear: large numbers of surviving casualties are a major financial and logistic burden on a nation engaged in total war.

In conclusion, the factors that govern the nature, severity and outcome of a war wound are many and include the weapon systems deployed, the environment in which the weapon systems are deployed, and the quality and timing of medical management. In short, there is no single entity that merits the description ‘the war wound’.

Wound ballistics and mechanisms of Injury

As a missile traverses the body it causes injury by transferring some or all of its available energy, and this is manifested by lacerating and crushing tissues in its path and, in some cases, injury remote from the missile path (see below). The amount of energy transferred may be expressed by the formula:

K.E – = 1/2M (v12-v22)

where KE is the available energy, M is the mass, and V1and V2 are the velocities at entry and at exit, respectively. In general, bullets fired from handguns and most modern fragment munitions are propelled at low velocity, have low available energy (100—5 00 J) and result in low-energy transfer wounds. Missiles with high available energy (2000—3000 J) include high-velocity assault rifle bullets (> 900 m/second) and some large fragments, and have potential to cause high-energy transfer wounds. Some modern high-performance handguns are now capable of firing high-velocity bullets with high available energy.

By convention, missile wounds are now described in terms of energy transfer, not velocity as was the custom, recognising that velocity is merely one factor determining energy available and its transfer to tissues. Low-energy transferwounds are characterised by injury confined to the wound track. High-energy transfer wounds also cause local laceration and crush injury but have, in addition, the potential to cause injury remote from the wound track associated with a phenomenon known as temporary cavitation.

The extent of cavitation depends upon the density and elasticity of the target organ or structure, and in certain circumstances is associated with injury many centimetres away from the missile wound track.

Cavitation within solid organs such as the liver, spleen and kidney results in shattering with high morbidity and mortality. The extent of injury to bowel is variable. In general, the small bowel fares better than the colon, particularly if the latter is loaded with faeces. A similar event in an elastic tissue  such as the lung may result in quite modest injury. In the limb the position is more complex and controversial. While voluntary muscle may merely stretch if injured in isolation, bone fares badly. As a rule, bone involvement results in severe injury due to high-energy transfer with disruption of the missile and involved bone, with generation of secondary missiles. Extensive devitalisation of muscle is a typical finding. Devitalised muscle in the depths of a missile wound provides the perfect culture medium for the growth of pathogenic bacteria, a fact recognised by military surgeons for centuries. Nerves and blood vessels respond unpredictably with injury, ranging from minimal bruising to complete disruption.

Within the closed skull there is, in addition, a rapid, high-pressure shock wave causing widespread disruption and injury at a distance. Thus, vital centres at the base of the brain may be injured by a wound of the cranium.

Management of missile Injuries

Missile wounds of soft tissue

Management of the soft tissue wound is a formal procedure consisting of clearly defined stages. This is the part of early management most frequently neglected by surgeons with limited or no experience of war surgery. The entrance and exit wounds do not indicate the considerable damage that may have occurred to deeper structures.

This can only be detected by full exploration. In limb wounds, exploration is followed by thorough wound exci­sion, after which, with very few exceptions, the wound should be left open. Delayed primary closure should follow within 4—7 days after injury. Having followed the Advanced Trauma Life Support (ATLS®) guidelines, the patient will have been completely undressed prior to surgery, but it is wise to retain any pressure dressings over a wound until the operation is due to begin. The operation should consist of the following stages.

1. After photographing the wound and cleaning it with au antiseptic, generous longitudinal incisions are made through the skin to allow visualisation and access to the deeper structures and to facilitate subsequent extension of the exposure, should this be required. A minimal amount of skin edge (i.e. only that which has been contaminated) should be excised around the entrance and exit wounds. Skin is remarkably resistant to injury — scrubbing with a nail brush will remove most contaminants and indriven debris, allowing skin excision to be kept to a minimum.
2. The deep fascia is exposed over the length of the skin incisions, and must be incised in a longitudinal direction to allow full inspection of the area damaged by the wounding missile and to decompress the underlying mus­cle which will swell subsequently. This is the true meaning of the much misused term débridement.
3. Neurovascular bundles in the wound track must be iden­tified and examined, but nerves should not be dissected out at the initial exploration. Nerves considered to be injured and warranting later exploration may have their position marked with a nonabsorbable suture marker to ease subsequent identification. It is important to examine the patient for nerve injury before the operation if this is possible and to record in the operation notes the nature of the nerve injury. The majority of nerve injuries is neuropraxias which do recover.
4. ‘Débridement (unbridling or unleashing). The term was introduced by Baron Dominique Jean Larrey, 1766—1842, Surgeon to Napoleon’s Imperial Guard. He used it to describe the process of laying a wound open to facilitate removal of bullets, bits of loose cloth, detached pieces of bone and soft tissue. He and his contemporaries did not excise tissue in the modern sense and his procedure was much less extensive than the formal wound excision practised today.
5. Foreign matter should be removed from the wound. Pieces of clothing are especially sought, both in the missile track and in the tissue planes on either side. It is not necessary to remove every piece of metal seen on a radiograph. Multiple, very small metal fragments from modern munitions may, in any case, be very difficult to locate and remove.
6. Dead muscle that does not bleed or contract, is mushy in consistency or has an unhealthy colour must be excised. These criteria comprise is the ‘4 Cs’ for muscle excision

The 4 Cs’

• Colour

• Contractility

• Consistency

• Capillary bleeding

1. Tendon repair should not be performed at this initial procedure. Tattered ends should be trimmed.
2. Major artery and vein damage must be noted. Where possible, the ends should be trimmed and sutured. If any tension is likely to develop, a reversed vein graft may be inserted to bridge the gap and the repair covered by healthy muscle. The rest of the wound should be left open for delayed primary closure. Synthetic grafts must not be used. A plastic shunt inserted into an injured artery can be used to revitalise tissue distal to the site of injury prior to definitive repair. In combined arterial and venous injury, concomitant shunting of both vessels may be undertaken. Temporary shunting has a vital role where major vascular damage is associated with fractures of long bones. In this instance, blood flow is established via the shunt(s), and the fracture is reduced and immobilised using an external fixator, after which definitive vascular repair is undertaken.
3. Bone shattered by high-energy transfer will in many instances still have attachment to periosteum or muscle. Such fragments must not be discarded. Loss of bone may result in malunion (e.g. shortening) or nonunion. Contaminated bone may be cleaned by using that useful instrument of military surgery, the Volkmann’s spoon or curette.
4. Injured joints need thorough inspection and cleaning by copious irrigation with saline to remove organic matter. Any exposed articular cartilage should be covered by at least one layer of healthy tissue, preferably synovium, otherwise muscle or skin should be used.
5. At the end of the operation the wound should be irri­gated thoroughly with saline to remove any remaining debris. Haemostasis should be secured with the aid of hot packs and the wound left open without closure of either fascial layer or skin, even in the presence of expos­ed bone. A lightly fluffed gauze dressing should be placed over the wound to allow free drainage. Packing must be avoided.
6. Immobilisation in a well-padded splint allows the soft tissues to recover, a principle expounded by Hugh Owen Thomas at the turn of the century. Split plaster of Paris splints are ideal even in the absence of a fracture. Femoral shaft fractures should be immobilised in a traction splint.
7. Antibiotic cover is advised for all wounds; third-genera­tion cephalosporins or agents with an equivalent spectrum being ideal. In all abdominal, pelvic and perineal wounds, metranidazole is given in addition.

Delayed primary closure

All wounds treated by wound excision and left open should be inspected about 4—6 days after injury. Provided the wound looks healthy, delayed primary closure is indicated. This should be by interrupted suture, split skin graft or a combi­nation of both.

Traumatic amputations

Traumatic amputations should be surgically tidied, completed at the lowest level possible and the skin left open for delayed primary closure. If there is much skin loss or if a limb is very swollen, split skin grafting may be used to effect wound closure in order to avoid skin tension. If, at the time of delayed primary closure, dead muscle is found, which is not uncommon in traumatic amputation due to antipersonnel mines, the muscle is excised and the wound left open for a further period before closure.

Missile wounds of the abdomen

Every penetrating and perforating missile wound of the abdomen should be explored by laparotomy. Before surgery, a nasogastric tube should be passed into the stomach and a urinary catheter into the bladder. Bladder catheterisation must be preceded by a digital rectal examination. Timing of exploration will vary. In some cases, operation will be under­taken as part of resuscitation leaving little or no time for planning. In others, preoperative stabilisation is possible and time is available for investigation, including haematology, bio­chemistry and radiology. In all cases blood in realistic quantities must be available.

A full midline incision from xiphisternum to pubis is rec­ommended. It has the advantage of facilitating rapid access and extension laterally or into the chest where required. The commonest source of bleeding in survivors is from the small bowel mesentery, but major haemorrhage may come from the solid organs, such as liver or spleen, or from the major ves­sels. Haemorrhage must be controlled and careful examina­tion is then made of all the abdominal contents.

In all wounds of the stomach, the lesser sac must be opened to inspect the posterior gastric wall. Retroperitoneal haematoma in the region of the duodenum requires inspection of its posterior wall by Kocher’s method. Haematoma surrounding the retroperitoneal parts of the ascending and descending colon may also necessitate exploration, but nonexpanding retroperitoneal haematomas over the kidneys are best left undisturbed.

Small intestinal perforations are either excised and closed transversely, or the damaged section is resected if there are multiple holes in a short length  Mesenteric tears may also require bowel resection.

Colon and rectal wounds

For most injuries of the right side of the colon, primary repair or primary resection is satisfactory. Occasionally, where severe wounding with extensive contamination has occurred, a vented ileotransverse anastomosts is warranted. Rarely, the two ends are brought to the surface as proximal ileostomy and distal mucous fistula, respectively.

On the left side a one-stage procedure may be undertaken if favourable circumstances pertain, i.e. minimal peritoneal contamination, limited blood loss, and a time interval between injury and operation of less than 8 hours. However, if injury is associated with high-risk factors, the injured colon is resected and the proximal end brought out as a colostomy and the distal end as a mucous fistula. If the distal end cannot be brought to the surface, as in low sigmoid or rectal injuries, it may be closed off as in a Hartmann procedure. Subsequent restoration of bowel continuity will be required.

Extraperitoneal rectal injuries are repaired if feasible and defunctioned by establishing a sigmoid end colostomy.Gooddependent drainage is best achieved by a presacral, retro­rectal drain brought out between the tip of the coccyx and the anus. The control of haemorrhage in pelvic injuries can be difficult and may require ligature of the internal iliac artery.

Rectal in jury

Renal injury is best treated conservatively if this is possible. Fortunately, immediate nephrectomy is rarely indicated. A divided ureter may be brought to the surface or may be repaired over a ‘pigtail’ stent.

Bladder and urethral injuries

Bladder and urethral injuries are treated by suprapubic cystostomy with placement of a suprapubic drain after wound excision.

Liver injuries

In 50 per cent of cases of hepatic injury surviving to reach a surgical centre, bleeding has stopped and is not a problem at laparotomy, a reassuring statistic for the youthful surgeons usually faced with such cases. Where bleeding is still occur­ring, damage control techniques are particularly appropriate in a warfare setting. Manual compression and perihepatic packing are recommended, and may allow a patient to survive to reach a more sophisticated surgical facility in the rear of the fighting area, If these simple measures do not work, and pro­vided that the operator is experienced, finger fracture with exposure of bleeding points followed by individual ligation, or more formal resection procedures, will be needed. These are rare eventualities. In all cases, gen­erous drainage of the spaces surrounding the liver is important.

Damage to the spleen and pancreas

Damage to the spleen and tail of pancreas may require resec­tion, although in some cases splenorrhaphy may be feasible. Missile injury of the head of the pancreas is seldom seen in the operating room because injury to it and surrounding structures is usually fatal. In a very few cases it may be possible to apply a Roux loop of jejenum to create an internal fistula.

Peritoneal toilet

Using warm saline, it is important to assist the removal of all spilled bowel contents and blood clot.

Closure

The laparotomy wound is closed using the mass closure technique. The missile entrance and exit wounds should be excised as described earlier and left open initially with a view to delayed primary closure at 4—6 days.

Missile wounds of the chest

Penetrating missile wounds of the chest are common in war and are associated with a high mortality if simple life-saving measures are neglected. Iris important to secure an airtight seal of open wounds of the chest to prevent a potentially fatal open pneumothorax. This is immediately followed by tube thoracostomy. This should been done during the primary survey. Failure to do so will result in collapse of the lung on the affected side with altera­tion of the ventilation/perfusion ratio and, in addition, will progressively decrease the quantity and quality of air entering the affected lung. As dyspnoea increases due to anoxia, the mediastinum shifts on respiration and decreases venous return to the heart — the clinical picture in the later stages is identical to a tension pneumothorax.

All penetrating wounds of the chest require adequate vent­ing of the pleura by formal tube thoracostomy. This simple procedure will prevent the accumulation of blood or air under tension. The position of the tube should be confirmed by chest radiography. Once pulmonary function has been stabilised, missile entry and exit wounds are excised. During the excision of a large chest wall wound, the pleural cavity is often entered; this need not cause concern. The opportunity should be taken to remove any retained foreign material, arrest haemorrhage (usually from an intercostal or internal mammary vessel) and to oversew or staple holes in the adja­cent lung. On completion the pleural opening must be sealed either by direct pleural closure (often difficult) or by utilising overlying healthy soft tissue, and the wound(s) left open for subsequent delayed primary closure.

These simple measures will suffice for more than 80 per cent of chest wounds. The remainder will require formal thoracotomy, often urgently. The usual indications are listed below.

Indications for formal thoracotomy

• More than 1.5 litres initial blood loss

• Continuing loss of > 200 mI/hour

• Cardiac tamponade

• Other mediastinal injuries

• Persistent air leak

• Retained foreign bodies > 1.5 cm in diameter

Even in cases where thoracotomy is indicated, considerable delay can often be tolerated provided adequate resuscitation is initiated quickly. Thoracotomy for retained foreign bodies is often a late and planned procedure.

In thoracoabdominal injuries, the thoracic component is treated by tube thoracostomy and the abdominal component by laparotomy through a midline incision. Formal thoraco­abdominal incisions risk contamination of the chest cavity by faeces and should be avoided.

Missile wounds of the head

The penetrating high-energy transfer missile wound of the head is usually lethal. The management of penetrating low-

energy transfer and tangential wounds depends initially on measures described in the primary survey and resuscitation phases. These will ensure a protected airway, adequate ventilation, and maintenance of blood pressure and perfusion pressure to permit oxygenation of the brain. Good radiographs are mandatory to localise foreign bodies and bone fragments. Computerised tomography (CT) images are invaluable in planning surgical exploration. Wound excision should be carried out using gentle irrigation and suction to remove devitalised brain and bony fragments. Every effort, including the use of temporalis fascia or fascia lata, should be made to close overlying dura. The skin overlying the head and face is an exception to the delayed primary closure rule. Blood supply is excellent, allowing primary closure which also serves to control blood loss from the scalp.

Intermittent positive pressure ventilation (IPPV) assists in the reduction of intracranial pressure by reducing brain swelling. Intracranial pressure transducers inserted through burr holes may be employed to monitor intracranial pressure in the postoperative phase.

Shotgun injuries

Accidents from large-bore shotguns are common and often lethal when injury is sustained at close range. It is never possible to retrieve all the shot and, indeed, to do so would result in unacceptable damage to uninjured soft tissues. Wound excision should be carried out on the major wound, particularly looking for indniven wadding and plugs of cloth­ing. Laparotomy is essential if it is thought that any of the shot has traversed an abdominal viscus. The retention of lead shot in the body can result in a dangerously high lead oncentration, which should be monitored. After a time, this 2oncentration will fall as a result of encapsulation of the lead pellets by fibrous tissue.

Summary:   dos and don’ts of missile injuries

Do:

•incise skin generously;

•incise fascia widely;

• identify neurovascular bundles; excise all devitalised tissue;

•remove all indriven clothing;

• leave wound open at end of surgery;

•dress wounds with fluffed gauze;

•record all injuries in the notes.

Don’t:

•excise too much skin;

•practise keyhole surgery; repair tendons or nerves;

•remove attached pieces of bone; close the deep fascia;

•insert synthetic prostheses;

•pack the wound;

•close the skin.

Injury severity scoring systems

Statistical analysis of injury severity and the most effective means of managing injured patients is relatively recent and is slowly replacing anecdote and unfounded assumptions. An example is the GCS, to which reference has already been made. The most widely applied is the Revised Trauma Score (RTS). Data combined from vital signs and level of consciousness are mathematically combined into a single variable that correlates with outcome. There is a myriad of others. Readers are referred to Professor Yates’ paper in the publication ABC of Major Trauma.

Major trauma outcome study (MTOS)

First developed in the USA, MTOS is an ongoing audit of the effectiveness of injury management and is now in widespread use in the UK. Utilising the TRISS (combination of the RTS and Injury Severity Score weighted for age and premorbidity) method with additional input on prehospital events, initial management including time to resuscitative interventions and the grading of medical staff, MTOS is applied to patients with severe injury and to those who die or are transferred to specialist units.

Benefits of MTOS

• Measures injury severity

• Records management and outcome

• Provides a database for audit

• Allows comparison of performance

In both major civil disasters and war, patient numbers may for a time exceed the capacity of medical teams to render normal care. Under these circumstances, it is necessary to sort casualties on the basis of need so that available resources and personnel can render the ‘most for the most’, to quote an American military surgeon. This is ‘triage’ and it is outlined below. Triage assessments and categorisation should be dele­gated to a senior, experienced and trained doctor. Failure to perform correct triage will disrupt optimal management for those most at need and divert scarce resources, often to those who can wait. Triage is a dynamic process and needs to be repeated at each level of care from point of injury until arrival in hospital. In general, field triage is for evacuation to hospital. Once in hospital, triage is for access to resuscitation and to operating rooms. The concept is at the heart of major incident planning and is outlined below.

Triage

Triage (from the French ‘trier’) means to sift or to sort and refers to the allocation of injured patients into certain categories for action by emergency teams. A common scheme of assessment is presented below.

• Triage sieve — a quick survey is made to separate the dead and the walking from the injured.

• Triage sort — remaining casualties are now assessed and allocated to three or four groups according to local protocols:

—    category 1 — critical and cannot wait. Airway obstruction and catastrophic haemorrhage are examples;

—    category 2 — urgent. Serious injury but can wait a short time, 30 minutes in most systems;

—    category 3 — less serious injuries. Not endangered by delay;

—    category 4 — expectant. Severe multisystem injury. Survival not likely;

—    (optional) — heavy manpower demands.

The system outlined above is only one of many. Readers should familiarise themselves with local custom and policy. The ABCDE of ATLS is now used increasingly as a means of assessment for grading.

Also called hypotensive resuscitation, this concept is of increasing interest to trauma surgeons faced with intra-abdominal or intrathoracic haemorrhage. The important question is whether the systolic blood pressure needs to be returned to premorbid levels utilising fluid resuscitation. In nontrauma patients, vascular patients for example, controlled preoperative hypotension is well established in certain situations. Further, recent research in the USA seems to deprecate the use of rapid infusion systems (RIS), with evidence emerging that large volume fluid resuscitation to achieve normal systolic blood pressures is associated with increased mortality compared with injured patients resuscitated with small fluid volumes prior to surgery. An increasingly accepted view holds that moderate hypotension — systolic blood pressure of 85—90 mmHg — is sufficient to maintain vital organ perfusion and avoids a hypertensive overshoot with the risk of precipitating further haemorrhage. The concept is still new in the care of the injured and further trials on optimal fluids, levels of permissive hypotension and the effects of delay before surgery are needed before it can be safely assimilated. The most important message to retain is that the best treatment for ongoing haemorrhage is to turn off the tap and not to continue infusion of fluids, including blood products.

Damage control — staged or abbreviated laparotomy

The concept of staged operative procedures for the severely injured patient is not new. The earliest uses of the approach concerned perihepatic packing for extensive liver injury. While the commonest indication remains catastrophic intra­abdominal haemorrhage, the technique now has wider appli­cation. The technique should usually be considered as part of the primary survey and resuscitation phases in patients who fail to respond to nonoperative resuscitation methods. The technical aspects of the procedure are dictated by the pattern of injuries. The objectives are listed below.

Objectives of staged or abbreviated laparotomy

• Arrest haemorrhage

• Control or limit coagulopathy

• Limit cavity contamination

• Protect viscera and limit fluid/protein loss

Having achieved the objectives, the patient is returned to a critical care environment for continuing monitoring, resusci­tation and in-depth investigation prior to a second definitive procedure. Moore terms this ‘physiological restoration in a surgical intensive care unit’. Timing for the definitive proce­dure varies but is usually within 24 hours of the damage-control procedure.

Focused abdominal sonogram for trauma (FAST)

Portable, hand-held ultrasound is now being used by trauma surgeons in the USA in the evaluation of patients with blunt thoracoabdominal trauma, and is the preferred initial tech­nological assessment of the patient. It belongs early on in the secondary survey, although some centres advocate its use during the ‘C’ component of the primary survey to localise intra-abdominal haemorrhage and to rule out cardiac tamponade in overtly shocked patients where no haemorrhage source is evident. The technique is rapid, with only four areas being scanned at the initial investigation. One of the greatest challenges will be to train trauma surgeons in the use of the technology.

Reception in hospital

Planning and preparation

Accident departments dealing with the injured must have purpose-built and well-equipped resuscitation rooms. Medical staff should ideally be trained in a trauma system — ATLS provides an ideal framework within which to work and certification will soon be compulsory in the UK. Certification is already compulsory in North America. Nursing and other professional staff should also be trained within the system. Another advantage of a structured approach relates to equip­ment and layout. Working within a system removes debate concerning intravenous fluid type and amounts, techniques and investigations to be performed, and the summoning of appropriate specialists. Agreement in these areas is laid down in advance and allows medical teams to work within a com­mon language and sequence.

The trauma team

While a suitably trained doctor can successfully assess and resuscitate an injured patient while working to a system, it is obvious that a team approach is more efficient and is quicker. This is the vertical (alone) versus the horizontal (team) argument. Dr Peter Driscoll in Salford has shown clearly the benefits of a team in improving outcome. The team should initially comprise four doctors, five nurses and a radiographer. Roles should be paired and tasks allocated on a pre­agreed basis. To avoid chaos, there should be no more than six people physically attending to the patient at any one time. Others should stand back until called to perform specific tasks such as vascular access, radiographic assessment or assisting in log rolling. The team should have a leader responsible for co-ordination and at least one member should be a trained general surgeon. Injury is a surgical disease and surgical consultation is required throughout.

Controversy once surrounded the mobilisation of the trauma team, with accusations of inappropriate call-out resulting in time wasted from clinics and operating lists. This has now been resolved by widespread acceptance of traumateam call-out criteria. Agreed factors indicating high risk of 7multiple injuries and justifying trauma team mobilisation are (after Champion):

• penetrating injury to the chest, abdomen, head, neck or groin;

• two or more proximal long bone fractures;

• flail chest and pulmonary contusion;

• evidence of high-energy impact:

—  falls of 2 m (6 feet) or more;

—    changes in velocity in an road traffic accident of 32 km/hour (20 miles/hour) or more estimated from outward deformity of car;

—    rearward displacement of front axle;

—    sideward intrusion of 35 cm or more on the patient’s side of the car;

—    ejection of the patient;

—    rollover;

—  death of another person in the same car;

—    pedestrian hit at more than 32 km/hour.

Initial assessment and resuscitation

The objectives in this phase are to seek and manage immediately life-threatening conditions. In ATLS language this is the ‘primary survey and resuscitation’, following an ABCDE sequence in every circumstance. The description that follows holds good for vertical (alone) or horizontal (team) management. The only radiographs permitted during this phase are:

• cross-table lateral cervical spine;

• antero-posterior supine chest X-ray;

• antero-posterior plain pelvic film.

A— Airway management and cervical spine control

Injury to the cervical spine is assumed in the presence of injury above the clavicle, loss or alteration of conscious level, involvement in high-speed collisions or where there is a his­tory of neck pain. Airway assessment and management is performed with the cervical spine immobilised in the neutral position by manual in-line immobilisation or by a well-fitting neck brace, sandbags and forehead tape. Many injured patients arrive in the accident department with neck protection already in situ. In a conscious patient, speaking in a normal voice, the airway is patent and the brain is being adequately perfused. If the patient does not reply to a simple question, the airway is opened and dealt with as described for prehospital personnel. If there is any doubt concerning the integrity of the airway, skilled anaesthetic help should be summoned if not already present as part of an attending trauma team. All injured patients require supplemental oxygen at 15 litres/minute via a mask with a rebreathing bag.

B— Breathing and ventilation

The neck and chest are exposed. Examination involves inspec­tion, palpation, percussion and auscultation. The examination starts in the neck with inspection for wounds, condition of neck veins, wounds and evidence of tracheal injury. The respiratory rate is counted and recorded, with the time noted. Chest symmetry and respiratory effort are assessed. Wounds and bruising are noted. Palpation, particularly to include the sides and back (without spinal movement), is performed gently followed by percussion and auscultation. A dull percus­sion note and absent breath sounds over a hemithorax in the presence of shock are indicative of massive haemothorax. The objective is to hunt out and treat the six life threatening thoracic conditions listed below

Immediately life-threatening thoracic conditions

• Airway obstruction (dealt with under ‘A)

• Tension pneumothorax

• Massive pneumothorax (> 1500 ml blood in a hemithorax)

• Open pneumothorax (sucking wound’)

• Flail segment with pulmonary contusion

• Cardiac tamponade (almost always penetrating injury)

Tension pneumothorax requires immediate needle thoracocentesis in the second intercostal space in the midclavicular line on the affected side, followed by tube thoracostomy through the fifth intercostal space just anterior to the midaxillary line. Massive haemothorax is a combined breath­ing (B) and circulation (C) problem with death likely from hypovolaemic shock and impaired ventilation. Management is therefore by vigorous support of the circulation followed by tube thoracostomy. Open pneumothorax is managed by sealing the wound with a dressing secured on three sides followed by tube thoracostomy. Following insertion of the tube, the dressing is sealed on the fourth side. Flail segment with underlying contusion (always present) requires consul­tation with anaesthetic colleagues as endotracheal intubation and mechanical ventilation may be required to maintain adequate arterial oxygen saturation. Diagnosis of cardiac tamponade requires a high index of suspicion, particularly if a penetrating wound is noted medial to the nipples anteriorly or medial to the scapulae posteriorly. Needle pericardiocentesis may be life-saving in the short term; thoracotomy and repair are required for definitive management.

C— Circulation and haemorrhage control

This begins with assessment for signs of shock. Tachycardia in a cold patient indicates shock. Equally, shock associated with injury is hypovolaemic until ruled out. Causes of shock are listed below.

Causes of shock following injury

•     Hypovolaemic — haemorrhagic (most common)

•   Cardiogenic or pump failure (cardiac tamponade, tension pneumo­thorax or myocardial contusion)

•      Neurogenic (often combined with hypovolaemic shock and masked)

• Septic (a late event > 24 hours and associated with missed faecal spillage)

An early attempt should be made to assess the degree of blood loss. Blood loss may be external and obvious, or internal and covert, or combinations of both. External bleeding sites are dealt with by direct pressure at this stage. A hunt must be undertaken for signs of covert bleeding. Bleeding in the chest will have been noted already. The abdomen and pelvis must be rapidly assessed for signs of injury. A good aidemémoire is ‘blood on the floor and four more’:

•  blood on floor or enviornment , including clothing.

• blood inthe chest (dull percussion note);

• abdomen (wounds, abrasions, tenderness but may be silent);

• pelvis (usually associated with obvious pelvic disruption);

• limbs (should be obvious).

The presence of shock demands the presence of a surgeon, appropriate to the region injured if this is obvious. Whereas intravenous fluid administration has a vital role, the emphasis must be on stopping the bleeding by surgical means. Vascular access for resuscitation is by cannulation of peripheral veins

— if this fails, venous cut-down at the ankle or elbow is recommended. Once a cannula is in position, 20 ml of blood should be withdrawn for group, type or full cross-match depending on the degree of urgency. Central access will be required later for monitoring but is not a good route for initial resuscitation owing to slow flow rates, technical difficulty and uncertainty concerning position of the catheter

tip. There is revival of interest in interosseous access for adults. It is too early to comment on its utility for general use. Its place is well established for children under the age of 6 years and should be resorted to without hesitation if peripheral access fails on two attempts. Special paediatric interosseous needles are available commercially.

In adults, 1—2 litres of warmed Hartmann’s (Ringer’s) solution is recommended as an initial fluid challenge. The initial volume in children is calculated according to weight and is by convention 20 mI/kg body weight. This bolus may be repeated once.

The patient should now be reassessed. The three responses that may be seen are given below.

Responses to initial fluid challenge

•      Immediate and sustained return to normal vital signs

• Transient response with later deterioration

• No improvement

Immediate responders are likely to have less than 20 per cent blood loss and bleeding will have ceased spontaneously or by direct pressure — an open fracture of tibia, for example. Transient responders may have intra-abdominal or thoracic bleeding, and surgical intervention will be required. Non-responders are bleeding actively, usually in a body cavity, or shock is nonhaemorrhagic in nature. Hypovolaemic patients have lost over 40 per cent of their blood volume, demanding immediate surgical intervention. Continuing intravenous fluid administration may actually be detrimental.

D— Dysfunction of the central nervous system

The AVPU and pupillary assessment carried out by pre­hospital personnel is repeated. In addition, a rapid assessment of motor and sensory function is performed looking only for gross and obvious signs. A more detailed assessment will be carried out during the secondary survey (see later).

E— Exposure and environment

Any remaining clothing should now be removed. The environment must be considered. If too cold, hypothermia will ensue. Blankets or air heaters should be used if available.

Critical decisions

The response of the injured patient to the primary survey and resuscitation phase will influence decision making. A patient in whom no life-threatening condition was found, or one whose condition responded well and in a sustained way, is now fit for a full secondary assessment which may be carried out in the resuscitation room or in a ward area following admission. Some patients will have failed to respond and require immediate removal to the operating theatre. Exam­ples include disruptive pelvic injury, major liver laceration or injuries to multiple body systems requiring immediate con­trol of blood loss — these are relatively rare. Initial surgery in this instance is part of the primary survey and a secondary survey, although deferred, must not be forgotten. Good note-keeping and records are vital. A significant number of patients will respond transiently and is best taken to a critical care environment where more advanced resuscitation techniques and assessments are possible. Such patients will require surgery but it is usually possible to investigate and plan in advance. Examples include splenic laceration, bowel injury, diaphragmatic disruption, or multiple fractures and soft-tissue wounds. In summary, the patient may be taken to the ward, critical care unit or to theatre.

Secondary survey

This phase comprises a head-to-toe examination of the undressed and stable patient. It is lengthy and includes a detailed history if this is feasible. The examination may be conducted in any order. The description here starts with the head and works distally. At this time check that vital signs monitoring devices are in situ. These should include a pulse oximeter and an oesophageal or a rectal thermometer. During this phase detailed radiographic procedures including computerised tomography (CT) and dye studies may be performed. Patients should be stable and can therefore travel safely for CT, ultrasound or even magnetic resonance imaging (MRI) investigations if these are indicated.

Head and Glasgow Coma Scale (GCS)

A thorough check is undertaken for signs of external injury such as bruising, laceration or bony deformity. Depressed skull fractures may or may not he palpable.

At this stage, the patient’s conscious level is determined by applying the GCS, which measures eye opening, best verbal response and best motor response. The use of this coding system is detailed fully in Chapter 35 on ‘Cranium and head injury’. Neurological deterioration may indicate a haemorrhagic space-occupying lesion or rising intracranial pressure, or it may be due to hypoxia and hypoperfusion. Hypercarbia and hypoxia are the commonest causes of the preventable ‘second injury’ in head-injured patients. Hypotension in a head-injured adult should lead to a further search for evidence of blood loss elsewhere.

The nostrils and external auditory meatus are examined for rhinorrhoea or otorrhoea. Cerebrospinal fluid from these orifices mixed with blood produces a double ring if dropped on a hospital sheet or pillowcase.

Face

Maxillofacial injuries are discussed in Chapter 38. In summary, the eyes are checked for foreign bodies, perforation, subconjunctival haemorrhage, visual acuity, and pupillary and corneal reflexes. The mandible is checked for fracture and stability. Maxillary stability is also assessed — fractures of the middle third of the face may be displaced with risk to the airway, either immediately or late as a result of expanding haematoma. The mouth is checked again for broken teeth, loose dentures and foreign bodies. Check also for retropharnygeal haematoma. This may be associated with previously undetected cervical spine injury.

Neck

Look for subcutaneous emphysema. Palpate (gently) the cervical spine. A lateral radiograph showing all seven cervical vertebrae and the upper border of the first thoracic is essential in all multisystem injury patients. Particular care should be taken not to miss lesions at Cl, C2 and C7 levels

— fractures and dislocations at these levels are notoriously unstable. Downward traction on the arms while the film is being taken will enhance the demonstration of the lower cervical and Ti vertebrae. In some cases a ‘swimmer~ s view may be necessary — see also Chapter 33 on the spine.

Thorax

Start by repeating the steps on thoracic assessment performed in the primary survey. The search is now for potentially life-threatening and less serious injuries. These are listed below. Remember, penetrating and blunt injury below the nipples (male patient) raises the likelihood of injury to intra-abdomi­nal structures, in particular the liver, spleen, stomach and transverse colon. Simple haemothorax and pneumothorax may be picked up on an anteroposterior (AP) supine chest radiograph. Tube thoracostomy will suffice in most instances. Check also for the integrity of diaphragm, particularly on the left.

Secondary survey — potentially life-threatening injuries

•  Pulmonary contusion

•  Myocardial contusion

• Aortic tear

•  Diaphragmatic tear

•   Oesophageal tear

•  Tracheobronchial tear

Abdomen

The secondary survey is the phase of ‘fingers and tubes’ in every orifice. This particularly applies to the abdomen. Nasogastric and urinary catheters are inserted for diagnostic and assessment purposes. The abdomen is now fully examined in the usual way. A rectal examination and inspection of the per­ineum is mandatory. At this time please read the relevant sec­tions on specific injuries in Chapters 50—61 inclusive. Wounds should be covered with sterile dressings or towels. Eviscerated bowel should be covered in warm wet packs and must not be returned to the peritoneum at this stage. Assessment of the abdomen in cases of penetrating trauma is relatively easy. In most instances the abdomen will need to he explored. In some large centres, protocols may permit local exploration of stab wounds in stable patients. Difficulty arises in cases of blunt injury, all the more when multiple injuries are present or where the conscious level is altered. Diagnostic peritoneal lavage, ultrasound examination or, in some specialist centres, laparoscopy may be required to detect covert intra-abdominal injury. The retroperitoneum is notoriously silent. All of the foregoing remarks refer to stable patients. Any deterioration should lead to consideration of rapid surgical exploration.

Pelvis

The pelvis is gently compressed and distracted manually to check for pain enhancement and pelvic stability. If not already to hand, an AP radiograph of the pelvic ring should be obtained. Blood at the urinary meatus may indicate urethral injury. If injury is suspected, get expert help. If not available, do not catheterise; instead, place a suprapubic catheter.

Spinal in juries

Tests are made for peripheral sensory and motor defects. In spinal injuries with unstable fractures, further neurological damage can be caused by moving the patient inappropriately. Full examination will require the patient to be log rolled when sufficient personnel are present. At least five people are needed. The team leader should control the neck and co­ordinate. Three others are needed to effect rolling the torso and limbs, and a doctor to examine the back and perineum. A rectal examination is performed if not done before. In large urban centres, severely injured patients may he transported to hospital on a long spine board. Removal from the board on to a hospital trolley requires the same care as for a log roll.

Extremities

The limbs should be fully assessed for evidence of injury. This should include a complete neurovascular examination. Appropriate radiographs may be obtained at this stage.

Drug administration

As part of the early management of the injured patient, con­sideration should be given to administration of analgesics. Opiates are best, given in small intravenous increments. Anti­biotics and tetanus prophylaxis may also be appropriate.

Definitive care plan

A position should now have been reached where a daily management and definitive plan is initiated. Patients with multiple injuries may require the attention of a number of specialists. A decision on ‘ownership’ must be made but with arrangements for all involved to have access. The patient should not ‘fall between two stools’, without anyone in overall charge. The most appropriate person to take primary responsibility in such cases is usually the general or orthopaedic surgeon.

The aim should be for rapid and smooth transfer of patients from the scene of the accident to a hospital that is well equipped and adequately staffed, with trained personnel to deal quickly and efficiently with all of the injuries encountered.

A ‘scoop and run’ policy is best where transfer time to hospital is short. A ‘stay and play’ policy may be required in the face of entrapment but prehospital personnel must be properly trained and equipped (to PHTLS standards, for example). In all cases, attention is first paid to securing an adequate airway. Gloves are worn and a two-finger ‘sweep’ is used to clear solid material from the mouth and pharynx combined with good suction under direct vision to remove fluid and debris. Airway patency is then maintained by chin lift or jaw thrust maneuvers, lifting the mandible forwards and, if appropriate, inserting an airway device (oropharyngeal/nasopharyngeal or endotracheal according to clinical

judgement and expertise available). If unable to open the airway by the above, a surgical cricothyroidotomy may be performed in patients over the age of 12 years by inserting a 6-mm paediatric cuffed tracheostomy tube through the cricothyroid membrane. Under the age of 12 years the cricoid membrane is very narrow and the cricoid cartilage is the only complete ring preventing airway collapse. Under these circumstances, a needle crico­thyroidotomy may buy some time (20 minutes) provided that a means of jet-insufflating oxygen through the needle is available. Proprietary mini-tracheostomy sets should not to be used. These have a very narrow internal diameter and do not allow spontaneous ventilation. They are indicated only in critical care environments for bronchial toilet. Finally, access to the trachea should not be attempted under these conditions — tracheostomy is time-consuming and fraught with danger.

Meanwhile, attention is paid to protecting the cervical spine by the use of a well-fitting semirigid neck brace, sandbags and forehead strapping. Modern spine boards incorporate neck restraint pads and straps, and may be used in lieu of sandbags and forehead strapping.

Other measures include ensuring adequate ventilation and oxygenation, covering and sealing open ‘sucking’ chest wounds, controlling external bleeding by direct pressure and monitoring the neurological status. The ‘AVPU’ method is recommended in the prehospital setting.

Prehospital mini-neurological examination

• A-Alert

• V — Responds to Voice

•  P — Responds to Pain

•  U — Unresponsive

• Pupils — Size and reaction

If there is any obvious long bone fracture of an extremity with gross deformity, the limb should be gently drawn into alignment and a traction splint applied.

Controversy exists regarding the prehospital role in resus­citation by intravenous fluid infusion. Vascular access in a cold, shocked injury victim is often difficult and time-con­suming, and there is emerging evidence that a degree of hypotension (systolic blood pressure 80—85 mmHg) may be safely tolerated (see later). If circumstances dictate that trans­fer time will be prolonged, or when entrapment and diffi­culty in extrication is encountered, then more sophisticated and advanced life-support measures may be instituted with the caveat made at the beginning of this section.

Following the death of his wife and serious injury to his three children in an air crash in the l970s, an American orthopaedic surgeon, Dr James Styner, introduced a structured trauma management training programme which was soon adopted by the American College of Surgeons and developed into the ATLS educational package now in widespread use in the UK and in 23 other countries. To date, over 200 000 doctors have been trained and the approach is now regarded as the gold standard in early trauma initial assessment and resuscitation.

The philosophy

ATLS management is based on a ‘treat lethal injury first, then reassess and treat again’ strategy. The steps in management are given below.

ATLS component steps

• Primary survey — identify what is killing the patient

• Resuscitation — treat what is killing the patient

•Secondary survey — proceed to identify all other injuries

• Definitive care — develop a definitive management plan

NB. Primary survey and resuscitation must be concurrent.

The philosophy is based on the urgency and crisis sur­rounding early management of a multiply injured patient whose life is in danger. Underpinning this approach is the quite recent realisation that death following injury is a function of time and occurs in a predictable and measurable way.

The ATLS approach focuses on the second or early death group where death is preventable. Within this so-called preventable group, death will follow if treatment is withheld or delayed and will do so in a predictable way. Early and effective treatment during the period when the second group of deaths occurs also reduces the number of deaths during the third phase of the trimodal distribution.

An obstructed airway in a victim with head injury will kill in 3—4 minutes, well before death might occur from the effects of injury to the brain. Equally, a life-threatening injury

within the thorax will kill before a life-threatening bleed within the abdomen. Finally, major haemorrhage in the limbs, chest or abdomen will kill before a life-threatening space-occupying lesion. While these are generalisations and exceptions do occur, they support the ‘primary survey and resuscitation’ management doctrine. The elements of this ABCDE approach are listed below and will be explained in more detail later.

Elements of the primary survey

• Airway with cervical spine control

• Breathing and ventilation

• Circulation with control of haemorrhage

• Dysfunction of the central nervous system

• Exposure in a controlled environment

Before turning to retrieval, hospital reception and care of the injured it is necessary to outline the fundamental changes in the management of the injured that have taken place in recent decades. The 1988 Royal College of Surgeons of England report on the management of the multiply injured highlighted that at least one in five, and possibly as many as one in three, trauma deaths in hospital were avoidable. They further concluded that death in such cases was due to medical mismanagement at every level and throughout all specialties. Later that year the Advanced Trauma Life Support Course (ATLS®) was introduced, followed by the Advanced Trauma Nursing Course (ATNC). More recently the Pre-Hospital

Trauma Life Support Course (PHTLS) was introduced for those working in the prehospital setting. These training courses have radically altered the way in which the injured patient is perceived and managed throughout the chain of care from point of injury onwards. In this chapter concern is focused on management by surgeons in hospital. Nevertheless, readers must be aware that recovery following injury is dependent upon a collaborative approach involving health professionals throughout the chain of care. A break in the chain at any point is likely to affect outcome adversely. ATLS and its derived variants such as ATNC and PHTLS provide a framework and a common language throughout the chain.