Volume 113, Number 2, August 2014
British Journal of Anaesthesia 113 (2): 201–2 (2014) doi:10.1093/bja/aeu253
EDITORIAL I
S. J. Howell Leeds Institute of Biomedical and Clinical Sciences, St James’s University Hospital, Level 7, Clinical Sciences Building, Leeds LS9 7TF, UK E-mail: [email protected]
Care of the trauma patient has been a field of remarkable change over the past decade. Lessons from the battlefield have been transferred to trauma care and have changed the conceptual framework for the management of individual patients. At the same time, there has been a revolution in the organization of trauma services in many countries and an increase in understanding of the role of team working in delivering good outcomes for trauma patients. The current issue of the British Journal of Anaesthesia contains a series of reviews that give an overview of this revolution in care. The reviews expand on a number of presentations that were given at a 2 day meeting on trauma care organized by the Royal College of Anaesthetists in the spring of 2014. We visit aspects of the trauma patient’s journey from the moment of injury to care in the field, on to triage, and arrival in a trauma centre finally to resuscitation and surgical care. A major step forward for trauma care in England since 2010 has been the establishment of a network of major trauma centres. This reorganization is described in an editorial by McCullough and colleagues.1 In a further editorial, Oakley and colleagues2 examine the impact of these changes in the care of trauma patients on the specialtiy of anaesthesia. Lockey and colleagues3 review the prehospital care of the trauma patient and offer insights into the dilemmas of prehospital airway management. They discuss the balance to be struck between the merits of early definitive airway control in the field and the risks associated with advanced airway management undertaken in a difficult setting by colleagues who have only limited opportunities to practice the relevant skills. The accompanying research paper highlights the challenges of advanced airway management in the prehospital setting.4 Modern trauma systems apply a bypass system whereby seriously injured patients are transported to a major trauma
centre bypassing other hospitals that may be closer. Cameron and colleagues5 describe the set-up and function of the trauma system in the Australian state of Victoria, one of the prototypes for this bypass system. Bypass can be demonstrated to significantly reduce the time to appropriate care in many patients but requires appropriate triage at the scene of injury. Seriously injured patients may undergo major surgery to treat their injuries at the outset, that is, early definitive surgery. However, many trauma patients arrive in hospital with severe metabolic, coagulation, and physiological derangement. Damage control resuscitation and surgery are directed towards correcting these derangements. Resuscitation is undertaken with blood products to correct coagulopathy and such surgery as is undertaken is directed towards haemorrhage control and limiting contamination. Definitive surgery to treat injuries is deferred until the patient is metabolically and physiologically stable. This strategy is examined in two reviews, one on the initial resuscitation of the trauma patient by MuCullough and colleagues,6 and the other by Lamb and colleagues,7 taking in initial surgical management. Radiology plays an increasing role in the management of major trauma and this is rehearsed in a separate review by Chakraverty and colleagues. While taking the unstable trauma patient to the CT scanner is a daunting prospect, there is increasing evidence that the patients with the most to gain from CT scanning are those who are most haemodynamically unstable.8 Effective care of the seriously injured patient requires the skills of clinicians of several clinical specialities. Tasks are carried out in parallel rather than sequentially and the management plan may change on a minute-by-minute basis as the clinical state of the patient evolves. Delivery of complex multifaceted care in a rapidly changing situation rests in the willingness and ability of clinicians to subsume themselves
& The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at Memorial Univ. of Newfoundland on July 18, 2014
Advances in trauma care: a quiet revolution
BJA Declaration of interest
S.J.H. is an Editorial Board member and Finance Director of the British Journal of Anaesthesia and has received consultancy payments from Lucid Consulting on behalf of CSL Behring.
References 1 McCullough AL, Haycock J, Forward DP, Moran CG. Major trauma networks in England. Br J Anaesth 2014; 113: 202– 6 2 Oakley P, Dawes, Rhys Thomas GO. The consultant in trauma resuscitation and anaesthesia. Br J Anaesth 2014; 113: 207–10 3 Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia; the same but different. Br J Anaesth 2014; 113: 211–19 4 Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. Br J Anaesth 2014; 113: 220 – 5 5 Cameron PA, Gabbe BJ, Smith K, Mitra B. Triaging the right patient to the right place in the shortest time. Br J Anaesth 2014; 113: 226– 33 6 McCullough AL, Haycock JC, Forward DP, Moran CG. Early management of the severely injured major trauma patient. Br J Anaesth 2014; 113: 234– 41 7 Lamb CM, MacGoey P, Navarro AP, Brooks AJ. Damage control surgery in the era of damage control resuscitation. Br J Anaesth 2014; 113: 242– 9 8 Chakraverty S, Zealley I, Kessel D. Damage control radiology in the severely injured patient: what the anaesthetist needs to know. Br J Anaesth 2014; 113: 250– 7 9 Tiel Groenestege-Kreb D, van Maarseveen O, Leenen L. Trauma team. Br J Anaesth 2014; 113: 258–65 10 Kirkman E, Watts S. Haemodynamic changes in trauma. Br J Anaesth 2014; 113: 266–75 11 Sheffy N, Chemsian RV, Grabinsky A. Anaesthesia considerations in penetrating trauma. Br J Anaesth 2014; 113: 276– 85 12 Lecky F, Woodford M, Edwards A, Bouamra O, Coats T. Trauma scoring systems and databases. Br J Anaesth 2014; 113: 286–94
British Journal of Anaesthesia 113 (2): 202–6 (2014) doi:10.1093/bja/aeu204
EDITORIAL II
Major trauma networks in England A. L. McCullough*, J. C. Haycock, D. P. Forward and C. G. Moran Nottingham University Hospital, Nottingham, UK * E-mail: [email protected]
Major trauma is a common cause of mortality and morbidity and remains the most common cause of death in the population under the age of 40. Major trauma usually results in a lifechanging injury that can affect either a single system, such as an
202
isolated severe head injury, or involve multiple-system trauma. Major trauma can be defined as an injury severity score (ISS) (Table 1) of .15 but, as this scoring system uses a single endpoint (mortality), this definition excludes a large group of
Downloaded from http://bja.oxfordjournals.org/ at Memorial Univ. of Newfoundland on July 18, 2014
into an integrated team. The functioning of trauma teams and the need for clear and effective of clinical leadership is discussed by Tiel Groenestege-Kreb and colleagues.9 Our understanding of the pathophysiology of resuscitation and trauma is evolving and changing. The haemodynamic response to haemorrhage may be changed by the type of injury. For example, blast injury to the chest may exacerbate the hypotension seen in seriously injured patients. Drugs such as morphine may modify the haemodynamic response to trauma resuscitation, but the response varies between species and research is currently being undertaken to characterize the impact of opiates on the haemodynamic response to injury in man. Our evolving understanding in this arena is reviewed by Kirkman and Watts.10 The implications of management of penetrating injuries are reviewed by Sheffy and colleagues.11 Bullets can take an unpredictable course through the body and seemingly innocuous gunshot injuries can cause extensive damage. Gunshot wounds to the thorax, abdomen, and pelvis can be associated with injuries that precipitate sudden haemodynamic deterioration. Lecky and colleagues12 describe the different scoring systems and tools that are available for triage and identify the tension between over-triage whereby too many patients are referred for major trauma care and under-triage which may lead to seriously injured patients not receiving trauma centre care from the outset. An effective trauma system requires a degree of over-triage to avoid the latter hazard. They go on to examine the central role of large databases such as the Trauma and Audit Research Network (TARN) in audit, governance, and quality improvement in trauma services. Taken together, the narrative is an inspiring story of advances in medical care improving outcomes for individual patients. Much has been done to advance trauma care in the UK and around the world and both organizations and individuals are working to build on this with further improvements.
Editorial II
British Journal of Anaesthesia 113 (2): 201–2 (2014) doi:10.1093/bja/aeu253
EDITORIAL I
S. J. Howell Leeds Institute of Biomedical and Clinical Sciences, St James’s University Hospital, Level 7, Clinical Sciences Building, Leeds LS9 7TF, UK E-mail: [email protected]
Care of the trauma patient has been a field of remarkable change over the past decade. Lessons from the battlefield have been transferred to trauma care and have changed the conceptual framework for the management of individual patients. At the same time, there has been a revolution in the organization of trauma services in many countries and an increase in understanding of the role of team working in delivering good outcomes for trauma patients. The current issue of the British Journal of Anaesthesia contains a series of reviews that give an overview of this revolution in care. The reviews expand on a number of presentations that were given at a 2 day meeting on trauma care organized by the Royal College of Anaesthetists in the spring of 2014. We visit aspects of the trauma patient’s journey from the moment of injury to care in the field, on to triage, and arrival in a trauma centre finally to resuscitation and surgical care. A major step forward for trauma care in England since 2010 has been the establishment of a network of major trauma centres. This reorganization is described in an editorial by McCullough and colleagues.1 In a further editorial, Oakley and colleagues2 examine the impact of these changes in the care of trauma patients on the specialtiy of anaesthesia. Lockey and colleagues3 review the prehospital care of the trauma patient and offer insights into the dilemmas of prehospital airway management. They discuss the balance to be struck between the merits of early definitive airway control in the field and the risks associated with advanced airway management undertaken in a difficult setting by colleagues who have only limited opportunities to practice the relevant skills. The accompanying research paper highlights the challenges of advanced airway management in the prehospital setting.4 Modern trauma systems apply a bypass system whereby seriously injured patients are transported to a major trauma
centre bypassing other hospitals that may be closer. Cameron and colleagues5 describe the set-up and function of the trauma system in the Australian state of Victoria, one of the prototypes for this bypass system. Bypass can be demonstrated to significantly reduce the time to appropriate care in many patients but requires appropriate triage at the scene of injury. Seriously injured patients may undergo major surgery to treat their injuries at the outset, that is, early definitive surgery. However, many trauma patients arrive in hospital with severe metabolic, coagulation, and physiological derangement. Damage control resuscitation and surgery are directed towards correcting these derangements. Resuscitation is undertaken with blood products to correct coagulopathy and such surgery as is undertaken is directed towards haemorrhage control and limiting contamination. Definitive surgery to treat injuries is deferred until the patient is metabolically and physiologically stable. This strategy is examined in two reviews, one on the initial resuscitation of the trauma patient by MuCullough and colleagues,6 and the other by Lamb and colleagues,7 taking in initial surgical management. Radiology plays an increasing role in the management of major trauma and this is rehearsed in a separate review by Chakraverty and colleagues. While taking the unstable trauma patient to the CT scanner is a daunting prospect, there is increasing evidence that the patients with the most to gain from CT scanning are those who are most haemodynamically unstable.8 Effective care of the seriously injured patient requires the skills of clinicians of several clinical specialities. Tasks are carried out in parallel rather than sequentially and the management plan may change on a minute-by-minute basis as the clinical state of the patient evolves. Delivery of complex multifaceted care in a rapidly changing situation rests in the willingness and ability of clinicians to subsume themselves
& The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at Memorial Univ. of Newfoundland on July 18, 2014
Advances in trauma care: a quiet revolution
BJA Declaration of interest
S.J.H. is an Editorial Board member and Finance Director of the British Journal of Anaesthesia and has received consultancy payments from Lucid Consulting on behalf of CSL Behring.
References 1 McCullough AL, Haycock J, Forward DP, Moran CG. Major trauma networks in England. Br J Anaesth 2014; 113: 202– 6 2 Oakley P, Dawes, Rhys Thomas GO. The consultant in trauma resuscitation and anaesthesia. Br J Anaesth 2014; 113: 207–10 3 Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia; the same but different. Br J Anaesth 2014; 113: 211–19 4 Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. Br J Anaesth 2014; 113: 220 – 5 5 Cameron PA, Gabbe BJ, Smith K, Mitra B. Triaging the right patient to the right place in the shortest time. Br J Anaesth 2014; 113: 226– 33 6 McCullough AL, Haycock JC, Forward DP, Moran CG. Early management of the severely injured major trauma patient. Br J Anaesth 2014; 113: 234– 41 7 Lamb CM, MacGoey P, Navarro AP, Brooks AJ. Damage control surgery in the era of damage control resuscitation. Br J Anaesth 2014; 113: 242– 9 8 Chakraverty S, Zealley I, Kessel D. Damage control radiology in the severely injured patient: what the anaesthetist needs to know. Br J Anaesth 2014; 113: 250– 7 9 Tiel Groenestege-Kreb D, van Maarseveen O, Leenen L. Trauma team. Br J Anaesth 2014; 113: 258–65 10 Kirkman E, Watts S. Haemodynamic changes in trauma. Br J Anaesth 2014; 113: 266–75 11 Sheffy N, Chemsian RV, Grabinsky A. Anaesthesia considerations in penetrating trauma. Br J Anaesth 2014; 113: 276– 85 12 Lecky F, Woodford M, Edwards A, Bouamra O, Coats T. Trauma scoring systems and databases. Br J Anaesth 2014; 113: 286–94
British Journal of Anaesthesia 113 (2): 202–6 (2014) doi:10.1093/bja/aeu204
EDITORIAL II
Major trauma networks in England A. L. McCullough*, J. C. Haycock, D. P. Forward and C. G. Moran Nottingham University Hospital, Nottingham, UK * E-mail: [email protected]
Major trauma is a common cause of mortality and morbidity and remains the most common cause of death in the population under the age of 40. Major trauma usually results in a lifechanging injury that can affect either a single system, such as an
202
isolated severe head injury, or involve multiple-system trauma. Major trauma can be defined as an injury severity score (ISS) (Table 1) of .15 but, as this scoring system uses a single endpoint (mortality), this definition excludes a large group of
Downloaded from http://bja.oxfordjournals.org/ at Memorial Univ. of Newfoundland on July 18, 2014
into an integrated team. The functioning of trauma teams and the need for clear and effective of clinical leadership is discussed by Tiel Groenestege-Kreb and colleagues.9 Our understanding of the pathophysiology of resuscitation and trauma is evolving and changing. The haemodynamic response to haemorrhage may be changed by the type of injury. For example, blast injury to the chest may exacerbate the hypotension seen in seriously injured patients. Drugs such as morphine may modify the haemodynamic response to trauma resuscitation, but the response varies between species and research is currently being undertaken to characterize the impact of opiates on the haemodynamic response to injury in man. Our evolving understanding in this arena is reviewed by Kirkman and Watts.10 The implications of management of penetrating injuries are reviewed by Sheffy and colleagues.11 Bullets can take an unpredictable course through the body and seemingly innocuous gunshot injuries can cause extensive damage. Gunshot wounds to the thorax, abdomen, and pelvis can be associated with injuries that precipitate sudden haemodynamic deterioration. Lecky and colleagues12 describe the different scoring systems and tools that are available for triage and identify the tension between over-triage whereby too many patients are referred for major trauma care and under-triage which may lead to seriously injured patients not receiving trauma centre care from the outset. An effective trauma system requires a degree of over-triage to avoid the latter hazard. They go on to examine the central role of large databases such as the Trauma and Audit Research Network (TARN) in audit, governance, and quality improvement in trauma services. Taken together, the narrative is an inspiring story of advances in medical care improving outcomes for individual patients. Much has been done to advance trauma care in the UK and around the world and both organizations and individuals are working to build on this with further improvements.
Editorial II
