Management of patients with major trauma

The management of patients with major trauma has evolved through organizational and technical advances. A multi-disciplinary trauma team should be activated before the patient arrives in the resuscitation room. The team must include doctors with skills for advanced airway management, intravenous and intraosseous cannulation, thoracotomy and laparotomy. Initial fluid resuscitation need not aim to return the systolic pressure to the patient's original level, but excessive hypotension may compromise organ perfusion. Patients with head injury and hypotension have a particularly poor outcome, and normotension is the only aim in this group initially. Recent studies on the care of patients with head injury support the use of protocols to ensure target cerebral perfusion pressure (CPP). Thus, patients who are comatose, or those with abnormal CT brain scans and altered conscious level, should be transferred to units capable of measuring intracranial pressure (ICP). These units should also use techniques to control ICP, such as external ventricular drain, jugular venous oximetry and decompressive neurosurgery. Patients with intra-abdominal visceral injuries may benefit from the use of guided ultrasound (FAST) to reduce the need for CT scan. There is increasing experience of the non-operative management of visceral injuries in adults, mirroring this long-standing practice in children. The non-operative technique requires close monitoring in an augmented care setting, particularly in units that see few of these patients. Recent advice on pelvic fracture management advocates radiological control of haemorrhage, following initial non-operative pelvic stabilization.