British journal of anaesthesia
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Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. ⋯ Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.
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Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. ⋯ The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.
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The introduction of trauma teams has improved patient outcome independently. The aim of establishing a trauma team is to ensure the early mobilization and involvement of more experienced medical staff and thereby to improve patient outcome. The team approach allows for distribution of the several tasks in assessment and resuscitation of the patient in a 'horizontal approach', which may lead to a reduction in time from injury to critical interventions and thus have a direct bearing on the patient's ultimate outcome. ⋯ Advanced Trauma Life Support training, simulation-based training, and video review have all improved patient outcome and trauma team performance. Developments in the radiology, such as the use of computed tomography scanning in the emergency room and the endovascular treatment of bleeding foci, have changed treatment algorithms in selected patients. These developments and new insights in shock management may have a future impact on patient management and trauma team composition.
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This review considers current trauma scoring systems and databases and their relevance to improving patient care. Single physiological measures such as systolic arterial pressure have limited ability to diagnose severe trauma by reflecting raised intracranial pressure, or significant haemorrhage. The Glasgow coma score has the greatest prognostic value in head-injured and other trauma patients. ⋯ Trauma registries are able to collate definitive injury descriptors and use survival prediction models to guide trauma system governance, through individual patient review and case-mix-adjusted benchmarking of hospital and network performance with robust outlier identification. Interrupted time series allow observation in the changes in care processes and outcomes at national level, which can feed back into clinical quality-based commissioning of healthcare. Registry data are also a valuable resource for trauma epidemiological and comparative effectiveness research studies.