British journal of anaesthesia
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Trauma and penetrating injury, mostly in the form of assault and self-inflicted gunshot and stab wounds, is a major contributor to mortality and morbidity in the modern world, specifically among younger populations. While the prevalence of this form of injury is drastically lower in the UK and Europe in comparison with the USA, it is still common enough to necessitate practising anaesthetists to have a good understanding and working knowledge of the principles in treating victims with penetrating injury. This review article aims to cover basic principles of attending to penetrating trauma victims starting at the pre-hospital level and continuing into the emergency department (ED) and the operating theatre. ⋯ We also suggest a work flow for treating life-threatening penetrating injury and review the major controversies in this field. Our perspective is based on the experience and procedures used at the University of Washington's Harborview Medical Center, the only level 1 trauma centre covering the states of Washington, Alaska, Montana, Idaho, and Wyoming in the USA. This region contains almost 11 000 000 persons over a surface area of more than 2 700 000 km(2).
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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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Letter Case Reports
Preoperative evaluation of Montgomery tube: a stitch in time saves nine.
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Trauma is the leading cause of death during the first four decades of life in the developed countries. Its haemodynamic response underpins the patient's initial ability to survive, and the response to treatment and subsequent morbidity and resolution. Trauma causes a number of insults including haemorrhage, tissue injury (nociception) and, predominantly, in military casualties, blast from explosions. ⋯ An alternative strategy ('hybrid resuscitation') whereby tissue perfusion is increased after the first hour of hypotensive resuscitation by adopting a revised normotensive target may ameliorate these problems. Finally, morphine also attenuates Phase 2 of the response to haemorrhage in some, but not all, species and this is associated with poor outcome. The impact on human patients is currently unknown and is the subject of a current physiological investigation.