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OCR for page 65
-
Trealment
The severity of an injury depends on the amount and
distribution of the energy absorbed by the body. A major
injury to the respiratory system, to the cardiovascular
system, to the brain (which controls both), or to the
upper spinal cord (which controls respiration) results in
early death. A patient with a less severe injury enters
the medical care system, but a cascade of events has been
set in motion by the primary damage; unless this can be
interrupted, death or disability can ensue. If the
patient survives, the intensity of this cascade and the
skill with which it is managed will play a major role in
determining the degree of functional recovery. Problems
lie in resuscitation and transportation of the injured
patient, In immediate care in an emergency department,
and in the speed with which diagnosis and surgical care
become available. Control of continuing hemorrhage from
any site, establishment of an adequate airway, and removal
of blood clots from the brain are the immediate surgical
tasks, and they require a wide range of advanced surgical
expertise.
PRE8OSPITAL CARE
Prehospital care of the injured has been improved over
the last few years. Rapid evacuation of the injured was
stressed during our recent military conflicts. The use
of helicopters in Vietnam saved many lives by getting
severely injured patients to definitive care in a minimum
of time.' In civilian life, the system is varied and
unstructured, but good ambulance standards have beep set
in some areas, and helicopter services are available in
65
OCR for page 66
66
others. 3 6 The civilian use of local military heli
copters has also improved the transport system.
The development of the teas ic emergency medical tech-
n ician and paramedic systems has provided professional
care at the scene. Well-trained paramedics are able to
attend to airways, treat shock with the administration of
fluids, and monitor a patient's condition.8 7 In addi-
tion, they can notify a receiving institution with an
estimate of that condition and an estimated time of
arrival.
A need for intensive study of what should be done at
the scene of an injury event under different geographic
circumstances remains. For example, patients in some
urban areas might benefit from a system of Scoop and
run,. in which the emphasis is on speedy transport to a
nearby injury center. In such a case, the need is for an
effective transportation system. In other urban areas, a
lack of municipal organization still constitutes a major
problem, and patients might be taken to inadequately
staffed and poorly equipped facilities. If an injury
occurs in a rural area miles from a major center, it
might be better for treatment to begin at the scene. If
so, major questions must be answered. For example,
should paramedics be trained to intubate a patient, start
intravenous f luids, and give medications? What is the
best method of getting a patient to a major center--by
air or ground transports' Between the extremes of
urban and rural, consideration should be given to a
system of movement to the nearest hospital, where
resuscitation can be initiated, the severity of the
injury assessed, and arrangements made for transfer to
center. We need to knaw whether and under what circus
stances patient care is improved by providing emergency
surgery at ~ local hospital and then transferring a
patient to a center immediately for continuing support.
Each of these possible approaches to treatment has
advocates, but little information is available to suppor t
any one approach over another.
Assessment based on an injury severity score needs to
be implemented at all levels of care, including prehos-
pital care. This allows a receiving unit to have
some idea of what is coming and to be prepared. It is of
particular value in a small hospital, where a physician
is not even called until a patient arrives; that can
impose a delay before definitive medical attention is
available. The use of a graded system of evaluation is
essential for measuring results. One example is the
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67
Glasgow Coma Scale for head injury, which is now inter-
nationally accepted. ~ ~ ~ 9
A reasonable immediate goal might be to document more
fully the extent of national failure in transportation,
in emergency room equipping and staffing, in provision of
diagnostic equipment (e.g., a computed tomographic scanner
is essential in head injury, and an ultrasonic scanner
and a computed tomographic scanner are necessary in torso
injury), and in immediate availability of diversified
surgical help. ~ The presence of differences in geo-
graphic distance, in type of in jury (e.g., automobile,
gunshot, or fire), in site of in jury (e.g., head or
chest), and in age and general health of the injured all
Comparisons
-
call for an extensive and versatile survey.
with the few centers where optimal treatment appears to
be available and with foreign centers where alternative
models are available (e.g., the West Germany helicopter
service and the southern Sweden community hospital system)
are essential. For our several population patterns, we
might require some combination of the above. Continued
review and updating of systems will be needed as we
strive toward the optimal system for delivery of care.
At the moment, neither the small community hospital nor
the hospital devoted exclusively to injury (as in
Birmingham, England) appears to be the perfect means for
providing adequate care in all instances. 2 ~ S One thing
is known: optimal care is not universally available, and
this lack results in otherwise avoidable mortality and
morbidity.
HOSPITAL CARE
Shock
One major result of injury is bleeding, either
internally or externally. There can also be major shifts
Of fluid in the body, which has three fluid compartments--
intravascular, interstitial, and intracellular . The
resulting reduction in vascular blood volume (shock)
leads to a reduction in cardiac output (blood pumped by
the heart) and affects most organs and their cells.
Another effect of the decrease in circulating blood is a
reduction in blood pressure. Thus, the entire system is
· ~ ~ ~ ~ 76
compromised by this phenomenon.7
As blood pressure decreases, baroreceptors (pressure-
sensitive areas) in the heart and great blood vessels
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68
detect the loss of blood volume and-in turn stimulate
various neuroendocrine responses. Neuroendocrine
receptors (see below) in turn trigger many responses that
are believed to compensate for, or protect against, the
decrease in blood pressure. 6 2
A reduction in circulating blood volume can be
assessed by measuring various functions, such as blood
pressure, central venous pressure, and urinary output.
The problem can be corrected in a crude way by adding to
blood volume with whole blood, blood substitutes, and
electrolyte solutions intravenously.2 B ~ ~ 9 ~ 74 But
there is a need for a better understanding of the response
and the factors that serve as mediators of the response
(such as kinins, prostaglandins, and myocardial depres-
sant factor). What stimulates these mediators? Should
we interfere with them? Are they all protective, or
might they at times be destructive7
Further information on the internal shifts of fluid is
also needed. Until these are fully elucidated, optimal
treatment will not be possible.
Neuroendocr ine Response
The brain and its closely associated neuroendocrine
system are the controllers of heart and lung function, of
water and electrolyte dynamics, of temperature regula-
tion, of hormone regulation, and of the compensatory and
reparative responses of the body to stress.
Injury tuba coos not involve the brain directly can
nevertheless lead to myriad changes in function of the
neuroendocr ine system.
The precise mechanisms by which
changed hormonal function leads to changed metabolism
have not been defined. Some metabolic changes lead to
increased availability of glucose to the wound and to
some critical tissues, such as the heart and brain, and
also support the restitution of lost blood volume. How-
ever, as injury becomes more severe, the compensatory
mechanisms tend to fail. The mechanisms underlying such
failure await def inition.
Some hormonal and metabolic responses to injury can be
detrimental--e.g., loss of protein, retention of salt and
water, and the loss of immune competence, which predis-
poses an injury victim to infection. Consequently, the
elucidation of the mechanisms of these responses is
important in providing opportunities to limit or prevent
them. Studies are needed to determine the degree to
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69
which therapy, such as the administration of fluids,
improves a patient's response. The best therapeutic
approach might bypass the neuroendocrine response and
consist of substitution therapy. When the brain is
injured, it loses the ability to control its own
metabolism and the metabolism of the body as a whole.
This loss of control leads eventually to a total collapse
of the respiratory and cardiovascular systems.
Infection
It was recognized years ago that most exposures of
most people to bacteria did not result in infection,
because of natural resistance. Eventually, this
resistance was demonstrated to be due to the immune
system of the body, but how this works and how to alter
it (if we should) are still under investigation. 3
In more recent years, it has been found that viral and
fungal agents play a role in in jury . Control and
treatment of fungal disease have been learned to some
extent, but there is almost no information on the effects
of viral agents in injury.
Sepsis is a major cause of death among injury patients
who survive beyond the first 6 or 12 hours after injury.
There is no way to predict which patients will become
septic. A morphologic change in the white blood cells
(part of the immune system) can often be identified
within 60 minutes; after injury, but whether and how it
should be altered are not known. An extensive inves-
tigation of what this response means and whether it is
helpful or harmful is needed.
CHARACTERISTICS OF INJURIES
THAT REQUIRE TREATMENT
Options for treatment are vast, because treatment can
involve every organ and its cellular components and every
type of injury. It seems prudent to classify injury into
several broad categories and discuss specific examples of
them, rather than dealing with each specific organ system.
Three broad categories can be considered: injuries in
which cellular changes alter function; injuries in which
deformation of a physical structure produces major prob-
lemfi; and injuries that lead to loss of an organ.
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70
Cellular Changes That Alter Function
Bruised, burned, or otherwise damaged tissue undergoes
a local reaction of which swelling, or the accumulation
of fluid, is a prominent part. In some regions of the
body, such as; the ankle, this reaction can be incidental .
In others, such as the intestine, it can seriously compli-
cate fluid and nutritional regulation. In the inexpansile
skull, brain swelling results in high intracranial pres-
sure and brain displacement within the skull, in failure
of blood to reach the brain, and finally in loss of
ability of the brain to regulate body function. Brain
swelling is commonly the major factor that determines
survival, death, or disability and the degree of dis-
ability--physical, intellectual, behavioral, and
epileptic .
We do not know what happens in the brain cells and in
their immediate surroundings to interrupt their function
and cause them to swell. This problem will be the central
theme of basic research in head injury during the next
few decades.
Lack of cerebral oxygen (anoxia ) or lack of available
glucose impairs cellular metabolism and function. Potas-
sium, sodium, calcium, and water concentrations change,
and a disadvantageous acidity develop';. Calcium-activated
proteases affect the basic structure of the brain. Blood
vessels become distended, and intracranial blood volume
increases. As vascular function fails, the bare ier
between blood and brain becomes impaired, and fluid leaks
from the bloodstream into the brain tissue. Brain cells,
with impaired energy, suffer further as fluid separates
them from their blood supply. Brain cell failure results
in disturbance of the brain 's regulating hormones and
cbemicale. Lack of blood to the cells results in libera
. . .
tion of free fatty acids that are toxic. A small amount
of work at this cellular laurel is being undertaken in
this country and abroad by basic biochemists, membrane
physiologists, cell biologists, pathologists, and
surgeons. This work needs to be greatly expanded and
intensified, because it is from such labors that future
progress will emerge.
Physical Alterations That Produce Major Problems
Injury to a Major blood vessel or nerve or fracture of
a major bone are examples of physical alterations that
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71
produce major problems. When a blood vessel is divided
or becomes obstructed as a result of an injury, movement
of nutrients to tissues beyond the point of injury ceases,
and organ and cellular dysfunction--including cellular
deatb--occurs. For each tissue of the body , there is a
small period during which circulation can be diminished
or absent without preventing partial or complete recovery.
For example, injury to a major vessel to the brain can
produce a stroke within a matter of minutes; an extremity
can withstand up to about 8 or 12 hours of diminished
circulation and yet recover completely when circulation
is restored. Most other organs and tissues are between
those extremes. Most tissues can recover if repair is
accomplished and the blood supply is restored. There
will be a scar at the site of repair, but normal or
almost normal function will still be possible.
Nervous tissue presents a special case. Even if
damaged brain heals, function might not return. Damage
to the brain can result in epilepsy, owing to the scar in
the healing process.
The spinal cord does not heal to the extent that func-
tion returns if it has been cut or severely contused.
Hemorrhage or inappropriate movement of the body (the
so-called second injury) can destroy function that had
been spared by the initial injury; bedsores, lung and
urinary infections, and skeletal contractures are all too
frequently the affliction of the inadequately treated
paraplegic.
Peripheral nerves might regenerate if they are care-
fully repaired, but the process is extremely slow, often
requiring 1-2 years for regrowth. In the meantime, tis-
sues distal to the point of injury are paralyzed and
undergo severe atrophy. Frequent physical therapy might
prevent some of the atrophy and has led to major improve-
ment in patients with injured nerves.
The whole class of skeletal injury comes under the
. . . .
heading of physical alterations that cause major prob-
lems--from milder injuries that cause a greenstick
angulation or accentuate intervertebral disk degenera-
tion, through hip fractures and band injuries, to major
injuries that dislocate the spine or sever a limb. The
optimal management of all these involves research into
microsurgical methods of repair, the use of synthetic
prosthetic materials, and the introduction of melody
that not only restore function early, but prevent late
degenerative changes.
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72
Loss of an Organ
Obviously, some organs can be lost without killing a
per son, including limbs, spleen, a k idney, over ies, and
testes . But the loss of others cannot be survived, such
as the brain, heart, and liver . Sometimes, an organ is
damaged severely enough to suggest that its function will
be temporarily lost, but physical repair is possible.
Examples are a smashed liver, kidney, pancreas, and
lung. In such a case, we need to tide the patient over
for a few days or a few weeks, until repair has occurred;
e.g., if a damaged kidney Is in failure, dialysis allows
survival of the patient until renal function is restored.
CONCLUSIONS
Injury can be superficial or deep, and it can affect
one organ or area of the body or several organs or areas
Acute treatment of the injured demands a special
approach. It requires a team effort, often involving
several specialists who lend their expertise in particular
organ systems. In jury is a time-demanding phenomenon
whose peak incidence is late in the day and on weekends,
when hospital staffing is minimal.
There is a need for designated centers for the manage-
ment of the severely injured. Many hospitals and many
physicians cannot manage the complexities of the severely
injured, nor should they be able to. As important as
knowledge are the backup facilities, including well-
stocked blood banks, computed tomographic scanners, and
capacity for cardiopulmonary bypass and renal dialysis.
We have come a long way in the last 40 years in the
management of injury, but muab remains to be learned.47
Table 5-1, at the end of this chapter, summarizes what we
know in a broad, general way and what we need to learn.
Not every known or needed item is listed; the intent is
to present rather broad categories, to demonstrate the
desperate need for research in a variety of problems that
affect the care of injury victims.
We have tried in this brief chapter to show where we
are and to suggest some of the things that need to be
done. Only through continued research will these prob-
lems be solved. We must recognize that injury is an
epidemic. The same effort and funding for research
should be applied to it that we would apply to any other
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73
health problem that is attended by similar morbidity and
mar tal ity .
RECOMMErNDATIONS
1. Long-term collaborative studies should be insti-
tuted by epidemiologists, statisticians, biomedical
engineers, trauma physicians, rehabilitation physi-
cians, behavioral scientists, and health economists, to
identify and evaluate factors that produce optimal
results, to identify factors that result in less than
optimal results, and to institute programs for
promulgating optimal management techniques.
2. Programs in basic research should be instituted
and supported, in collaboration with morphologists,
biochemists, membrane physiologists, pharmacologists,
neurobiologists, bacteriologists, virologists, and
others, to study shock, infection, tissue responses and
healing, and brain and spinal cord swelling.
3. Biomedical and biomechanical programs should be
instituted and supported in relation to injury mechanism
and prevention and the development and evaluation of
biomedical materials, including prostheses and artif icial
organs.
4. Clinical studies should be instituted and
supported in development and evaluation of pharmacologic
options, surgical techniques, and management options.
5." Programs designed to train professionals in the
research and care of injury should be instituted and
supported .
OCR for page 74
74
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Representative terms from entire chapter:
blood pressure
