Freelance Traveller

by Robert O'Connor

Assessment and Management of Trauma Victims

Triage (Fr., roughly, "to sort")

The effective use of limited resources in a battlefield or other disaster situation requires medical personnel to rapidly assess casualties and prioritise them.

General priorities

• Support life
• Control haemorrhage
• Prevent brainstem compression or spinal cord damage
• Diagnose and treat all other injuries

The Primary Survey

Identify and treat the immediately life-threatening problems. (=resuscitation or Immediate Action) OR Keep the patient alive until someone can provide definitive treatment.

The method to do this is best summarised by the first aid mnemonic

1. Airway : ensure that it is patent. Assess the patient.
2. Breathing : supply oxygen, treat pain
3. Circulation : maintain a blood pressure sufficient to perfuse vital organs (brain, heart/lungs, kidneys)

Tasks for Resuscitation/Immediate Action

To Assess Injury Severity (overview):

Average, Medical/First Aid, Edu, uncertain

Difficult if in the field.

Medical scanner +5 to uncertainty roll.

Varying amounts of truth change the estimate up or down levels (ref's choice).

To Check for Catastrophe:

Difficult, Medical/First Aid, patient's End.

Failure - 1D more damage.

 

To Maintain Consciousness (patient task)

Difficult, End

Patients with Major level damage or greater will show signs of shock, i.e. altered level of consciousness (decreased or delirious), impaired breathing (A, B, or C causes?), decreased blood pressure and usually an increased pulse (hypotension and tachycardia).

Airway

Anatomy: In a human (or Vargr or Aslan, for that matter), the nose and mouth join in a common pathway at the back of the throat - the pharynx. Just above the 'Adam's apple' in a human is the entry to the windpipe (trachea) ; this is the larynx. The vocal cords are in the upper part of the larynx. A muscular flap, the epiglottis, sits above the laryngeal opening. It normally protects the lungs from being soiled with food on eating or vomitting. (This requires an intact reflex arc which may not be present in a severely ill person). The trachea continues into the chest, where it birfucates to supply each lung.

The most basic airway manoeuvres aim to keep the pathway from pharynx to trachea open.

Airway tubes can be placed

• Nasopharyngeal airway (nostril to pharynx).
• Oropharyngeal aiway (mouth to pharynx).
• Laryngeal mask (inserted into the mouth, the end of the mask covers the laryngeal opening).
• Endotracheal tube (can be inserted through the nose or the mouth). The end sits in the trachea above the bifurcation to guarantee ventilation of both lungs.

Alternately, surgical airways can be formed. Just below the laryngeal prominence ("Adam's apple") is a small gap in the cartilage in the midline. This is the cricothyroid membrane. Making an incision or puncture here and passing an airway tube is relatively easy. Tracheostomies - holes in the trachea - can be made at this level or lower. Bleeding and air tracking into the chest can ensue if you go too low, though. The utility of surgical airways becomes evident in the context of severe facial injury.

Airway Manoeuvre tasks

Difficulty, Med/First Aid, Dex (Difficulty from table as follows)

All airway manoeuvres have a risk of mishap : disrupting the cervical spine, base of skull (making existing injuries worse) or putting an endotracheal tube into the oesophagus (unrecognised, this is a lethal error) instead of the trachea readily spring to mind.

* On Spectacular Failure : 1D further damage. Tasks may be repeated. You must secure an airway, else all other effort will be wasted!

Breathing

• Give high-flow oxygen through a mask or down a tube if one is placed.
• Give drugs to reduce pain (especially) from rib or sternum fractures, so it doesn't hurt to breathe.
• Drain collections of air or blood in the chest or stomach that may be preventing lung inflation.
• Assisted ventilation is the ultimate measure (expired air or 'bagging' with ventilator).

Breathing Tasks

Difficulty, Medical/First Aid, Dex

The end of a chest drain is meant to sit between the chest wall and the lung, to drain air or fluid which may have collected there.

Gastric tubes can be passed either through the nose or mouth.

* Inserting drainage tubes can make things worse. Hearts have been perforated by personnel inserting chest drains. Stomachs have been perforated inserting gastric tubes. Never, never introduce a gastric or airway tube through the nose of someone who may have a base of skull fracture ; it may end up poking into the brain...

On Spectacular failure : 1D damage

Circulation

• Shock occurs when cardiac output cannot meet the metabolic demands of the rest of the body. It is usually due to a low (falling?!) blood volume (hypovolaemic shock) in the context of trauma, but can be due to injury to the heart (cardiogenic shock).
• Control obvious external bleeding with direct pressure.
• Establish reliable venous access, with at least one big cannula/IV.
• Aggressive fluid resuscitation will be required with significant blood loss (20% of circulating volume or more for an otherwise fit individual). An adult can lose a litre of blood into their thigh from a fractured femur without it being clinically apparent (apart from a sharp drop in blood pressure and fast, thready pulse).
• In extreme situations, draining collections of blood or air from the chest or the sac covering the heart may be life-saving, as is external or direct cardiac massage. Chest compression will be required if the heart stops beating.

Circulation Tasks

Difficulty, Medical/First Aid, Dex

Volume resuscitation

(wound difficulty), Med/First Aid, victim's End (co-operative), bonuses from previous steps

Success restores consciousness if not anaesthetised/sedated or Destroyed level damage (nearly dead!). A safe blood pressure is maintained in the presence of a patent airway and adequate oxygenation.

On Failure : catastrophe check. On Spectacular failure : catastrophe check +1D damage. On Spectacular success : 'rolls back' half die (D3) of damage.

These tasks permit catastrophe checks and Spectacular Failure damage to be reversed or ignored. Success leads to a restoration of normal heart rhythm with stable blood pressure. Failure causes 1D damage. Ventilation and cardiac massage will need to be continued until definitive treatment can be performed.

Pericardium

The  sac covering the heart. Fluid can accumulate in the sac and depress heart function, as the pericardium is relatively stiff. When this occurs, it is called cardiac tamponade.

Volume resuscitation

Adding blood, blood products (e.g., clotting factors), colloids (protein or starch solutions), crystalloids (salt solutions) into patient circulatory system.  Possible at TL 4+. Crystalloids or colloids can be used until blood is available. Blood and blood products should be used only when bleeding is controlled (except for very dire circumstances).

 

5. Stabilised or not?

Further catastrophe checks can be made every ten minutes or so or at important points (transfer onto or off a vehicle, or for dramatic effect...)

 

The Secondary Survey

Evaluate injury by region and treat accordingly.

Evaluation.

Clinical examination can be supplemented by

• Laboratory investigations (TL 4+) : blood haemoglobin the most important value. Arterial blood oxygen and carbon dioxide tensions, and measures of clotting times, may also be useful.
• X-rays (TL4+) : cervical spine (neck) and chest views are the most important ones to take! Other obvious fractures should be evaluated once the patient is stable, so that the Orthopaedic surgeon can sort them out.
• Diagnostic peritoneal lavage (TL5+) : a small incision is made into the abdomen and sterile saline instilled. If the aspirated fluid contains blood, significant internal injury is likely and surgery is necessary.
• Angiography (TL 5+) : Contrast media (X-ray/MR/nuclear scan) can be injected to delineate bleeding sites. Bleeders can be made to stop by injecting procoagulants or placing obstructing objects (TL 7+) - embolisation. Sometimes this works.
• Ultrasound (TL6+) : identification of organ injuries from blunt trauma are more readily spotted this way (air, blood or fluid has a different echotexture to tissue). This supercedes peritoneal lavage.
• CT scanning (TL 7+) : the investigation of choice in the initial evaluation of head injury at this TL, as it permits detailed brain imaging.
• MR scanning (TL 8+) : like CT, but good for other tissues ; higher resolution. Some logistic and clinical problems arise because of the intense magnetic field (shifting bullets, shrapnel...)
• Antiproton CT (TL 10+) : better resolution than MR, no magnetic problems....
• Gravisonic modulator (TL 11+) : gravisonic imaging enables high resolution (not as good as antiproton CT) radiation free imaging.
• Meson scanner (TL 11+) : comparable to antiproton CT, not reliant upon expensive antimatter (meson decay serves as gamma source). (Thanks Bruce Mac!)

To diagnose injury

Average, Medical, Edu, uncertain

This task can be co-operative (either with sophont physicians or expert systems). The practical upper limit is three medics. Higher technology level investigations reduce uncertainty:

*To perform a successful embolisation

Difficult, Medical, Dex. Equipment is required to attempt this task.

Indication :- Major or more severe abdominal damage. Surgery is required if embolisation fails.

At lower tech levels, more surgery is performed. At higher tech levels, more sophisticated tests are performed.

Catastrophe checks should be made during the evaluation process.

 

Injury rating system

The abbreviated injury score (AIS) is a Real World system used to evaluate the management of trauma victims. It was initially devised to develop standards of care for road accident casualties, but the scope of its use has increased.

The body is divided into regions: head, neck and face, thorax, abdomen, pelvis and extremities, external (skin!).

Injuries are rated on the following scale

0: no injury

1: minor

2: moderate

3: serious, not life threatening

4: severe, survival probable

5: critical, survival uncertain

6: unsurvivable

This scale readily lends itself to Traveller application.

0 to 1: superficial

2 to 3: minor (one characteristic at zero)

4 to 5: serious (two characteristics at zero)

6: destroyed (all chars at zero)

Treatment.

Examples of Injuries and Their Treatment

Superficial injuries

e.g., Shallow lacerations or cuts, abrasions (scrapes), simple fractures or dislocations (closed, (non)reduced, not hand, femur, spine or depressed skull), corneal abrasions or foreign bodies.

Treatments may include suturing (TL 2+), bandaging and dressing (TL 1+), immobilisation in plaster cast or splinting (TL 1+), pain relief (TL 1+).

Suturing a wound, or reducing a fracture/dislocation requires either local anaesthesia (TL 5+) or reliable sedation up to and including general anaesthetic (TL 4+).

Minor

e.g., deep lacerations (skin traversed), multiple simple limb or facial or individual compound fractures (bone through skin) of same, simple pneumothoraces (collections of air in the chest outside the lungs), superficial foreign bodies (bullets/shrapnel), penetrating eye injuries.

Treatments may include exploration and suturing of wounds (local or general anaesthesia required, so TL 4+) or placement of a chest drain (TL 4+). Complicated fractures (eg. hand/wrist, femur, depressed skull) and eye injuries require surgery (general anaesthetic, TL 4+). All require analgesia.

Major

e.g., Head injuries with symptomatic intracranial haemorrhage or compound fracture, pelvic ring fractures, multiple rib or sternum fractures (if three or more adjacent ribs are fractured, a so called flail segment is produced. Ventilating the lung becomes difficult.), blunt or penetrating cardiac or chest injury, blunt or penetrating abdominal trauma, multiple compound fractures, limb crush injuries or (near-)amputations.

Surgical intervention after resuscitation is mandatory, if only to control bleeding and remove dead tissue. Resuscitation and placement into low berth is an alternative if technology permits.

Destroyed

e.g., combinations of Major injuries, above, with the additional complication of cardiac arrest (actual or imminent).

Resuscitation is required within five minutes of cardiac standstill to permit brain salvage (in the absence of mitigating protective factors like severe hypothermia or some drugs).

Placement in a low berth and transport to a TL 13+ medical facility offers the best chance for long-term survival, in the absence of prompt heroic medical and surgical intervention.

The following task covers any area not previously specified.

To treat injuries

variable, Medical/First Aid, Edu/Dex.  + evaluation mods, as above.

This is a co-operative task ; the surgeon's first assistant provides half their skill. Optionally, up to two surgical teams (surgeon+first assistant) can operate at the same time on different parts of the patient. This permits wounds to be separated into different tasks.

Regions (1 team per region)

Head

Arms/chest/abdo

Legs

Surgery requiring general anaesthetic, or resuscitation for Destroyed injuries requires an endotracheal tube to control the airway and an anaesthetist.

+1 difficulty level for impromptu/inadequate tools (e.g., suturing without local anaesthetic) and/or setting (in the field vs. operating theatre).

**The usual outcome for this task is to enable healing. On a Spectacular Success, 1D damage points are 'rolled back'. On Spectacular Failure inflict additional 1D damage.

The anaesthetist can make a task roll as above to try and reverse Spectacular Failure. He or she cannot improve on Spectacular Success.

Aftercare and Outcomes

Survival depends primarily on two factors

The rapidity and appropriateness of resuscitation. The concept of 'the golden hour' is well established. People tend to survive if definitive treatment after resuscitation has started within the first hour after injury.

The severity of head injury sustained. There are three mortality peaks: immediate (massive injuries), hours later (decompensated shock, usually in the emergency room or operating theatre), and days to weeks later (from head injury complications or multi-organ failure, usually in the wards or ICU).

Healing rates

Superficial 1 point, all affected chars, per day

Minor 1 point, all affected chars, per day

Major 1 point, one characteristic, per day

Destroyed 1 point, one characteristic, per week, until 50% of points recovered - then treat as Major

Slow drug speeds this up by a factor of ten. Its use is confined to ICU and Major or more severe damage.

A patient is transferred from ICU to Ward when one characteristic is recovered or patient is conscious.

A patient is transferred from Ward to Home when all chars 50% of original value

 

For Superficial and Minor injuries

Enhanced wound healing doubles the rate of recovery at TL 9+, triples it at TL 12+ (gentle growth quickening and tissue culture tech)

To Avoid Infection

Average, (patient) End.  If in hospital, Average, Medical (attendant), End (patient).

Infection occurs only on Spectacular Failure. When infection occurs, healing stops until the infection is treated.

 

To diagnose causative organism

Difficult, Medical, End, uncertain

Laboratory investigations can reduce uncertainty:

To treat infection

(difficulty), Medical, patient's End, uncertain if organism unknown.

Difficulty Level is Easy for Superficial damage, Average otherwise.

Laboratory investigations reduce uncertainty.

Spectacular Success rolls back 2D of damage. Spectacular Failure causes 1D of damage. Failure: catastrophe check.

To Check for Consciousness

Difficult, End. Wake up if successful.

 

To Check for Catastrophe

Difficult, Medical (attendant), End (patient)
Spectacular Failure leads to the development of some problem. 1D damage is applied promptly.

 

Effects

All characteristics to zero: cardiac arrest, any cause

Two characteristics to zero: e.g., severe infection, bleeding, pulmonary embolism (blood clot to lungs), heart attack (myocardial infarction).

One characteristic to zero: minor infection or wound breakdown.

Miscellaneous Medical Tasks

To thaw from low berth

Difficult, Med, Edu.

Spectacular Failure leads to automatic Destroyed damage (cardiac arrest).

 

Reanimation

Formidable, Medical, Edu task (co-operative OK).

+1 difficulty level if fast drug used instead of low berthing.

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