Strengthening the trauma chain of survival


This special issue on trauma highlights established and emerging areas in injury care ranging from epidemiology to epigenetics. It does not attempt to cover the complete trauma chain of survival (Fig.1); rather, the collection reflects areas of current and ongoing interest, explores translational aspects of pathophysiology in trauma care, discusses changes in concepts and paradigms, and gives ‘best evidence’ even where this is still guided largely by expert opinion and limited data. Randomized clinical trials, systematic reviews and meta-analyses demonstrate that rigorous methodology can, however, be applied in trauma studies resulting in better quality evidence. Mathematical modelling and narrative review of experimental research with translational applications also show that research in trauma care can move from the laboratory to the bedside.

Figure 1.

The trauma chain of survival. First displayed at the TraumaCare2002 conference in Stavanger, Norway, and reproduced with permission from Laerdal Medical, Stavanger, Norway. BLS, basic life support; ALS, advanced life support.

A mix of commissioned and unsolicited material has been evaluated and edited for inclusion. Several papers are followed by expert commentaries that may foster further reflection and discussion. Interest in publication has been enormous. Following a call for papers on this topic, those selected represent only 10 per cent of all submissions.

The care of injured patients is based on appropriate, timely and correct intervention through each link in the trauma chain of survival (Fig.1). Breaks in the chain result in suboptimal outcomes. A systems approach to the injured patient ensures appropriate care at each level. This involves many clinicians and management plans that defy specialty-drawn borders1. The potential benefits with appropriate care are substantial. Many injured patients are young with many working years ahead and a considerable number of life-years to gain if death and disability can be avoided2. Evaluation of outcomes other than mortality is urgently needed, although few trauma registries contain such information3. Exactly which link in the chain has the greatest influence on outcome for each injured patient is largely unknown. Strengthening one part of the chain may have greater benefits in certain situations than others, but the surgeon has much to offer both in maintaining the chain and in making it stronger. While focus on optimizing resuscitative strategies and training of surgical technique may be important in areas with mature systems with few breaks in the chain, focus on logistics and resource allocation may be the cornerstone in other settings, such as in disaster management or the development of strategies in resource-poor locations.

Despite a global rise in trauma and an increasing volume of surgical work, trauma care seems poorly represented in most federal funding programmes, global organizations and patient interest groups. The lack of global and uniform standards for collecting, reporting and auditing data is in stark contrast to other health problems, for instance relating to cancer or cardiovascular disease. There are no agreed uniform standards for measuring the various relevant outcomes other than death, but attempts to harmonize definitions are in development4 and hopefully these will enable improved European and global networks for data collection, sharing and comparison.

The surgeon has always played an important role in the care of the injured patient. Indeed trauma has been a part of BJS publishing history since the first volume in 1913. It is interesting to see how surgeons understood shock in the past5, and reassuring to see the change in knowledge of its pathophysiology a century later, as reviewed in this supplement. It is disturbing to note, however, that management is still often based on expert opinion and emerging concepts. The reviews in this series are intended both to instruct where evidence is available and to highlight gaps in knowledge.

Research in difficult environments and urgent situations where there is a need for rapid decisions and interventions is particularly challenging in terms of methodology, logistics, practicality and ethics. Not every new theory and principle can be tested in a controlled environment before being brought to clinical use. It should not be forgotten, however, that surgeons have adopted experimental approaches to common injuries in the past6 and have brought these concepts to saving life and limbs for better outcomes. This supplement points to clinical challenges with vascular and extremity injuries with novel approaches likely to result in further advances and better outcomes in years to come. At the other end of the scale, gaining experience in understanding and dealing with rare, complex and highly lethal injuries, such as those of the pancreas7, is always likely to have its basis in the realities of clinical practice. The series of over 200 penetrating pancreas injuries managed in Cape Town, described in this supplement, is one of the largest of its kind and represents a compelling experience8. Most surgeons will see few, if any, such injuries during a lifetime.

Hippocrates urged surgeons who wanted to learn about wounds and injuries to follow the army into war. While all surgeons cannot go to war to learn, recent acts of civilian terror remind us of the need for domestic preparedness. Knowledge of patterns of injury seen in warfare has become important even for civilian surgeons9. The unpredictable events of nature also call on surgeons to respond following earthquakes, floods and other natural disasters. Unintentional injuries, dominated by road traffic accidents, are responsible for an increasing number of deaths and disability, particularly in a young population2, 10. Despite all of this, the shift towards specialized modern surgery has left trauma in many countries as a Cinderella activity within general surgery. William Halsted once stated that every hospital should have at least one surgeon who was particularly adept with all surgical emergencies and injuries. In many healthcare systems this is no longer the case, owing to subspecialization, yet it behoves the surgical community to face up to the demands of modern trauma care.

The potential for research in trauma to spill over into care of the elective surgical patient should not be overlooked. This may be true for clinical experience, but also for understanding mechanisms of disease. Understanding the ways in which a single-nucleotide polymorphism makes patients respond to a traumatic insult in different ways and react to therapies that affect outcome11 leads the researcher to investigate cellular pathways involved, potentially applying new knowledge in a non-trauma context as well. Advances in blood component therapy and increased understanding of the activated coagulation system are now used in several situations. Military drivers for the development of artificial or haemoglobin-based oxygen carriers and dried blood products stored at ambient temperatures12 may be used to replace human blood transfusions in civilian medicine. Studies in the laboratory may translate into new modes of haemostatic resuscitation and protection for cellular damage, including epigenetic manipulation at the DNA level13. A better understanding of the potential value of fluids that preserve cellular functions and avoid secondary organ reperfusion injury or exploration of the role of deep therapeutic hypothermia may lead to applications valuable for a number of clinical disciplines. Damage considered irreparable, such as complete spinal cord injuries, may be viewed differently in the future, for example by using neuronal stem cells14 and engineering nanostructured matrices into neuroprosthetics15 to regenerate axons for eventual neurological recovery. Inevitably, the results of some of these studies will challenge existing concepts regarding human physiology and cellular biology, and change our views of possible outcomes and potential in rehabilitation.

It is hoped that that this supplement will be thought-provoking and stimulate ideas and new research in trauma. BJS welcomes future submissions of papers that are likely robustly to confirm, translate, change or redirect the thinking and care of injured patients. In doing so, it is hoped that this reinforces the role of the surgeon in the trauma chain of survival.


The author declares no conflict of interest.