Initial Evaluation and Treatment of the Multiple Trauma Victim

EpidemiologyTrauma is a disease of the young, and is the leading cause of death in patients between the ages of 1-44. In 2001 there were 38,000 traffic fatalities, 39% were alcohol related.In 1999 28,000 deaths from firearms, 115,000 injuries annuallyFatalities represent only a fraction of all patients that suffer from traumatic injuries.

Mechanism of InjuryKnowledge of the mechanism of injury can alert one to specific injuries.Auto crashes: Broken windshield, bent steering wheel, knees to dashboard, restraint type, type of accident, speed of accident, extrication time.Penetrating injuriesGSW’sFalls : LD50 for falls is 4 stories (48 ft)Strangulation

Initial Triage of the Trauma Patient

Assess Vital Signs and LOC: SBP<90, RR<10 or >29, GCS <14, or RTS

Initial Triage of the Trauma Patient

Assess Injury: Penetrating injuries, flail chest, trauma with burns, two or more proximal long bone injuries, pelvic fx, paralysis, amputations.Assess Mechanism: Ejected, death in same accident, long extrication time, fall >20 ft, rollover, high speeds, intrusion, major auto damage, motorcycle crash >20 mph, auto-ped or auto-bicycle over 5 mphConsideration of Other factors: extremes of age, pregnancy, bleeding d/o, serious underlying diseases like cardiac or pulmonary disease, diabetes, cirrhosis, etc.

Initial ApproachTeam approach with team leader directing care is optimal, may vary with institution. Assume the most serious injury is presentTreatment based on limited assessment, before diagnosis.Start with brief initial survey, followed by resuscitation, then secondary survey as patient is stabilized.Frequent reassessment and constant monitoring.

Primary Survey

A: Airway with c-spine control

B : Breathing

C : Circulation -control external bleeding.

D : Disability-neurological status

E : Exposure (undress patient)/Environment (Warmed fluids/blankets)

Initial Stabilization

ABC’s- initial assessment of airway and ventilation.

Assess airway: look for obstruction with debris, blood, teeth, etc. vs. obstruction from displaced anatomical structures.

Assess ventilation: look at the rate and quality of respirations. Ventilation may be compromised by decreased LOC, flail segments, penetrating wounds, look for tracheal deviation, distended neck veins.

Airway Maintenance with Cervical Spine Protection.

GCS score of 8 or less require the placement of definite airway.Spinal precautions must be maintained during airway manipulation.A normal neurological exam alone does not exclude a cervical spine injury.Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or distracting injury.

CirculationLook for signs of shock by assessing

LOCskin colorpulseurine output

Control bleedingDirect pressureLimited use for tourniquets, MAST

Establish IV access

CirculationInitial Fluid with crystalloid

Blood loss replaced with 2-3x volume in crystalloidHypertonic saline

Indications for TransfusionPatient clinically unstable after 2-3 Liters or 40-50 ml/kg crystalloid Type O uncrossmatched blood/type specific bloodOn-going blood loss usually located in one of the three body cavities: chest, abdomen, retroperitoneum.

Disability ( Neurological Evaluation)

Assess Patient’s level of consciousnessA : Alert

V : Responds to Vocal stimuli

P : Responds to Painful stimuli

U : Unresponsive to all stimuli

P: Assess pupils

Assess patient for signs of impending herniation

Keep patient in full spinal precautions until full evaluation is complete

Exposure / Environmental Control

Completely undress patient,

Warm ambient temperature, warmed blankets to decrease heat loss

All fluids/blood products should be warmed

Early control of hemorrhage.

Initial EvaluationMultiple trauma patients should have constant cardiac monitoring, continuous pulse ox, and initial set of vitals upon arrival. Vitals should be reassessed frequently to determine response to initial resuscitationOxygen should be routinely administered.In patients who do not need immediate intervention based on primary survey should have initial radiological evaluation including a chest and pelvis.

Secondary SurveyAMPLE history Physical consists of a head to toe evaluation of patient.Thorough evaluation of neurological status, and complete exam of cardiac, abdominal, musculoskeletal and soft tissue systems.Reassess vitals/EKGPlacement of NG tube/ Foley after evaluation for contraindications

Secondary Exam: Neurological Evaluation

Secondary Exam - Neuro

Complete Neuro exam should include evaluation of level of consciousness, pupil responses, careful cranial inspection, and evaluation for spinal tenderness and spinal and peripheral nerve function, including rectal tone

Head injury Classification:Mild : GCS 14-15

Moderate : GCS 9-13

Severe : GCS 3-8

Secondary Exam- Neuro

Intracranial NG Tube Placement

Incomplete Cord Syndromes

Secondary Exam :Lethal Thoracic Injuries

Lethal Thoracic Injuries

Tension pneumothorax

Hemothorax

Pulmonary contusion

Tracheobronchial-bronchial tree injury

Cardiac contusion/tamponade

Traumatic aortic disruption

Traumatic diaphragmatic injury

Mediastinal traversing wounds.

Secondary Exam: Abdominal Evaluation

Secondary Exam- Abdominal Evaluation

Initial stabilization of vital signs with fluid/blood.

Any patient with altered mental status, or distracting injuries requires an objective evaluation of the abdomen via DPL, CAT scan, or Ultrasound.

CAT scan is noninvasive, and sensitive. Also allows evaluation of the retroperitoneum. Limited use in patients who are unstable and do not respond to initial resuscitation.

Secondary Exam- Abdominal Evaluation

Ultrasound is noninvasive and can be used at bedside to detect hemoperitoneum.

Useful in unstable patients

FAST exam evaluates the RUQ (Morison’s pouch), LUQ(splenorenal recess), pericardium, and pouch of Douglas in less than 5 minutes.

FAST Exam

Secondary Exam- Abdominal Evaluation

Unstable patients with decreased level of consciousness and + DPL or U/S needs urgent laparotomy; head CT should not be performed unless there is lateralizing neurological findings.

Unstable patients with a wide mediastinum and + DPL or U/S; laparotomy is recommended before arch aortography