Multiple Injuries

Polytrauma -- Multisystem trauma

Terminology:

• Injury = the result of harmful event that arises from the release of specific forms of energy.

• Trauma = defined as the morbid condition of body produced by external violence.

• “polytrauma” = Multisystem trauma = injury of two or more systems, one or the combination imperil vital signs.

Pathophysiology of Trauma

• A major trauma is characterized by a series of complex pathophysiological reactions, some directly as a result of the event itself, others as part of a compensatory response.

• The main features are triggered by: hypoxia shock neurohumoral responses

INJURY BIOMECHANICS AND ACCIDENT PREVENTION

The magnitude of an injury is related to energy transferred to the victim during the event,the volume/area of tissue involved and the time taken for the interaction.

Trauma deaths have a trimodal distribution

• First peak –Within minutes of injury –Due to major neurological or vascular injury –Medical treatment can rarely improve

outcome

• Second peak –Occurs during the 'golden hour' –Due to intracranial haematoma, major

thoracic or abdominal injury –Primary focus of intervention for the

Advanced Trauma Life Support (ATLS) methodology

• Third peak –Occurs after days or weeks –Due to sepsis and multiple organ failure

Types of Blast Injuries

• Primary –Due to direct effect of pressure

• Secondary–Due to effect of projectiles from explosion

• Tertiary–Due to structural collapse and from persons

being thrown from the blast wind• Quaternary –Burns, inhalation injury, exacerbations of

chronic disease

Other Primary Blast Injuries

• Eye – Globe rupture, serous retinitis, hyphema, lid

laceration, traumatic cataracts, injury to optic nerve

– Signs and symptoms include eye pain, foreign body sensation, blurred vision, decreased vision, drainage

• Brain – TBI due to barotrauma of gas embolism – Signs and symptoms include headache,

fatigue, poor concentration, lethargy, anxiety, and insomnia

Tertiary Blast Injuries

• Due to persons being thrown into fixed objects by wind of explosions

• Also due to structural collapse and fragmentation of building and vehicles

• Structural collapse may cause extensive blunt trauma.

–Crush syndrome • Damage to muscles and subsequent release of

myoglobin, urates, potassium, and phosphates• Oliguric renal failure

–Compartment syndrome • Edematous muscle in an inelastic sheath

promotes local ischemia, further swelling, increased compartment pressures, decreased tissue perfusion, and further ischemia

Quaternary Blast Injuries

• Explosion related injuries or illnesses not due to primary, secondary, or tertiary injuries – Exacerbations of preexisting conditions, such as

asthma, COPD, CAD, HTN, DM, etc.

Burns (chemical and thermal) •White Phosphorous (WP) from munitions

causes extensive burns, hypocalcemia and hyperphosphatemia

–Toxic inhalation–Radiation exposure–Asphyxiation (carbon monoxide and

cyanide)

Triage

• Pre-hospital triage• At the scene of trauma• On arrival at the receiving hospital

Managing a major trauma situation

1. Plan for eventuality2. Set up the trauma team before the patient arrive.3. Organize lines of communication and command.

Primary survey and resuscitation

• Airway with cervical spine protection• Breathing and ventilation• Circulation and control of bleeding• Disability• exposure

Adjuncts to the primary survey

• Full blood counts• Coagulation studies• Plasma chemistry• Transfusion screening• ECG

• Radiography–Cervical spine–Chest–pelvis

• Urinary and gastric catheter

Secondary survey

• Head and face• Neck• Chest• Abdomen and pelvis• extremities

Treatment for Burns

• Cover burns to minimize heat and fluid loss • WP burns require special management –Copious lavage and removal or particles and

debris

–Rinse with 1% copper sulfate solution• Combines with phosphorous particles and impedes further

combustion

–Cardiac monitor • Hypokalemia and hyperphsophatemia common

–Use moistened face masks to protect from phosphorous pentoxide gas exposure

–Avoid use of flammable anesthetic agents and excessive oxygen

Definitive care and transfer

• Golden hour concept• Transfer when haemodynamically and

cardiovascularly stable

Summary -Management

• Assessment and resuscitation are vital. • Diagnostic delays must be avoided. • Organ specific diagnosis is not required.

Guidelines for Admission

• High risk patients who require admission– Significant burns– Suspected air embolism–Radiation

–Contamination–Abnormal vital signs–Abnormal lung examination findings–Clinical or radiographic evidence of

pulmonary contusion or pneumothorax–Abdominal pain or vomiting –Penetrating injuries to the thorax,

abdomen, neck, or cranial cavity

Selected References

• Bailey & Love’s SHORT PRACTICE of SURGERY 26th EDITION

• www.trauma.org