Multisystem Trauma

Overview of the Critically Injured Patient

Trauma is…

Single System: an injury involving a single isolated body system

Multiple System: an injury that involves two or more body systems

Trauma System Compenents

Access Prehospital Initial Resuscitation Acute Care Rehabilitation

Types of Trauma

Blunt Penetrating Blast Intentional Nonintentional

Types of Injury

Primary: occurs at the time of injury Secondary: occurs as the result of

secondary insults (hypoxia, hypotension, infection etc.)

Mitigating Factors

Younger than 5, older than 55 Medical / surgical hx. Substance abuse Severity of injury Time of injury to definitive care Quality of care

General Approach

Assessment

Primary Survey / resuscitation Secondary assessment Psychological, social and

environmental factors

Mechanism of Injury and Kinematics

Mechanism=detailed cause or type of event

Kinematics = physics of trauma, how is energy dispersed

Part of primary survey…listen to prehospital caregivers

Fundamentals of Initial Resuscitation

Concepts Assessment and resuscitation occur

simultaneously Reassess frequently Establish priorities and anticipate needs Life over limb Preparedness, organization, communication Someone must be in control Do no further harm If condition progressively worsens…definitive

care is needed.

Goals of Resuscitation

Oxygenation of vital tissues….it’s all about perfusion

Primary Assessment

Subjective Data› Mechanism of Injury› Chief Complaint

Airway / cervical spine Signs / Symptoms

› Decreased LOC› Agitation› Stridor› Cyanosis› Accessory Muscles› Hoarseness› No air movement

Treatment› Establish airway

without manipulation of cervical spine

› Jaw thrust› Suction› NP / OP airways› ETT

Breathing

Signs / Symptoms› Cyanosis, decreased breath sounds, increased

resp. rate, decreased LOC, noisy resp., hypoxia, acidosis.

Diagnosis› Assess clinical presentation, ABG’s, oximetry

trends, CO2 monitoring, CXR Treatment

› High flow O2, assist ventilation, treat tension pnuemo, open pnuemo, flail chest or hemothorax, PAIN MANAGEMENT

Circulation

Signs of hypovolemic shock› Altered LOC, tachycardia, hypotension,

tachypnea, cool diaphoretic skin, low UOP, slow capillary refill time.

Diagnosis› CBC, PT, PTT, X rays, DPL, US, arteriograms

Treatment of hypovolemia› Direct pressure to external bleeding, high flow

O2, 2 lg bore IV’s, fluids, blood› Rule out sources of obstructive shock

Spinal Immobilization Based on mechanism, not neuro deficit SCI may occur with or without bony

involvement High index of suspicion

› Pain, paralysis, paresthesia, ptosis, priapism, presenting position, pregnancy, MOI.

Diagnostics› Initial AP/ lateral to include C-7 and T-1› Correlate with physical exam› CT

Disability / Neuro Assessment

AVPU Trend Glasgow Coma Scale score Trend pupillary size Assess motor function of all four ext. Diagnostics…rule out

› Decreased perfusion or direct cerebral injury, Drugs / ETOH, Hypoxia, Hypotension

Disability – Treatment

Complete primary survey Treat life threatening injury Complete secondary survey Rapid resuscitation Avoid prolonged hyperventilation Avoid hypotension SBP>90 Serial monitoring of VS / NS Consider Narcan or Mannitol

Exposure

Judicious nakedness. Keep patients WARM. Monitor temperature carefully

Secondary Survey

Should not be initialized until life threatening injuries are treated and primary assessment is complete

AMPLE History Head to Toe physical

exam, including posterior surfaces

Preparation for Further Diagnostics

Foley (if no contraindications) › maintain UOP >30 ml / hr

Decompress stomach with NG› If no CSF leak, midface fx

Special Populations Pediatrics

Geriatrics

The Pregnant Trauma Patient Resuscitation

priorities are identical to those on non-pregnant trauma patient.

Consult OB resources early in resuscitation.