Multiple Trauma-1

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.

Title: Handbook of Fractures, 3rd Edition

Multiple Trauma

• High-velocity trauma is the number 1 cause of death in the 18- to 44-year age group worldwide.
• Blunt trauma accounts for 80% of mortality in the <34-year age group.
• In the 1990s in the United States alone, income loss resulting from death and disability secondary to high-velocity trauma totaled 75 billion dollars annually; despite this, trauma research received less than 2% of the total national research budget.

The polytrauma patient is defined as follows:

• Injury Severity Score >18
• Hemodynamic instability
• Coagulopathy
• Closed head injury
• Pulmonary injury
• Abdominal injury

FIELD TRIAGE

Management Priorities

• Assessment and establishment of airway and ventilation
• Assessment of circulation and perfusion
• Hemorrhage control
• Patient extrication
• Shock management
• Fracture stabilization
• Patient transport

TRAUMA DEATHS

Trauma deaths tend to occur in three phases:

• Immediate: This is usually the result of severe brain injury or disruption of the heart, aorta, or large vessels. It is amenable to public health measures and education, such as the use of safety helmets and passenger restraints.
• Early: This occurs minutes to a few hours after injury, usually as a result of intracranial bleeding, hemopneumothorax, splenic rupture, liver laceration, or multiple injuries with significant blood loss. These represent correctable injuries for which immediate, coordinated, definitive care at a level I trauma center can be most beneficial.
• Late: This occurs days to weeks after injury and is related to sepsis or multiple organ failure.

GOLDEN HOUR

• Rapid transport of the severely injured patient to a trauma center is essential for appropriate assessment and treatment.
• The patient’s chance of survival diminishes rapidly after 1 hour, with a threefold increase in mortality for every 30 minutes
  

  
  

  of elapsed time without care in the severely, multiply injured patient.

RESUSCITATION

• Follows ABCDE
• Airway, breathing, circulation, disability, exposure

AIRWAY CONTROL

• The upper airway should be inspected to ensure patency.
• Foreign objects should be removed, and secretions suctioned.
• A nasal, endotracheal, or nasotracheal airway should be established as needed. A tracheostomy may be necessary.
• The patient should be managed as if a cervical spine injury is present. However, no patient should die from lack of an airway because of concern over a possible cervical spine injury. Gentle maneuvers, such as axial traction, are usually possible to allow for safe intubation without neurologic compromise.

BREATHING

• This involves evaluation of ventilation (breathing) and oxygenation.
• The most common reasons for ineffective ventilation after establishment of an airway include malposition of the endotracheal tube, pneumothorax, and hemothorax.
  • Tension pneumothorax
    • Diagnosis: tracheal deviation, unilateral absent breath sounds, tympany, and distended neck veins
    • Treatment: insertion of a large-bore needle into the second intercostal space at the midclavicular line; then placement of a chest tube
  • Open pneumothorax
    • Diagnosis: sucking chest wound
    • Treatment: occlusive dressing not taped on one side to allow air to escape, followed by surgical wound closure and a chest tube
  • Flail chest with pulmonary contusion
    • Diagnosis: paradoxical movement of the chest wall with ventilation
    • Treatment: fluid resuscitation (beware of overhydration); intubation; positive end-expiratory pressure may be necessary
  • Endotracheal tube malposition
    • Diagnosis: malposition evident on chest radiograph, unilateral breath sounds, asymmetric chest excursion
    • Treatment: adjustment of the endotracheal tube with or without reintubation
  • Hemothorax
    • Diagnosis: opacity on chest radiograph, diminished/ absent breath sounds
    • Treatment: chest tube placement
• Indications for intubation
  • Control of airway
  • Prevent of aspiration in an unconscious patient
  • Hyperventilation for increased intracranial pressure
  • Obstruction from facial trauma and edema

CIRCULATION

• Hemodynamic stability is defined as normal vital signs that are maintained with only maintenance fluid volumes.
• In trauma patients, shock is hemorrhagic until proven otherwise.
• At a minimum, two large-bore intravenous lines should be placed in the antecubital fossae or groin with avoidance of injured extremities. Alternatively, saphenous vein cutdowns may be used in adults, or intraosseous (tibia) infusion for children <6 years of age.
• Serial monitoring of blood pressure and urine output is necessary, with possible central access for central venous monitoring or Swan-Ganz catheter placement for hemodynamic instability. Serial hematocrit monitoring should be undertaken until hemodynamic stability is documented.
• Peripheral blood pressure should be assessed.
• Blood pressure necessary to palpate a peripheral pulse.

  Peripheral pulse	Blood pressure
  Radial	80 mm Hg
  Femoral	70 mm Hg
  Carotid	60 mm Hg

INITIAL MANAGEMENT OF THE PATIENT IN SHOCK

• Direct control of obvious bleeding: direct pressure control preferable to tourniquets or blind clamping of vessels.
• Large-bore venous access, Ringer lactate resuscitation, monitoring of urine output, central venous pressure, and pH.
• Blood replacement as indicated by serial hematocrit monitoring.
• Traction with Thomas splints or extremity splints to limit hemorrhage from unstable fractures.
• Consideration of angiography (with or without embolization) or immediate operative intervention for hemorrhage control.

DIFFERENTIAL DIAGNOSIS OF HYPOTENSION IN TRAUMA

Cardiogenic Shock

• Cardiac arrhythmias, myocardial damage
• Pericardial tamponade
  • Diagnosis: distended neck veins, hypotension, muffled heart sounds (Beck triad)
  • Treatment: pericardiocentesis through subxiphoid approach

Neurogenic Shock

• This occurs in patients with a thoracic level spinal cord injury in which sympathetic disruption results in an inability to maintain vascular tone.
• Diagnosis: hypotension without tachycardia or vasoconstriction. Consider in a head-injured or spinal cord-injured patient who does not respond to fluid resuscitation.
• Treatment: volume restoration followed by vasoactive drugs (beware of fluid overload).

Septic Shock

• Consider in patients with gas gangrene, missed open injuries, and contaminated wounds closed primarily.
• Diagnosis: hypotension accompanied by fever, tachycardia, cool skin, and multiorgan failure. This occurs in the early to late phases, but not in the acute presentation.
• Treatment: fluid balance, vasoactive drugs, antibiotics.

Hemorrhagic Shock

• More than 90% of patients are in shock acutely after trauma.
• Consider in patients with large open wounds, active bleeding, pelvic and/or femoral fractures, and abdominal or thoracic trauma.
• Diagnosis: hypotension, tachycardia. In the absence of open hemorrhage, bleeding into voluminous spaces (chest, abdomen, pelvis, thigh) must be ruled out. This may require diagnostic peritoneal lavage, angiography, CT, MRI, or other techniques as dictated by the patient presentation.
• Treatment: aggressive fluid resuscitation, blood replacement, angiographic embolization, operative intervention, fracture stabilization, and other techniques as dictated by the source of hemorrhage.

CLASSIFICATION OF HEMORRHAGE

Class I:	<15% loss of circulating blood volume
	Diagnosis: no change in blood pressure, pulse, or capillary refill
	Treatment: crystalloid
Class II:	15% to 30% loss of circulating blood volume
	Diagnosis: tachycardia with normal blood pressure
	Treatment: crystalloid
Class III:	30% to 40% loss of circulating blood volume
	Diagnosis: tachycardia, tachypnea, and hypotension
	Treatment: rapid crystalloid replacement, then blood
Class IV:	>40% loss of circulating blood volume
	Diagnosis: marked tachycardia and hypotension
	Treatment: immediate blood replacement

BLOOD REPLACEMENT

• Fully cross-matched blood is preferable; it requires approximately 1 hour for laboratory cross-match and unit preparation.
• Saline cross-matched blood may be ready in 10 minutes; it may have minor antibodies.
• Type O negative blood is used for life-threatening exsanguination.
• Warming the blood will help to prevent hypothermia.
• Monitor coagulation factors, platelets, and calcium levels.

PNEUMATIC ANTISHOCK GARMENT (PASG) OR MILITARY ANTISHOCK TROUSERS (MAST)

• Used to control hemorrhage associated with pelvic fractures.
• May support systolic blood pressure by increasing peripheral vascular resistance.
  P.14
  
  
• May support central venous pressure by diminution of lower extremity blood pooling.
• Advantages: simple, rapid, reversible, immediate fracture stabilization.
• Disadvantages: limited access to the abdomen, pelvis, and lower extremities, exacerbation of congestive heart failure, decreased vital capacity, potential for compartment syndrome.
• Are contraindicated in patients with severe chest trauma.

INDICATIONS FOR IMMEDIATE SURGERY

Hemorrhage secondary to:

• Liver, splenic, renal parenchymal injury: laparotomy
• Aortic, caval, or pulmonary vessel tears: thoracotomy
• Depressed skull fracture or acute intracranial hemorrhage: craniotomy

DISABILITY (NEUROLOGIC ASSESSMENT)

• Initial survey consists of an assessment of the patient’s level of consciousness, pupillary response, sensation and motor response in all extremities, rectal tone and sensation.
• The Glasgow coma scale (Table 2.1) assesses level of consciousness, severity of brain function, brain damage, and potential patient recovery by measuring three behavioral responses: eye opening, best verbal response, and best motor response.

  Table 2.1. Glasgow coma scale

  Glasgow Coma Scale Score A Eye Opening (E) 1. Spontaneous 2. To speech 4 3. To pain 3 4. None 2 B. Best Motor Response (M) 1 1. Obeys commands 2. Localizes to stimulus 6 3. Withdraws to stimulus 5 4. Flexor posturing 4 5. Extensor posturing 3 6. None 2 C. Verbal Response (V) 1 D. Oriented 5 E. Confused conversation 4 F. Inappropriate words 3 G. Incomprehensible phonation 2 H. None 1 GCS = E+M+V (range, 3–15). Note: Patients with a Glasgow coma scale of <13, a systolic blood pressure of <90, or a respiratory rate of >29 or <10/min should be sent to a trauma center. These injuries cannot be adequately evaluated by physical examination.