10 Management of multiple trauma

Essential facts

1. Clinical evaluation, resuscitation, investigation and treatment have to be performed systematically to avoid errors leading to an adverse outcome for the patient.

2. The primary survey identifies immediate life-threatening injuries that compromise airway, breathing or circulation.

3. The secondary survey identifies other injuries that are not life-threatening but will require treatment.

4. The most useful and accurate diagnostic investigation in multiple trauma patients is a computed tomography (CT) from the head to the symphysis pubis, which will identify the most significant injuries.

5. Early skeletal stabilization of major long-bone fractures reduces complication and mortality rates.

Patients with multiple injuries are a difficult challenge, and a multidisciplinary approach is required to evaluate and treat all injuries present. Clinical evaluation, resuscitation, investigation and treatment have to be carried out in a systematic fashion to avoid errors leading to an adverse outcome for the patient. The standard method of initial assessment and management is the Advanced Trauma Life Support (ATLS) system, which has been developed to guide clinicians in the early stages of management. The ATLS system recognizes that the usual model of a detailed history followed by a systematic head-to-toe physical assessment is ideal for the multiply injured patient. The ATLS system is based on recognizing life-threatening conditions immediately, instituting treatment even if the exact diagnosis is not established, and limiting the history obtained in the acute setting to collecting facts relevant to the initial task of saving the patient’s life. There are equivalent systems for the child, e.g. Paediatric Advanced Life Support (PALS) system.

History

The history obtained is defined by the mnemonic AMPLE:

• Allergies

• Medications

• Past illnesses/pregnancy

• Last meal

• Events/environment of injury.

This abbreviated history will collect the essential information needed about the patient in the acute situation.

Initial assessment

The initial assessment after hospital admission is divided into the following phases:

1. Primary survey

2. Adjuncts to primary survey and resuscitation

3. Secondary survey (head-to-toe evaluation and history)

4. Adjuncts to the secondary survey

5. Continued post-resuscitation monitoring and re-evaluation

6. Definitive care.

Primary survey

The primary survey is aimed at detecting and simultaneously treating injuries that pose an immediate threat to survival. The sequence is identified by the mnemonic ABCDE:

Airway maintenance with cervical spine protection

Breathing and ventilation

Circulation with haemorrhage control

Disability: neurological status

Exposure/Environmental control – undress the patient but prevent hypothermia.

The patency of the airway must be established and intubation may be required. It has to be assumed that the cervical spine may be injured and it should be immobilized in a collar. Excess motion of the cervical spine must be avoided until injury has been excluded by radiography or other imaging. Once the airway is secure the chest must be examined, particularly to detect a tension pneumothorax, flail chest or open pneumothorax, which may compromise ventilation. The major cause of early death after multiple injury is haemorrhage. Disability refers in this situation to the neurological status, which may be impaired due to the presence of a head injury. The Glasgow Coma Scale is the simplest way of documenting this. The patient needs to be fully exposed to allow a thorough examination – this entails removal of clothing. Once this is done, the patient’s environment needs to be controlled by warm blankets and warm intravenous fluids to prevent hypothermia.

The most useful radiographic investigations initially are: