Multiple Trauma





In 2007, the National Center for Health Statistics noted there were 182,479 injury-related deaths. Unintentional injuries ranked as the fifth most common cause of death. The leading causes of death by mechanism of injury in 2007 were classified as follows:




  • Motor vehicle traffic—32,031



  • Firearm—31,224



  • Poisoning—40,059



  • Fall—23,443



These mechanisms accounted for 74.9% of all injury deaths.


In 2010, the American College of Surgeons (ACS) National Trauma Data Bank indicated the highest rate of injury occurs between the ages of 14 and 29 years. Deaths by age have two distinct peaks: first, around 20 years of age, and second, at 50 years of age. Previously in 2005, the second peak was 80 years. Injuries related to motor vehicle traffic and firearms account for the first peak, and deaths from falls and motor vehicle traffic account for the second peak.


The trimodal distribution of mortality associated with trauma is categorized as immediate, early, and late. Immediate deaths occur as a result of brain laceration, high spinal cord or brainstem injury, or major vessel or cardiac injury. Given the poor survival from this type of injury, prevention is the best approach in reducing this distribution of fatalities. The ACS Committee on Trauma reported that 62% of all in-hospital deaths occurred in the first 4 hours of admission, which emphasizes the need for expedient and definitive intervention. A trauma systems approach to care for this cohort of the injured population has reduced morbidity and mortality. At the other end of the spectrum, late deaths occur several days to weeks after admission. Of these deaths, 80% are secondary to head injury, and 20% are attributed to multiple organ failure and sepsis.


Hospital Resuscitation


Once the trauma patient reaches the hospital, resuscitation is continued while following the principles of a primary, secondary, and tertiary survey as established by the ACS Committee on Trauma. The primary survey encompasses the ABCs (airway, breathing, and circulation and, more recently CAB), disability, and exposure. The secondary survey involves a head-to-toe evaluation of the patient’s injuries and implementation of appropriate interventions. Chapter 1 reviews these basic initial stabilization principles of trauma care. The tertiary survey involves serial re-evaluation of the patient’s status during his or her hospital course. The next section reviews the process of trauma resuscitation and reviews diagnostic modalities and treatment options for specific injuries.


Airway


A definitive airway should be established in patients with GCS of 8 or less or if airway protection is in jeopardy for any reason.


Breathing


Breathing (ventilation) should be adequate including treating chest injuries such as hemothorax or pneumothorax ( Table 5-1 ).



Circulation


Obvious life-threatening bleeding should be controlled immediately.




Airway


A definitive airway should be established in patients with GCS of 8 or less or if airway protection is in jeopardy for any reason.




Breathing


Breathing (ventilation) should be adequate including treating chest injuries such as hemothorax or pneumothorax ( Table 5-1 ).





Circulation


Obvious life-threatening bleeding should be controlled immediately.




Primary Survey


Patients who transiently respond or do not respond to resuscitation usually have ongoing bleeding and require further investigation and possibly operative intervention ( Boxes 5-1 and 5-2 ). Radiographs of the chest and pelvis can quickly rule out these areas as a source of hemorrhage. Another adjunct to the primary survey that can be used to determine sources of bleeding is the focused abdominal sonography for trauma (FAST) examination. The pericardial view of FAST can quickly evaluate a patient for pericardial effusion and possible cardiac tamponade. The hepatorenal, splenorenal, and pelvic views look for intraperitoneal blood.



Box 5-1

Primary Survey





  • Airway —rapidly assess and secure airway if needed



  • Breathing —listen for breath sounds and treat pneumothorax/hemothorax



  • Circulation —control bleeding, assess pulses and hemodynamic status, and obtain intravenous access



  • Disability —assess neurologic function



  • Exposure/Environment —look for obvious external injury and ensure patient warmth




Box 5-2

Five Locations of Blood Loss Resulting in Hemorrhagic Shock





  • Thorax



  • Abdomen



  • Pelvis/retroperitoneum



  • Long bone fractures



  • Obvious bleeding source




Hemothorax is managed as previously described ( Table 5-1 ). Blood contained in the pelvis secondary to a fracture is best controlled by stabilization of the pelvis. Temporary stabilization with pelvic binders or bed sheets or operative stabilization using external fixators immediately returns the pelvis to its original size and may be indicated if the pelvic ring is grossly disrupted. This maneuver decreases the volume of the pelvis and compresses the pelvic hematoma. This is an excellent way to control pelvic venous hemorrhage but is not as effective for pelvic arterial bleeding, which may require angiographic embolization in the interventional radiology suite. Other contained areas of significant bleeding occur with long bone fractures. These injuries should be managed by a splint to decrease the potential space into which hemorrhage can occur. Realignment is advantageous to extremity viability and restoring arterial circulation, as evidenced by a return of distal pulses and perfusion. Blood loss associated with intra-abdominal injuries may require angiographic embolization or operative intervention or both. The patient may also be in shock for reasons other than hemorrhage ( Table 5-2 ).



TABLE 5-2

Five Traumatic Causes of Hypotension Not Attributable to Hemorrhage

































































Condition Treatment
Tension Pneumothorax
Distended neck veins Relieve by needle thoracostomy
Ipsilateral tympanum on percussion Placement of chest tube
Contralateral tracheal deviation
Cardiac Tamponade
Distended neck veins Operative decompression
Muffled heart sounds
Hypotension
Pericardial stripe on ultrasound
Myocardial Infarction
ST segment changes on 12-lead electrocardiogram or monitor Increase oxygen supply, pain control
Elevation of cardiac enzymes and troponin Aspirin and cardiology consultation
May need cardiac catheterization
Blunt Cardiac Injury
Suspect in patients with thoracic trauma and sternal injury Supportive
Tachycardia most common arrhythmia
Abnormal echocardiogram
Neurogenic Shock
Bilateral motor and sensory deficits Volume resuscitation
Warm skin Pressors
Possible inotrope


After the patient’s airway, breathing, and circulation concerns have been addressed, the focus can turn to reducing disability. If at any time there is a change in vital signs, mental status, or ability to protect the airway or ventilate adequately, the primary survey should be repeated.


Disability


An initial brief neurologic evaluation should be performed to ascertain the level of consciousness, the pupillary response, and whether there is any gross neurologic deficit either centrally or in any of the four extremities. A quick way to describe the level of consciousness is using the acronym AVPU ( A lert, responds to V oice commands, responds to P ain, U nresponsive). The Glasgow Coma Scale (GCS) ( Table 1-2 ) is a more detailed assessment of the level of consciousness. Patients with a GCS score of 3 to 8 are considered to have a severe head injury and require airway control. A GCS score of 9 to 13 signifies a moderate head injury, and a score of 14 to 15 is consistent with a minor head injury. It is essential to obtain a baseline disability examination before sedating the patient for intubation, if needed. The cervical, thoracic, and lumbar spines are protected from injury by being placed on a long board with cervical spine immobilization.


Exposure and Environmental Control


All clothing should be removed from the patient to facilitate a complete examination. After completion of the examination, the patient should be covered with a warm blanket to prevent hypothermia. Patients with hypothermia need prompt warming.


Patients with thermal burns should have any burned clothing rapidly removed to prevent further injury and should be covered with sterile sheets. Patients with a chemical burn should have their clothes removed and the burn site irrigated. The skin should be reexamined to ensure that burning is not continuing. The patient is then covered with sterile dry dressings.




Disability


An initial brief neurologic evaluation should be performed to ascertain the level of consciousness, the pupillary response, and whether there is any gross neurologic deficit either centrally or in any of the four extremities. A quick way to describe the level of consciousness is using the acronym AVPU ( A lert, responds to V oice commands, responds to P ain, U nresponsive). The Glasgow Coma Scale (GCS) ( Table 1-2 ) is a more detailed assessment of the level of consciousness. Patients with a GCS score of 3 to 8 are considered to have a severe head injury and require airway control. A GCS score of 9 to 13 signifies a moderate head injury, and a score of 14 to 15 is consistent with a minor head injury. It is essential to obtain a baseline disability examination before sedating the patient for intubation, if needed. The cervical, thoracic, and lumbar spines are protected from injury by being placed on a long board with cervical spine immobilization.




Exposure and Environmental Control


All clothing should be removed from the patient to facilitate a complete examination. After completion of the examination, the patient should be covered with a warm blanket to prevent hypothermia. Patients with hypothermia need prompt warming.


Patients with thermal burns should have any burned clothing rapidly removed to prevent further injury and should be covered with sterile sheets. Patients with a chemical burn should have their clothes removed and the burn site irrigated. The skin should be reexamined to ensure that burning is not continuing. The patient is then covered with sterile dry dressings.

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Sep 30, 2019 | Posted by in ORTHOPEDIC | Comments Off on Multiple Trauma
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