Initial Evaluation and Treatment of the Multiple Trauma Victim

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Initial Evaluation and Treatment of the Multiple
Trauma Victim
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Epidemiology

• Trauma is a disease of the young, and is the
  leading cause of death in patients between the
  ages of 1-44.
• In 2001 there were 38,000 traffic fatalities, 39
  were alcohol related.
• In 1999 28,000 deaths from firearms, 115,000
  injuries annually
• Fatalities represent only a fraction of all
  patients that suffer from traumatic injuries.

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Mechanism of Injury

• Knowledge of the mechanism of injury can alert
  one to specific injuries.
• Auto crashes Broken windshield, bent steering
  wheel, knees to dashboard, restraint type, type
  of accident, speed of accident, extrication time.
• Penetrating injuries
• GSWs
• Falls LD50 for falls is 4 stories (48 ft)
• Strangulation

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Initial Triage of the Trauma Patient

• Assess Vital Signs and LOC SBPlt90, RRlt10 or gt29,
  GCS lt14, or RTS

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Initial Triage of the Trauma Patient

• Assess Injury Penetrating injuries, flail chest,
  trauma with burns, two or more proximal long bone
  injuries, pelvic fx, paralysis, amputations.
• Assess Mechanism Ejected, death in same
  accident, long extrication time, fall gt20 ft,
  rollover, high speeds, intrusion, major auto
  damage, motorcycle crash gt20 mph, auto-ped or
  auto-bicycle over 5 mph
• Consideration of Other factors extremes of age,
  pregnancy, bleeding d/o, serious underlying
  diseases like cardiac or pulmonary disease,
  diabetes, cirrhosis, etc.

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Initial Approach

• Team approach with team leader directing care is
  optimal, may vary with institution.
• Assume the most serious injury is present
• Treatment based on limited assessment, before
  diagnosis.
• Start with brief initial survey, followed by
  resuscitation, then secondary survey as patient
  is stabilized.
• Frequent reassessment and constant monitoring.

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Primary Survey

• A Airway with c-spine control
• B Breathing
• C Circulation -control external bleeding.
• D Disability-neurological status
• E Exposure (undress patient)/Environment
  (Warmed fluids/blankets)

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Initial Stabilization

• ABCs- initial assessment of airway and
  ventilation.
• Assess airway look for obstruction with debris,
  blood, teeth, etc. vs. obstruction from displaced
  anatomical structures.
• Assess ventilation look at the rate and quality
  of respirations. Ventilation may be compromised
  by decreased LOC, flail segments, penetrating
  wounds, look for tracheal deviation, distended
  neck veins.

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Airway Maintenance with Cervical Spine Protection.

• GCS score of 8 or less require the placement of
  definite airway.
• Spinal precautions must be maintained during
  airway manipulation.
• A normal neurological exam alone does not exclude
  a cervical spine injury.
• Always assume a cervical spine injury in any pt
  with multi-system trauma, especially with an
  altered level of consciousness or distracting
  injury.

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Circulation

• Look for signs of shock by assessing
• LOC
• skin color
• pulse
• urine output
• Control bleeding
• Direct pressure
• Limited use for tourniquets, MAST
• Establish IV access

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Circulation

• Initial Fluid with crystalloid
• Blood loss replaced with 2-3x volume in
  crystalloid
• Hypertonic saline
• Indications for Transfusion
• Patient clinically unstable after 2-3 Liters or
  40-50 ml/kg crystalloid
• Type O uncrossmatched blood/type specific blood
• On-going blood loss usually located in one of the
  three body cavities chest, abdomen,
  retroperitoneum.

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Disability ( Neurological Evaluation)

• Assess Patients level of consciousness
• A Alert
• V Responds to Vocal stimuli
• P Responds to Painful stimuli
• U Unresponsive to all stimuli
• P Assess pupils
• Assess patient for signs of impending herniation
• Keep patient in full spinal precautions until
  full evaluation is complete

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Exposure / Environmental Control

• Completely undress patient,
• Warm ambient temperature, warmed blankets to
  decrease heat loss
• All fluids/blood products should be warmed
• Early control of hemorrhage.

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Initial Evaluation

• Multiple trauma patients should have constant
  cardiac monitoring, continuous pulse ox, and
  initial set of vitals upon arrival.
• Vitals should be reassessed frequently to
  determine response to initial resuscitation
• Oxygen should be routinely administered.
• In patients who do not need immediate
  intervention based on primary survey should have
  initial radiological evaluation including a chest
  and pelvis.

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Secondary Survey

• AMPLE history
• Physical consists of a head to toe evaluation of
  patient.
• Thorough evaluation of neurological status, and
  complete exam of cardiac, abdominal,
  musculoskeletal and soft tissue systems.
• Reassess vitals/EKG
• Placement of NG tube/ Foley after evaluation for
  contraindications

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Secondary Exam Neurological Evaluation
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Secondary Exam - Neuro

• Complete Neuro exam should include evaluation of
  level of consciousness, pupil responses, careful
  cranial inspection, and evaluation for spinal
  tenderness and spinal and peripheral nerve
  function, including rectal tone
• Head injury Classification
• Mild GCS 14-15
• Moderate GCS 9-13
• Severe GCS 3-8

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Secondary Exam- Neuro
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Intracranial NG Tube Placement
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Incomplete Cord Syndromes
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Secondary Exam Lethal Thoracic Injuries
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Lethal Thoracic Injuries

• Tension pneumothorax
• Hemothorax
• Pulmonary contusion
• Tracheobronchial-bronchial tree injury
• Cardiac contusion/tamponade
• Traumatic aortic disruption
• Traumatic diaphragmatic injury
• Mediastinal traversing wounds.

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Secondary Exam Abdominal Evaluation
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Secondary Exam- Abdominal Evaluation

• Initial stabilization of vital signs with
  fluid/blood.
• Any patient with altered mental status, or
  distracting injuries requires an objective
  evaluation of the abdomen via DPL, CAT scan, or
  Ultrasound.
• CAT scan is noninvasive, and sensitive. Also
  allows evaluation of the retroperitoneum. Limited
  use in patients who are unstable and do not
  respond to initial resuscitation.

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Secondary Exam- Abdominal Evaluation

• Ultrasound is noninvasive and can be used at
  bedside to detect hemoperitoneum.
• Useful in unstable patients
• FAST exam evaluates the RUQ (Morisons pouch),
  LUQ(splenorenal recess), pericardium, and pouch
  of Douglas in less than 5 minutes.

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FAST Exam
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Secondary Exam- Abdominal Evaluation

• Unstable patients with decreased level of
  consciousness and DPL or U/S needs urgent
  laparotomy head CT should not be performed
  unless there is lateralizing neurological
  findings.
• Unstable patients with a wide mediastinum and
  DPL or U/S laparotomy is recommended before arch
  aortography