Initial Evaluation and Treatment

of the Multiple Trauma Victim

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.
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
GSW’s
Falls : LD50 for falls is 4 stories (48 ft)
Strangulation
Initial Triage of the Trauma
Patient
Assess Vital Signs and LOC: SBP<90,
RR<10 or >29, GCS <14, or RTS
 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 >20 ft,
rollover, high speeds, intrusion, major auto
damage, motorcycle crash >20 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.
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.
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)
Initial Stabilization
ABC’s- 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.
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.
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
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.
Disability ( Neurological
Evaluation)
Assess Patient’s 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
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.
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.
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
Secondary Exam: Neurological
Evaluation
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
Secondary Exam- Neuro
Intracranial NG Tube Placement
Incomplete Cord Syndromes
Secondary Exam :Lethal
Thoracic Injuries
Lethal Thoracic Injuries
Tension pneumothorax
Hemothorax
Pulmonary contusion
Tracheobronchial-bronchial tree injury
Cardiac contusion/tamponade
Traumatic aortic disruption
Traumatic diaphragmatic injury
Mediastinal traversing wounds.
Secondary Exam: Abdominal
Evaluation
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.
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 (Morison’s
pouch), LUQ(splenorenal recess),
pericardium, and pouch of Douglas in less
than 5 minutes.
FAST Exam
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