Multisystem Trauma

Overview of the Critically Injured Patient

Trauma is… Single System: an injury involving a single isolated body system Single System: an injury involving a single isolated body system Multiple System: an injury that involves two or more body systems Multiple System: an injury that involves two or more body systems

Trauma System Compenents Access Access Prehospital Prehospital Initial Resuscitation Initial Resuscitation Acute Care Acute Care Rehabilitation Rehabilitation

Types of Trauma Blunt Blunt Penetrating Penetrating Blast Blast Intentional Intentional Nonintentional Nonintentional

Types of Injury Primary: occurs at the time of injury Primary: occurs at the time of injury Secondary: occurs as the result of secondary insults (hypoxia, hypotension, infection etc.) Secondary: occurs as the result of secondary insults (hypoxia, hypotension, infection etc.)

Mitigating Factors Younger than 5, older than 55 Younger than 5, older than 55 Medical / surgical hx. Medical / surgical hx. Substance abuse Substance abuse Severity of injury Severity of injury Time of injury to definitive care Time of injury to definitive care Quality of care Quality of care

General Approach

Assessment Primary Survey / resuscitation Primary Survey / resuscitation Secondary assessment Secondary assessment Psychological, social and environmental factors Psychological, social and environmental factors

Mechanism of Injury and Kinematics Mechanism=detailed cause or type of event Mechanism=detailed cause or type of event Kinematics = physics of trauma, how is energy dispersed Kinematics = physics of trauma, how is energy dispersed Part of primary survey…listen to prehospital caregivers Part of primary survey…listen to prehospital caregivers

Fundamentals of Initial Resuscitation

Concepts Assessment and resuscitation occur simultaneously Assessment and resuscitation occur simultaneously Reassess frequently Reassess frequently Establish priorities and anticipate needs Establish priorities and anticipate needs Life over limb Life over limb Preparedness, organization, communication Preparedness, organization, communication Someone must be in control Someone must be in control Do no further harm Do no further harm If condition progressively worsens…definitive care is needed. If condition progressively worsens…definitive care is needed.

Goals of Resuscitation Oxygenation of vital tissues….it’s all about perfusion Oxygenation of vital tissues….it’s all about perfusion

Primary Assessment Subjective Data Subjective Data Mechanism of InjuryMechanism of Injury Chief ComplaintChief Complaint

Airway / cervical spine Signs / Symptoms Signs / Symptoms Decreased LOCDecreased LOC AgitationAgitation StridorStridor CyanosisCyanosis Accessory MusclesAccessory Muscles HoarsenessHoarseness No air movementNo air movement Treatment Treatment Establish airway without manipulation of cervical spine Jaw thrust Suction NP / OP airways ETT

Breathing Signs / Symptoms Signs / Symptoms Cyanosis, decreased breath sounds, increased resp. rate, decreased LOC, noisy resp., hypoxia, acidosis.Cyanosis, decreased breath sounds, increased resp. rate, decreased LOC, noisy resp., hypoxia, acidosis. Diagnosis Diagnosis Assess clinical presentation, ABG’s, oximetry trends, CO2 monitoring, CXRAssess clinical presentation, ABG’s, oximetry trends, CO2 monitoring, CXR Treatment Treatment High flow O2, assist ventilation, treat tension pnuemo, open pnuemo, flail chest or hemothorax, PAIN MANAGEMENTHigh flow O2, assist ventilation, treat tension pnuemo, open pnuemo, flail chest or hemothorax, PAIN MANAGEMENT

Circulation Signs of hypovolemic shock Signs of hypovolemic shock Altered LOC, tachycardia, hypotension, tachypnea, cool diaphoretic skin, low UOP, slow capillary refill time.Altered LOC, tachycardia, hypotension, tachypnea, cool diaphoretic skin, low UOP, slow capillary refill time. Diagnosis Diagnosis CBC, PT, PTT, X rays, DPL, US, arteriogramsCBC, PT, PTT, X rays, DPL, US, arteriograms Treatment of hypovolemia Treatment of hypovolemia Direct pressure to external bleeding, high flow O2, 2 lg bore IV’s, fluids, bloodDirect pressure to external bleeding, high flow O2, 2 lg bore IV’s, fluids, blood Rule out sources of obstructive shockRule out sources of obstructive shock

Spinal Immobilization Based on mechanism, not neuro deficit Based on mechanism, not neuro deficit SCI may occur with or without bony involvement SCI may occur with or without bony involvement High index of suspicion High index of suspicion Pain, paralysis, paresthesia, ptosis, priapism, presenting position, pregnancy, MOI.Pain, paralysis, paresthesia, ptosis, priapism, presenting position, pregnancy, MOI. Diagnostics Diagnostics Initial AP/ lateral to include C-7 andInitial AP/ lateral to include C-7 andT-1 Correlate with physical examCorrelate with physical exam CTCT

Disability / Neuro Assessment AVPU AVPU Trend Glasgow Coma Scale score Trend Glasgow Coma Scale score Trend pupillary size Trend pupillary size Assess motor function of all four ext. Assess motor function of all four ext. Diagnostics…rule out Diagnostics…rule out Decreased perfusion or direct cerebral injury, Drugs / ETOH, Hypoxia, HypotensionDecreased perfusion or direct cerebral injury, Drugs / ETOH, Hypoxia, Hypotension

Disability – Treatment Complete primary survey Complete primary survey Treat life threatening injury Treat life threatening injury Complete secondary survey Complete secondary survey Rapid resuscitation Rapid resuscitation Avoid prolonged hyperventilation Avoid prolonged hyperventilation Avoid hypotension SBP>90 Avoid hypotension SBP>90 Serial monitoring of VS / NS Serial monitoring of VS / NS Consider Narcan or Mannitol Consider Narcan or Mannitol

Exposure Judicious nakedness. Judicious nakedness. Keep patients WARM. Keep patients WARM. Monitor temperature carefully Monitor temperature carefully

Secondary Survey Should not be initialized until life threatening injuries are treated and primary assessment is complete Should not be initialized until life threatening injuries are treated and primary assessment is complete AMPLE History AMPLE History Head to Toe physical exam, including posterior surfaces Head to Toe physical exam, including posterior surfaces

Preparation for Further Diagnostics Foley (if no contraindications) Foley (if no contraindications) maintain UOP >30 ml / hr maintain UOP >30 ml / hr Decompress stomach with NG Decompress stomach with NG If no CSF leak, midface fxIf no CSF leak, midface fx

Special Populations Pediatrics Pediatrics Geriatrics Geriatrics

The Pregnant Trauma Patient Resuscitation priorities are identical to those on non-pregnant trauma patient. Resuscitation priorities are identical to those on non-pregnant trauma patient. Consult OB resources early in resuscitation. Consult OB resources early in resuscitation.

Questions?