High-velocity trauma is a major cause of death among those aged 18-44 years of age throughout the world. Many die from blunt trauma (80 percent), especially in those aged 34 and under. These types of injuries have cost the US $75 billion USD in lost income alone each year.
The Multiple Injury Patient
Multiple injured patients often have an injury severity score of greater than 18. They also often suffer from the following:
- Abdominal injuries
- Pulmonary injuries
- Closed head injury
- Hemodynamic injury
The goal of the EMTs in the field when dealing with the multiple traumatized patient is to triage according to airway and breathing concerns, circulation and perfusion, control of hemorrhage, ability to extricate quickly, management of shock and transport. Fractures often take secondary or tertiary status to other types of injuries.
Most people die from their injuries in three different phases. Those that die immediately die from brain injury, circulatory collapse, and things that can be reversed somewhat by education about helmets, seat belts and other safety gear. People also die a few hours after injury due to intracranial bleeding, rupture of a major organ, pneumothorax with blood in the lung space, and major blood loss. This is where level I trauma centers can intervene. Late onset death can occur days to weeks after injury and occur from things like pulmonary embolism, sepsis or failure of multiple organs. The older the patient is, the greater is their risk of death.
Because many die early, the “golden hour” is very important in order to get the patient to a tertiary care facility within an hour of injury. For every half hour after the first hour, there is a threefold increase in mortality if not cared for at a trauma center.
The Trauma Team
Usually, the general surgeon leads the trauma team but the orthopedic surgeon is important as well. All musculoskeletal injuries fall under the realm of the orthopedic surgeon, who must manage things like:
- Pelvic injuries, often requiring internal fixation
- Open fractures
- Splinting and traction
- Nailing of long bones
The ABC’s of Resuscitation
The ABC’s of resuscitation results in immediate attention paid to the airway. This includes removing foreign bodies, suctioning of secretions, tracheostomy placement and other airway concerns, with special attention made to protecting the cervical spine at the same time.
Breathing is also important to resuscitation. This means that ventilation must be adequately managed through diagnosing things like tension pneumothorax, flail chest, open pneumothorax, malposition of the endotracheal tube and evaluation/treatment of hemothorax.
Intubation is necessary to control the airway if impaired, to prevent aspiration if the patient is unconscious, for hyperventilation in those with increased intracranial pressure and for help in managing the airway in a patient who has multiple facial traumas with edema of the upper airway.
- Circulation means that the patient is hemodynamically stable with a normal heart rate and blood pressure. If the patient is hypotensive, they are suffering from hemorrhage until otherwise proven. Because circulation is important, two large bore IVs are necessary to help maintain circulation and to prevent shock. Remember that children may be able to have tibial interosseous infusion. Cutdowns of the saphenous vein can be done in adults.
Blood pressure and urine output should be monitored on a continual basis to make sure that the patient has an adequate circulation at all times. The blood pressure needs to be at least 60 systolic in order to feel a carotid pulse and at least 80 systolic to feel a radial pulse.
The Patient in Shock
Shock needs to be managed by control of obvious areas of bleeding through direct pressure. Large bore IVs are important to correct shock and to maintain urine output, which should be continually monitored. Blood may need to be given. Traction of some extremity fractures will may help decrease hemorrhaging from fractured areas. Angiography may be necessary to decide what types of injuries need to go to the operating room right away and what can wait.
Shock can be due to more than one thing. When in doubt, assume that some of the shock is due to blood loss. Cardiogenic shock can also be due to a cardiac arrhythmia, pericardial tamponade, or myocardial damage. Treatment is to do a pericardiocentesis if pericardial tamponade is shown to be the cause.
Neurogenic shock is often due to those who have a thoracic spine injury. There is no tachycardia or vasoconstriction as is seen in hemorrhagic shock. Treatment is to restore volume and to give vasoactive drugs.
Septic shock can be due to gas gangrene, open fractures and contaminated wounds. The presentation is that of fever, cold skin, tachycardia and failure of major organs. This is a late phase phenomenon.
Hemorrhagic shock accounts for more than 90 percent of patients who suffer from acute shock following trauma. The patient often has tachycardia and low blood pressure. Internal or external bleeding can be a part of the problem. CT scan or MRI scan can show areas of internal hemorrhage. The treatment of this type of shock includes reversal of fluid loss, blood transfusions and angiographic embolization in some cases where bleeding can’t otherwise be controlled.
- Class 1: Less than 15 percent of blood loss has occurred. BP, pulse and capillary refill often do not change. Crystalloid fluids can help.
- Class 2: This is when 15-30 percent of blood has been lost. There is usually a normal blood pressure but tachycardia is present. Crystalloid fluid replacement will take care of this in most cases.
- Class 3: Thirty to 40 percent loss of circulating blood volume has been lost. There is low blood pressure and elevated pulse along with rapid respiratory rate. Crystalloid and blood products both need to be given with crystalloid given first to restore BP and then blood products to give hemoglobin back to the system.
- Class 4: More than 40 percent of blood volume has been lost. There is significant hypotension and tachycardia. Blood products need to be given as soon as possible.
Blood should be matched if possible but if there is no time, then O- blood is given if the situation is dire. Saline cross-matched blood can be available within 10 minutes. Fully cross-matched blood takes up to an hour. Warming the blood is important when giving large quantities of blood so that the patient does not become hypothermic. Coagulation status needs to be looked at when giving a lot of blood because these are not part of packed red blood cells and things like platelets and coagulation factors may need to be given.
These are good for pelvic fractures and lower extremity fractures. Peripheral vascular resistance is improved with anti-shock garments and blood is less pooled in the lower extremities. It can limit access to the abdomen and lower extremities if open fractures are present. It can worsen congestive heart failure in high-risk patients and compartment syndrome can ensue. The advantages, on the other hand, include rapid return of centralized blood pressure. If there is severe chest trauma, it should not be used because it can interfere with respirations.
This is the injury severity score, which helps understand patients with multiple trauma. These areas are scored from looking at certain body areas. ISS is the score given to a given body area squared added to the next body area squared. The body areas included are:
- Soft tissue
- Head and neck
The score is given from 1-6, with one being minor and 6 being fatal. The maximum score is 75 for all body areas.
The Glasgow Coma Score
This evaluates the neurological status of the patient and looks at things like eye opening, motor responses, verbal responses, and orientation. The range is from 3-15, with higher numbers being better than lower scores.
Revised Trauma Score
This takes into account the Glasgow coma score, the systolic blood pressure and the respiratory rate, with higher scores being better than lower scores.
X-Rays to be taken
- Lateral C-spines are taken to see all 7 vertebrae and T1. CT scan of the head and cervical spine may need to be indicated. CXR should be done along with a pelvic x-ray. Nowadays, CT scans of these areas can be done almost as quickly as x-rays and have replaced some of these plain films in trauma cases.
- Stabilizing the Patient
- The idea is to restore respirations, hemodynamic stability, organ perfusion, oxygenation, and kidney function. Bleeding disorders should be treated, if present. Risk of DVT is high during this stage because blood flow is sluggish and the patient isn’t moving. There may be up to 60 percent chance of DVTs in patients who are multiply injured, especially with those who have spinal injuries, fractures of the femur, tibial fractures and fractures of the pelvis. Low molecular weight heparin or warfarin can be given in those who are not actually bleeding. Vena caval filters can be used to prevent DVTs from travelling to the lungs to become pulmonary embolisms.
Patients are also at risk for lung injuries, multi-organ failure, sepsis, and adult respiratory distress syndrome following a major injury, especially fractures to long bones. Early fracture repair should be done in femur fractures and pelvic fractures because they have high lung complications. If there is risk for compartment syndrome, surgery should be done early. Open fractures need urgent surgery to prevent infection. Patients with unstable spinal fractures need urgent surgery. Those fractures that carry the risk of necrosis of parts of the fracture, such as of the talar neck or femoral neck should be treated in the operating room early.
Major Sources of Injury
These are major injuries associated with multiple trauma:
- Head injury. These should be diagnosed early in the injury assessment. The Glasgow coma scale can be used to identify these types of injuries. CT scan of the head should be done if a head injury is suspected. Things like cerebral contusions epidural hematomas, subdural hematomas and subarachnoid hemorrhages are possible.
- Thoracic injuries. These can be blunt or penetrating traumas. If the scapula is fractured, the lungs are likely affected, too. Chest tube placement may be necessary for pneumothorax or hemothorax (or both).
- Abdominal injuries. These also can be blunt or penetrating injuries. CT scans can show areas of bleeding or other trauma to the gut or major organs. Pelvic fractures can be picked up on CT scans of the abdomen. Peritoneal lavage is currently the best way to prove or disprove an abdominal injury.
- Genitourinary injuries. These are high risk in pelvic fractures. About 15 percent of abdominal injuries also have injuries to the genitourinary system. A catheter should be done if blood is seen at the opening to the urethra. A retrograde urethrogram, however, should be done first to make sure the area is patent. IVPs, voiding cystourethrograms and cystograms should be done if there is blood in the urine.
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