Multisystem Trauma

Multisystem Trauma

Overview of the Critically Injured Patient

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

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

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

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

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

General Approach

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

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

Fundamentals of Initial Resuscitation

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

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

Primary Assessment • Subjective Data • Mechanism of Injury • Chief Complaint

Airway / cervical spine • Signs / Symptoms • Decreased LOC • Agitation • Stridor • Cyanosis • Accessory Muscles • Hoarseness • No air movement • Treatment • Establish airway without manipulation of cervical spine • Jaw thrust • Suction • NP / OP airways • ETT

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

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

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

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

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

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

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

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

Pediatrics Geriatrics Special Populations

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

Multisystem Trauma