ABC’s of Multi System
Trauma
Christopher Freeman M.D.
Multi system trauma

Invention of
Motor Vehicles

High Forces

Multiple Injuries
Multi system trauma

The most dramatic injury
usually is NOT the most
dangerous

Primary Survey
Secondary Survey
Re-evaluation


Initial Management

Airway
Breathing
Circulation
Disability
Exposure

Correct problem before moving on




Airway




Assess for Patency
Look

FB in Airway

Blood/Vomit/Secretions
Listen

Noisy Breathing = Obstructed Breathing

Normal speech = No Obstruction
Feel

Tracheal Location and Midline Shift
Airway Obstruction

Be Vigilant with

Maxillofacial Trauma

Neck Trauma

Laryngeal Trauma

Nonverbal Patients
Airway Interventions

Remove FB/Secretions/Emesis
Chin lift/Jaw Thrust
Oral/Nasopharyngeal airways

Reassess after interventions

Maintain C spine precautions


Breathing


Open airway = Ventilation
Look


Listen


Chest rise/Symmetric movement
Symmetric and adequate BS/Adequate rate
Feel

Crepitus
Breathing

Danger Signs
 Respirations <10
 Respirations >24
 Poor Chest Rise
 Labored breathing
 Crepitus
Breathing

If inadequate ventilation/airway

BVM 2>1

LMA

Combitube

ET intubation
Breathing



Remember:
If Adequate BVM +/- Intubating
All trauma patient deserve Oxygen


Face mask is best
Protect the Spine
Circulation

Look



Skin Color
Listen

BP Late sign

Level of Consciousness
Feel

Pulse

Perfusion
Circulation



Interventions

IV Fluids

Control Hemorrhage
Tourniquet uncontrolled bleeding in unstable
patient
Reassess after interventions
Disability

GCS

APVU
Exposure

Remove from toxic exposures

Remove wet clothing

Prevent hypothermia

Expose for exam
Secondary Survey

After primary  If stable

No Secondary  No problem
Multiple Trauma





Goal  Stabilize patient and transport to
definitive care
Definitive Care unstable patient  OR
Minimum time on scene
Maximum treatment in route
Continue reassessment  ABC’s
Case 1

20’s y/o M, single car
MVA into tree,
ejected, found on
ground, unresponsive
Airway

Look


Listen


Blood in airway
Gurgling
Feel

Midline trachea
Airway Intervention

Suction
Jaw thrust/Chin lift

Reassessment


Clear respirations, No FB present in airway
Breathing

Look


Listen


Symmetric, adequate chest rise, no paradoxical
movement
Rate 20, equal BS B/L
Feel

Crepitus over L chest Wall
Breathing Intervention


???
Crepitus  No respiratory distress
Circulation

Look


Listen


Pale, no obvious bleeding
100/60, Arousable to stimuli
Feel

HR 130’s, Cool to touch
Circulation Intervention

Place 2 Large bore IV
Bolus 2 L NS

Reassess Vitals

Disability

GCS

Eyes 2

Verbal 3

Motor 5

Total 10
Exposure



Wet clothes removed
No obvious limb injury
Blanket applied
Reassessment

Airway


Gurgling Suction with improvement
Breathing

RR 34, Decreased BS on L, L sided Crepitus…
Diagnosis

Tension Pneumothorax
Breathing Intervention

Needle Decompression L chest Wall
Reassessment

Airway



Clear, no gurgling, trachea midline
Breathing

RR 20, Equal chest expansion, good chest wall rise

Needle 2nd intercostal space midclavicular line
Circulation

HR 110, BP 110/70, Skin Warm/Well perfused
Secondary Survey

Blah, Blah, Blah
Disposition






To ED, Stable
Admitted
Concussion
R CT, PTX/HTX
Grade 3 liver laceration
D/c from hospital 1 week later
Case 2




27 Y/O MCA into Car
Unhelmeted, thrown from vehicle
Found on ground
Bystander called EMS
Airway

Look


Listen


Blood in airway
Gurgling respiration
Feel

Midline trachea
Airway Intervention

Suction
Jaw thrust/Chin lift
Oropharengeal Airway placed

Reassessment



Quiet, No FB present in airway
Breathing

Look


Listen


Symmetric, Poor chest rise, no paradoxical
movement
Rate 6, diminished BS B/L
Feel

Crepitus over B/L chest Wall
Breathing Intervention

BVM
Breathing Reassessment

Look


Listen


Symmetric, Poor chest rise, no paradoxical
movement
Rate 18 by BVM, diminished BS B/L
Feel

Crepitus over B/L chest Wall
Breathing Intervention

B/L Needle Decompression
Breathing Reassessment

Look


Listen


Symmetric, Adequate chest rise, no paradoxical
movement
Rate 20 by BVM, equal BS B/L
Feel

Crepitus over B/L chest Wall
Circulation

Look


Listen


Pale, Bleeding from LLE, LUE
80/50, unconscious, unarousable
Feel

HR 140’s, Cool to touch
Circulation Intervention

Place 2 Large bore IV
Bolus 2 L NS
Pressure on bleeding sites

Reassess Vitals


Circulation Reassessment

Look


Listen


Pale, Persistent bleeding LLE, Bleeding controlled
LUE
80/50, unconscious, unarousable
Feel

HR 150’s, Cool to touch
Circulation Intervention

Tourniquet to LLE
Disability

GCS

Eyes 1

Verbal 2

Motor 4

Total 7
Exposure



Wet clothes removed
Limb deformity, Bleeding LUE, LLE
Blanket applied
Reassessment

Airway


Oropharngeal Airway in place, No FB
Breathing

RR 20, Decreased BS on B/L, Increased Airway
resistance
Intervention



Chin Lift/ Jaw Thrust
Oral Suction
Needle decompression
Reassessment

Airway


Breathing


Oropharngeal Airway in place, No FB
RR 20, Equal BS on B/L, Normal resistance
Circulation

HR 120’s, BP 90/50, Bleeding controlled with
tourniquet
Secondary Survey

Not Done prior to arrival
Disposition



To ED, Unstable
Arrest In ED
ED Thoracotomy  Unsuccessful
Summary

Keep it Simple

ABC’s

Airway Management = Intubation

Minimize time to Definitive treatment  OR
Questions?