Management of patients with
multiple trauma
Prof. M K Alam MS; FRCS
ILO’s
 Incidence of trauma
 Causes and types of trauma
 Timing and mode of death in trauma patients and its effect on trauma
management.
 Pre-hospital care and triage
 Hospital care
 Primary survey and initial management
 Secondary survey
 Pathophysiology of common injuries
 Investigations during primary and secondary survey
 A brief outline of management of major injuries.
Epidemiology
• Trauma remains the most common cause of
death between the ages of 1 and 44 years.
• Affects a disproportionate number of young
people- the burden to society in terms of lost
productivity, premature death, and disability is
considerable.
• A major public health issue.
Arab News 16th Feb. 2014
Arab News 3rd March 2014
Arab News 16th Feb 2014
• 20 deaths daily on the Kingdom's roads.
• Last year- 707 amputations due to RTA.
• Accidents increased by 78% in the KSA recently
• Affecting mostly young between 18 and 22 years
• Around 30% of those injured are permanently disabled.
• The state has spent SR21 billion treating such patients
Causes of trauma
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RTA or MVA
Pedestrian trauma
Fall from height
Assault
Firearm injuries
Knife
Industrial accidents
Natural disasters
Explosions
Types of trauma
• Blunt trauma results of an impact from blunt
object
• Penetrating trauma results from an object
piercing the body
• Assessment and diagnosis of blunt injuries are
more difficult than of penetrating injuries
• Multi-trauma- injury affecting simultaneously
different organ and body system
Trimodal death in trauma
• Immediate: Within seconds or minutes after injury- 50% of
deaths due to injury to the aorta, heart, brainstem, or
spinal cord or by acute respiratory distress.
• Early: Within hours of injury- approximately 30% of deaths.
Half of these deaths are caused by hemorrhage and the
other half by central nervous system (CNS) injury.
These patients can be saved by appropriate treatment
(golden hour).
• Late: peaks from days to weeks, mortality due to infection
and multiple organ failure.
Improvement in mortality
• Early deaths: Prevention and control program
by legislation and behavior modification
• Later deaths:
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Trauma centers providing better care.
Better understanding of pathophysiology of
multiple organ failure and brain injury
Pre-hospital care
• Delivery to the hospital for definitive care as rapidly
as possible- scoop and run
• Only critical interventions at the scene
• Airway established, hard collar, spine board, control
any external hemorrhage
• Infusion on way to the hospital
Triage
• Definition:
Prioritizing victims into categories based on
their severity of injury, likelihood of survival,
and urgency of care.
• Goals:
– Identify high-risk injured patients who would
benefit from the resources available in a trauma
center.
– Limit the excessive transport of non-severely
injured patients so that the trauma center is not
overwhelmed.
Hospital care
• ATLS approach
• A well defined order
• Primary survey- initial assessment and management
• Treat the greatest threat to life
• Immediate intervention as the threat to life is identified
• Detailed history not essential
• Re-evaluation of initial management
• Secondary survey- a head to toe evaluation
Primary survey
• ABCDE
• Airway & cervical spine protection
• Breathing
• Circulation
• Disability (neurologic assessment)
• Exposure and Environmental control
Primary survey- a team approach
• Simultaneous diagnosis and treatment by multiple
providers
• Reduces the time to assess and stabilize a multiple
trauma patients
• Team should be organized before patient arrival.
• Leadership and unity of command are essential
Primary survey-one clinician
Do not perform subsequent steps in
the primary survey until after
addressing life-threatening conditions
in the earlier steps.
Part II
A
Airway & cervical spine
• Verbal response: Salam! How are you?
Airway is compromised if:
• No response- unconscious , airway obstruction
• Noisy breathing
• Severe facial trauma
• Oropharyngeal bleeding or foreign body
• Patient agitated - hypoxia
Airway & Cervical spine
• Adequacy of airway- completed within seconds
• Open the front of the collar for airway manipulation
• Maintain manual stabilization by an assistant
• Oropharyngeal airway/ bag valve mask ventilation
• Oxygen supplement + pulse oximetry
• Rapid-sequence endotracheal intubation
• Frequent reassessment for airway compromise
Difficult airway
• Surgical airway when oral intubation cannot
be accomplished:
– Cricothyroidotomy –Surgical
– Percutaneous needle technique- only temporary
– Tracheostomy (laryngeal injury)
B
BREATHING
Life threatening injuries to look for:
• Tension pneumothorax
• Open pneumothorax (open chest wound)
• Flail chest with underlying pulmonary contusion
• Massive hemothorax
BREATHING
• Dyspnoea
• Unilateral diminished chest expansion
• Bruising/ abrasion
• Distended neck vein
• Trachea deviated to the opposite side
• Percussion: dull - haemothorax
Hyper resonant - Pneumothorax
• Diminished/ absent breath sound
Tension pneumothorax
Pathophysiology
• Collapsed lung acts as a one-way valve
• Each inhalation- additional air accumulate in the pleural space.
• Normal negative intrapleural pressure becomes positive,
depressing the ipsilateral hemidiaphragm, pushing the
mediastinal structures into the contralateral chest
• Contralateral lung is compressed, the heart is rotated about
the superior and inferior vena cava, decreasing venous return
and cardiac output while distending the neck veins
Tension pneumothorax
Clinical features & treatment
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Respiratory distress
Tracheal deviation away from the affected side
Lack of or decreased breath sounds
Distended neck veins or systemic hypotension
Subcutaneous emphysema, hyper resonance
Treatment: x-ray confirmation not required
Wide bore needle in 2nd inercost. space, mid clavicular
Chest tube in 5th intercost. space, ant. axillary line
Open pneumothorax or sucking chest wound
Pathophysiology
• Full-thickness loss of the chest wall: free communication
between the pleural space and the atmosphere.
• Collapse of the lung on the injured side
• If the diameter of the injury is greater than the narrowest
portion of the upper airway, air will preferentially move
through the injury
• impair ventilation on the contralateral side
Open pneumothorax
Management
• Complete occlusion of the injury may result in
converting an open pneumothorax into a
tension pneumothorax.
• Initial treatment: occlusive dressing, which is
taped on three sides over the wound
• Dressing permits effective ventilation, while the
untaped side allows accumulated air to escape
from the pleura
• Definitive treatment: wound closure and tube
thoracostomy
Flail chest with pulmonary contusion
Pathophysiology
• Four or more ribs fractured in at least two locations
• Paradoxical movement of free-floating segment may
occasionally compromise ventilation.
• More importantly, an underlying pulmonary contusion
may compromise oxygenation or ventilation
• Initial chest x-ray underestimates the degree of contusion.
• The lesion evolve with time and fluid resuscitation.
Flail chest with pulmonary contusion
Management
• Respiratory failure in these patients may not
be immediate
• Frequent re-evaluation is needed.
• Intubation and mechanical ventilation is
required
Massive hemothorax
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Accumulation of >1.5L of blood
Disruption of large vessel
Flat neck vein
Dullness on percussion
No breath sound
Shock
Management: Chest tube in 5th space, fluid resuscitation.
Thoracotomy if significant bleeding continues.
Part III
C
Circulation
• Assessment of cardiovascular compromise and
management
• Is the patient in shock?
• Is there any external bleeding source?
• Any internal hemorrhage?
Circulation
Pathophysiology
• Shock is secondary to hemorrhage in most trauma patients
• Patient can be in shock before developing hypotension
• Hypotension- a sign of decompensation (class III )
• 5 locations for major blood loss:
Chest
Abdomen
Pelvis and retroperitoneum
Multiple long bone fractures ( lower limb)
External hemorrhage
Pathophysiology of blood loss
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Responses are compensatory
Progressive vasoconstriction- skin, muscle, viscera
Tachycardia to preserve cardiac output
Increased peripheral resistance- catecholamines
Venous return preserved in early stage by reduced
blood volume in venous system
• Continued bleeding- shock develops
• Inadequate tissue perfusion, metabolic acidosis
Classes of hemorrhagic shock
Class I
Class II
Class III
Class IV
Blood loss Up to 750
(ml)
750- 1500
1500- 2000
> 2000
Pulse
<100
>100
>120
>140
BP
Normal
Normal
Decreased
Decreased
Circulation
Indicators of shock in trauma patients
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Tachycardia*
Agitation
Tachypnea
Sweating
Cool extremities
• Weak peripheral pulse
• Decreased pulse
pressure
• Hypotension
• Oliguria
Circulation
Cardiogenic shock
• Tension pneumothorax- most common cause,
Pericardial tamponade(penetrating trauma),
Myocardial contusion
• Beck’s triad- hypotension, distended neck vein
(raised CVP >15 cm H2O), muffled heart sound
• CVP: Hemorrhagic <5 cmH2O
• Dysrhythmias in contusion
• Ultrasonography : helpful in diagnosis
• Treatment: fluid resuscitation, pericardiocentesis
Circulation
Neurogenic shock
• Loss of sympathetic tone due to cord injury
• Hypotension, warm well perfused limbs,
diminished/absent motor function
• Bradycardia
• Management: IV fluid, vasopressor, corticosteroids
Circulation
Septic shock
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Delayed arrival
Penetrating abdominal injuries
Early septic shock- normal circulating volume
Tachycardia
Warm skin
Systolic close to normal,
Wide pulse pressure
Circulation
Initial management
• External haemorrhage- compression dressing
• IV access- two peripheral catheters
• ECG monitoring
• Blood sample- typing and lab. investigations
• Initial resuscitation:1-2L of Ringer's lactate or NS
• Packed red blood cells if no response
• Foley’s catheter: urine output is .5 mL/kg/hour in adult
Circulation
Initial management
Search for any source of blood loss:
• CXR, X-ray pelvis, FAST (focused abdominal
sonography in trauma)
• If fracture pelvis is found pneumatic antishock
garment or a bed sheet wrapped around the pelvis
may be applied
Evaluation of fluid resuscitation
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BP and pulse rate
Urine output (0.5ml/kg/hour)
Mental status and skin color/temperature
CVP
Acid/base status
Management decisions
Rapid responders
• Hemodynamics return to normal after fluid
resuscitation
• Hemodynamics remain stable even after
reducing infusion to maintenance rate.
• Probably bleeding has stopped spontaneously
• Continued evaluation for source of bleeding
• May still need surgery
Management decisions
Transient responders
• Decompensate once fluid resuscitation is slowed
down
• There is ongoing bleeding or inadequate resuscitation
• Increase fluid resuscitation and blood transfusion
(type specific or O negative)
• ?Surgical intervention
Management decisions
Non-responders
• Fail to respond to fluid and blood resuscitation
• Major blood loss (>40%) & ongoing loss
• Immediate surgical intervention
• ? Non-hemorrhagic shock (cardiogenic)
• Echocardiography
• CVP
Part IV
D
Disability
Neurologic evaluation
• Level of consciousness measured by the
Glasgow Coma Scale (GCS)
• If the GCS is used in intubated and paralyzed
patients, record should be made
• Pupillary response can still be assessed in a
paralyzed patient
Glasgow Coma Scale (GCS), Total = 15
Eye response Vocal response
Motor response
Spontaneous 4
Oriented
5
Obeys commands 6
To voice
3
Confused
4
Purposeful movement to pain 5
To pain
2
Inappropriate words 3
None
1
Incomprehensible words 2 Flexion to pain
3
None
Extension to pain
2
None
1
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1
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Withdraw from pain 4
Head injury severity
• Mild
• Moderate
• Severe
GCS ≥ 13
GCS 9- ≤ 12
GCS ≤ 8
E
Exposure/ Environment control
• Completely undress the patient
• Perform a rapid head-to-toe examination
• Identify any injuries to the back, perineum, or other
areas that are not easily seen in the supine position
• Unexpected injuries may be discovered
• Once assessment completed, cover the patient with
blanket ( prevent cold exposure)
Secondary Survey
• Only after completion of primary survey(ABCDE)
• Life threatening injuries have been dealt
• Normalization of vital signs
• A head to toe evaluation
• Detailed history and examination
• Continuous reassessment of vital signs
• Additional lab. & radiological tests and collecting results
• Additional tubes, lines and monitoring devices
• Priorities and plan definitive management of all injuries
Head injury
• Traumatic brain injury (TBI)- the leading cause of death in
trauma patients- 50% of all traumatic deaths.
• Primary injury- the anatomic and physiologic disruption
that occurs as a direct result of trauma
• Secondary injury- extension of the primary injury, result
from local swelling, increased ICP, hypoperfusion,
hypoxemia, or other factors.
• Aim- detection and treatment of primary injury and
prevention of secondary injury
Head injury- management
• Maintain BP >90 mmHg, PaO2 >60 mmHg
• Assess GCS and lateralizing signs- pupil and motor function
• Pupillary asymmetry >1 mm suggests intracranial injury
• Larger pupil is on the side of the mass lesion
• Extremity weakness- detected by testing motor power
• CT scan head- accurate localization of the lesion
• Epidural or subdural hematoma causing mass effect evacuated
• Diffuse axonal injury- maintain cerebral perfusion and prevent
rise in ICP
Spinal cord injuries
• Intensive hospital care, long-term rehabilitation, life-long care.
• Initial care- strict immobilization of the spine
• Complete neurologic assessment
• Steroid therapy must be initiated within a few hours of injury
• Injuries above C3- are apneic, need intubation
• between C3 and C5 – may need intubation later
• Complete transection- poor prognosis
• Preservation of remaining function
Thoracic injuries
• Life-threatening : tension pneumothorax, massive
hemothorax, open pneumothorax, flail chest, and cardiac
tamponade
• Rib fractures, sternal fracture, lung contusion, Injuries to
trachea, bronchi, heart, diaphragm, esophagus, thoracic
aorta
• Diagnostic modalities: CXR, ultrasonography, chest CT,
esophagography, esophagoscopy, bronchoscopy, and
angiography
Part V
Abdominal injuries
• 25% of all trauma victims require abdominal exploration.
• Physical examination- inadequate to identify intraabdominal injuries
• Diagnostic modalities- CXR, FAST, DPL,CT & laparoscopy
• Blunt trauma:
• Hemodynamically stable- CT scan ,
• Hemodynamically unstable- FAST
Diagnostic peritoneal lavage (DPL)
• Insert catheter below umbilicus under LA and full
asepsis and saline (1L NS) infusion into
peritoneum
• Returning fluid is bloody- +ve lavage
• Rapid and safe
• Bloody aspirate- laparotomy
• Do not determine origin of blood
• Too sensitive
• Does not evaluate retroperitoneal injury
• Replaced by FAST and CT scan
FAST- focused abdominal sonography in trauma
• Superseded DPL in
assessment of
abdominal trauma
• 98% sensitivity for
hemoperitoneum
Abdominal injuries (penetrating)
• All gun shot injuries- urgent surgery
• Stab (knife) injury:
Hemodynamically stable- CT scan,
surgery only if intra-abdominal injuries found
Hemodynamically unstable- surgery
Splenic injury
• Most frequently injured in blunt trauma (personal series)
• History of injury to the left side of the chest, flank, or left
upper part of the abdomen
• Bruising, pain tenderness- lower chest and upper
abdomen on left side
• Diagnosis- CT in hemodynamically stable patients
FAST or exploratory laparotomy in an unstable patients
Splenic injury
Non-surgical management (70%)
• Hemodynamically stable patients:
• FAST, CT for diagnosis
• No other intra-abdominal injury requiring operation
• Admission to ICU for continuous monitoring
• Serial Hb. , & repeated abdominal assessment
• If hypotension develops - taken for surgery
Splenic injury
Surgical management
• Hemodynamically unstable
• FAST: splenic injury, free fluid (hemoperitoneum)
• Surgery- splenectomy
• Polyvalent pneumococcal vaccine (pneumovax)
Liver injury- pathophysiology
• Susceptible to injury due to large size(1200-1600 g)
• Covered by bony thoracic cage
• Injury frequency - only 2nd after spleen( personal series)
• Highly vascular- only 4% of body weight but 28% of total
body blood flow
• Double blood supply- portal vein & hepatic artery
• Draining hepatic veins- short and thin walled
Liver injury
• Spontaneous hemostasis- 50% of small lacerations
• Profuse bleeding from deep hepatic lacerationsa formidable challenge
• Mortality rate 8%- 10%, morbidity rate from 18%-30%,
• Diagnosis: FAST in hemodynamically unstable,
CT scan in hemodynamically stable
• Management based on hemodynamic status
Liver injury
Non-operative management
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Hemodynamically stable patients
CT scan
No other indications for abdominal exploration
ICU admission for close observation
Serial hemoglobin estimation
Transfusion requirements of <2 units of blood
Surgery- if become unstable
Liver injury
Surgical management
• Principles of surgical management: control of bleeding,
removal of devitalized tissue, and adequate drainage.
• Bleeding vessels & biliary radicles are individually ligated
• Pringle’s maneuver
• Perihepatic packing- when fail to control hemorrhage
• Packs removed in 48 hours
Pancreatic injuries
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Pancreatic injury is rare
Caused by penetrating injury or direct blow
Diagnosis is difficult to make
CT scan, elevated serum amylase may help
No duct injury: simple drainage
Ductal injury: distal resection
Bowel injuries
• Mostly due to penetrating trauma
• Also seen after blunt trauma
• Features of peritonitis
• CT scan free air in peritoneum/ contrast leak
• Small bowel: Suture repair
• Colon: suture repair± proximal colostomy
Renal injuries
• Minor- renal contusion (85%)
Conservative management
• Major:
Deep medullary injuries with extravasation
Vascular injuries
Surgical repair
Thank you!
Part VI
Case for discussion
• An ambulance is bringing a young man who
was riding a motor bike. He was thrown from
the speeding motor bike on a bending road.
He was not wearing a safety helmet. His left
leg appears grossly deformed.
• The ambulance has informed ER before
bringing him.
• You are the only doctor in ER
• What to do?
Preparation before patient arrival
• Airway equipment, cervical collar, pulse oximetry,
ECG monitor, oxygen
• Laryngoscope, Needles, chest tubes, under-water
seal,
• Minor op. set, local anaesthetic,
• IV fluids at room temp.
• Blood sample tubes
• Splints
• Radiologist and technician
• Foley catheter and urine bag
Management in a hospital
• Patient arrives in hospital
• Patient is on a spinal board
• Deformed left lower limb with blood stain on cloth?
• What to do next?
Primary survey
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A
B
C
D
E
Assessment of airway
• Talk to the patient
Danger signs
• Not talking
• Oro-facial bleeding
• Confused
• Agitated
• Neck hematoma
Airway management
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Clearing oral cavity
Oropharyngeal / bag valve mask
Chin lift / jaw thrust
Oral endotracheal intubation
Surgical methods
Adjuncts: oximetry, oxygen
Cervical collar if not applied during transport
Manual in-line support by an assistant
Breathing
• Patient continues to be dyspnoeic?
• Oxygen saturation not improving?
• Chest injuries to look for and manage
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2.
3.
4.
Tension pneumothorax
Massive hemothorax
Flail chest
Open chest wound
pO2 and respiratory rate improves
Circulation
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Pulse, BP,RR
Any external bleeding? Look at his deformed limb
2 IV line, blood samples
RL or NS 1-2 L as bolus rapidly
Quick response: slow down iv to maintenance
Transient response: BT ?bleeding
No response: ?Major bleeding ? Inadequate resuss.
?non- hemorrhagic shock ( cardiogenic, spinal,
septic)
Hemorrhagic vs Non-hemorrhagic shock
• Neck vein
• Pulse (rhythm, volume, rate)
• Heart sound
• ECG
• CVP
Later :
Spinal injury
Late presentation with abdominal injury
Major bleeding sources
• Chest: massive hemothorax
• Abdomen: hemoperitoneum
• Pelvis: pelvic & retroperitoneal hematoma
• Lower limb fractures
Investigations for bleeding source
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CXR*
FAST
DPL
CT
X-ray pelvis*
*X-ray c spine- the
only other x-ray allowed during Primary survey
Disability & Exposure
• GCS
• Full exposure including the blood mark on his
lower limb.
• Splint the limb- if not already done during
assessment for external hemorrhage
• Cover patient with a blanket
• Reassess ABCD
Secondary survey
• Only after completion of primary survey(ABCDE)
• Life threatening injuries have been dealt
• Normalization of vital signs
• A head to toe evaluation
• Detailed history and examination
• Continuous reassessment of vital signs
• Additional lab. & radiological tests and collecting results
• Additional tubes, lines and monitoring devices
• Priorities and plan definitive management of all injuries
Thank you!