Multisystem Trauma. Overview of the Critically Injured Patient

Multisystem TraumaMultisystem Trauma

Overview of the Critically Injured Overview of the Critically Injured PatientPatient

Trauma is…Trauma is…

Single System: an injury involving a Single System: an injury involving a single isolated body systemsingle isolated body system

Multiple System: an injury that Multiple System: an injury that involves two or more body systemsinvolves two or more body systems

Trauma System CompenentsTrauma System Compenents

AccessAccess PrehospitalPrehospital Initial ResuscitationInitial Resuscitation Acute CareAcute Care RehabilitationRehabilitation

Types of TraumaTypes of Trauma

BluntBlunt PenetratingPenetrating BlastBlast IntentionalIntentional NonintentionalNonintentional

Types of InjuryTypes of Injury

Primary: occurs at the time of injuryPrimary: occurs at the time of injury Secondary: occurs as the result of Secondary: occurs as the result of

secondary insults (hypoxia, secondary insults (hypoxia, hypotension, infection etc.)hypotension, infection etc.)

Mitigating FactorsMitigating Factors

Younger than 5, older than 55Younger than 5, older than 55 Medical / surgical hx.Medical / surgical hx. Substance abuseSubstance abuse Severity of injurySeverity of injury Time of injury to definitive careTime of injury to definitive care Quality of careQuality of care

General ApproachGeneral Approach

AssessmentAssessment

Primary Survey / resuscitationPrimary Survey / resuscitation Secondary assessmentSecondary assessment Psychological, social and Psychological, social and

environmental factorsenvironmental factors

Mechanism of Injury and Mechanism of Injury and KinematicsKinematics

Mechanism=detailed cause or type Mechanism=detailed cause or type of eventof event

Kinematics = physics of trauma, how Kinematics = physics of trauma, how is energy dispersedis energy dispersed

Part of primary survey…listen to Part of primary survey…listen to prehospital caregiversprehospital caregivers

Fundamentals of Initial Fundamentals of Initial ResuscitationResuscitation

ConceptsConcepts

Assessment and resuscitation occur Assessment and resuscitation occur simultaneously simultaneously

Reassess frequently Reassess frequently Establish priorities and anticipate needsEstablish priorities and anticipate needs Life over limbLife over limb Preparedness, organization, communicationPreparedness, organization, communication Someone must be in controlSomeone must be in control Do no further harmDo no further harm If condition progressively worsens…definitive If condition progressively worsens…definitive

care is needed.care is needed.

Goals of ResuscitationGoals of Resuscitation

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

Primary AssessmentPrimary Assessment

Subjective DataSubjective Data• Mechanism of InjuryMechanism of Injury• Chief ComplaintChief Complaint

Airway / cervical spineAirway / cervical spine

Signs / SymptomsSigns / Symptoms• Decreased LOCDecreased LOC• AgitationAgitation• StridorStridor• CyanosisCyanosis• Accessory MusclesAccessory Muscles• HoarsenessHoarseness• No air movementNo air movement

TreatmentTreatment• Establish airway Establish airway

without without manipulation of manipulation of cervical spinecervical spine

• Jaw thrustJaw thrust• SuctionSuction• NP / OP airwaysNP / OP airways• ETTETT

BreathingBreathing

Signs / SymptomsSigns / Symptoms• Cyanosis, decreased breath sounds, increased Cyanosis, decreased breath sounds, increased

resp. rate, decreased LOC, noisy resp., hypoxia, resp. rate, decreased LOC, noisy resp., hypoxia, acidosis.acidosis.

DiagnosisDiagnosis• Assess clinical presentation, ABG’s, oximetry Assess clinical presentation, ABG’s, oximetry

trends, CO2 monitoring, CXRtrends, CO2 monitoring, CXR TreatmentTreatment

• High flow O2, assist ventilation, treat tension High flow O2, assist ventilation, treat tension pnuemo, open pnuemo, flail chest or hemothorax, pnuemo, open pnuemo, flail chest or hemothorax, PAIN MANAGEMENTPAIN MANAGEMENT

CirculationCirculation

Signs of hypovolemic shockSigns of hypovolemic shock• Altered LOC, tachycardia, hypotension, Altered LOC, tachycardia, hypotension,

tachypnea, cool diaphoretic skin, low UOP, slow tachypnea, cool diaphoretic skin, low UOP, slow capillary refill time.capillary refill time.

DiagnosisDiagnosis• CBC, PT, PTT, X rays, DPL, US, arteriogramsCBC, PT, PTT, X rays, DPL, US, arteriograms

Treatment of hypovolemiaTreatment of hypovolemia• Direct pressure to external bleeding, high flow Direct pressure to external bleeding, high flow

O2, 2 lg bore IV’s, fluids, bloodO2, 2 lg bore IV’s, fluids, blood• Rule out sources of obstructive shockRule out sources of obstructive shock

Spinal ImmobilizationSpinal Immobilization

Based on mechanism, not neuro deficitBased on mechanism, not neuro deficit SCI may occur with or without bony involvementSCI may occur with or without bony involvement High index of suspicion High index of suspicion

• Pain, paralysis, paresthesia, ptosis, Pain, paralysis, paresthesia, ptosis, priapism, presenting position, priapism, presenting position, pregnancy, MOI.pregnancy, MOI.

DiagnosticsDiagnostics• Initial AP/ lateral to include C-7 and Initial AP/ lateral to include C-7 and T-1T-1• Correlate with physical examCorrelate with physical exam• CT CT

Disability / Neuro Disability / Neuro AssessmentAssessment

AVPUAVPU Trend Glasgow Coma Scale scoreTrend Glasgow Coma Scale score Trend pupillary sizeTrend pupillary size Assess motor function of all four ext.Assess motor function of all four ext. Diagnostics…rule outDiagnostics…rule out

• Decreased perfusion or Decreased perfusion or direct cerebral injury, direct cerebral injury, Drugs / ETOH, Hypoxia, Drugs / ETOH, Hypoxia, HypotensionHypotension

Disability – TreatmentDisability – Treatment

Complete primary surveyComplete primary survey Treat life threatening injuryTreat life threatening injury Complete secondary surveyComplete secondary survey Rapid resuscitationRapid resuscitation Avoid prolonged hyperventilationAvoid prolonged hyperventilation Avoid hypotension SBP>90Avoid hypotension SBP>90 Serial monitoring of VS / NSSerial monitoring of VS / NS Consider Narcan or MannitolConsider Narcan or Mannitol

ExposureExposure

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

Secondary SurveySecondary Survey

Should not be initialized until life Should not be initialized until life threatening injuries are treated and threatening injuries are treated and primary assessment is completeprimary assessment is complete

AMPLE HistoryAMPLE History Head to Toe physical Head to Toe physical

exam, including exam, including posterior surfaces posterior surfaces

Preparation for Further Preparation for Further DiagnosticsDiagnostics

Foley (if no contraindications) Foley (if no contraindications) • maintain UOP >30 ml / hr maintain UOP >30 ml / hr

Decompress stomach with NGDecompress stomach with NG• If no CSF leak, midface fxIf no CSF leak, midface fx

Special PopulationsSpecial Populations

PediatricsPediatrics

GeriatricsGeriatrics

The Pregnant Trauma PatientThe Pregnant Trauma Patient

Resuscitation Resuscitation priorities are priorities are identical to those identical to those on non-pregnant on non-pregnant trauma patient.trauma patient.

Consult OB Consult OB resources early in resources early in resuscitation.resuscitation.

Questions?Questions?