Management of Multiple Trauma

Question 1

Initial Assessment

After hospital admission

Answer 1

The initial assessment after hospital admission is divided into the following phases:

• Primary survey
• Adjuncts to primary survey and resuscitation
• Secondary survey (head-to-toe evaluation and history)
• Adjuncts to the secondary survey
• Continued post-resuscitation monitoring and re-evaluation
• Definitive care.

Question 2

Primary survey

Answer 2

The primary survey is aimed at detecting and simultaneously treating injuries that pose an immediate threat to survival. The sequence is identified by the mnemonic ABCDE:

• Airway maintenance with cervical spine protection
• Breathing and ventilation
• Circulation with haemorrhage control
• Disability: neurological status
• Exposure/Environmental control – undress the patient but prevent hypothermia.

The most useful radiographic investigations initially are:

• Lateral cervical spine
• Chest X-ray
• Plain antero-posterior (AP) view of pelvis.

Computed tomography (CT) is the most accurate investigation to detect head, chest and abdominal injury. It should ideally be obtained in all multiply injured patients with scans from the head to the symphysis pubis,

Question 3

Shock

Answer 3

Haemorrhagic shock is the most common cause of shock in a patient with multiple trauma, but other causes need to be considered:

• Cardiogenic shock
• Tension pneumothorax
• Neurogenic shock
• Septic shock.

Key signs of Haemorrhagic shock:

• Tachycardia
• Cutaneous vasoconstriction
• In yound adults hypotension occurs later, signifies blood loss of 1500-2000mls

Treatment:

• control blood loss
• rapid fluid replacement
• two large bore cannulas inserted
• warmed isotonoc electrolytes given 1-2ltrs bolus for adults and 20ml/kg for children
• blood transfusion given
• restoration of urinary output to 0.5ml/kg/hr suggests adequate renal perfusion restored

Question 4

Thoracic trauma

Answer 4

There are six causes of life-threatening respiratory compromise that must be sought in the primary survey:

• Upper airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest
• Massive haemothorax
• Cardiac tamponade.

Open pneumothorax is when air gets into the pleural space from an injury to the chest. This can happen with stab wounds, like from a knife. It can also happen after a gunshot injury.

Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this ‘one-way-valve’ effect

Question 5

Abdominal trauma

Answer 5

A rectal (and vaginal examination in females) should be performed. A gastric tube should be inserted. CT is the most accurate investigation. Diagnostic peritoneal lavage (DPL) is sensitive but non-specific. Abdominal ultrasonography is more sensitive but is dependent on the skill of the user. Laparotomy is indicated for:

• Blunt abdominal trauma with hypotension and evidence of intraperitoneal blood loss
• Blunt abdominal trauma with blood-stained lavage, or a positive abdominal ultrasound or CT scan
• Hypotension with penetrating intra-abdominal wound
• Evisceration
• Peritonitis
• Free intra-abdominal air.

Question 6

Head injury

Answer 6

Head injuries can be classified using the Glasgow Coma Scale (GCS):

• Mild GCS score 14–15
• Moderate GCS score 9–13
• Severe GCS score 3–8.

The scale is calculated from the response (1–6), verbal response (1–5) and eye opening (1–4).

CT is the most useful additional investigation. It should be considered in all patients with a GCS score of less than 15, loss of consciousness for more than 5 minutes, or any patient with a focal neurological deficit. Space-occupying lesions or a midline shift greater than 5 mm are indications for craniotomy.

Question 7

Musculoskeletal injuries in multiple trauma

Answer 7

Most patients with multiple trauma have fractures. The present evidence strongly supports a policy of early skeletal stabilization of all major long-bone fractures. This has a number of benefits:

• Reduction in severity and incidence of pulmonary problems (acute respiratory distress syndrome and fat embolism syndrome)
• Reduction in blood loss
• Reduction in pain
• Earlier mobilization – reduced risk of deep vein thrombosis, pulmonary embolus and other complications associated with immobility.