Multiple Trauma

Background and Importance

Unintentional injury remains the leading cause of death in persons 1 to 44 years of age. ^, Each day, approximately 9 people are killed and more than 1000 injured by distracted drivers that have led to new laws prohibiting texting while driving. Firearm-related deaths are a significant concern, especially in the United States. ^, The economic cost of traumatic injuries and death (medical costs and lost productivity) is estimated in the hundreds of billions of dollars. ^,

Stabilization, evaluation, and treatment of trauma patients are central to the practice of emergency medicine. Effective management of critically ill trauma patients requires decisiveness, technical skill, and effective leadership. A methodical, team-based approach is necessary, capitalizing on a strong clinical partnership between emergency medicine and surgery. Coordination with emergency medical services (EMS) providers, nursing, radiology, and other trauma-related specialties is needed to optimize outcomes. Prompt and safe transfer to the operating room requires collaboration and effective communication with other specialists such as surgeons, and anesthesiologists.

Anatomy, Physiology, and Pathophysiology

In blunt trauma victims, the mechanism of injury can be associated with particular injury patterns. These are listed in Table 32.1 . Knowledge of these associations can help the clinician evaluate for injuries that may not be readily identified by initial examination.

Older patients commonly sustain extremity, craniofacial, and closed head injuries. Most of these occur as a result of a fall or motor vehicle collision (MVC). Thirty million older adults fall each year, resulting in about 30,000 deaths. Older trauma patients typically have comorbid illnesses, usually on medications (especially anticoagulants), and also have age-related changes in organ-system function. These factors can increase susceptibility to injury, morbidity, and mortality. Obese patients are also at risk for increased morbidity and mortality from trauma.

In penetrating trauma from knife wounds or injuries from low-velocity sharp objects, tissue damage can be expected to occur primarily along the track of the object. However, the type and severity of injuries inflicted by gunshot wounds depend on several factors. The amount of tissue damage is related to the kinetic energy of the bullet, which is a factor of the bullet weight (caliber) and velocity. Gunshot wounds cause trauma to the surrounding tissue by direct laceration, crush injury, shock waves, and cavitation—the displacement of tissue forward and radially. Owing to these dynamic forces, high-velocity weapons, such as rifles, cause more widespread injuries than low-velocity weapons (handguns). Similar to knives, handgun bullets and shotgun pellets (from long range) generally cause injury based on direct laceration and crush generated by the missile along its track. Shotgun wounds from close range are characterized by massive tissue injury.

Primary Survey

A focused and methodical primary survey should be initiated immediately in the emergency department (ED). The goal of the primary survey is to diagnose critical, life-threatening injuries rapidly, and begin treatment at the time of diagnosis. Figs. 32.1, 32.2, and 32.3 show the recommended algorithms for the evaluation of airway, breathing, and circulation. Fig. 32.4 highlights special considerations between blunt and penetrating mechanisms that should be considered during the primary survey.

In the absence of obvious direct trauma involving the airway, management decisions are based on the overall patient condition and potential for deterioration. Following initial airway assessment, decisions surrounding airway management should focus on the ability of the patient to protect their airway, adequacy of ventilation and oxygenation, and anticipated clinical course.

Inadequate ventilation, which may lead to respiratory acidosis, can be noted by the rate and quality of respirations and can be monitored using end-tidal carbon dioxide monitoring. Pulse oximetry will detect inadequate oxygenation, which may manifest clinically as agitation and restlessness, as opposed to hypercapnia which usually manifests as somnolence. Assessment of injuries that may compromise oxygenation or ventilation requires careful inspection and auscultation of the chest and may be augmented by use of point-of-care ultrasound. Signs of such compromising injury include increased work of breathing, tachypnea, penetrating wounds, subcutaneous emphysema, chest wall instability, flail segments, tracheal deviation, and distended neck veins. See Fig. 32.2 .

Assessment of hemodynamic and circulatory status (see Fig. 32.3 ) follows evaluation of the airway and ventilation. Clinical indicators of adequate perfusion include normal mental status, skin color and temperature, heart rate, blood pressure, and capillary refill. However, a normal finding for any single sign does not rule out significant hemorrhage or even shock. Mental status changes associated with hypoperfusion can include anxiety, agitation, and depressed consciousness. Cool pale skin or extremities with delayed capillary refill suggest inadequate perfusion and shock. Vital signs can be misleading in well-conditioned athletes and children. Medications may also blunt expected physiologic responses. A normal heart rate, blood pressure, or both can be present, despite significant hemorrhage. Conversely, tachycardia could be seen without significant volume loss.

Traditionally, direct pressure to external bleeding sites was advocated, while the use of tourniquets was discouraged. While direct pressure remains first-line therapy, there is good evidence to support the early use of tourniquets for massive extremity hemorrhage that is not otherwise easily controlled. Similarly, studies of newer hemostatic agents have shown potential application in combat and out-of-hospital settings. ^,

Early intravenous (IV) access is required in the assessment of circulation. Two short, large-bore (14- or 16-gauge) IV catheters are preferred. Routine IV access may be difficult or unobtainable in certain cases. Intraosseous (IO) vascular access can be obtained rapidly in pediatric and adult patients, and this allows the safe infusion of large amounts of fluid or blood products. ^, Battery operated drills are widely available and can facilitate IO placement. Ultrasound-guided peripheral venous access by nurses and emergency clinicians should be considered in patients with challenging peripheral vascular anatomy. Central venous access may also be indicated in the appropriate clinical scenario or based on the emergency clinician’s discretion. The use of ultrasound has been shown to increase successful vein cannulation and decrease complications in the placement of central venous lines. ^, A straight leg raise test or real-time ultrasound of the vena cava can be performed to determine adequacy or response to resuscitation. An extended, focused, abdominal sonography in trauma (eFAST) examination should be performed on all patients during transition from the primary to secondary survey.