MULTIPLE TRAUMA

INTRODUCTION

High-velocity trauma is the number one cause of death in the 18- to 44-year-old age group worldwide.

The cost to the healthcare system for blunt trauma is greater than any other disease. There is no consensus definition, but the polytrauma patient can be defined as follows:

Injury severity score (ISS) >18

Hemodynamic instability or coagulopathy present on admission

More than one system involvement: central nervous system (CNS), pulmonary, abdominal, musculoskeletal, etc.

FIELD TRIAGE

Management Priorities

Assessment and establishment of airway and ventilation

Assessment of circulation and perfusion

Hemorrhage control

Patient extrication

Shock management

Fracture stabilization

Patient transport

TRAUMA DEATHS

Trauma deaths tend to occur in three phases:

Immediate: This is usually the result of severe brain injury or disruption of the heart, aorta, or

large vessels. It is amenable to public health measures and education, such as the use of safety helmets and passenger restraints.

Early: This occurs minutes to a few hours after injury, usually as a result of intracranial bleeding, hemopneumothorax, splenic rupture, liver laceration, or multiple injuries with significant blood loss. These represent correctable injuries for which immediate, coordinated, definitive care at a level I trauma center is most beneficial.

Late: This occurs days to weeks after injury and is related to sepsis, embolus, or multiple organ failure.

Mortality increases with increasing patient age (Fig. 2.1).

GOLDEN HOUR

Rapid transport of the severely injured patient to a trauma center is essential for appropriate assessment and treatment.

The patient’s chance of survival diminishes rapidly after 1 hour, with a threefold increase in mortality for every 30 minutes of elapsed time without care in the severely, multiply injured patient.

THE TEAM

The trauma team is headed by the trauma general surgeon, who acts as the “captain of the ship” in prioritizing and directing patient care.

The orthopaedic consult is available to assess all musculoskeletal injuries, provide initial bony stabilization, and work in concert with the trauma general surgeons to treat shock and hemorrhage.

RESUSCITATION

Follows ABCDE: airway, breathing, circulation, disability, exposure

AIRWAY CONTROL

The upper airway should be inspected to ensure patency.

Foreign objects should be removed and secretions suctioned.

A nasal, endotracheal, or nasotracheal airway should be established as needed. A tracheostomy may be necessary.

The patient should be managed as if a cervical spine injury were present. However, no patient should die from lack of an airway because of concern over a possible cervical spine injury. Gentle maneuvers, such as axial traction, are usually possible to allow for safe intubation without neurologic compromise.

BREATHING

This involves evaluation of ventilation (breathing) and oxygenation.

The most common reasons for ineffective ventilation after establishment of an airway include malposition of the endotracheal tube, pneumothorax, and hemothorax.

• Tension pneumothorax

  • Diagnosis: tracheal deviation, unilateral absent breath sounds, tympany, and distended neck veins

  • Treatment: insertion of a large-bore needle into the second intercostal space at the

    midclavicular line to allow immediate decompression, then placement of a chest tube

• Open pneumothorax

  • Diagnosis: sucking chest wound

  • Treatment: occlusive dressing not taped on one side to allow air to escape, followed by surgical wound closure and a chest tube

• Flail chest with pulmonary contusion

  • Diagnosis: paradoxical movement of the chest wall with ventilation

  • Treatment: fluid resuscitation (beware of overhydration), intubation, positive end-expiratory

    pressure may be necessary

• Endotracheal tube malposition

  • Diagnosis: malposition evident on chest radiograph, unilateral breath sounds, asymmetric chest excursion

  • Treatment: adjustment of the endotracheal tube with or without reintubation

• Hemothorax

  • Diagnosis: opacity on chest radiograph, diminished/absent breath sounds

  • Treatment: chest tube placement

Indications for intubation

• Loss (or anticipated loss) of airway control

• Prevention of aspiration in an unconscious patient

• Hyperventilation for increased intracranial pressure

• Obstruction from facial trauma and edema

   

  CIRCULATION

Hemodynamic stability is defined as normal vital signs (blood pressure, heart rate) that are maintained with only maintenance fluid volumes.

In trauma patients, shock is hemorrhagic until proven otherwise.

At a minimum, two large-bore intravenous lines should be placed in the antecubital fossae or groin with avoidance of injured extremities. Alternatively, saphenous vein cutdowns may be used in adults or intraosseous (tibia) infusion for children <6 years of age.

Serial monitoring of blood pressure and urine output is necessary, with possible central access for central venous monitoring or Swan-Ganz catheter placement for hemodynamic instability. Serial hematocrit monitoring should be undertaken until hemodynamic stability is documented.

Peripheral blood pressure should be assessed.

Blood pressure is necessary to palpate a peripheral pulse.

Peripheral Pulse Blood Pressure

Radial 80 mm Hg

Femoral 70 mm Hg

Carotid 60 mm Hg

INITIAL MANAGEMENT OF THE PATIENT IN SHOCK

Direct control of obvious bleeding: direct pressure control preferable to tourniquets or blind clamping of vessels

Large-bore venous access, fluid resuscitation (normal saline or Ringer’s lactate), monitoring of urine output, central venous pressure, and pH

Blood replacement as indicated by serial hematocrit monitoring

Traction with Thomas splints or extremity splints to limit hemorrhage from unstable fractures

Consideration of angiography (with or without embolization) or immediate operative intervention for hemorrhage control

DIFFERENTIAL DIAGNOSIS OF HYPOTENSION IN TRAUMA

Cardiogenic Shock

Cardiac arrhythmias, myocardial damage

Pericardial tamponade

• Diagnosis: distended neck veins, hypotension, muffled heart sounds (Beck triad)

• Treatment: pericardiocentesis through subxiphoid approach

   

  Neurogenic Shock

This occurs in patients with a thoracic level spinal cord injury in which sympathetic disruption results in an inability to maintain vascular tone.

Diagnosis: Hypotension without tachycardia or vasoconstriction. Consider in a head-injured or spinal cord–injured patient who does not respond to fluid resuscitation.

Treatment: Volume restoration followed by vasoactive drugs (beware of fluid overload).

Septic Shock

Consider in patients with gas gangrene, missed open injuries, and contaminated wounds closed primarily.

Diagnosis: Hypotension accompanied by fever, tachycardia, cool skin, and multiorgan failure. This occurs in the early-to-late phases, but not in the acute presentation.

Treatment: fluid balance, vasoactive drugs, antibiotics.

Hemorrhagic Shock

More than 90% of patients are in acute shock after trauma.

Consider in patients with large open wounds, active bleeding, pelvic and/or femoral fractures, and abdominal or thoracic trauma.

Diagnosis: Hypotension, tachycardia. In the absence of open hemorrhage, bleeding into voluminous spaces (chest, abdomen, pelvis, thigh) must be ruled out. This may require diagnostic peritoneal lavage (DPL), Focused Assessment with Sonography for Trauma (FAST) angiography, computed tomography (CT), magnetic resonance imaging (MRI), or other techniques as dictated by the patient presentation.

Treatment: Aggressive fluid resuscitation, blood replacement, angiographic embolization, operative intervention, fracture stabilization, and other techniques as dictated by the source of hemorrhage.

CLASSIFICATION OF HEMORRHAGE

Class I: <15% loss of circulating blood volume

Diagnosis: no change in blood pressure, pulse, or capillary refill

Treatment: crystalloid

Class II: 15% to 30% loss of circulating blood volume

Diagnosis: tachycardia with normal blood pressure

Treatment: crystalloid

Class III: 30% to 40% loss of circulating blood volume

Diagnosis: tachycardia, tachypnea, and hypotension

Treatment: rapid crystalloid replacement, then blood

Class IV: >40% loss of circulating blood volume

Diagnosis: marked tachycardia and hypotension

Treatment: immediate blood replacement

BLOOD REPLACEMENT

Fully cross-matched blood is preferable; it requires approximately 1 hour for laboratory cross-match and unit preparation.

Saline cross-matched blood may be ready in 10 minutes; it may have minor antibodies.

Type O negative blood is used for life-threatening exsanguination.

Warming the blood will help to prevent hypothermia.

Monitor coagulation factors, platelets, and calcium levels.

PNEUMATIC ANTISHOCK GARMENT OR MILITARY ANTISHOCK TROUSERS (USED IN FIELD ONLY)

Used to control hemorrhage associated with pelvic fractures.

May support systolic blood pressure by increasing peripheral vascular resistance.

May support central venous pressure by diminution of lower extremity blood pooling.

Advantages: simple, rapid, reversible, immediate fracture stabilization.

Disadvantages: limited access to the abdomen, pelvis, and lower extremities, exacerbation of congestive heart failure, decreased vital capacity, potential for compartment syndrome.

Are contraindicated in patients with severe chest trauma.

INDICATIONS FOR IMMEDIATE SURGERY

Hemorrhage is secondary to:

Liver, splenic, or renal parenchymal injury: laparotomy

Aortic, caval, or pulmonary vessel tears: thoracotomy

Depressed skull fracture or acute intracranial hemorrhage: craniotomy

DISABILITY (NEUROLOGIC ASSESSMENT)

Initial survey consists of an assessment of the patient’s level of consciousness, pupillary response,

sensation, and motor response in all extremities, rectal tone, and sensation.

The Glasgow Coma Scale (Table 2.1) assesses level of consciousness, severity of brain function, brain damage, and potential patient recovery by measuring three behavioral responses: eye opening, best verbal response, and best motor response.

A revised trauma score results from the sum of respiratory rate, systolic blood pressure, and Glasgow Coma Scale and can be used to decide which patients should be sent to a trauma center (Table 2.2).

INJURY SEVERITY SCORE (TABLE 2.3)

This anatomic scoring system provides an overall score for patients with multiple injuries.

It is based on the Abbreviated Injury Scale (AIS), a standardized system of classification for the severity of individual injuries from 1 (mild) to 6 (fatal).

Each injury is assigned an AIS score and allocated to one of six body regions (head, face, chest, abdomen, extremities including pelvis, and soft tissue).

The total ISS score is calculated from the sum of the squares of the three worst regional values. It is important to emphasize that only the worst injury in each body region is used.

The ISS ranges from 1 to 75, with any region scoring 6 automatically giving a score of 75.

The ISS limits the total number of contributing injuries to three only, one each from the three most injured regions, which may result in underscoring the degree of trauma sustained if a patient has more than one significant injury in more than three regions or multiple severe injuries in one region.

To address some of these limitations, Osler et al. proposed a modification to the system which they termed the New Injury Severity Score (NISS). This is defined as the sum of squares of the AIS scores of each of a patient’s three most severe injuries regardless of the body region in which they occur. Both systems have been shown to be good predictors of outcome in multiple trauma patients.

EXPOSURE

It is important to undress the trauma patient completely and to examine the entire body for signs and symptoms of injury.

RADIOGRAPHIC EVALUATION

C-spine should not be cleared without imaging if any of the following NEXUS criteria are present (N Engl J Med 2001):

• Posterior midline cervical tenderness

• Neurologic deficit

• Painful distracting injuries (that hinder the reliability of questioning and examination)

• Altered level of alertness

• Evidence of intoxication

In cases where C-spine imaging is needed, CT scanning has replaced conventional radiography. MRI may be necessary to rule out disc herniation, epidural hematoma, spinal cord compression, and ligamentous injuries (see Chapter 9).

Anteroposterior (AP) chest is required.

AP pelvis when the mechanism of injury suggests.

CT scanning of these various regions is used as an adjunct to the primary survey.

FAST (ultrasound of abdomen) screen for intra-abdominal blood has replaced DPL when available.

STABILIZATION

The stabilization phase occurs immediately following initial resuscitation and may encompass hours to days, during which medical optimization is sought. It consists of:

• Restoration of stable hemodynamics

• Restoration of adequate oxygenation and organ perfusion

• Restoration of adequate kidney function

• Treatment of bleeding disorders

Risk of deep venous thrombosis is highest in this period and may be as high as 58% in multiply injured patients. Highest risk injuries include spinal cord injuries, femur fractures, tibia fractures,

and pelvic fractures. A high index of suspicion must be followed by duplex ultrasonography.

Low-molecular-weight heparin in patients without risk factors for hemorrhage has been shown to be more effective than sequential compression devices in preventing thrombosis. It is contraindicated in patients at risk for hemorrhage, especially following head trauma. Prophylaxis should be continued until adequate mobilization of the patient out of bed is achieved.

Vena caval filters may be placed at time of angiography and are effective in patients with proximal venous thrombosis. Removable filters are effective and available.

Pulmonary injuries (e.g., contusion), sepsis, multiorgan failure (e.g., because of prolonged shock), massive blood replacement, and pelvic or long bone fractures may result in acute respiratory distress syndrome (ARDS).

DECISIONS TO OPERATE

Most patients are safely stabilized from a cardiopulmonary perspective within 4 to 6 hours of presentation.

Early orthopaedic operative intervention is indicated for

• Femur or pelvic fractures, which carry high risk of pulmonary complications (e.g., fat embolus syndrome, ARDS)

• Active or impending compartment syndrome, most commonly associated with tibia or forearm

  fractures

• Open fractures

• Vascular disruption

• Unstable cervical or thoracolumbar spine injuries

• Patients with dislocated joints of the shoulder, elbow, wrist, carpus, hip, knee, ankle, hindfoot, and midfoot that are irreducible in the emergency department (ED)

Determination of patient medical stability

• Activation of immune system results in release and suppression of mediators

  • May lead to second hit phenomena (Fig. 2.2)

     

     

     

• Adequacy of resuscitation

  • Vital signs of resuscitation are deceptive.

  • Laboratory parameters of base deficit and lactic acidosis are most accurate.

• No evidence of coagulopathy

• As long as homeostasis is maintained, no evidence exists that the duration of the operative procedure results in pulmonary or other organ dysfunction or worsens the prognosis of the patient.

• Must be ready to change plan as patient status dictates

• Patients who are hemodynamically stable without immediate indication for surgery should receive medical optimization (i.e., cardiac risk stratification and clearance) before operative intervention.

Decision making

• Determined by general surgery, anesthesia, and orthopaedics.

• Magnitude of the procedure can be tailored to the patient’s condition.

• Timing and extent of operative intervention based on physiologic criteria.

• Early total care (ETC) is a concept that favors definitive stabilization/fixation of all orthopaedic injuries at the earliest opportunity.

• Patients unable to undergo ETC may require damage control surgery as a temporizing and

  stabilizing measure.

Incomplete resuscitation

• Based on physiologic assessment.

• Intensive care includes monitoring, resuscitation, rewarming, and correction of coagulopathy and base deficit.

• Once the patient is warm and oxygen delivery is normalized, reconsider further operative

  procedures.

  CONCOMITANT INJURIES

  Head Injuries

The diagnosis and initial management of head injuries take priority in the earliest phase of treatment.

Mortality rates in trauma patients are associated with severe head injury more than any other organ system.

Neurologic assessment is accomplished by the use of the Glasgow Coma Scale (see earlier).

Intracranial pressure monitoring may be necessary.

Evaluation

Emergency CT scan without intravenous contrast is indicated to characterize the injury radiographically after initial neurologic assessment if indicated: http://www.itim.nsw.gov.au/images/2/2b/Head_injury_CPG_full_report.pdf

Cerebral contusion

• Diagnosis: history of prolonged unconsciousness with focal neurologic signs

• Treatment: close observation

Epidural hemorrhage (tear of middle meningeal artery)

• Diagnosis: loss of consciousness with intervening lucid interval, followed by severe loss of consciousness

• Treatment: surgical decompression

Subdural hemorrhage (tear of subdural veins)

• Diagnosis: Neurologic signs may be slow to appear. Lucid intervals may be accompanied by progressive depressed level of consciousness.

• Treatment: surgical decompression

Subarachnoid hemorrhage (continuous with cerebrospinal fluid)

• Diagnosis: signs of meningeal irritation

• Treatment: close observation

   

  Thoracic Injuries

These may result from blunt (e.g., crush), penetrating (e.g., gunshot), or deceleration (e.g., motor vehicle accident) mechanisms.

Injuries may include disruption of great vessels, aortic dissection, sternal fracture, and cardiac or pulmonary contusions, among others.

A high index of suspicion for thoracic injuries must accompany scapular fractures.

Emergency thoracotomy may be indicated for severe hemodynamic instability.

Chest tube placement may be indicated for hemothorax or pneumothorax.

Evaluation

AP chest radiograph may reveal mediastinal widening, hemothorax, pneumothorax, or

musculoskeletal injuries.

CT with intravenous contrast is indicated with suspected thoracic injuries and may demonstrate thoracic vertebral injuries.

Abdominal Injuries

These may accompany blunt or penetrating trauma.

Evaluation

CT scan with oral and intravenous contrast may be used to diagnose intra-abdominal or intrapelvic injury. Pelvic fractures, lumbosacral fractures, or hip disorders may be observed.

DPL has been the gold standard for immediate diagnosis of operable intra-abdominal injury. Usually, it is reserved for situations in which the patient is too unstable for the CT scanner.

Positive peritoneal lavage

• Gross blood, bile, or fecal material

• >100,000 red blood cells per milliliter

• >500 white blood cells per milliliter

Ultrasound (FAST) has been increasingly utilized to evaluate fluid present in the abdominal and chest cavities. A rapid, noninvasive, bedside, repeatable method to document fluid in the pericardial sac, hepatorenal fossa, splenorenal fossa, and pelvis or pouch of Douglas.

Genitourinary Injuries

Fifteen percent of abdominal trauma results in genitourinary injury.

Evaluation

If genitourinary injury is suspected (e.g., blood seen at the urethral meatus), a retrograde urethrogram should be performed before indwelling bladder catheter insertion. Urethral injury may necessitate placement of a suprapubic catheter. If a pelvic fracture is present, communication with the urologist is mandatory.

If hematuria is present, a voiding urethrogram, cystogram, and intravenous pyelogram are indicated.