multipel trauma

MULTIPLE TRAUMA

Goal
• Early management Required Simultaneous Evaluation & Treatment
• 1st Goal is to establish adequate DO2 to vital organ by following an established sequence of priorities “


ABC “
• 2nd Identification & Treatment of immediate life threatening injury ( Primary Assessment )
• 3th Resuscitation is continued, Patient systematically evaluated from head to toe to identify potentially life and non life threatening injury ( Secondary Assessment )
• 4th On going evaluation ( Tertiary assessment ) & potential intervention are important component of optimal care


• I. Early Management :
A. Initial Evaluation and Resuscitation ( Primary Assessment )
1. Airway – Breathing
• After blunt trauma airway control should be assumption unstable cervical spine fracture
• Any movement including neck hyperextension should be avoid
• The patency airway must be established, supplement 02 must be supplied as adequacy ventilation is assessed.
• Nasotracheal intubation useful technique in the non apneic patient with confirmed or suspected C spine Injury
• In apneic patients, expertise in NT is lacking, or patient judged to be near respiratory arrest OT Intubation should be perform
• In line manual stabilization of the head & neck for OT and NT
• When airway cannot be secured by other means, Crcothyrotomy is indicated
• Tension pneumothorax should be diagnosis by Clinical Criteria and not by chest radiograph:
• Hypotension
• Unilateral decrease breath sounds
• Poor chest wall movement and tympany
• Tracheal deviation is a hall mark
• Distended neck veins may or may not be present
Initial treatment needle decompression, Followed tube thoracostomy for definitive tx.

2. Circulation

• Hemorrhage most cause post injury shock
• Crystalloid infusion via two large bore IV line, targets volume therapy normalization BP, Reversal Tachycardia, and maintenance Adequate Organ Perfusion
• Control external hemorrhage by manual compression
• In extremity trauma blind clamping potential injury adjacent structure, Tourniquets are generally not necessary and occlude collateral flow
• Urinary catheter should be inserted as soon as practical to monitor urine out put as gauge of organ perfusion

3. Disability

• GCS to assessing Post Injury Neurologic Dysfunction.
– Severe GCS score 3 – 8
– Moderate GCS score 9 – 12
– Mild GCS score 13- 14
• Other neurologic exam should be repeated frequently to identify evolving mass lesions include pupil size, response to light, presence lateralizing sensory or motor neurologic abnormalities

B. Dx &Tx of Immediately Life Threatening Injuries
1. Response to resuscitation

• SBP,HR,RR and patient appearance can be used to approximate acute blood loss
• 1200 ml blood loss in adult may occur with out hypotension & minimal tachycardia
• Class II hemorrhage is uncomplicated shock
• Class III hemorrhage requires crystalloid and often blood replacement
• Class IV hemorrhage pre terminal and requires aggressive measures to restore volume and red blood cell and control bleeding
• Failure to respond volume resuscitation suggest ongoing hemorrhage

2. Bleeding

– The most frequent sites are : Chest, Abdomen, Pelvis
– Hemo thorax
• A chest radiograph, ideally upright after the spine cleared for fractures is reliable screen for intra thoracic bleeding
• Hemo thoraces should be drained by tube thoracostomy
– Intra-abdominal Hemorrhage
• DPL to identifying intra peritoneal hemorrhage
• CT scan appropriate in stable patients
– Pelvic Hemorrhage
• Patient with pelvic fracture are at high risk for mayor bleeding
• Initial management blood volume replacement & mechanical tamponade

3. Non hemorrhagic Shock

• Cardiac Tamponade
– Classic sign may absent: Hypotension, distant heart sound, jugular venous distension, Pulsus paradoxus )
– Pericardiocentesis should be considered .
• Myocardial Contusion
– ECG , cardiac enzyme usually non specific
– Tx : correction acidosis, hypoxia, electrolyte abnormal
• Neurogenic Shock
– Occur in some patient with cervical & thoracic spine cord injury,
– Characterized by hypotension, bradycardia.
– Flaccid paralysis, loss of extremity reflexes, and priapism are associated neurologic finding
– Tx for hypotension include : Volume, Vaso pressors, Atropine

4. Severe Brain Injury

• Diagnosis of Brain Injury made by Head CT scan
• Initial management : Control ICP, Maintenance D02 and CPP to prevent SBI :
1. Supplemental oxygen
2. Intubation
3. Hyperventilation
4. Elevation of Head
5. Limitation of excess free water and excess vol. Resuscitation
6. Osmotic diuretic
7. Cardiopulmonary Support
8. Blood transfusion
9. CT of the Head
10. Prompt Craniotomy when necessary.

C. Resuscitation
1. Management of Hemorrhagic Shock
2. Special Consideration in Trauma

• Crystalloid versus Colloid : à
• Blood Production :
• Blood should be add when crystalloid > 50 ml/kg
• O negative PRC should be used, if is not available O positive PRC may be used
• Monitoring :
Serial vital sign, fluid administration, UOP, Continuous ECG, Pulse oximetry, CVP, PA

D. Dx & Tx of Other Injuries ( 2nd Assessment )

1. History : Essential component of the patient history include :
• Mechanism of Injury
• Previous Medical illness
• Current Medication
• Allergies and Tetanus Immunization
2. Physical Examination
• The patient examination from head to toe
• All clothes are removed, Beware of Hypothermia
• The skulls is carefully inspected to identify occult injuries
• Extra ocular eye movement are check to exclude muscle or nerve injury
• Facial bones, mandible, and neck are palpated
Chest auscultated and palpated for tenderness & crepitus

• The patient is log rolled so that the thoracic and lumbar Spine can be palpated for tenderness
• Abdomen, pelvic bones, rectum are assessed and assure that are not problem
• Extremities are inspected, palpated and range of motion evaluated
• Tenderness over the C spine, neck pain, or injuries at historically high risk for C spine trauma
3. Laboratory study
• Minimal testing : Complete blood count, electrolytes, blood glucose, urinalysis, alcohol level, and toxicology screening
• In any patient with hypo volume, blood sample for blood group typing and coagulation profile should be sent
• BGA should be analyzed in selected patient
4. Radiologic Evaluation :
1. Based of Primary & Secondary Assessment
5. Other Issues
1. NGT to decompress stomach & reduce risk of pulmonary aspiration.
2. Blood in gastric aspirate may be the sign of occult injuries of stomach or duodenum
3. Tetanus prophylaxis is routine
4. Systemic antibiotics should be use until a specific indication exists

II. On Going Evaluation : ( Tertiary Assessment )

• After life threatening injuries and Metabolic
• derangements have been corrected, a tertiary
• periodic systematic re examination is done to
• identify occult injuries not evident at presentation
• And, If the patient required consultation, Transfer
• to another institution, Call trauma center for advice
• and discuss potential problem or concerns with
• transport personnel