Multiple Trauma

By admin On Jun 26, 2024

Ovid: Handbook of Fractures

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.

Title: Handbook of Fractures, 3rd Edition

> Table of Contents > I – General Considerations > 2 – Multiple Trauma

Multiple Trauma

High-velocity trauma is the number 1 cause of death in the 18- to 44-year age group worldwide.
Blunt trauma accounts for 80% of mortality in the <34-year age group.
In the 1990s in the United States alone,
income loss resulting from death and disability secondary to
high-velocity trauma totaled 75 billion dollars annually; despite this,
trauma research received less than 2% of the total national research
budget.

The polytrauma patient is defined as follows:

Injury Severity Score >18
Hemodynamic instability
Coagulopathy
Closed head injury
Pulmonary injury
Abdominal injury

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 can be most beneficial.
Late: This occurs days to weeks after injury and is related to sepsis or multiple organ failure.

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

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of elapsed time without care in the severely, multiply injured patient.

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 is 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;
    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
- Control of airway
- Prevent of aspiration in an unconscious patient
- Hyperventilation for increased intracranial pressure
- Obstruction from facial trauma and edema

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CIRCULATION

Hemodynamic stability is defined as normal vital signs 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 necessary to palpate a peripheral pulse.

Peripheral pulse Blood pressure

Radial 80 mm Hg

Femoral 70 mm Hg

Carotid 60 mm Hg

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, Ringer lactate resuscitation, 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).

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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 shock acutely 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, angiography, CT, 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 (PASG) OR MILITARY ANTISHOCK TROUSERS (MAST)

Used to control hemorrhage associated with pelvic fractures.
May support systolic blood pressure by increasing peripheral vascular resistance.

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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 secondary to:

Liver, splenic, 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.

Table 2.1. Glasgow coma scale

Glasgow Coma Scale			Score
A	Eye Opening (E)
	1.	Spontaneous
	2.	To speech	4
	3.	To pain	3
	4.	None	2
B.	Best Motor Response (M)		1
	1.	Obeys commands
	2.	Localizes to stimulus	6
	3.	Withdraws to stimulus	5
	4.	Flexor posturing	4
	5.	Extensor posturing	3
	6.	None	2
C.	Verbal Response (V)		1
D.	Oriented		5
E.	Confused conversation		4
F.	Inappropriate words		3
G.	Incomprehensible phonation		2
H.	None		1
GCS = E+M+V (range, 3–15). Note: Patients with a Glasgow coma scale of <13, a systolic blood pressure of <90, or a respiratory rate of >29 or <10/min should be sent to a trauma center. These injuries cannot be adequately evaluated by physical examination.

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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).

Table 2.2. Revised trauma score: trauma scoring systems

Revised Trauma Score (RTS)	Rate	Score
A. Respiratory Rate (breaths/min)	10–29	4
	>29	3
	6–9	2
	1–5	1
	0	0
B. Systolic Blood Pressure (mm Hg)	>89	4
	76–89	3
	50–75	2
	1–49	1
	0	0
C. Glasgow Coma Scale (GCS) Conversion	13–15	4
	9–12	3
	6–8	2
	4–5	1
	3	0
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR. The RTS correlates well with the probability of survival.

INJURY SEVERITY SCORE (ISS) (Table 2.3)

Table 2.3. Evaluation of multiple trauma patient injury severity score (ISS)

Abbreviated Injury Scale defined body areas (external structures)

Soft tissue
Head and neck
Chest
Abdomen
Extremity and/or pelvis
Face

Severity code

Minor
Moderate
Severe (non-life-threatening)
Severe (life-threatening)
Critical (survival uncertain)
Fatal (dead on arrival)

ISS = A² + B² + C². A, B, and C represent individual body area severity code.

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
individual injuries from 1 (mild) to 6 (fatal).
Each injury is assigned an AIS score and
is allocated to one of six body regions (head, face, chest, abdomen,
extremities including pelvis, and external structures).
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

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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

A radiographic trauma series consists of the following:

Lateral cervical spine: must see all seven vertebrae and the top of T1
- Can perform swimmer’s view or CT scan if needed.
- In the absence of adequate cervical spine
  views of all vertebrae, the cervical spine cannot be “cleared” from
  possible injury, and a rigid cervical collar must be maintained until
  adequate views or a CT scan can be obtained.
- Clinical clearance cannot occur if the
  patient has a depressed level of consciousness for any reason (e.g.,
  ethanol intoxication).
Anteroposterior (AP) chest
AP pelvis
Possibly a lateral thoracolumbar spine
Possibly a CT of the head, cervical spine
(if not cleared by plain radiographs), thorax, abdomen, or pelvis with
or without contrast as dictated by the injury pattern

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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, or low-dose
warfarin has been shown to be more effective than sequential
compression devices in preventing thromboses, but 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.
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 the
adult respiratory distress syndrome (ARDS).

DECISION TO OPERATE

Most patients are safely stabilized from a cardiopulmonary perspective within 4 to 6 hours of presentation.
Early 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 fractures of the femoral neck, talar neck, or other bones in which fracture has a high risk of osteonecrosis.
Determination of patient medical stability
- Adequacy of resuscitation
  - Vital signs of resuscitation are deceptive.
  - Laboratory parameters include base deficit and lactic acidosis.
- 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.
- 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 use of the Glasgow Coma Scale (see earlier).
Intracranial pressure monitoring may be necessary.

Evaluation

Emergency computed tomography (CT) scan with or without
intravenous contrast is indicated to characterize the injury
radiographically after initial neurologic assessment.

Cerebral contusion
- Diagnosis: history of prolonged unconsciousness with focal neurologic signs
- Treatment: close observation

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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 intraabdominal or intrapelvic injury.
Pelvic fractures, lumbosacral fractures, or hip disorders may be
observed.
Diagnostic peritoneal lavage remains the gold standard for immediate diagnosis of operable intraabdominal injury.
Ultrasound has been increasingly utilized to evaluate fluid present in the abdominal and chest cavities.
Positive peritoneal lavage
- Gross blood, bile, or fecal material
- >100,000 red blood cells/mL
- >500 white blood cells/mL

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