Multiple Injuries

Introduction

The multiple injured patient is that patient with injury to more than one organ system.
They are often victims of motor vehicle crashes, motor bike accidents, pedestrians hit by cars, or falls from heights.
Present a challenge to the managing team in terms of priority of medical intervention. If the priorities are not well ordered, the results can be catastrophic
It is difficult to outline clinical features for these patients as virtually any injury is possible

Treatment objectives

  • Identify life threatening injuries and treat
  • Identify all injuries, institute primary management and limit progress of injuries and further tissue damage
  • Restore patient’s physiology paying special attention to the triad of:
    • hypothermia,
    • acidosis
    • coagulopathy
  • Format a prioritized plan of definitive treatment and rehabilitation

Management

  • Advanced trauma life support (ATLS)Vprinciples should apply
  • Patient should be received by a trauma team consisting of at least:
    • A trauma team leader
    • An airway and a procedure doctor
    • Two nurses in similar capacity
    • A radiographer
    • A scrub nurse
    • A social worker

It is important that hospitals which regularly manage trauma patients should maintain a standing trauma team on a 24-hour basis.

  • This helps to optimize outcome in patient management

Pre hospital information

The trauma team needs this information from the pre-hospital team relayed in the MIST format, preferably before the patient’s arrival to enable adequate preparation to be made before hand

  • M: Mechanism of injury
  • I: Injuries sustained
  • S: Prehospital vital signs: pulse, blood pressure, respiratory rate, oxygen saturation, temperature
  • T: Treatment given e. g cervical collar, intravenous fluids etc.

Primary Survey

Quick survey to identify life threatening injuries and treat

Airway

  • Talking? Assume airway is alright. If not suction, Guedel’s airways
  • Careful with airway manoeuvers such as the jaw thrust and chin lift
  • Always protect the cervical spine
  • Apply rigid cervical collar
  • May need endotracheal intubation.

Breathing

  • Check the breathing, respiratory rate, oxygen saturation

Examine the chest:

  • Tension pneumothorax?
  • Haemothorax?
  • Flail chest?
  • Chest tube decompression?
  • Always obtain a chest radiograph before decompression if possible
  • Perform arterial blood gas estimations

Circulation:

  • Check the pulse, blood pressure, capillary refill
  • Listen to the heart sounds.
  • Apply electrocardiograph leads
  • Set up an intravenous line with a large bore cannula size 14 or 16 FG
  • Collect blood for investigations:
    • ABGs, FBC, electrolytes and urea, grouping and cross matching; pregnancy tests
  • Focused Assessment using Sonography in Trauma (FAST)

Disability and Neurology

  • Assess patient’s level of consciousness using the Glasgow coma scale
  • Check the state of the pupils and their reaction to light
  • Expose the patient to perform a quick general examination but prevent hypothermia
  • Cover with warm blanket or put on
  • artificial warmer if available
  • Record core temperature

The trauma series of radiographs is part of the primary survey. These are

  • A-P chest view
  • A-P pelvic view
  • Lateral cervical view.

(In the above order)

Secondary survey

This is a total body examination to detect
injuries sustained
It involves obtaining the AMPLE history
(allergies, medications, past medical history, pregnancy, last meal, environment including details of the accident)

Head:

  • Check for scalp haematomas,
    lacerations, skull fractures,
  • CSF leaks: (rhinorrhoea, otorhoea); facial fractures, raccoon eyes
  • Remove contact lenses; examine pupils,
  • oral examination; Battle sign

Neck:

  • Perform a careful neck examination
  • Leave in collar if there is a high index of suspicion for cervical injury

Chest:

  • Inspect for dyspnoea, tachypnoea, chest movements, flail chest, open pneumothorax or obvious penetration
  • Palpate for chest expansion, crepitus (subcutaneousbemphysema) and rib fractures
  • Assess position of the trachea and determine any tracheal shift
  • Determine percussion notes in both lung fields (dull in haemothorax and hyperresonant in pneumothorax)
  • Auscultate for breath sounds and air entry

Abdomen:

  • Examination findings often unreliable in the multiply injured patient
  • This may be as a result of altered
    sensorium due to head injury, inebriation or drugs, neurological injury, or distracting injury
  • There is need to augment examination with bedside investigations like FAST and DPL (Diagnostic Peritoneal Lavage) if indicated
  • In the haemodynamically stable patient, the best imaging modality is the CT scan with contrast
  • Inspect for seat belt marks, lacerations, abdominal contour and movements with respiration
  • Palpate for tenderness, rebound tenderness and rigidity
  • Percuss if indicated
  • Auscultate for bowel sounds
  • Pass a nasogastric tube Pelvis:
  • Perform anteroposterior and lateral
    compression tests to check for pelvic fractures
  • If fracture is suspected, apply a pelvic girdle or pelvic sheet to decrease pelvic volume, improve tamponade and decrease pelvic haemorrhage

Examine the perineum:

  • Check for perineal bruising, bogginess, scrotal haematomas, and blood at the tip of the penis
  • If there is blood at the tip of the penis it is inadvisable to pass a urethral catheter: a partial urethral rupture may be converted to a complete rupture. Do an urethrocystogram to confirm urethral rupture
  • If not contraindicated pass an indwelling urethral catheter to monitor urinary output and tissue perfusion
  • Haematuria is suggestive of bladder or kidney injury
  • Perform a vaginal examination, checking for bleeding and
    lacerations

Lower limb examination:

  • Check for obvious lacerations, deformity, fractures and dislocations
  • Undertake an appropriate neurovascular assessment
  • Assess muscle power in each limb Upper

Upper limb examination:

  • Same as for lower limb.

‘LOG ROLL’

  • The patient is now log rolled by four persons so as to examine the back
  • The spine is examined from the occiput to the coccyx checking for deformity, swellings, steppings, and tenderness
  • While still in this position perform a digital rectal examination to assess anal tone, presence of blood in the rectum and the position of the prostate
  • A high riding prostate is suggestive of urethral rupture
  • Return patient to the supine position

Neurological examination:

  • Perform a detailed neurological examination as indicated
  • The trauma team should now note all the observed injuries and format a plan for:
    • The further management of the patient
    • Removal from the emergency department and
    • Definitive management of the patient under the appropriate surgical units and consultants