Approach to Multi-trauma Patient

Phases of trauma care

  • Prehospital phase
  • Hospital phase
    • Acute + primary periods → most common causes of death are blood loss, lethal head injury
    • Secondary period → most common causes of death are early organ failure, especially pulmonary failure
    • Tertiary period → most common causes of death are sepsis, pulmonary failure, delayed organ failure
  • Rehabilitation phase

Acute Hospital Period (Initial 1-2 hours)

  • Primary survey with rapid assessment of vital signs + patient status

Primary Evaluation of Multi-trauma Patient

A – Airway maintenance with cervical spine control

B – Breathing + ventilation

C – Circulation with haemorrhage control

D – Disability evaluation (neurologic status)

E – Exposure + environmental control

  • Lateral cervical spine Xray to C7/T1

Pelvis

  • Xray AP pelvis. If fracture pattern unstable then inlet + outlet views, Judet views
  • Tile’s ABC classification
  • Young’s classification
    • Lateral compression characterised by oblique anterior ring Fracture. Associated with ↓pelvis volume, intraperitoneal + intrathoracic haemorrhage, head injury. High mortality in lateral compression injury secondary to associated injuries
    • AP compression characterised by vertical pubic rami fractures. Sequential disruption of sacrotuberous + sacrospinous ligaments, anterior + posterior sacroiliac ligaments, ± neurovascular structures. Internal hemipelvectomy carries highest blood loss of all pelvic fractures
    • Vertical shear
    • Combined
  • Haemorrhage can be managed with
    • Embolisation
    • ORIF pelvis
    • Direct ligation
    • External fixateur stabilises pelvic ring, controls pelvic volume, minimises clot dislodgment. Pins inserted between cortices of ilium
    • Antishock garment

Primary Hospital Period (3-12 hours)

  • Wounds
    • Examine once in +E
    • Theatre on urgent basis to debride wound, remove all devitalised tissue, muscle fascia, bone
    • Pulsatile lavage
    • Different prep + drape for ORIF
    • Repeat debridement in 48 hours, early soft tissue coverage
    • Prophylactic 1st generation cephalosporin 48 hours (second antibiotic for farmyard + brackish water contamination)
    • Antibiotics specific for bacteria identified at time of debridement
  • Musculoskeletal morbidity is primary source of long term disability in multitrauma notably spinal trauma. Early ROM + patient mobilisation can ↓ rehabilitation time + long term disability
  • No prospective study to demonstrate ↑infection or ↑nonunion in early fixation
  • Fat embolism syndrome
    • Marrow fat can embolise to pulmonary vessels. This activates coagulation cascade, complement, ↑platelet function, release vasoactive substances
    • Clinically = acute hypoxia, mental status alteration, CXR interstitial infiltration
    • Incidence in isolated long bone fracture = 0.5-2%, multitrauma patient = 10-15%
    • Early fracture stabilisation = ↓incidence of fat embolism syndrome. Riska + Myllynen → incidence fat embolism syndrome 1.4% with early fixation vs. 22% delayed fixation
  • ARDS
    • Refractory hypoxia + CXR diffuse infiltrative changes
    • Prolonged intubation usually necessary
    • Associated with late septic complications, multiorgan failure, high mortality
    • Delaying fixation >24 hours = 5 fold ↑ARDS