MULTIPLE INJURIES
The management of every severely injured
patient requires a coordinated
approach, such as that taught in advanced
trauma life support (ATLS)
and the equivalent early management of severe
trauma (EMST) courses.
This involves a rapid primary survey,
resuscitation of vital functions, a
detailed secondary survey, and the initiation of
definitive care.
The primary survey is a rapid patient
assessment to identify lifethreatening conditions
and establish immediate priorities.
• The resuscitation phase optimizes the patient’s
respiratory and circulatory status. The response
to resuscitation is recorded with comprehensive
non-invasive monitoring.
• Once resuscitation is under way, a trauma series
of X-rays is taken, bloods are sent, and
additional procedures such as a rapid bedside
ultrasound, nasogastric tube insertion and
urinary catheterization are performed.
The secondary survey commences after
the primary survey is complete and the
resuscitation phase well under way.
• A detailed head-to-toe examination is
made.
• Special X-rays, repeat ultrasound, CT scan
and angiographic
• studies are performed as indicated.
Definitive care is the management of all the injuries
identified, including surgery, fracture stabilization, hospital
admission or preparation of the patient for transfer, if
required.
Expect serious injuries in patients presenting after the
following high-risk mechanisms or with altered physiology:
• Abnormal vital signs: systolic blood pressure under 90
mmHg,
• GCS score 12 or less, respiratory rate less than 10/min or
• more than 30/min.
• Motorcyclist or pedestrian struck.
• Fall greater than 5 metres (15 feet).
• Entrapment.
• High-speed impact, ejection or death of another vehicle
• occupant.
Call senior Emergency Department
staff immediately for any multiple-
injury patient, to organize an
integrated team response
incorporating anaesthetic, intensive
care, surgical and orthopaedic
colleagues.
The time-honoured mnemonic for the initial
sequence of care is
ABCDE
A Airway maintenance with cervical spine
control
B Breathing and ventilation
C Circulation with haemorrhage control
D Disability: brief neurological evaluation
E Exposure/environmental control:
completely undress the
patient, but prevent hypothermia
IMMEDIATE MANAGEMENT
Airway
• Assess the airway to ascertain patency and
identify potential obstruction:
• clear the airway of loose or broken dentures and
suck out any debris
• insert an oropharyngeal airway if the patient is
unconscious
• give 100% oxygen by tight-fitting mask with
reservoir bag
• aim for an oxygen saturation above 94%.
Intubation:
• a definitive procedure to protect and maintain the airway
is indicated if the patient is unconscious, or has a
reduced or absent gag reflex
• take great care to minimize neck movements in the
unconscious head injury or suspected neck injury by
maintaining in-line manual immobilization during airway
assessment and endotracheal intubation
• rapid sequence induction (RSI) intubation
– this is the airway technique of choice, provided the
operator is skilled in the technique
– use an i.v. induction agent such as thiopentone
(thiopental) 0.5–5 mg/kg; etomidate 0.3 mg/kg; or
midazolam 0.1 mg/kg plus fentanyl 2.5–5 μg/kg after pre-
oxygenation ideally for 3 min
• Intubation:
– follow with a muscle relaxant, usually
suxamethonium 1.5 mg/kg, applying cricoid
pressure as muscle tone is lost
– insert the endotracheal tube under direct
vision, visualizing its passage between the vocal
cords, and inflate the cuff
– confirm correct tube placement using
capnography to measure end-tidal carbon dioxide
(ETCO2). Only release cricoid pressure when
happy with tube position
– tie the tube in place and carefully monitor the
patient as a CXR is arranged.
Warning:
never attempt RSI unless you have been
trained. Use a bag–valve mask technique
instead while awaiting help.