Approach to the multi-trauma patient (Proceedings)

The patient with multi-trauma can present a challenging case for a clinician.Damage to the respiratory system, cardiovascular system, or neurologic system can all be fatal by themselves, and a combination of these injuries can present as a resuscitation nightmare.

There are three intervals in which death may result from trauma.Deaths that occur within one hour following trauma are usually from catastrophic, unsalvageable injury to the respiratory and cardiovascular system. The second interval occurs within 2-4 hours after trauma ("Golden Period").In these patients, prompt, aggressive treatment makes a difference in survival.The third interval occurs 3-5 days following trauma, and deaths occur secondary to organ failure, sepsis, and unmasked injuries.

Plan for First Two Hours of Acute Care

      Eliminate all immediate threats to life

      Initial exam and resuscitation

      Stabilization and re-evaluation

      Once stable, definitive repair of injuries

Primary Survey: Evaluate for any immediate life-threatening injuries

The golden rule is to treat the most life-threatening problems first before assessing and treating for other injuries.Therapeutic failures are generally not from ignorance but from failure to act expediently at a crucial moment.

During the primary survey, we start by evaluating our ABCD's—Airway, Breathing, Circulation, and Disability (nervous system). Ensure the patient has patent airway with no obstructions.Evaluate the patient for severe dyspnea, restrictive breathing patterns, and cyanosis.Evaluate for active, ongoing hemorrhage, mucous membrane pallor, poor pulse quality, or cold extremities.Evaluate for intracranial or spinal injury leading to alterations in level of consciousness, paralysis, or loss of sensation.Based on our findings from our primary survey, we will choose therapeutic options to remove immediate life-threatening problems.

Airway and Breathing

The thorax is a common area of injury with both blunt and penetrating traumas.The thoracic triage should include evaluation of the respiratory rate and pattern, mucous membrane color, and thoracic auscultation.A restrictive breathing pattern (rapid, shallow breathing) can indicate pleural space disease, thoracic wall disease, or pain.Labored, abdominal breathing may indicate pulmonary parenchymal disease.An airway obstruction should be suspected with the presence of stridor or the lack of passage of air during attempted respirations.Subcutaneous emphysema indicates loss of integrity of an air-filled space or airway.Radiographs are generally delayed during the unstable phase, as the patient may die in the process.

Treatment options for thoracic injuries may involve oxygen therapy, thoracocentesis, tracheostomy, thoracostomy, and positive pressure ventilation. Supplemental oxygen early in the course of illness has been shown to lead to less reperfusion injury and is associated with fewer infections.As a rule of thumb, it is recommended to start oxygen therapy on any patient presenting with trauma and continue until assessment of the patient is complete.

Circulation

Hypovolemic shock is the most common presentation of trauma patients and can occur from hemorrhage, or third spacing of fluids secondary to vasodilation, tissue trauma, or severe pain.Intravenous fluids should be administered to correct perfusion deficits.Isotonic crystalloids are often our first fluid choice in these instances.The choice of the type of crystalloid to use will depend on the needs of the individual patient.

Hypertonic saline is a good resuscitation fluid choice in some circumstances.Its hypertonicity creates an osmotic gradient and increases intravascular volume rapidly.This is a good early fluid for hypovolemia, but it is also short lived.Other fluid choices may include synthetic colloids and blood products.

Severe hemorrhage is a concern in any patient with blunt or penetrating trauma.The hemorrhage may be external or internal.Therapy for severe hemorrhage involves first controlling any external hemorrhage with direct pressure or ligation.IV fluids or blood products should be administered if necessary. Emergency surgery should be considered if unable to stabilize internal hemorrhage.

Secondary Survey

Once the airway is secured, ventilation is adequate, volume replacement has begun, and obvious hemorrhage is controlled, perform a complete and thorough examination of all the body systems to evaluate for other injuries and sources of destabilization.

Vital signs should be monitored, including blood pressure, heart rate, pulse quality, respiratory rate and pattern, mucous membrane color and capillary refill times, and SpO2.A minimum database should include a PCV/TS, electrolytes, venous blood gas, blood lactate, and evaluation of abdominal or thoracic fluid. Thoracic and abdominal radiographs and/or ultrasound are recommended in all trauma cases as a screen.Frequent recheck of vital signs and serial physical examinations should be performed to assess for occult, decompensating conditions.Cover open wounds with sterile dressings, immobilize unstable fractures, and administer pain medications and prophylactic antibiotics as needed at this time.

Thoracic Trauma

Pneumothorax is a common sequela to thoracic trauma and should be suspected in any animal presenting with signs of respiratory difficulty following trauma. Consider a thoracocentesis whenever there is any possibility of thoracic trauma or index of suspicion of pneumothorax.

An open pneumothorax may be caused by blunt or penetrating trauma.Immediate treatment for an open chest wound involves covering the wound with water-soluble gel and bandage material. Immediate thoracocentesis should follow to relieve the pneumothorax.A thoracostomy tube may be needed if the pneumothorax is recurring.Aggressive antibiotics should be instituted, and debridement and closure of the wound should be performed after complete stabilization.

A tension pneumothorax can occur if a leaky area of lung or airway acts as a one-way valve.With inspiration the thorax fills with air, increasing pressure and collapsing the lung lobes and great veins.Air cannot escape on expiration, as the valve closes.These patients present with severe dyspnea and decreased to absent lung sounds.A thoracocentesis should be performed.If a tension pneumothorax exists, there may be a puff of air when first placing the needle in the chest, and negative pressure will not be established. Treatment involves the immediate placement of a thoracostomy tube.

Hemothorax may occur from rupture or tear of intrathoracic vessels.The diagnosis may be made in a patient presenting with a restrictive breathing pattern, dull respiratory noises ventrally, and the presence of non-clotting blood on thoracocentesis.Treatment involves evacuation of the blood if the hemothorax leads to compromise of lung function.Only evacuate enough blood to restore lung function, as the body will reabsorb the remainder.A thoracotomy is rarely indicated, but should be performed if vital signs worsen despite attempted evacuation of blood.

Pulmonary contusions occur with blunt trauma to the pulmonary parenchyma leading to bleeding and edema in the interstitium with extension into the alveoli and airways.It can range from mild and non-symptomatic to severe and life threatening.Severity will usually worsen over the first 24 hours.Contusions may be suspected if the animal presents with dyspnea, hemoptysis, and crackles, moist rales or bronchial sounds on thoracic auscultation.Radiographs should be performed once the animal is stable.Radiographic signs may take as many as eight hours to appear and will worsen over the first 24 hours.Interstitial to alveolar infiltrates are often noted.

Treatment of pulmonary contusions is mainly supportive.Oxygen should be administered with ventilatory support if severe.Fluid therapy should be carefully considered, as fluids can lead to worsening edema.If the patient is hypotensive, low-volume resuscitation should be performed.The goal is to raise the blood pressure to > 70mmHg but < 110mmHg.Pharmacological agents are rarely beneficial.Bronchodilators may be of some benefit, but be careful of sympathetic stimulation.Furosemide is not indicated in most cases.

Rib fractures are generally treated conservatively with pain control and oxygen if needed. Flail chest occurs when there are multiple (2+) fractures of at least two adjacent ribs leading to loss of intrinsic costal arch support.The patient presents with asynchronous "flail" during respiration.Underlying pulmonary damage (i.e. contusions, pneumothorax) is the primary cause of respiratory dysfunction.Pain often compounds respiratory impairment in these patients.

Treatment of flail chest involves early stabilization of rib segments if the flail segments are severely impairing ventilation. Oxygen therapy and pain management using systemic analgesics, intercostal nerve blocks, or intrapleural bupivicaine should be administered.Positive pressure ventilation should be administered if necessary.

Treatment of an airway obstruction includes oxygen supplementation.A transtracheal oxygen cannula may be used to bypass the obstruction if necessary.Anesthesia and intubation should be performed if the obstruction is severe and can't be relieved in time to save the patient's life.A tracheostomy may be required if necessary to by-pass the obstruction.

Abdominal Trauma

Hemoabdomen is relatively common with blunt or penetrating trauma.With blunt trauma, it is most often caused by hepatic or splenic lacerations.The diagnosis is made when the patient presents with pale mucous membranes, tachycardia, and weak pulses with a distended abdomen and fluid wave.An abdominocentesis should be performed via a 4 quadrant tap, diagnostic peritoneal lavage, or ultrasound-guided centesis.Perform a PCV/TS, cytology, creatinine, and bilirubin on fluid to rule out injuries to other organs.To determine if hemorrhage is ongoing, serial PCV/TS, and serial abdominal measurements can be performed.

Treatment of hemoabdomen involves the use of low-volume, hypotensive resuscitation to prevent dislodgement of clots.Transfusions should be administered if indicated using whole blood, packed RBC's, or autotransfusion. Compressive abdominal wraps are generally not recommended as they may severely impair ventilation. Surgery is reserved for those who cannot be stabilized with aggressive medical intervention.

Uroabdomen may occur with blunt or penetrating abdominal or pelvic trauma leading to bladder (most common), kidney, urethra, or ureteral rupture.Uroabdomen results in dehydration, metabolic acidosis, and electrolyte abnormalities.Diagnosis is based on clinical symptoms such as pain on abdominal palpation, dysuria, anuria, hematuria or lack of bladder filling with fluid therapy.Later in the course the animal may exhibit vomiting, depression, and dehydration.Biochemical changes also will occur with uroabdomen, including increased BUN, creatinine and phosphorus.Hyperkalemia often follows, as well as hyponatremia and hypochloremia.Radiographs may reveal loss of abdominal or retroperitoneal detail.The presence of a bladder on plain films does not rule out rupture.Contrast studies often help with the diagnosis.An abdominal ultrasound may show retroperitoneal or abdominal fluid.Abdominocentesis may result in fluid with a higher creatinine than peripheral blood.

Treatment for uroabdomen involves surgery for definitive repair once stable.Pre-surgical stabilization for volume depletion, hyperkalemia, acidemia, azotemia, and other trauma-induced injuries, as these patients are risky surgical candidates. Abdominal fluid drainage or lavage should be considered prior to surgery if the azotemia or hyperkalemia are severe.

Diaphragmatic hernia can occur with compressive trauma, and displacement of liver, gall bladder, spleen, intestines, and stomach are possible.Life-threatening complications include respiratory compromise, concurrent injuries, internal hemorrhage, and hypovolemic shock.Compounding complications may include hemothorax, gastric tympani, and strangulation of a viscous.Diagnosis is made by palpation of "empty feeling" abdomen, borborygamus on thoracic auscultation or dull lung sounds, and radiographic findings of disruption of the diaphragm and organs within thoracic cavity.A contrast study, CT or ultrasound may be helpful in more difficult diagnoses.

Treatment involves surgical repair once the patient is stable.Treat more life-threatening complications first if the hernia is not causing significant ventilatory compromise.Emergency surgery is indicated if the animal has severe dyspnea, massive herniation, or if the stomach herniated into thoracic cavity.

Other traumatic hernias include body wall hernia and prepubic tendon rupture.For both of these, surgery is indicated once the patient is stable, emergent if a strangulated viscous or a ruptured organ is present.Herniation of bladder and small intestines is common, and these injuries are also often associated with pelvic fractures, urinary tract and GI damage.

Other injuries found following abdominal trauma can include bowel necrosis or rupture secondary to crushing or penetrating injuries.Biliary tract injury may occur as well and can be diagnosed if the abdominal bilirubin is higher than peripheral.Penetrating abdominal wounds also may occur.Surgical abdominal exploratory is indicated in any of these cases.

Head Trauma

The pathophysiology of head trauma occurs in two stages.The primary injury that occurs at the time of trauma includes vessel disruption and tearing or crushing of brain parenchyma.The damage is done when the animal presents.Secondary Injury follows and involves tissue ischemia, increased intracranial pressure, hemorrhage, and edema.This is the area where we can interfere.Diagnosis involves a physical and neurologic examination. Skull radiographs may only reveal severe injuries or fractures.A computed tomography may shows skull fractures or hematomas, but an MRI is a better modality for showing brain ischemia and edema.

Treatment goal for head trauma is to reduce ischemia and minimize cytotoxicity.These are often "multi-trauma" patients, so look for and treat other life-threatening injuries.Hypotension will lead to brain ischemia and worsen head trauma quickly, so correct this immediately.Consider using hypertonic saline in the resuscitation protocol, as this may help control brain edema.Ventilatory or respiratory impairment should be corrected quickly, as hypoxia leads to brain ischemia.If the patient is unconscious, intubate and start ventilations immediately.Oxygen supplementation should be initiated in all head trauma patients.

Drugs used in the treatment of head trauma include mannitol, which dehydrates the cerebral interstitium, decreases blood viscosity, improves cerebral perfusion, and acts as a free radical scavenger.Furosemide may also be considered.The patient's neurologic status should be monitored hourly, including level of consciousness, breathing patterns, menace response, pupil size and responsiveness, ocular position, and long-tract signs.

Musculoskeletal Trauma

Open fractures are graded I-III based on size of wound, extent of soft tissue damage, and severity of fracture.Open fractures are always emergencies, and as soon as the animal is stable should be debrided, lavaged, and stabilized with a sterile bandage.Broad spectrum antibiotics should be started immediately, and culture all wounds.

Closed fractures should be evaluated carefully.Clip surrounding hair to check for open wounds.Stabilize fractures before moving patient around to prevent from becoming open fractures.Splint should immobilize joint above and below fracture.

Luxations are the common with coxofemoral luxation making up 90% of all luxations.Diagnosis can be made on physical exam.Treatment may involve open or closed reduction.Closed reduction should be performed as soon as the animal is stable to improve the outcome.

Traumatic Wounds

Bite wounds can have a deceptive initial appearance, as most of the damage is in the deeper tissues.Look for fractured bones, penetration of the abdominal or chest cavity, and crushed muscle and subcutaneous tissue with dead space.Treatment involves clipping the area thoroughly to evaluate extensiveness of punctures.Wounds should be debrided and lavaged to minimize bacterial population.Wounds over the thorax or abdomen should be evaluated with radiographs or exploration for penetration into a body cavity.Penetrating bite wounds always require surgical exploratory.Broad-spectrum antibiotics should be instituted, and wounds should be cultured.

Other wounds include abrasions or shearing wounds, degloving, lacerations, and punctures.Apply direct pressure to bleeding wounds.Keep wounds moist, clean, and covered until definitive treatment can be performed once the animal is stable.

References available by request