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Emergency and Acute Medicine – Trauma, Multiple
Multiple trauma refers to patients with more than one serious injury requiring a structured and prioritized approach to maximize survival. Management follows a standardized system designed for rapid assessment and intervention, recognizing that life-threatening injuries must be addressed immediately. Although often described sequentially, many steps occur simultaneously in real clinical practice. Continuous reassessment is critical—any deterioration requires repeating the primary survey.
The causes of multiple trauma are varied and include motor vehicle and motorcycle crashes, falls from height, assaults, aviation or train accidents, and mass-casualty incidents such as terrorism. Triage decisions are guided by local protocols, but patients with unstable vital signs or those requiring surgical, neurosurgical, or orthopedic intervention should be transported to a Level I trauma center whenever possible.
Initial evaluation begins with the primary survey using the ABCDE approach. Airway assessment is the first priority, ensuring patency while maintaining cervical spine immobilization in patients with significant mechanisms of injury or altered mental status. Signs such as stridor, gurgling, or absent air movement indicate immediate airway intervention is required before proceeding further.
Breathing is assessed next by evaluating chest wall movement, breath sounds, respiratory rate, and oxygen saturation. Findings such as asymmetry, hypoxia, or decreased breath sounds may indicate life-threatening conditions like tension pneumothorax or hemothorax, which require immediate intervention such as needle thoracostomy followed by chest tube placement.
Circulation focuses on identifying and managing shock. Assessment includes blood pressure, heart rate, pulse quality, mental status, urine output, and capillary refill. Early signs like tachycardia and decreased urine output suggest evolving shock, while hypotension is a late and critical finding. Hemorrhage must be rapidly identified and controlled, including external bleeding with direct pressure and internal bleeding through appropriate imaging and intervention.
Disability involves a rapid neurologic assessment, commonly using the Glasgow Coma Scale. A score of 8 or less indicates severe brain injury and necessitates airway protection and intracranial pressure management. Pupillary size and reactivity help assess brainstem function, while motor function provides clues to spinal cord injury.
Exposure requires complete undressing of the patient to identify hidden injuries while preventing hypothermia. Once the patient is stabilized, a secondary survey is performed, consisting of a thorough head-to-toe examination and detailed history, often obtained from emergency medical services.
Diagnostic evaluation includes essential imaging such as cervical spine and chest radiographs, with pelvic imaging when indicated. Laboratory studies include hemoglobin, coagulation profile, arterial blood gases, and type and crossmatch. Advanced imaging depends on patient stability: hemodynamically stable patients typically undergo CT scanning, while unstable patients benefit from bedside ultrasound such as the FAST (Focused Assessment with Sonography for Trauma) exam. Many centers now use “pan-CT” imaging to reduce missed injuries, though this increases radiation exposure.
Treatment parallels the primary survey. Airway management may involve rapid sequence intubation or surgical airway if necessary. Breathing is supported with oxygen and interventions for conditions like pneumothorax or pulmonary contusion. Circulatory support includes large-bore IV access, aggressive fluid resuscitation, blood transfusion when needed, and control of hemorrhage. Special situations such as pericardial tamponade require emergent procedures like pericardiocentesis. Neurologic management includes measures to reduce intracranial pressure, such as head elevation and osmotic therapy.
Definitive management is often surgical, and early involvement of trauma surgeons and subspecialists is essential. Most patients with significant trauma require hospital admission, frequently to an intensive care unit for close monitoring. Patients with minor injuries and negative evaluations may be observed and discharged if stable.
Key principles include strict adherence to the ABCDE approach, maintaining a high suspicion for occult injuries, and rapid escalation of care when needed. Trauma systems rely on coordinated, multidisciplinary care to optimize outcomes, and early transfer to appropriate facilities plays a crucial role in survival.
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