Multiply Injured Patient

Injury has been mans constant companion

since the earliest time.
The first recorded medical text, the Smith
Papyrus (written over 5000 years ago), gives
an account of 48 different injuries described
from the head downwards, an approach to the
wounded individual that is still used today.
Modern trauma care is increasing in
sophistication all the time; however, despite
its huge importance, trauma has been called
the neglected disease of modern society.
The Smith Papyrus 3000 BC.

Unfortunately, most of the victims of trauma
are young individuals.Injury is the commonest
cause of death among people aged 1-34 years,
a leading cause of disability and a major
contributor to health costs.
World Health Organization data suggests that
1 in 10 deaths worldwide is the result of an
injury.
Initial Assessment and Management
Objectives :
-Priorities of emergency medical care
-Evaluation surveys : 1ry , 2ry
-History : Patient Trauma
incident
-Initial resuscitative and definitive-care
phases
-guide lines & techniques

-1ry treatment and stabilization
e.g ; While conducting rapid assessment of the
patient's respiratory , circulatory and neurologic
status, the patient's history and events related to
injury must also be obtained.
Also the patient's response to the question
"WHAT HAPPENED" can provide information
about his airway, breathing and neurological
status, while the examiner can assess the patient's
pulse, skin colour and capillary filling time, also
the physician must understand the kinetics of
trauma.
I- Establishing Assessment and
Management "PRIORITIES":
Based on their injuries and the stability of their
vital signs and the mechanism of traumatic
incident.
The patient's vital functions must be assessed
quickly and efficiently.
Patient's management must consist of a rapid 1ry
evaluation and resuscitation of vital functions, a
more detailed 2ry evaluation and finally the
initiation of definitive care.
A- 1ry Survey :
Life threatening conditions are identified
and management is started
simmultaneously.
a-airway maintenance with cervical spine
control
b-breathing and ventilation
c-circulation and haemorrhage control
d-disability: neurologic status
e- exposure:completely undress the patient.
B- Resuscitation phase:
Shock management is initiated, oxygenation
reassessed , haemorrhage control re-
evaluated.
Life threatening conditions identified in the
1ry survey are constantly reassessed as
management is continued, urinary catheter
and nasogastric tube may also be inserted if
their use is not contra-indicated.
C- 2ry Survey :
does not begin until the 1ry survey has been
completed and resuscitation phase has begun .
It is a head-to-toe evaluation of the trauma patient
:
vital signs assessment :B.P. , pulse ,resp., temp.
Look, listen and feel techniques evaluating the
body by region.


Each region (H+N, chest , abdomen ,
extremities ,neurologic) is examined
individually, the stethoscope is used over
each body cavity and major vessel area, the
hands palpate for bony defects and other
abnormalities, a neurologic examination ,
chest and circulatory X-ray.
Special procedures e.g peritoneal lavage , x
rays and lab studies.
Assessment of the eyes ,ears ,nose
,mouth,rectum and pelvis should not be
neglected.
D- Definitive care phase:
in which all the patient's injuries are
managed ; includes comprehensive
management of fractures stabilization and
any necessary operative intervention and
preparation for transfer to a higher level
medical care.
E- Triage :
sorting of patient's based on need for treatment based on
the A B C priorities.
Two types of situation usually exist:
1-Number of patients and severity of their injuries do not
exceed the ability of the facility to render care. In this
case, patients with life threatening problems and those
sustaining multiple system injuries are treated first.
2-Number of patients and severity of their injuries exceed
the capability of the facility and staff . In this case ,those
patients with the greatest chance of survival ,with the least
expenditure of time, equipment, supplies and personnel are
managed 1st.
II- Priority Plan Treatment and
Management
A-1ry Survey :
1-Airway and cervical spine:-
-chin lift or jaw thrust
-clear airway from foreign bodies
-oropharyngeal airway
-orotracheal or naso-tracheal intubation
-cricothyroidectomy
-Maintain the cervical spine in a neutral position
with manual immobilization as necessary when
establishing an airway
2-Breathing control:-
-expose the chest
-determine the rate and depth of respiration
inspect and palpate for unilateral and
bilateral chest movement and signs of injury
-ausculate the chest bilaterally
-alleviate tension pneumothorax
-seal open pneumothorax
3-Circulatory and hemorrhage control:
-pulse: quality,rate and regularity
-colour of skin ,capillary blanch test
-hamorrhage
-I.V. catheters and obtain blood for cross
matching and haematologic and chemical analysis
and arterial blood gases
-initiate Ringer lactate solution and blood
transfusion.
-apply the pneumatic antishock garment if
necessary
-apply direct pressure to bleeding site
-E.C.G Monitor
-insert urinary catheter and N.G. tube unless
contraindicated.
4-Disability Brief neurological example :
determine the level of consciousness ; alert,
response to vocal stimulation ,response to
painful stimulation and unresponsive.
assess the pupils for size , equality and
reaction
5-Exposure:
completely undress the patient
B- 2ry Survey and Management :
1-Head and face: inspection,palpation ,re-evaluate
pupils and cranial nerve function.Maintain airway
and haemorrhage control.
2-Neck: inspection ,palpation,auscultation, X-ray
spine.Maintain adequate immobilization of spine.
3-Chest: inspection, palpation,auscultation
,percussion,pleural decompression
,thoracentesis,pericardiocentesis and chest X-ray.
4-Abdomen: inspection, percussion,
auscultation, palpation and peritoneal lavage if
needed.
5-Perineal and rectal examination: anal
sphincter tone, rectal blood ,bowel wall
integrity, prostate position,blood at urinary
meatus,scrotal haematome.
6-Back: bony deformity and evidence of
penetrating or blunt trauma
7-Extrimities: deformity, expanding
haematoma, tenderness, cripitation, abnormal
movements,splint for #
8-Neurologic: senseromotor paralysis or
paresis.


C-Stabilization and transport:
outline rational for patient transfer
transfer procedures
patient's needs during transfer
III-History
A-Patient: allergies ,medications ,past
illness, last meal, events related to injury.
B-Mechanism of injury: injury types can be
classified according to the direction and
amount of energy force
1-Blunt trauma : falls,automobile
,motorcycle .The direction of impact
determine the pattern of injury in the
affected body cavities: front, side, rear
impact, ejection from a vehicle.
2-Penetrating trauma:
The region of the body specific organ
injury
The transfer of energy determine the injury
itself.
The velocity of the missile and its
massamount of injury
The distance from the source of impact
3-Burns:Thermal injury to skin ,smoke
inhalation and heat injury to lung.
Carbon monoxide inhalation and effects of
any chemicals involoved
4-Hypothermia and cold injuries
5-Hazardous environment:
chemicals, toxins and radiation
IV. Records & Legal Considerations