Chapter 15 Trauma patients admitted to the intensive care unit (ICU) are initially seen in the Emergency Department setting. A large percentage of these patients sustain injuries involving more than one body region. This is particularly so in motor vehicle crashes where the specific injuries may not be immediately obvious. Yet, management decisions need to be made and implemented before a specific diagnosis is made in order to ensure survival. This requires application of a priority system of intervention based on an understanding of the relative threat to life posed by the changes resulting from the injuries. Although the trimodal distribution of deaths following trauma1 has been modified as a result of institution of trauma systems, it is still useful to consider it broadly applicable in most situations. In the first peak of this trimodal distribution death occurs immediately after the injury and includes catastrophes such as decapitation, major brain tissue destruction, cardiac rupture etc. for which medical/surgical intervention is futile. During the second peak of this trimodal distribution death can result from abnormalities such as airway and ventilatory compromise, hemorrhage, cervical cord injury etc. Deaths in the third phase of the trimodal distribution results from complications of the trauma such as sepsis, renal failure, and multiple organ failure. Implementation of simple resuscitative measures during the second phase of this trimodal distribution can decrease deaths not only during the second phase but also indirectly during the third phase by prevention of complications, which may result from inadequate resuscitation. For example, late mortality from sepsis and organ failure secondary to prolonged hypo-perfusion states could be decreased by prompt treatment of contaminated wounds, open fractures, and early diagnosis and treatment of hollow viscous perforation within the abdomen as well as aggressive fluid resuscitation all of which should be instituted during the second phase of this trimodal distribution. This chapter discusses the system of priority in multiple system trauma management, its rationale, methods of implementation, and its uniform application in all types of injuries. The order of priorities in the management of the multiple injured patient is based on the premise that early trauma deaths occur as a result of the effects of the injuries on the patient’s biologic life sustaining systems and that the resulting effects consist of derangements in normal physiology. These physiologic changes may occur from varying types of injuries but with similar manifestations e.g., the airway may be compromised as a result of direct physical trauma to the airway or from a head injury interfering with the patient’s ability to maintain patency of the airway. The end result and principles of management of the airway in both instances is essentially the same. Therefore, it is not necessary initially to know the specific cause of the airway compromise, but merely to know and identify airway compromise and to deal with it appropriately. Another important concept is that the degree of life threat posed by the physiologic derangements can be categorized in terms of time i.e., the greatest life threat is the one from which the patient will die most rapidly. An order of priority in assessing and managing the patient initially can then be based on this time-related sequence of life threat. The process of identifying this order of life threat in trauma is termed: The Primary Survey (2-Advanced Trauma Life support course). This Primary survey may be considered a physiologic approach to management during which the immediately life threatening abnormalities are identified and resuscitation is instituted on a priority basis. This resuscitation phase is followed by the Secondary Survey which is an anatomic head to toe evaluation of the patient allowing identification and management of other injuries which may not be immediately life threatening but if left unattended could later pose a life threat or increase morbidity. Most multi-trauma patients are brought to hospital stabilized on long spine boards. The patients should be removed from the spine board as early as possible to prevent decubitus ulcers and the spine board used thereafter only for transporting the patients. Spine stability is maintained on a flat firm mattress with frequent log rolling while maintaining in-line immobilization of the entire spine until a spine injury has been ruled out by clinical examination and definitive imaging. The Primary Survey follows the ABCDE approach and the sequence is based on relative life threat as follows: A—Airway and c-spine control — identification and correction of airway compromise with c-spine precaution. B—Breathing with oxygenation and ventilation. C—Circulation with hemorrhage control. D—Disability (identification and correction of neurologic disability and prevention of secondary brain injury). E—Exposure (total exposure for complete assessment while preventing hypothermia). The order of these priorities is based on the degree of life threat in terms of time so that A is before B because there is less time to correct airway compromise before death or irreversible damage occurs compared to breathing or ventilation abnormalities. The same rationale applies to C, D, and E being in the order indicated. This order of priorities also allows abnormalities to be corrected as soon as they are identified because they are discovered in the order of life threat. Thus, assessment and resuscitation are conducted simultaneously. This order of priorities remains the same in all patients regardless, of gender, age or whether the patient is pregnant. However, in pregnancy there are two patients — the mother and the fetus — and the best treatment for the fetus is resuscitation of the mother by adhering to primary survey principles while monitoring the fetus. In the elderly, comorbidities, medications such as beta blockers, anticoagulants, pacemakers, and brittleness of the cardiorespiratory response to trauma and blood loss must be considered (see chapter on Geriatric Patient). The pediatric patient has a very strong compensatory response initially, but decompensation can be very rapid — these factors must be considered in resuscitating the pediatric patient (see chapter on Pediatric Trauma). Although all the adjuncts mentioned here are not indicated in every patient, all multiple injured patients should have Oxygen (O2) administered to maintain O2 saturation of at least 95%, pulse oximetry, Electrocardiography (ECG), arterial line, large bore venous access (14–16 gauge), gastric intubation (orogastric route preferred when suspecting basal skull fracture), urinary catheterization to monitor urinary output (transurethral route is contraindicated when urethral injury is suspected e.g., blood at the urethral meatus, high riding prostate on rectal examination, perineal ecchymosis — urethrogram is then required to determine the integrity of the urethra), chest X-ray, and pelvic X-ray (if concerned about pelvic fractures as a source of hemorrhage). Because the trauma patient’s status could change at any time, constant monitoring is required to detect these changes as soon as they occur prompting re-assessment which begins with a repeat of the primary survey and institution of corrective measures. Loss of tone of the muscles supporting the tongue may occur from brain hypo-perfusion in shock or Central Nervous system (CNS) injury leading to one of the commonest causes of airway obstruction in the trauma patient because the tongue produces obstruction by receding into the pharynx. Movement of the tongue anteriorly by such simple maneuvers as the jaw thrust or chin lift will temporarily open the airway and allow suctioning of secretions and foreign material as well as delivery of administered oxygen. With prompt resuscitation maneuvers including volume infusion, if the patient is fully conscious, vocalizing clearly, and not in shock an artificial airway is not required. Caution should be exercised during the chin lift and jaw thrust maneuvers to protect the cervical spine. This is best accomplished by having one person maintain manual in-line stabilization of the cervical spine while the other secures and suctions the airway. The simplest technique should be used first for effective ventilation and oxygenation and in over 90% of cases endotracheal intubation is not necessary. In these circumstances suction of the airway is followed by insertion of an oropharyngeal airway device and 100% oxygen administered by a bag valve mask. Many patients who have an intact gag reflex would not tolerate an oropharyngeal airway and the oxygen is then administered without insertion of this device. This device should be inserted gently to avoid trauma and bleeding especially in elderly patients whose oral mucosa is quite friable. In the adult, the device is inserted first with the tip pointed upward and then rotated 180° when the tube reaches the base of the tongue, which is positioned anteriorly making space for the tube. Because of the risk of injury to the soft tissues this rotation technique is not practiced in the child. A nasopharyngeal tube may also be used, but all nasopharyngeal tubes should be avoided if there is concern about the presence of a basal skull fracture as evidenced by rhinorrhea, otorrhea, hemotympanum, battle’s sign, or raccoon eyes. Other temporary airway devices may be used such as Laryngeal Mask Airway (LMA), Laryngo Tracheal Airway (LTA) and esophageal airway, but none of these devices are classified as a Definitive Airway which is defined as a secured cuffed tube placed in the trachea. When the patient is unable to spontaneously maintain a patent airway, a definitive airway is required and should be accomplished promptly and expeditiously, starting with pre-oxygenation using 100% oxygen delivered with a bag valve mask. Prolonged unsuccessful attempts at intubation should be avoided by intermittently providing manual bag valve mask ventilation with 100% oxygen to avoid hypoxia. All airway equipment should always be available and in proper working condition including laryngoscopes, LMA, Gum Elastic Bougies, glidescopes, and fiberoptic bronchoscopes together with appropriate drugs including topical anesthetic, sedatives, and short as well as medium acting neuromuscular paralyzing agents before proceeding to definitive airway. Whenever possible back up help must be available in anticipation of a difficult intubation. Marked obesity with a short fat neck, severe cervical spine arthritis, or limitation of cervical spine movements by other forms of disease, major facial trauma, and anatomical variations can all pose major challenges to successful intubation. One quick assessment to determine the likelihood of a difficult intubation also includes the LEMON3 signs: L—Look for outside signs e.g., beard, short fat neck, receded chin, etc. E—Evaluate the 3-3-2 rule: Distance between the incisors should be at least three finger-widths; distance between the hyoid bone and the chin should be at least three finger-widths; distance between the thyroid notch and floor of mouth should be at least two finger-widths. M—Mallampati score4 visualization of the hypopharynx with the tongue protruded looking for the soft palate, uvula, fauces, and pillars. In Class I, all four structures are clearly visible; Class II, only the first three structures; Class III, only the soft palate and base of uvula visible; Class IV, only the hard palate is visible. O—Obstruction due to trauma, inflammatory disorders edematous tissue, peritonsillar abscess etc. could make intubation technically very difficult. N—Neck Mobility. If there are no signs of cervical spine trauma, neck mobility can be assessed by asking the patient to have the chin touch the chest and then attempt to look towards the ceiling. If the patient is able to accomplish this maneuver without difficulty, it suggest that mobility of the neck should not be an impediment to intubation.
Priorities in Multiple Trauma
Management
Jameel Ali
Chapter Overview
The Order of Priorities
Removal of the spine board
The Primary Survey
Adjuncts to the primary survey and re-evaluation
Airway, oxygenation, ventilation, and cervical spine control
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