Multitrauma

Multitrauma occurs when 2 or more traumatic injuries occur in at least 2 areas of the body. A systematic management approach is necessary for individuals who have undergone trauma to maximize outcomes and reduce the risk of undiscovered injuries. Assessment of multitrauma starts with a primary survey followed by the A-B-C-D-E scheme, involving securing of the airway (A), and evaluating breathing (B), circulation (C), recognition of neurologic deficits or disability (D), and exposure to environmental control (E). Once the primary survey is completed, a secondary survey is performed to obtain pertinent history and nature of the trauma based on a thorough examination and diagnostic studies. The A-B-C-D-E approach is crucial for the overall stabilization, treatment, and identification of any missed injuries.

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Overview

Definition

Multitrauma or polytrauma is defined as 2 or more severe injuries in at least 2 areas of the body (with at least 1 life-threatening injury).

Epidemiology

Trauma is a leading cause of mortality and morbidity globally.

  • Worldwide, motor vehicle fatality is the leading cause of accidental death in the 18–29-year-old age group.
  • Homicide is the leading cause of death in non-Hispanic Black boys in their teens.

Hemorrhage is the most common preventable cause of mortality in trauma.

Factors associated with poor outcomes in trauma:

  • Old age
  • Obesity
  • Major comorbidities

Primary Survey

Primary survey is the initial evaluation used to identify and manage life-threatening injuries in an individual with trauma. The survey consists of 5 assessments performed in a stepwise manner: airway, breathing, circulation, disability, and exposure.

Airway

  • Purpose:
    • To establish airway patency
    • To assess an individual’s ability to protect the airway
    • To protect the airway:
      • Oropharyngeal airway to prevent obstruction by the tongue in unconscious but breathing individuals
      • Intubation if necessary
    • Spinal immobilization using a backboard and rigid cervical collar
  • Causes of airway compromise:
    • Traumatic injury
    • By the tongue of the affected individual
    • Foreign body (e.g., swallowing an external object)
    • Vomit, blood, and secretions
    • Localized swelling due to infection or anaphylaxis
  • Airway assessment:
  • Affected individuals can speak normally → airway is intact
  • Signs of an unprotected airway:
    • Paradoxical chest and abdominal movements
    • Cyanosis
    • Abnormal breathing sounds (e.g., snoring, stridor, gurgling, expiratory wheezing)
    • Presence of subcutaneous emphysema
    • Glasgow Coma Scale (GCS) < 9
  • Airway management:
    • Adequate ventilation with 100% oxygen using a bag and mask
    • Pulse oximetry to monitor oxygen levels
    • Special maneuvers:
      • Chin lift, jaw thrust
      • Oral (oropharyngeal tube) or nasal (nasopharyngeal tube) airways can be used to temporarily maintain the airway.
  • If maneuvers fail, establish a definitive airway:
    • Endotracheal (orotracheal) intubation:
      • Insertion of a tube into the trachea through the mouth (less commonly through the nose)
      • 1st-line procedure
    • Cricothyrotomy:
      • Incision of the membrane between the thyroid cartilage and cricoid cartilage
      • In severe traumatic injuries, if intubation fails or if the airway is severely swollen (anaphylaxis)
      • Easier to perform than tracheostomy
      • Temporary procedure
    • Tracheotomy:
      • Incision to the trachea and insertion of a tracheal tube
      • Preferred in pediatric individuals (< 8 years of age) as the cricoid is smaller
Neck collar attachment for multitrauma patient

Application of the backboard and C-collar by emergency medical services (EMS) in the field:
If the affected individual arrives in a personal vehicle, the C-collar is applied during the airway (A) portion of the primary survey.

Image: “Neck collar attachment for multitrauma patient” by Senior Airman Janiqua P. Robinson. License: CC0 1.0

Breathing

  • Purpose:
    • To detect signs of respiratory distress
    • To maintain sufficient oxygenation and ventilation
    • If breathing problems occur at this step, it may be necessary to perform procedures (thoracostomy) to correct the problem.
  • Breathing assessment:
    • Listen to breath sounds.
    • Determine the respiratory rate: 12–20 breaths/minutes is normal.
    • If the respiratory rate is ↓ or ↑, consider airway assistance
    • 40% of individuals who have had a cardiac arrest may exhibit agonal breathing (series of noisy gasps).
  • Signs of respiratory distress:
    • Inspection:
      • Central cyanosis
      • Jugular venous distention
      • ↑ Effort to breathe (e.g., use of accessory muscles)
    • Percussion: hyperresonance (pneumothorax) or dullness (hemothorax)
    • Palpation: tracheal shift, subcutaneous emphysema, flail segments
    • Auscultation: ↓ air entry during auscultation
    • Oxygen saturation: < 88%
    • ↓ End-tidal CO2 (capnography)
  • Breathing management:
    • Depends on the cause
    • Return to A (airway) to establish a definitive airway if there is respiratory distress.
    • Tube thoracostomy (small incision on the chest wall and insertion of a chest tube) is needed in:
      • Tension pneumothorax, open pneumothorax
      • Flail chest
      • Massive hemothorax
    • Pericardiocentesis (insertion of a needle and small catheter into the pericardial sac to drain excess fluid) is necessary for cardiac tamponade.

Circulation

  • Purpose:
    • To determine the effectiveness of cardiac output
    • To secure adequate tissue perfusion
    • To treat external bleeding
  • Causes of poor circulation:
    • Shock (including hypovolemia, septic, or anaphylactic shock)
    • Traumatic injury to arteries (compartment syndrome, arterial lacerations, crush injury)
    • Cardiac arrhythmias
    • Heart failure
    • Pulmonary embolism
  • Circulation assessment:
    • Nonbreathing (apneic) individuals: CPR
    • Individuals who are breathing:
      • Blood pressure assessment: indication of the effectiveness of the cardiac output, considered ↓ if systolic blood pressure < 90 mm Hg
      • Check skin (cold, clammy skin is an indication of hypovolemia).
      • Check capillary refill time (abnormal if > 2 seconds).
      • Check urinary output (< 0.5 mL/kg/h is considered low).
      • Check HR (↑ HR (> 100/minute) could mean shock).
  • Circulation management:
    • Direct pressure to control any external hemorrhage
    • 2 large-bore IV lines to be placed in all affected individuals. If unfeasible, alternatives include:
      • Central access into femoral, jugular, subclavian veins
      • Intraosseous access
      • Percutaneous and cutdown catheters in the saphenous vein of the lower limb (less common)
    • Consider mass transfusion blood protocol.
    • Signs of shock (pale, cool, and moist skin, hypotension) may not appear initially until the affected individual loses up to 30% of blood.
    • Check the need for reversal of anticoagulation.

Disability

Disability assessment:

  • Examine pupils: Pupil dilation suggests ipsilateral brain mass or blood collection causing compression of the 3rd cranial nerve.
  • Motor and sensory examination
  • Assess the level of consciousness and mental status using GCS:
    • The affected individual receives a score for the best response in each area.
    • Scores in each area are combined to achieve a total score of 3–15.
    • ↑ Number → the better the prognosis
    • A score ≤ 9 indicates coma and the need for endotracheal intubation.
  • Life-threatening neurological injuries include:
    • Penetrating cranial injury
    • Intracranial hemorrhage
    • Diffuse axonal injury
    • High spinal cord injury
Table: Glasgow coma scale
FeatureResponseScore
Eye openingOpen spontaneously4
Open to verbal commands3
Open to pain2
No eye opening1
Verbal responseOriented and appropriate5
Disoriented but conversant4
Nonsensical words3
Moaning2
Silent1
Motor responseFollows commands6
Localizes pain5
Withdraws from pain4
Flexor posturing3
Extensor posturing2
Flaccid1

Exposure

The goal of this step is to evaluate and manage negative environmental effects:

  • Completely undress the individual and perform a full physical examination.
  • Keep the individual warm, as hypothermia can trigger coagulopathies.

Secondary Survey

Technique

The goal of the secondary survey is to rapidly and thoroughly examine the affected individual from head to toe and identify all potentially significant injuries.

  • Performed after the primary survey and initial stabilization are complete
  • Performed after all life-threatening injuries have been identified and stabilized
  • Gather the history including injury type (blunt or penetrating) and past medical data.
  • Examine the affected individual from head to toe, including all orifices (ears, nose, mouth, vagina, rectum):
    • Vital signs
    • Head and neck:
      • Look for scalp hematoma, skull depression, laceration.
      • Palpate facial bones.
      • Check nose for septal hematoma.
      • Check ears for hemotympanum or retroauricular ecchymosis (Battle’s sign).
      • Ocular examination
      • Immobilize the individual and palpate the neck.
    • Chest:
      • Check for crepitus, tender areas, bruises.
      • Check respiratory effort.
    • Abdomen:
      • Check for distension and bruising.
      • Auscultate for bowel sounds.
    • Extremities:
      • Check for tenderness and range of motion.
      • Check for pelvic instability.
    • Skin:
      • Check from head to toe (especially the back, perineum, and axillary and gluteal folds).
      • Look for lacerations, hematomas, and abrasions.
    • Neurologic exam: Repeat GCS.
  • Order imaging and other tests as needed:
    • Plain radiography
    • FAST is an essential component of the primary circulation survey and is primarily used to detect:
      • Pericardial blood
      • Intraperitoneal blood
    • Emergency CT scan
  • Go back frequently to the primary survey for reassessment!

Mnemonic

For focused history, recall the mnemonic “AMPLE”:

  • Allergy
  • Medications
  • Previous medical history/ illness
  • Last meal
  • Events related to the injury

Avoiding missed injuries

Pertinent history, thorough physical examination, and appropriate diagnostic studies help avoid missed injuries such as:

  • Blunt abdominal trauma: hollow viscus injury, pancreatoduodenal damage, diaphragmatic rupture
  • Penetrating abdominal trauma: perineal injuries (includes rectal and ureteral damage)
  • Thoracic trauma: pericardial tamponade, esophageal perforation or rupture, aortic injuries
  • Extremity trauma: fractures, vascular injuries, compartment syndrome

Mechanisms and Associated Injuries

The tables below summarize the different mechanisms of trauma and their associated specific injuries.

Motor vehicle collisions

Table: Motor vehicle collisions and associated injuries
Mechanism of injuryPotential associated injuries
Head-on collision
  • Facial injuries
  • Lower extremity injuries
  • Aortic injuries
Rear-end collision
  • Hyperextension injuries of the cervical spine
  • Cervical spine fractures
  • Central cord syndrome
Ejected from vehicleSpinal injuries
Windshield damage
  • Closed head injuries (coup and contrecoup injuries)
  • Facial fractures
  • Skull fractures
  • Cervical spine fractures
Steering wheel damageThoracic injuries
Dashboard involvement/damage
  • Pelvic and acetabular injuries
  • Dislocated hip

Pedestrian versus automobile injuries

Table: Pedestrian versus automobile and associated injuries
Mechanism of injuryPotential associated injuries
Low speed (braking automobile)
  • Tibia and fibula fractures
  • Knee injuries
High speedWaddle’s triad (in pediatric pedestrians):
  • Tibia/fibula or femur fractures
  • Ipsilateral thoracoabdominal injuries
  • Contralateral craniofacial injuries

Bicycle accidents

Table: Bicycle accidents and associated injuries
Mechanism of injuryPotential associated injuries
Automobile related
  • Closed head injuries
  • “Handlebar” injuries (spleen/liver lacerations, additional intraabdominal injuries)
Nonautomobile-related
  • Extremity injuries
  • “Handlebar” injuries

Falls

Table: Falls and associated injuries
Mechanism of injuryPotential associated injuries
Vertical impact
  • Calcaneal and lower extremity fractures
  • Pelvic fractures
  • Closed head injuries
  • Lumbar vertebral fractures
  • Renal vascular injuries
Horizontal impact
  • Craniofacial fractures
  • Hand and wrist fractures
  • Abdominal and thoracic visceral injuries
  • Aortic injuries

Clinical Relevance

  • ABC assessment: the mainstay management approach used for critically ill individuals. Assessment of ABCs is an essential 1st step to perform in many situations including the management of unresponsive individuals, those who have undergone cardiac arrest, and also those who have undergone trauma and are critical. In such cases, ABC is included in the primary survey, initial evaluation, and management of injuries.
  • Epidural hematoma: rapidly expanding blood collection between the bone and dura mater due to rupture of middle meningeal arteries. Epidural hematoma is marked by a lucid interval, cranial nerve palsies, and altered mental status. A CT scan shows biconvex (lens shaped), hyperdense blood collection that does not cross the suture lines. Epidural hematoma is a life-threatening condition that requires surgical decompression.
  • Subdural hematoma: collection of blood between the dura mater and arachnoid membrane due to the rupture of bridging veins. A CT scan shows crescent-shaped blood collection that crosses the suture lines. A subdural hematoma can be both acute and chronic and may require prompt care, usually surgery.
  • Subarachnoid hemorrhage (SAH): a type of stroke caused by bleeding into the cranial and/or spinal subarachnoid space surrounding the brain. Subarachnoid hemorrhage may occur spontaneously or after trauma. A sudden, violent “thunderclap headache” is the main symptom of SAH. Intracerebral hemorrhage is mostly caused by the rupture of an aneurysm and requires surgical repair of the aneurysm.
  • Aortic dissection: occurs when a fissure develops in the inner coat (tunica intima) of the aortic wall that causes blood to enter the tunica media. Aortic dissection is marked by severe tearing pain and is a serious medical emergency that needs urgent diagnosis and management. Risk factors include hypertension, genetic diseases, and trauma.
  • Central cord syndrome: typically occurs with hyperextension injuries, especially in older individuals with preexisting degenerative changes of the cervical spine. Central cord syndrome affects the corticospinal tracts and the decussating fibers of the lateral spinothalamic tract and is characterized by greater weakness in the upper versus the lower extremities, bladder dysfunction, and sensory loss.
  • Head trauma: can be divided into fractures, traumatic brain injuries, hematomas (both extraaxial and parenchymal), and diffuse axonal injuries. Rapid recognition, stabilization, and dedicated diagnostic imaging lead to proper treatment, which can be conservative or surgical.

References

  1. Advanced trauma life support (ATLS®): the 9th edition. J Trauma Acute Care Surg. (2013). 74, 1363–1366.
  2. Dziubiński, D., Abramczyk, U., Ciechanowicz, D., Kozłowski, J., Pakulski, C., Żyluk, A. (2019). An analysis of causes of trauma, spectrum of injuries and treatment outcomes in patients treated at Multitrauma Centre of the University Teaching Hospital No 1 in Szczecin in 2015. Comparison of results from years 2015 and 2007. Pol Przegl Chir. 91, 29–35.
  3. Harvey, L.A., Close, J.C. (2012). Traumatic brain injury in older adults: characteristics, causes and consequences. Injury. 43, 1821–1826. 
  4. Paz, M.S., Mendez, M.D. (2020). Waddell Triad. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537094/
  5. Raja, A., Zane, R. (2020). Initial management of trauma in adults. Retrieved January 10, 2021, from https://www.uptodate.com/contents/initial-management-of-trauma-in-adults
  6. Thim, T., Krarup, N.H., Grove, E.L., Rohde, C.V., Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine, 5, 117–121.
  7. Van Olden, G.D., Meeuwis, J.D., Bolhuis, H.W., Boxma, H., Goris, R.J. (2004). Clinical impact of advanced trauma life support. Am J Emerg Med. 22, 522–525. 
  8. Zemaitis, M.R., Planas, J.H., Waseem, M. (2021). Trauma Secondary Survey. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441902/

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