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Physicians Overview of Catastrophic Multiple Injuries
Many victims of car accident injuries and other traumatic incidents including falls or pedestrian accidents come to the emergency room with multiple injuries. The injuries can involve fractures, burns, respiratory damage, cardiac damage, hemorrhages, head trauma and/or abdominal organ damage.
The biggest challenge for doctors and personnel at the scene is to determine which of the multiple trauma injuries to tackle first and which aren’t life threatening and can wait. Doctors use a protocol when dealing with multiple trauma patients so that they get treated in order of severity.
Doctors sometimes use the “ABCs” to gauge which body areas to manage first. They go as follows:
- Airway. The airway must be open before any breathing can begin. The doctor must make sure the airway is patent so that air can flow through it. Problems with the airway can be blockage of the trachea due to a direct blow to the airway, a blood clot in the airway, or a maxillofacial injury that damages the airflow in the upper airway. This blockage must be fixed in order to have proper breathing.
- Breathing. After the airway is established, it needs to be determined that the person is breathing completely on their own. If the breathing is adequate, then nothing further is done. If, however, the breathing is inadequate the patient needs a bag ambu device in order to temporarily improve the breathing. Ultimately, this kind of patient may need to be on a ventilator that can breathe for them until the person’s breathing is restored.
- Circulation. Circulation problems can be as simple as a bleeding blood vessel or as complicated as a case of total body shock. Even though shock is serious, it cannot be tackled until the airway and breathing are fixed. The treatment of shock involves volume replacement with IV fluids, ideally blood products. A trauma patient can have bleeding externally or internally so, if the patient’s blood pressure is below 90/50 and there is evidence of trauma, an IV is placed and blood products are given until the area of bleeding can be surgically corrected.
- Neurological. Once the ABCs are taken care of, the doctor looks at the neurological status of the patient. Are they alert and talking or are they in a coma? If they have a reduced level of consciousness, tests need to be done that can identify bleeding in the brain or bruising of the brain. A CT scan of the head is the best screening tool for brain bleeding and bruising and can tell the severity of the head injury.
Circulatory problems must be treated according to their severity. For example, a ruptured spleen is likely more dangerous than bleeding from a leg wound. Any internal bleeding is considered serious and usually means that the person goes into surgery as soon as possible to remove the spleen or to fix a ruptured liver. A ruptured viscus means that bacteria can enter the abdomen and can cause peritonitis if not treated early.
Burns and fractures are treated last. Burns are treated by debriding the dead and damaged skin from the underlying healthy skin so that the healthy tissue can be treated with skin grafts. Skin grafting with the patient’s own skin can only be accomplished if there is enough healthy skin to use as a graft. If not, then cadaver skin is used until normal skin grows through and colonizes the burned area.
Fractures are handled by the orthopedist, who uses surgery or closed reduction to set bones such as pelvic bones, upper extremity bones, vertebral fractures, femur fractures and tib/fib fractures. Such fractures are usually easy to repair and are usually the last things to get treated in multiple trauma.
As mentioned, multiple trauma can happen in a number of situations. The first is a car accident. In this case, the forces of the car accident can be so severe as to cause multiple fractures, head trauma, ruptured viscus, cerebral or lumbar spine injuries, and hemorrhaging. The airway and breathing can be compromised and the person may have hemorrhaging that is so severe, transfusions and surgery are necessary. In not uncommon cases, the spine may be injured and the person might need spinal immobilization. The greater the number of injuries, the greater is the risk of death.
Military injuries are typical of multiple trauma patients. They receive mortar fire and are bombed as major types of injuries. When suffering from a bomb injury, the person can have loss of or a mangled leg or arm, cervical, thoracic or lumbar fractures and cord trauma, head injuries and puncture-type wounds. These people still need to be treated with the ABCs but really need a total body assessment as soon as possible because of the high risk of ballistic injuries causing internal bleeding that ultimately will require one or more surgeries.
Falls from great heights result in death or in multiple trauma patients. These patients often have fractures, including cervical, thoracic and lumbar vertebral fractures. These can lead to spinal injuries such as disruption of the spinal cord and paralysis. The other major source of injuries includes head injuries, traumatic brain injuries, and extremity fractures.
Sports injuries can result in a multiply traumatized patient, although this is less likely. The forces of the injury tend to go in one direction and are less than in a car accident or a great fall. Even so, patients can sustain closed head trauma, which is evaluated after the ABCs are established. Closed head trauma can be as simple as a concussion or more serious, such as bleeding inside or around the brain. This causes swelling of the brain within a solid skull, and the patient can suffer a fatal herniation of the brain parts through the hole at the base of the brain.
Multiple trauma patients represent an impressive challenge to the doctor in charge. The urge of course is to go after everything at once or treat the obviously bleeding artery when other, more crucial, things have not been addressed. This is why the ABCs of multiply injured patients must be followed.