MULTIPLE INJURIES &

ATLS

PRESENTED BY HS DR PHOO PWINT KHAING

 MULTIPLE INJURIES

• Head & neck injuries

• Thoracic injuries
• Abdominal injuries
• Pelvic injuries
 Cervical injury
• Tfv
 Thoracic Injuries

• Thoracic injuries account for 25% of deaths from trauma.

• Fifty per cent of patients who die from multiple injuries also have a
significant thoracic injury.
• Open injuries are caused by penetrating trauma from knives or
gunshots.
• Closed injuries occur after blasts, blunt trauma, and deceleration.
(Road traffic accidents (RTAs) are the most common cause.)
 LETHAL SIX INJURIES

1. Tension pneumothorax
2. Open pneumothorax
3. Flail chest
4. Massive haemothorax
5. Cardiac temponade
6. Airway obstruction or disruption
 HIDDEN SIX INJURIES

1. Thorax injuries (non-massive haemothorax, simple pneumothorax)

2. Oesophageal perforation
3. Fistula (bronchopleural) and other tracheobronchial injury
4. Mascular diaphragmatic injury
5. Contusion to the heart or lungs
6. Aortic injury
 Tension Pneumothorax
• A clinical diagnosis. There is no time for X-
rays.
• Patient has respiratory distress, is
tachycardic and hypotensive.
• Look for tracheal deviation, decreased
movement, hyperresonant percussion note,
and absent breath sounds over affected
hemithorax.
• Treat with immediate decompression.
Insert a 12G cannula into the second
intercostal space in the mid-clavicular line.
Follow this with insertion of an underwater
seal chest drain into the fifth intercostal
space between the anterior and mid-axillary
 Open Pneumothorax

• Occlude with a three-sided dressing.

• Follow by immediate insertion of an intercostal drain through a
separate incision.
 Flail Chest
• Results in paradoxical motion of the chest wall. Hypoxia is caused by
restricted chest wall movement and underlying lung contusion.
• If the segment is small and respiration is not compromised, nurse
patient in HDU with adequate analgesia. Encourage early ambulation
and vigorous physiotherapy. Do regular blood gas analysis.
• In more severe cases, endotracheal intubation with positive pressure
ventilation is required.
 Massive Haemothorax
• Accumulation of >1500mL of blood in pleural cavity.
• Suspect when shock is associated with dull percussion note and absent
breath sounds on one side of chest.
• Simultaneously restore blood volume and carry out decompression by
inserting a wide bore chest drain.
• Consider need for urgent thoracotomy to control bleeding if there is
continued brisk bleeding and need for persistent blood transfusion.
Consult with a regional thoracic centre.
 Cardiac Temponade
• Most commonly results from penetrating injuries, but blood can also
accumulate in pericardial sac after blunt trauma.
• Recognize by haemodynamic instability. Hypotension, tachycardia,
raised JVP, pulsus paradoxus, and faint heart sounds.
• If critically ill with suspected tamponade, perform ‘blind’
pericardiocentesis and call cardiothoracic or general surgeons to
consider emergency thoracotomy.
• If unwell, but responding to treatment, arrange urgent transthoracic
echo or focused abdominal ultrasound in A&E.
 Airway Obstruction or Disruption
Recognition
 External neck deformity or haematoma
 Crepitus from laryngeal fracture
 Surgical emphysema
 Horse voice or gurgling

Complete airway obstruction – silent chest, paradoxical chest movements

Partial airway obstruction – stridor, respiratory distress, cyanosis
 Simple pneumo-/haemothorax
• Treat with a chest drain if large or symptomatic or in any patient likely
to undergo GA.
 Oesophageal perforation

• Tfv
 Tracheobronchial Rupture
• Suspect when there is persistent large air leak after chest drain
insertion. Seek immediate (cardiothoracic) surgical consultation.
• Thoracic CT scan usually diagnostic.
 Diaphragmatic Rupture
• Usually secondary to blunt trauma in restrained car passengers (seat
belt compression causes ‘burst’ injury commonly on the left side).
• Suspect in patient with a suitable history and a raised left
hemidiaphragm on CXR.
• Penetrating trauma below the fifth intercostal space can produce a
perforation.
• Thoracoabdominal CT scan usually diagnostic.
 Blunt Cardiac Injury
(myocardial contusion/traumatic infarction)

• Suspect when there are significant abnormalities on ECG or

echocardiography.
• Seek cardiological/cardiothoracic surgical advice.
 Pulmonary Contusion
• Most common potentially lethal chest injury.
• Risk of worsening associated consolidation and local pulmonary
oedema.
• Treat with analgesia, physiotherapy, and oxygenation.
• Consider respiratory support for a patient with significant hypoxia
 Aortic Disruption
• Patients survive immediate death because the haematoma is
contained.
• Suspect when history of decelerating force and where there is widened
mediastinum on CXR.
• Thoracic CT scan is diagnostic.
• Consider cardiothoracic surgical referral
 Abdominal injuries
• Abdominal injuries are present in 7–10% of trauma patients. These
injuries, if unrecognized, can cause preventable deaths.

• Blunt trauma. Most frequent injuries are spleen (45%), liver (40%),
and retroperitoneal haematoma (15%).
• Blunt trauma may cause:
Compression or crushing, causing rupture of solid or hollow organs.
Deceleration injury due to differential movement of fixed and non-
fixed parts of organs, causing tearing or avulsion from their vascular
supply, e.g. liver tear and vena caval rupture.
• Remember that a lower chest injury may be associated with splenic or
liver injuries.
• Penetrating trauma
These may be:
Stab wounds and low velocity gunshot wounds. Cause damage by
laceration or cutting; stab wounds commonly involve the liver (40%),
small bowel (30%), diaphragm (20%), colon (15%).
High velocity gunshot wounds transfer more kinetic energy and also
cause further injury by cavitation effect, tumble, and fragmentation;
commonly involve the small bowel (50%), colon (40%), liver (30%), and
vessels (25%).
The size of the external wound bears little relationship to the severity
of intra-abdominal injuries. These injuries have medicolegal
implications
 Renal Trauma
• Most renal injuries result from direct blunt abdominal trauma, the
kidney being crushed against the paravertebral muscles or between
the twelfth rib and the spine.
• Indirect trauma (eg a fall from a height) can tear the major blood
vessels at the renal pedicle or rupture the ureter at the pelviureteric
junction. Penetrating injuries are relatively rare.
 Pelvic Injuries
• Bladder injury
• Uterine injury
 Advanced Trauma Life Support (ATLS)
• The ATLS ® concept was introduced by the American College of
Surgeons in an attempt to improve the immediate treatment of
patients with serious injury.
• The ATLS ® (and now the european Trauma Course) approach enables
standardization of trauma resuscitation. Treatment of all patients with
major trauma passes through the same phases:
1) Primary survey.
2) Resuscitation phase.
3) Secondary survey.
4) Definitive care phase.
 (1) Primary Survey
• On initial reception of a seriously injured patient, identify and address
life-threatening problems as rapidly as possible.
• Adopt a ‘cABCDe’ approach, quickly evaluating and treating:
 c—catastrophic haemorrhage control (pressure on external bleeding).
 A—airway maintenance, with cervical spine control.
 B—breathing and ventilation.
 C—circulation and haemorrhage control.
 D—disability (rapid assessment of neurological status).
 E—exposure (the patient is completely undressed to allow full
examination).
 Catastrophic Haemorrhage Control
• Bleeding must be controlled immediately by the application of packs
and pressure directly onto the bleeding wound and proximal artery
• Haemostatic dressings that contain agents that augment local
coagulation are now available.
• Failure to control bleeding in the limb by direct pressure with surgical
dressings should be followed by the application of a tourniquet
proximal to the wound.
• It is vital to appreciate that once a tourniquet is applied the limb
becomes ischaemic; therefore, the length of time for which the
tourniquet is applied must be recorded on the patient and the patient
requires urgent surgical control of the bleeding in order to reperfuse
the limb.
 Airway with Cervical Spine Control
• All trauma patients should have their cervical spine immobilised and
protected throughout.
• Access airway for patency. If patient can speak, airway is not
immediately threatened.
• First, clearing the airway by suctioning secretions or blood, followed by
simple airway manoeuvres such as a jaw thrust, chin lift and insertion
of an oropharyngeal or nasopharyngeal airway.
• Advanced airway manoeuvres necessitate the insertion of a cufed
endotracheal tube. This may require an anaesthetic with rapid
sequence induction or a surgical airway
• If patient unable to maintain airway integrity, secure a definitive airway
(orotracheal, nasotracheal, cricothyroidotomy).
 Breathing & Ventilation
• Administer high-flow O 2using a non-rebreathing reservoir.
• Inspect for chest wall expansion, symmetry, respiratory rate, and
wounds.
• Percuss and auscultate chest. Look for tracheal deviation, surgical
emphysema.
• Identify and treat life-threatening conditions: tension pneumothorax,
open pneumothorax, flail chest with pulmonary contusion, massive
haemothorax.
• Equipment and expertise for rapid insertion of intercostal chest drains
should be available.
 Circulation & Haemorrhage Control
• All patients require adequate intravenous (IV) access with at least two
large-bore IV cannulae.
• Blood should be taken for cross-match and laboratory assessment,
including haemoglobin and venous lactate.
• An assessment of the haemodynamic status should be made to identify
shocked patients: the skin may be cool and sweaty, the pulse rate
raised to over 100 per minute and the blood pressure low.
• A pelvic binder should be applied to all haemodynamically unstable
patients following blunt trauma and not removed until after a pelvic
fracture has been excluded.
• Consider surgical control of haemorrhage (laparotomy, thoracotomy)
• Target systolic blood pressure is 70–90 mmHg, although a higher
pressure of >90 mmHg should be the target if a head injury is
suspected.
• Excessive IV crystalloid or colloid solutions should be avoided because
they cause haemodilution, increase coagulopathy and increase the risk
of adult respiratory distress syndrome.
• All hospitals managing severe trauma should have a massive
transfusion protocol that aims to provide blood and blood products in
a ratio of 1 packed red cells : 1 fresh-frozen plasma : 1 platelets.
• Tranexamic acid is an antifbrinolytic drug that reduces the risk of
mortality from bleeding in both blunt and penetrating trauma.
• One gram is given intravenously over 10 minutes, followed by a further
1-g dose over 8 hours.
• Tranexamic acid should be given to all trauma patients suspected to
have signifcant haemorrhage, including those with a systolic blood
pressure of <110 mmHg or a pulse of over 110 per minute.
• It needs to be administered as early as possible and ideally within the
frst hour from injury; the frst dose should not be administered more
than 3 hours from injury.
 Disability (rapid assessment of neurological status)

• Perform a rapid neurological evaluation.

• AVPU method (Alert, responds to Vocal stimuli, responds only to
Painful stimuli, Unresponsive to all stimuli)
• Glasgow coma scale (GCS).
• After excluding hypoxia and hypovoleamia, consider changes in level of
consciousness to be due to head injury.
• The core temperature must be recorded.
• Patients are managed with cervical spine protection (cervical collar and
blocks) and protection of the thoracolumbar spine using standard log
roll techniques until a spinal injury has been excluded.
 Exposure (the patient is completely undressed to allow full
examination).

• Undress patient for through examination.

• Prevent hypothermia by covering with warm blankets/warming
device.Use warm IV fluids.
• Adjuncts to primary survey
 Monitoring. Pulse, non-invasive BP, ECG, pulse oximetry.
 Urinary catheter (after ruling out urethral injury).
 Diagnostic studies. X-rays (lateral cervical spine, AP chest, and AP
pelvis), ultrasound scan, CT scan, diagnostic peritoneal lavage.
 (2)Resuscitation Phase
• During this period, treatment continues for the problems identified
during the primary survey. Further practical procedures (eg insertion of
oro-/nG tube, chest drain, and urinary catheter) are performed.
• Occasionally, immediate surgery (damage control surgery) is required
for haemorrhage control before the secondary survey.
 (3)Secondary Survey
• This involves a full clinical examination and a focused history.
• Head-to-toe examination
 including spine and digital rectal examGCS, Glasgow Coma Score.
 take care to inspect the ‘hidden zones’ such as axillae, perineum and
natal cleft.
• AMPLE history
 Allergies
 Medications currently taking
 Past medical history/pregnancy
 Last meal/drank
 Events related to injury/ Environment
• Imaging
 determined by physiology, mechanism and anatomy of injury and the
clinical question.
• Continue reassessment of all vital signs.
• Perform specialized diagnostic tests that may be required
• The secondary survey may be delayed until after life-saving procedures
are performed, including surgery or interventional radiology.
• The primary and secondary surveys are repeated within 24 hours to
identify evolving or previously missed injuries.
 Investigations
• Select specific investigations according to the presentation, but most patients
with major trauma require: group and save/cross-match, FBC, U&e, CT and/or
X-rays, and VBG (including lactate and glucose levels).
 SpO2
 Attach a pulse oximeter on eD arrival, then monitor continuously.
 Blood tests
 Check U&e, FBC, and glucose.
 Request a group and save or cross-match & a baseline clotting screen in
patients with major haemorrhage or those at special risk (eg alcoholics or
those on anticoagulants)
 Request FFP and platelets early for patients with major haemorrhage.
Thromboelastography (TeG) and rotational thromboelastometry (ROTeM) may
have a role in identifying trauma-induced coagulopathy.
X Rays
 The traditional approach of obtaining cervical spine, chest, and pelvis
X-rays for blunt trauma has been largely replaced by CT.
Urinalysis
 Test the urine for blood if there is suspicion of abdominal injury
 Microscopic haematuria is a potential marker of intra-abdominal injury.
Arterial blood gas
 ABG provides useful information about the degree of hypoxia,
hypoventilation, and acidosis.
Electrocardiogram
 Monitor all patients; record an ECG if >50y or significant chest trauma.
 Computed tomography scan
 CT is the standard way to evaluate head, neck and truncal injuries
 Co-location of the scanner within the ED helps issues of transfer and
monitoring whilst scanning.
 USS (FAST) and diagnostic peritoneal lavage
 Focussed assessment with sonography for trauma (FAST)
 To identify free fluid (or gas) in the peritoneal, pleural, or pericardial cavities.
It can be performed by a trained ED doctor, surgeon, or radiologist.
 Diagnostic peritoneal lavage (DPL) is rarely used now in developed countries,
given the availability of FAST and CT. DPL still plays an important role if FAST
and CT are not available.
 Other investigations
 Angiography is indicated in certain specific circumstances (major pelvic
fracture, aortic injury). Occasionally, other tests requiring specialist expertise
(eg echocardiography) may prove to be useful.
 (4)Definitive Care Phase
• The early management of all injuries is addressed, including fracture
stabilization and emergency operative intervention.
 References
Principles and Practice of Surgery, 7th Edition
Bailey and Love’s Short Practice of Surgery, 28th Edition
Clinical Emergency Medicine
Oxford Handbook of Emergency Medicine, 5th Edition
Oxford Handbook of Clinical Surgery, 4th Edition