What are the steps in managing patients involved in Motor Vehicle Collisions (MVC)?

Management of Patients Involved in Motor Vehicle Collisions (MVC)

The management of patients involved in motor vehicle collisions should follow a structured, step-wise approach prioritizing physiologic parameters, anatomical injury patterns, mechanism of injury, and special considerations to reduce morbidity and mortality.

Initial Assessment and Triage

• Patients should be assessed using a combination of physiologic parameters, anatomical injury patterns, mechanism of injury, and response to initial resuscitation 1
• Field triage should include evaluation of vital signs, anatomical injuries, mechanism of injury, and special considerations such as age and comorbidities 1
• Ejection from a vehicle is a significant mechanism of injury warranting immediate transport to a trauma center, even if the patient appears stable initially (associated with 27.4% risk of severe injury) 2
• Rollover crashes with roof intrusion of 24 inches are associated with a 19.3% risk of severe injury 3

Transport Decision Making

• Transport to a trauma center is indicated for auto vs. pedestrian/bicyclist cases where the victim was thrown, run over, or struck with significant impact 1
• Patients involved in rollover crashes who meet Step One (physiologic) or Step Two (anatomic) criteria should be transported preferentially to the highest level of care within the defined trauma system 3
• Counties with 24-hour availability of specialists (general surgeon, orthopedic surgeon, neurosurgeon), CT scanners, and operating rooms have demonstrated decreased MVC-related mortality 4
• Elderly patients struck by vehicles require special consideration for transport to trauma centers due to their higher mortality risk 1

Pre-Hospital Management

Airway and Breathing

• Secure airway if GCS <13, oxygen saturation <90%, or respiratory distress 2
• Avoid hyperventilation in patients with suspected traumatic brain injury unless signs of herniation are present 2

Circulation

• Apply external pelvic compression immediately if pelvic trauma is suspected 2
• Establish large-bore IV access and begin fluid resuscitation if systolic BP <90 mmHg 2
• Target systolic BP of 80-100 mmHg until major bleeding is controlled (except in traumatic brain injury) 1, 2

Spinal Precautions

• Maintain full spinal immobilization due to high risk of spinal injuries in ejected patients 2
• Position patient with 20-30° head-up tilt if possible while maintaining spinal immobilization 2

Hospital Management

Initial Trauma Bay Assessment

• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to identify free fluid in the abdomen, chest, and pericardium 2
• Obtain pelvic X-ray for hemodynamically unstable patients 2
• For stable patients, proceed directly to whole-body CT scan with IV contrast 2

Resuscitation

• Implement a restricted volume replacement strategy with target systolic blood pressure of 80-90 mmHg until major bleeding is controlled 1
• For patients with severe traumatic brain injury, maintain a mean arterial pressure ≥80 mmHg 1
• Initiate fluid therapy using 0.9% NaCl or balanced crystalloid solution 1
• If erythrocyte transfusion is necessary, aim for a target hemoglobin of 70-90 g/L 1

Bleeding Control

• Patients with ongoing hemorrhage should undergo immediate surgical control of bleeding 2
• For pelvic injuries with hemodynamic instability despite stabilization, consider early angiographic embolization or surgical packing 2

Pain Management

• Implement a multimodal analgesic approach, especially in elderly patients 1, 5
• Regular intravenous administration of acetaminophen every 6 hours is effective for traumatic pain relief 1
• For moderate to severe pain, consider opioids with caution, especially in elderly patients 1, 5
• NSAIDs should be used with caution in elderly patients due to potential adverse events 1, 5

Monitoring and Follow-up

• Monitor serum lactate and base deficit to estimate and track the extent of bleeding and shock 1, 2
• Apply early mechanical thromboprophylaxis with intermittent pneumatic compression 1
• Combined pharmacological and intermittent pneumatic compression should be employed within 24 hours after bleeding has been controlled 1
• Schedule appropriate follow-up visits based on injury severity and recovery trajectory 5

Special Considerations for Elderly Patients

• Elderly patients struck by vehicles require special attention due to decreased physiological reserve, increased frailty, and higher prevalence of comorbidities 1
• Management should include early assessment of frailty, early activation of trauma protocols, consideration for early ICU admission, and venous thromboembolism prophylaxis 1
• Be particularly cautious with medication management, considering age-related changes in pharmacokinetics 5
• Evaluate fall risk and implement prevention strategies as appropriate 5

Common Pitfalls to Avoid

• Failing to recognize the high likelihood of multiple injuries in ejected patients 2
• Underestimating the severity of injuries due to lack of external signs of trauma 2
• Undertriage of elderly pedestrians struck by vehicles, who have higher mortality rates than younger patients 1
• Inadequate pain management, particularly in elderly patients 1
• Neglecting to apply pelvic binders early when pelvic trauma is suspected 2
• Failing to recognize that ambulation after a collision does not rule out serious injury (patients who are ambulatory at the scene may still present with significant injuries) 6

Return to Activities

• Provide clear guidance on return to work, school, and daily activities based on injury severity and job requirements 5
• Address driving restrictions as appropriate, considering both physical limitations and potential psychological impact 5
• For patients with residual deficits that might affect driving, consider referral to adaptive driving programs 5
• Discuss legal requirements regarding driving after injury, which vary by state 5