What is the initial management approach for a patient with multiple injuries?

Initial Management of Multiple Injury Patients

The initial management of multiple injury patients must follow a systematic ABCDE approach with immediate hemorrhage control taking absolute priority, followed by airway management, while maintaining specific hemodynamic targets that differ critically based on the presence or absence of traumatic brain injury. 1

Pre-Hospital Phase: Critical First Actions

Control life-threatening hemorrhage BEFORE addressing airway concerns - this represents a fundamental shift from traditional ABC priorities. 1

• Apply tourniquets immediately for extremity bleeding that threatens exsanguination 1
• Place pelvic binders around the greater trochanters (NOT the iliac crests) for suspected pelvic trauma before airway management 1
• Systematically consider pelvic trauma in all patients presenting with shock or altered consciousness 1
• Transport directly to a Level 1 trauma center, not the nearest hospital - this reduces mortality by 20-30% 1

Airway and Ventilation Management

• Secure the airway via tracheal intubation with mechanical ventilation and end-tidal CO2 monitoring, even in the pre-hospital setting 2, 1
• Maintain normoventilation (PaCO2 35-40 mmHg) - NEVER hyperventilate routinely as this increases mortality through cerebral vasoconstriction and decreased venous return 2, 1
• The only exception for hyperventilation is imminent cerebral herniation 1
• Target PaO2 between 60-100 mmHg during all interventions 2

Hemodynamic Management: The Critical TBI Exception

The hemodynamic targets differ dramatically based on traumatic brain injury status:

For patients WITHOUT severe TBI:

• Maintain systolic blood pressure 80-90 mmHg (MAP 50-60 mmHg) using restricted fluid resuscitation until bleeding is controlled 1
• Never give large-volume crystalloid resuscitation pre-hospital - volumes >2000ml increase coagulopathy to >40% 1

For patients WITH traumatic brain injury:

• Maintain systolic blood pressure >100 mmHg or MAP ≥80 mmHg to ensure adequate cerebral perfusion 2, 1
• For adults 15-49 years or >70 years, target systolic blood pressure ≥110 mmHg 2
• Once ICP monitoring is available, maintain cerebral perfusion pressure (CPP) ≥60 mmHg, individualized based on neuromonitoring and autoregulation status 3, 2
• Permissive hypotension is absolutely contraindicated in TBI patients 2, 1

Neurological Assessment

• Assess severity using Glasgow Coma Scale motor response, pupillary size, and reactivity 3, 2
• Perform urgent brain CT scan without delay in all severe TBI patients 2
• Consider CT angiography for patients with risk factors for vascular injury 2
• Document timeline of injury, loss of consciousness, and any lucid intervals 4

Hemorrhage Control Strategy

All exsanguinating patients with life-threatening hemorrhage require immediate intervention for bleeding control before addressing brain injuries. 2

• Assess hemorrhage severity using patient physiology, anatomical injury pattern, mechanism of injury, and response to initial resuscitation 1
• Perform FAST (Focused Assessment with Sonography in Trauma) ultrasonography for intraperitoneal hemorrhage 5
• Emergency thoracotomy for penetrating chest injuries with massive hemothorax 5
• Emergency laparotomy for signs of hollow viscus perforation 5
• Consider damage control surgery focusing on hemostasis and avoiding secondary damage rather than definitive repair 5

Blood Product Management in Polytrauma with TBI

• Transfuse red blood cells for hemoglobin <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery 2
• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage, with higher values for emergency neurosurgery including ICP probe insertion 2
• Maintain PT/aPTT <1.5 times normal control during all interventions 2

Simultaneous Multisystem Surgery (SMS)

For patients requiring both intervention for life-threatening hemorrhage AND emergency neurosurgery, develop protocols for simultaneous multisystem surgery. 3, 2

• This approach requires established protocols and strict collaboration between surgical teams including interventional radiologists 3
• SMS is associated with shorter times to CT scanning/emergency surgery and fewer unfavorable outcomes at 6 months 3
• The main objective is control of bleeding while avoiding/minimizing secondary brain insults 3

Intracranial Pressure Management

• Implement ICP monitoring in patients with severe TBI (GCS ≤8) and abnormal CT findings, regardless of need for emergency extra-cranial surgery 4, 2
• Consider external ventricular drainage for persisting intracranial hypertension despite sedation and correction of secondary brain insults 2, 1
• Use a stepwise approach to elevated ICP, reserving aggressive interventions for non-responders 3
• Consider decompressive craniectomy for refractory intracranial hypertension in multidisciplinary discussion 1

Severe Limb Trauma Considerations

For patients meeting Vittel criteria with limb injuries (AIS ≥3): 3

• Assess for limb ischemia, vascular injury, amputations, degloving injuries, or crushing injuries proximal to ankle/wrist 3
• Implement strategies to prevent thromboembolic complications 3
• Monitor for compartment syndrome and rhabdomyolysis 3
• Provide adequate acute trauma-induced pain management 3

Critical Pitfalls to Avoid

• Never hyperventilate routinely - increases mortality through cerebral vasoconstriction 1
• Never apply permissive hypotension in TBI patients - they require MAP ≥80 mmHg 2, 1
• Never place pelvic binders incorrectly - must be positioned around greater trochanters, not iliac crests 1
• Never delay transport to reach the nearest hospital - go directly to a trauma center 1
• Never assume a patient with a lucid interval will remain stable - deterioration can be sudden 4
• Never use hypotonic fluids that can worsen cerebral edema 4
• Never use prolonged hyperventilation as it causes cerebral ischemia 4

Implementation Strategy

• Each institution should implement an evidence-based treatment algorithm for bleeding trauma patients 1
• Use treatment checklists to guide clinical management 1
• Assess adherence to institutional algorithms as part of quality management 1