What is the optimal treatment approach for a young to middle-aged adult patient with traumatic injuries in a Mobile Army Surgical Hospital (MASH) unit setting, considering potential multiple injuries and complications?

Optimal Treatment Approach for Traumatic Injuries in MASH Settings

In a MASH unit setting, prioritize immediate surgical hemorrhage control for patients with traumatic hemorrhagic shock, using a damage control surgery approach with rapid assessment following the ATLS protocol, while maintaining systolic blood pressure ≥100 mmHg and implementing early coagulation support. 1

Initial Assessment and Triage

Rapidly assess using mechanism of injury, patient physiology, anatomical injury pattern, and response to initial resuscitation to identify patients requiring immediate surgical intervention. 1 The ATLS protocol provides the structured A-B-C-D-E framework (airway, breathing, circulation, disability/neurologic, exposure/examination) that should guide your systematic evaluation. 2

Key Assessment Components:

• Mechanism of injury screening: Falls from >6 meters (20 feet), high-energy deceleration impacts, penetrating trauma, and blast injuries indicate high risk for severe hemorrhage 1
• Hemodynamic classification: Identify transient responders and non-responders to initial fluid resuscitation as candidates for immediate surgical bleeding control 1
• FAST ultrasound: Perform focused assessment with sonography for trauma to rapidly detect intraperitoneal hemorrhage 2

Hemorrhage Control Strategy

Early surgical intervention is critical for traumatic hemorrhagic shock, with evidence showing that minimizing time between admission and surgical bleeding control directly impacts survival. 1

Damage Control Surgery Principles:

• Primary goal: Achieve hemostasis and prevent secondary damage rather than definitive repair 2
• Packing and temporary measures: Use surgical packing, external fixation for fractures, and avoid prolonged definitive procedures in unstable patients 1, 2
• Tourniquet use: Apply tourniquets for life-threatening extremity bleeding from mangled injuries, traumatic amputations, or penetrating/blast wounds—keep in place until surgical control achieved but minimize duration (ideally <2 hours, though up to 6 hours has been tolerated) 1

Simultaneous Multisystem Surgery (SMS):

For polytrauma patients requiring both hemorrhage control and neurosurgical intervention, implement simultaneous multisystem surgery protocols with coordinated surgical teams. 1 This approach, proven in military settings, significantly reduces time to intervention and improves functional outcomes. 1

Resuscitation Targets

Blood Pressure Management:

• Maintain systolic blood pressure ≥100 mmHg in bleeding trauma patients, particularly those with traumatic brain injury 1
• Avoid hypotension <90 mmHg: This threshold is associated with poor neurological outcomes; lower values should be tolerated for the shortest possible time 1
• Normoventilation: Avoid hyperventilation unless signs of imminent cerebral herniation, as hyperventilation increases mortality 1

Coagulation Support:

Implement coagulation monitoring and hemostatic therapy as early as possible following injury. 1

• Platelet transfusion: Maintain platelet count >50×10⁹/L in patients with ongoing bleeding and/or traumatic brain injury 1
• Early coagulation factor replacement: Use fresh frozen plasma and consider prothrombin complex concentrates for coagulopathy 1

Special Considerations for MASH Environment

Polytrauma Management:

Code and document all significant injuries across multiple body regions using specific anatomical injury codes (S-codes) rather than generic multiple injury codes. 3 This captures true injury burden and guides severity assessment.

Resource-Limited Decision Making:

• Triage for immediate transport: In life-threatening multi-system trauma, complete rapid primary assessment, airway/cervical spine control, cardiovascular support, gross whole-body immobilization on backboard, and immediate transport rather than prolonged field stabilization 4
• Damage control mindset: Accept temporary stabilization over definitive repair when physiologic reserves are exhausted 2

Critical Pitfalls to Avoid

• Under-triage of elderly patients: Age is an independent risk factor for complications; maintain lower threshold for aggressive intervention 1, 5
• Delayed hemorrhage control: Time to surgical intervention directly correlates with survival in hemorrhagic shock 1
• Hyperventilation: Routine hyperventilation worsens outcomes in trauma patients 1
• Prolonged tourniquet application: While life-saving, tourniquets can cause nerve paralysis and limb ischemia if left beyond 2 hours 1
• Inadequate cerebral perfusion: In TBI patients, maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring available 1

Thromboprophylaxis

Apply mechanical thromboprophylaxis (intermittent pneumatic compression and/or anti-embolic stockings) as soon as possible, with pharmacological prophylaxis within 24 hours after bleeding control. 1