What are the principles of managing a patient with multiple trauma in the emergency room?

Multiple Trauma Management in the Emergency Room

Primary Survey: The ABCDE Approach

The cornerstone of multiple trauma management is the systematic ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure), which must be executed rapidly and sequentially to identify and treat life-threatening injuries before proceeding to detailed diagnostic evaluation. 1

A - Airway with Cervical Spine Protection

• Establish and maintain a patent airway while simultaneously protecting the cervical spine in all trauma patients 1
• Exclude traumatic cervical injury before any airway manipulation 1
• Use oro- or nasopharyngeal airways as temporary measures for patients with decreased consciousness 1
• Perform endotracheal intubation for definitive airway protection in patients with GCS ≤8, significantly deteriorating consciousness, loss of protective laryngeal reflexes, or inability to maintain adequate oxygenation 2, 1
• Apply manual in-line stabilization of the cervical spine during intubation following trauma 2

Induction regimen for intubation:

• High-dose fentanyl (3-5 µg/kg) or remifentanil (target concentration ≥3 ng/ml); use lower doses in hemodynamically unstable patients 2
• Ketamine 1-2 mg/kg is particularly useful in hemodynamically unstable trauma patients 2
• Neuromuscular blockade with rocuronium 1 mg/kg or suxamethonium 1.5 mg/kg 2

B - Breathing and Ventilation

• Ensure adequate oxygenation with initial normoventilation if no signs of imminent cerebral herniation are present 1
• Maintain PaCO₂ between 35-40 mmHg after stabilization in patients with traumatic brain injury to prevent cerebral vasoconstriction and ischemia 1, 3
• Critical pitfall: Avoid hyperventilation, which significantly increases mortality compared to non-hyperventilated patients 1
• Perform immediate needle decompression for suspected tension pneumothorax with hemodynamic instability, followed by definitive chest tube placement 1
• Use protective ventilation with low tidal volume and moderate PEEP in bleeding trauma patients at risk of acute lung injury 1

C - Circulation and Hemorrhage Control

Control life-threatening external hemorrhage immediately—this takes absolute priority. 1

Hemorrhage Classification (ATLS):

• Class I: Blood loss up to 750 ml (15% blood volume) 1
• Class II: Blood loss 750-1500 ml (15-30% blood volume) 1
• Class III: Blood loss 1500-2000 ml (30-40% blood volume) 1
• Class IV: Blood loss >2000 ml (>40% blood volume) 1

Immediate Hemorrhage Control:

• Apply tourniquets to stop life-threatening bleeding from open extremity injuries in pre-surgical settings 1
• Leave tourniquets in place until surgical control is achieved, but keep this timespan as short as possible (ideally under 2 hours) to prevent complications such as nerve paralysis and limb ischemia 1
• Assess the extent of traumatic hemorrhage using mechanism of injury, patient physiology, anatomical injury pattern, and response to initial resuscitation 1

Response to Resuscitation:

• Rapid Response: Vital signs return to normal and remain stable—continue monitoring 1
• Transient Response: Initial improvement followed by deterioration—requires immediate surgical intervention 1
• Minimal or No Response: Ongoing instability despite resuscitation—requires immediate surgical intervention 1

Critical pitfall: Relying solely on blood pressure as an indicator of hemodynamic stability is misleading, as patients may maintain "normal" blood pressure despite significant ongoing blood loss. 1

Blood Pressure Management:

• Maintain systolic blood pressure >90 mmHg, as hypotension significantly worsens neurological prognosis 3
• Use vasopressors (e.g., metaraminol infusion) judiciously when other causes of hypotension have been excluded 2
• Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedure unless initial resuscitation measures are successful 1

D - Disability (Neurological Assessment)

• Rapidly assess neurological status using Glasgow Coma Scale 1
• Control seizures if present, especially in cases of traumatic brain injury 1
• Monitor intracranial pressure (ICP) in patients at risk of intracranial hypertension, regardless of the need for emergency extracranial surgery 3
• Use a stepped approach to elevated ICP, reserving more aggressive interventions for situations without response 3

E - Exposure and Environmental Control

• Completely undress the patient to facilitate thorough examination 1
• Record core temperature and initiate rewarming immediately 1

Hypothermia Management Protocol:

• Level 1 (Temp >36°C): Passive and active external warming with two warm blankets; monitor temperature every 15 minutes 1
• Level 2 (Temp 32-36°C): Add heating pads, radiant heaters, warming blankets, and humidified gases; monitor temperature every 5 minutes 1
• Level 3 (Temp <32°C): Implement invasive strategies including cavity lavage or extracorporeal circuits 1

Coagulation Management

Implement coagulation monitoring and support measures as early as possible following traumatic injury to guide haemostatic therapy. 2

• Approximately one-third of bleeding trauma patients present with coagulopathy on admission, which significantly increases mortality 2
• Use viscoelastic coagulation tests at the point of care (TEG, ROTEM) for rapid diagnosis of relevant coagulopathies 3
• During massive transfusion protocol, transfuse red blood cells/plasma/platelets in a 1:1:1 ratio, with subsequent adjustments based on laboratory values 3
• Administer platelets to maintain a platelet count above 50×10⁹/l in patients with ongoing bleeding and/or traumatic brain injury 2
• Transfuse red blood cells for hemoglobin <7 g/dL during interventions for potentially life-threatening hemorrhage or emergency neurosurgery 3

Surgical Priorities and Damage Control

A damage control approach to surgical procedures must guide patient management. 2

Priority Algorithm for Polytrauma with Brain Injury:

1. First Priority: Control of potentially life-threatening hemorrhage (damage control surgery and/or interventional radiology) 3
2. Second Priority: Urgent neurological evaluation (GCS motor + pupils + brain CT) 3
3. Third Priority: Consultation with neurosurgeon and intervention after control of hemorrhage in salvageable patients with potentially life-threatening cerebral lesions 3

• Develop protocols for multisystem simultaneous surgery (including interventional radiology procedures) in patients requiring both hemorrhage control and emergency neurosurgery 3
• Include closure and stabilization of pelvic ring disruptions, packing, embolization, and local haemostatic measures 2

Diagnostic Imaging Strategy

The imaging approach must be tailored to the patient's hemodynamic stability:

Hemodynamically Stable Patients:

• Whole-body computed tomography (CT) is the most immediate radiological procedure, allowing examination of all body parts and reducing missed injuries 3

Hemodynamically Unstable Patients:

• Use ultrasonography (FAST) or radiography for rapid detection of free fluid in torso trauma 3
• Critical pitfall: Delaying definitive intervention by performing CT scan in hemodynamically unstable patients is a major error that increases preventable deaths 4

Secondary Survey

• Perform a comprehensive head-to-toe examination only after completing the primary survey 1
• Obtain relevant medical history using the AMPLE approach: Allergies, Medications, Past medical history, Last meal, Events/Environment related to injury 1
• Reassess vital signs frequently 1
• Critical pitfall: Neglecting to perform a thorough examination for physical trauma when other conditions (like intoxication) are present 1

Thromboprophylaxis

• Apply mechanical thromboprophylaxis with intermittent pneumatic compression and/or anti-embolic stockings as soon as possible 2
• Employ pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled 2

Multidisciplinary Approach and Protocols

Each institution must develop, implement, and adhere to an evidence-based management protocol adapted to local conditions—this is essential for optimal patient care. 2

• A multidisciplinary approach involving emergency physicians, anesthesiologists, surgeons of multiple specialties, and radiologists is the cornerstone of optimal trauma care 2
• ATLS training significantly increases knowledge, improves practical skills, and enhances critical decision-making in managing multiple trauma patients 4, 5
• As the number of ATLS-trained professionals increases, rates of potentially preventable or preventable death fall 4
• The main errors leading to preventable deaths include delay in initiating suitable treatment, performing CT scans in hemodynamically unstable patients, initiating incorrect treatment, or omitting essential procedures 4