Multiple trauma
introduction
A multiple trauma describes the simultaneous injury of several body regions, whereby according to Tscherne at least one of these injuries is life-threatening. According to the "Injury Severity Score", a patient is considered to be poyltraumatized with an ISS> 16 points.
Mortality and epidemiology
80% of all polytrauma arise as a result of a traffic accident (Motorcycle, car and pedestrian). But also Falls from great heights can lead to multiple trauma. Thanks to significantly improved first aid and diagnostics, the Mortality in the past 20 years significantly decreased.
The prognosis depends directly on the Time interval between Accident event and the definitive care of the patient together. The longer the time interval, the worse the prognosis.
Guidelines
The guidelines of the professional associations state that a patient with multiple trauma no later than 60 minutes after the accident should be included in the clinic. This is the so-called "golden hour of shock". No later than 90 minutes after the emergency call was received should the Patient to be operated on. As soon as these times extend significantlythat sinks Survival probability of the victim rapidly.
Care for multiple trauma at the scene of the accident
Since the forecast is directly from Time interval until definitive therapy depends, should the Start therapy at the scene of the accident. Polytrauma sufferers often develop one hemorrhagic shock due to massive blood loss inward or outward.
There internal bleeding hard to see is on one Circulatory centralization to pay attention. This shows through very cold and pale extremities, since in the case of centralization only the vital organs with oxygen are supplied. In addition, there is often a multiple trauma Oxygen deficiency (Hypoxia) and one to high carbon dioxide concentration (Hypercapnia).
The cause of this are
- collapsed lung parts
- Obstruction of airways and
- Disturbance of the central respiratory regulation
In multi-center studies it has been shown that early intubation, volume administration and ventilation for prophylaxis of a shock lung, as well as corresponding pain therapy, have a significant effect on the survival of polytraumatized accident victims. In order to make the therapy on site as efficient as possible, there is a list with the corresponding therapy measures that should be initiated before transport to the clinic:
1. Intubate as early as possible to avoid shock lung. The head should not be hyperextended backwards (reclined) to avoid possible injuries to the cervical spine.
2. Lay several large-lumen intravenous accesses and fix them well. A sufficient amount of volume is provided in this way to avoid a shock situation. In any case, the patient should be given pain therapy and sedation, possibly also anesthetized.
3. If there is a tension pneumothorax, this is relieved on site,
4. Immobilize and fix bone fractures on site.
5. Avoid the patient becoming too cold, cover with a rescue blanket and then deliver to a suitable hospital as quickly and gently as possible, possibly by helicopter.
A multiple trauma patient should always be registered before arrival at the clinic so that the team in the shock room can adjust to the patient and that all the necessary doctors, nurses and equipment are available.
Also read that Articles on the topic: First aid
Procedure for multiple trauma in the clinic
In the clinic, too, you have to work as efficiently as possible in a short period of time, a requirement for this is a well-organized emergency room team. This usually consists of surgeons and anesthetists, or. Depending on the case, additional specialists such as neurologists, paediatricians, etc. In order to avoid confusion, a shock room leader is appointed who coordinates the therapies and procedures.
In order to initiate therapy as quickly as possible, the emergency room team is ready when the patient arrives. The treatment phases are then divided into two phases.
1. Acute phase
The patient's vital functions are ensured in accordance with the ATLS protocol and a short "Body check“To get an overview of the injuries. The ATLS protocol (Advanced Trauma Life Support) is a standard concept of American trauma surgeons and is regarded as the standard procedure for the treatment of seriously injured people in the acute phase: The emergency room team follows the ABCDE rule:
- A = Airway = securing the airway
- B = Breathing = ventilation if necessary
- C = Circulation = volume and bleeding control
- D = disability = neurological status
- E = Exposure = complete stripping under the control of a cooling
2nd stabilization phase (Primary phase)
In this the patient is further stabilized. Large-lumen access and a central venous catheter (CVC) are inserted. In addition, the patient is given pain therapy and sedation, a large 12-channel ECG is written and an overacidification of the patient is corrected. The volume must be given very carefully in order to avoid an increase in intracranial pressure.
In addition to isotonic solutions, blood preparations are also used to compensate for the large volume loss. In this primary phase, the early operations are also carried out if they are necessary. The first operation should take place as soon as possible, not more than 90 minutes after the emergency call. Since the lethality of multiple trauma patients is caused by the presence of the lethal triad
- Hypothermia (Hypothermia)
- Hyperacidity (metabolic acidosis) and
- increased coagulation (Coagulopathy)
increases significantly, the operations should be kept as short as possible. Because these parameters can significantly worsen the above-mentioned factors and thus further endanger the survival of the patient. A sequence of priorities for the operations could be established through various studies:
1. Stop bleeding in the abdomen, such as injuries to large vessels, spleen, liver, kidneys, etc. Is it Mass bleeding the bleeding is initially supplied by stuffing with numerous abdominal towels (packing) and then supplied further in the more stable condition of the patient.
2. Hemostasis in the chest area or a Tension pneumothorax. The rib cage is only opened when a Drainage insert insufficient or large vessels such as the heart and aorta are affected.
3. bleeding in pelvic fractures, these come often in traffic accidents and lead to massive blood loss in the pelvis, which is not visible externally for a very long time. Hemostasis in the pelvis is only possible through stabilization from the outside using pelvic forceps or a operational care through a Internal / external fixator possible.
4. Increase in intracranial pressure due to hemorrhage. The only helpful and quick therapy is that Relief of the hematoma by means of a Skull drilling, or. Opening the skull.
Seriously injured patients who are still unstable after emergency care are transferred to the intensive care unit under the principle of "Damage Control". The primary goal is that Restoration of physiological parameters how:
- Oxygen saturation
- Coagulation
- Blood gases
- Excretory function of the kidney
- Blood pressurek and
- temperature
If the patient is stable enough again to have a Survive the operation can, the further surgical treatment tackled. After the operations there is often a long stay in the clinic as well possibly further operations and Rehabilitation measures.
Summary
A multiple trauma is always one acutely life-threatening situation for the patient and above all requires quick and controlled action. Both the Emergency doctor at the scene of the accident strongly challenged to refer the patient to the appropriate clinic as quickly and correctly cared for as possible. It then hangs in the clinic Patient survival of the Competence, efficiency and controlled and well organized treatment of the emergency room team. For this purpose, precise guidelines are established to deal with the acute Emergency therapy in the emergency room as routine as possible to expire.
So no confusion or misunderstandings occur, a shock room leader is appointed who Controlled activities of other doctors and keep track. This emergency room phase is followed by the early operative phase. The motto here is: "As much as necessary, as little as possible." further stress for the patient is, therefore, only the life-threatening injuries should be treated as quickly and effectively as possible in the early operation.
The further, final operations will follow as soon as the patient is in one better and more stable condition is located. These include above all Ttemperature, oxygen supply, volume, kidney function and the blood gases. Due to the numerous studies and guidelines for the treatment of multiple trauma patients, the Survival numbers meanwhile increased significantly. Still, all patients are first life threatening injuryt and many can no longer be helped. The surviving patients often have one long hospital and rehabilitation phase in front of them until they can participate in normal everyday life again.
