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  • Successful outcome in multisystem trauma requires prioritization of therapeutic interventions.

  • Altered physiology secondary to the injury determines degree of life threat, which determines order of priority.

  • Immediate priority is given to airway control and to maintenance of ventilation, oxygenation, and perfusion.

  • Cervical spine protection is crucial during airway assessment and manipulation.

  • When several personnel are involved, a trauma team leader is important to coordinate management in the multiply injured patient.

  • Safe effective techniques for airway control, chest decompression, and the establishment of intravenous access are key skills in the management of multiple trauma.

  • After immediately life-threatening abnormalities have been corrected, systematic anatomic assessment is required to identify and manage other injuries.

  • Repeated assessment is necessary to identify changes in the patient’s status and institute appropriate treatment.


For most clinical conditions, a detailed history and physical examination allow formulation of a differential diagnosis. This leads to a specific anatomic and pathophysiologic diagnosis that can direct therapeutic interventions. In contrast, multiple trauma often mandates timely, targeted therapeutic intervention in the absence of a specific anatomic diagnosis. The situation is made more complex because there are frequently many simultaneous anatomic areas of injuries each with differing degrees of life threat, which are not always immediately evident. Yet, therapeutic intervention must be timely and accurate to optimize survival.

Optimal survival of the multisystem trauma patient requires a different prioritized approach. Initially, this is based on the physiologic derangements resulting from anatomic injury(ies) and the relative degree to which they threaten life, with time to intervention being a vital element. For instance, if a trauma patient presents in hemorrhagic shock from a pelvic fracture, hemorrhage control with volume resuscitation is important for survival; however, if hemorrhagic shock is severe enough to cause cerebral hypoperfusion with unconsciousness and loss of airway protective reflexes, then airway control may take priority over hemorrhage per se. With a trauma team available, airway control, vascular access, and pelvic binder application could be provided simultaneously with a team leader directing resuscitation priorities.

Although the institution of trauma systems has altered the pattern of mortality distribution following multiple injuries,1 it is still useful to consider the trimodal distribution pattern.2,3 The first peak of this trimodal distribution represents deaths occurring at the scene and results from such injuries as cardiac rupture or disruption of the major intrathoracic vessels, and severe brain injury that is incompatible with survival. Death from such injuries occurs within minutes of the traumatic event and medical intervention is usually futile. The second peak in mortality following multiple injuries occurs minutes to a few hours after the event. Mortality during this phase is related to injuries that are immediately life-threatening, such as airway compromise, tension pneumothorax, and cardiac tamponade. Simple appropriate resuscitative measures can significantly affect the outcome during this phase. The third peak occurs as a result of complications of ...

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