Chapter 92. Priorities in Multisystem Trauma

• To improve survival, injury management must be prioritized in the multiply injured patient.
• The order of priority among injuries is related to time and degree of life threat posed by each injury.
• Immediate priority is given to airway control and to maintenance of ventilation, oxygenation, and perfusion.
• Cervical spine protection is crucial during airway intubation.
• A trauma team leader is important to coordinate management in the multiply injured patient.
• Complete familiarity with techniques for airway control, chest decompression, and the establishment of intravenous access is essential in management of multiple trauma.
• Complete in-depth assessment of the multiply injured patient is required only after immediately life-threatening injuries have been treated.
• Repeated assessment is necessary to diagnose and treat injuries that are not obvious on initial presentation.

Mortality from multiple injuries follows a trimodal distribution.1,2 The first peak represents death 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 from 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. This is also a period during which simple appropriate resuscitative measures can significantly affect the outcome. The third peak occurs as a result of complications of the injury, such as sepsis or multiple-system organ failure.3 However, mortality in this third phase can also be significantly affected by the type of intervention during the second phase. The intensivist dealing with the multiple trauma patient is very likely to be involved in the institution of resuscitative measures during the second phase as well as the management during the third phase of the complications of the injury or complications arising from inadequate treatment. Many of the chapters in this text deal with the complications of trauma, such as sepsis and multiple organ failure. This chapter will deal with treatment priorities during the second peak of the trimodal distribution of trauma-related mortality.

Blunt trauma from motor vehicle collision is the most frequent cause of injuries in general. This type of impact usually results in injuries to many different parts of the body simultaneously. Figure 92-1 shows the distribution of motor vehicle driver injuries over a 2-year period at Sunnybrook Health Science Centre in Toronto, Canada, where 338 drivers with 2566 injuries were treated. Head and neck injuries were the most frequent, occurring at a frequency of 1.88 per patient, and the overall frequency of injuries was 7.6 per patient.