Multiple Trauma
Multiple trauma section
Calling the Emergency Medicine consultant
Please contact the on-call consultant in emergency medicine for all cases with CRAMS score of 8 or less
Circulation |
Normal capillary refill and SBP>100 |
2 |
|---|---|---|
Delayed capillary refill or SBP 85-99 |
1 |
|
No capillary refill or SBP<85 |
0 |
|
Respiration |
Normal |
2 |
Abnormal (laboured, shallow, or rate>35) |
1 |
|
Absent |
0 |
|
Abdomen |
Abdomen and thorax not tender |
2 |
Abdomen and/or thorax tender |
1 |
|
Abdomen rigid, thorax flail, or deep penetrating injury to either |
0 | |
Motor |
Normal - obeys commands |
2 |
Responds only to pain, no posturing |
1 |
|
Only posturing or flaccid to pain |
0 |
|
Speech |
Normal - obeys commands |
2 |
Confused or inappropriate |
1 |
|
No intelligible word or silence |
0 |
|
Total |
0-10 |
AT risk major injury
- Pedestrian knockdown
- Pedal cyclist vs. car
- Collisions with impacts > 50km per hour
- Vehicle rollover
- Ejection from a vehicle
- Entrapment
- Intrusion into the passenger cabin
- Fall > 3 meters
- Motorcyclists
- Death of an occupant in the same vehicle
- Where the mechanism is suggestive e.g. thrown from a horse, crush under a large weight.
Management of Multiple Trauma Patients in CUH
- Please contact the on-call consultant in emergency medicine for all trauma cases with a CRAMS score of 8 or less.
- When there is controversy or debate over which service should take primary responsibility for the patient, the senior emergency medicine doctor (Consultant or Registrar) should make the final decision about which service the patient is admitted under.
- There has to be one main consultant, as above, but surgeons or other specialties who are involved in the patient's care should also be listed so that there is a clear chain of command for all involved in that person's care.
- There has to be more registrar-to-registrar or consultant-to-consultant discussion of these cases
At CUH
- 300 people are assessed each year in the Resusc room for multisystem trauma
- Many of these ultimately prove to have significant injury
- Multiple trauma is defined as an Injury Severity Score (ISS) of greater than 15
- But someone with an isolated femoral fracture faces a mortality of up to 10%
- The ambulance service work to guidelines as to potential for multiple trauma in a patient
- The following broad groups of patients are deemed at high risk.
CUH MUH SIVH Mallow General Hospital
The first priority for a doctor receiving a case of possible multiple injury is adequate preparation. This includes calling for help. Familiarise yourself with the Resusc room and the resources available in it. You should follow the principles and guide to Resusc room practice outlined in this handbook.
- The priorities of care are the ABCDEs - if necessary call the anaesthetists immediately
- An anaesthetist should be alerted in any situation where basic airway manoeuvres are deemed inadequate or insufficient to maintain the airway and there is no one present with the necessary skill in the room.
- Full Cx Spine immobilisation should be maintained at all times and spinal precautions continued throughout the patient's stay or until clearance by the most senior, appropriate, doctor is given.
- All patients should be oxygenated with Hi Flow oxygen through a non-rebreathing mask. Oxygen saturations and respiratory rates should be monitored. Check tracheal position and air entry in both lung fields. Ventilate if necessary.
- Check pulse and BP. Stop obvious bleeding. Secure IV access with 2 large bore (16G) cannulae. Take bloods at this stage. Start fluid replacement with crystalloid (saline or Hartmanns). We give 3l of crystalloid initially followed by blood. Fluids are titrated according to patient response. Avoid hypothermia and give warmed fluids (available from the heated cabinet).
- All patients have a back as well as a front - log roll all patients
- Cross match , FBC and U&RE all. Please see "Massive Transfusion" page as required.
- No life saving (including going to the operating theatre) intervention should be delayed to undertake investigations
- Good quality x-rays of cervical spine (lateral), chest and pelvis should be obtained in all cases of suspected multiple trauma in the resuscitation room. X-rays in isolated trauma should be as indicated.
- Further investigation will be as determined by the patient's presentation and condition. Beware the 'Donut of Death'.
- CT scans are never therapeutic
- Multiple trauma management is lead by the ED staff (call the senior doctor on duty) together with the duty doctors in anaesthesia, general surgery and orthopaedic surgery as required.
- Always try to complete all three trauma series x-rays
- Clearly record procedures "To Be Done", e.g. "Cervical Spine Not Cleared", "Secondary Survey Incomplete"
The Emergency Department adheres to ATLS ethos and principles.
- Rapid primary survey (Airway with Cx spine control, Breathing, Circulation)
- Resuscitation
- Secondary Survey
- Safe transfer to definitive care
Tranexamic acid
- Tranexamic acid should be used in in adult trauma patients at risk of significant bleeding.[CRASH-2 RCT Lancet 2010] (Local copy)
- CRASH-2 - Tranexamic acid v placebo : Risk of death from bleeding reduced [4·9%] vs [5·7%]; (RR 0·85, 95% CI 0·76–0·96)
- Tranexamic acid loading dose 1 g over 10 min then infusion of 1 g over 8 hours
