Multiply Injured Patient

Injury has been man’s constant companion since the earliest time. Injury has been man’s constant companion since the earliest time. The first recorded medical text, the Smith Papyrus (written over 5000 years ago), gives an account of 48 different injuries described from the head downwards, an approach to the wounded individual that is still used today. The first recorded medical text, the Smith Papyrus (written over 5000 years ago), gives an account of 48 different injuries described from the head downwards, an approach to the wounded individual that is still used today. Modern trauma care is increasing in sophistication all the time; however, despite it’s huge importance, trauma has been called ‘the neglected disease of modern society’. Modern trauma care is increasing in sophistication all the time; however, despite it’s huge importance, trauma has been called ‘the neglected disease of modern society’.

The Smith Papyrus 3000 BC.

Unfortunately, most of the victims of trauma are young individuals.Injury is the commonest cause of death among people aged 1-34 years, a leading cause of disability and a major contributor to health costs. Unfortunately, most of the victims of trauma are young individuals.Injury is the commonest cause of death among people aged 1-34 years, a leading cause of disability and a major contributor to health costs. World Health Organization data suggests that 1 in 10 deaths worldwide is the result of an injury. World Health Organization data suggests that 1 in 10 deaths worldwide is the result of an injury.

Initial Assessment and Management Objectives : Objectives : -Priorities of emergency medical care -Priorities of emergency medical care -Evaluation surveys : 1ry, 2ry -Evaluation surveys : 1ry, 2ry -History : Patient Trauma incident -History : Patient Trauma incident -Initial resuscitative and definitive-care phases -guide lines & techniques -Initial resuscitative and definitive-care phases -guide lines & techniques

-1ry treatment and stabilization -1ry treatment and stabilization e.g ; While conducting rapid assessment of the patient's respiratory, circulatory and neurologic status, the patient's history and events related to injury must also be obtained. e.g ; While conducting rapid assessment of the patient's respiratory, circulatory and neurologic status, the patient's history and events related to injury must also be obtained. Also the patient's response to the question "WHAT HAPPENED" can provide information about his airway, breathing and neurological status, while the examiner can assess the patient's pulse, skin colour and capillary filling time, also the physician must understand the kinetics of trauma. Also the patient's response to the question "WHAT HAPPENED" can provide information about his airway, breathing and neurological status, while the examiner can assess the patient's pulse, skin colour and capillary filling time, also the physician must understand the kinetics of trauma.

I- Establishing Assessment and Management "PRIORITIES": Based on their injuries and the stability of their vital signs and the mechanism of traumatic incident. Based on their injuries and the stability of their vital signs and the mechanism of traumatic incident. The patient's vital functions must be assessed quickly and efficiently. The patient's vital functions must be assessed quickly and efficiently. Patient's management must consist of a rapid 1ry evaluation and resuscitation of vital functions, a more detailed 2ry evaluation and finally the initiation of definitive care. Patient's management must consist of a rapid 1ry evaluation and resuscitation of vital functions, a more detailed 2ry evaluation and finally the initiation of definitive care.

A- 1ry Survey : Life threatening conditions are identified and management is started simmultaneously. Life threatening conditions are identified and management is started simmultaneously. a-airway maintenance with cervical spine control a-airway maintenance with cervical spine control b-breathing and ventilation b-breathing and ventilation c-circulation and haemorrhage control c-circulation and haemorrhage control d-disability: neurologic status d-disability: neurologic status e- exposure:completely undress the patient. e- exposure:completely undress the patient.

B- Resuscitation phase: Shock management is initiated, oxygenation reassessed, haemorrhage control re- evaluated. Shock management is initiated, oxygenation reassessed, haemorrhage control re- evaluated. Life threatening conditions identified in the 1ry survey are constantly reassessed as management is continued, urinary catheter and nasogastric tube may also be inserted if their use is not contra-indicated. Life threatening conditions identified in the 1ry survey are constantly reassessed as management is continued, urinary catheter and nasogastric tube may also be inserted if their use is not contra-indicated.

C- 2ry Survey : does not begin until the 1ry survey has been completed and resuscitation phase has begun. does not begin until the 1ry survey has been completed and resuscitation phase has begun. It is a head-to-toe evaluation of the trauma patient : It is a head-to-toe evaluation of the trauma patient : vital signs assessment :B.P., pulse,resp., temp. vital signs assessment :B.P., pulse,resp., temp. Look, listen and feel techniques evaluating the body by region. Look, listen and feel techniques evaluating the body by region.

Each region (H+N, chest, abdomen, extremities,neurologic) is examined individually, the stethoscope is used over each body cavity and major vessel area, the hands palpate for bony defects and other abnormalities, a neurologic examination, chest and circulatory X-ray. Each region (H+N, chest, abdomen, extremities,neurologic) is examined individually, the stethoscope is used over each body cavity and major vessel area, the hands palpate for bony defects and other abnormalities, a neurologic examination, chest and circulatory X-ray. Special procedures e.g peritoneal lavage, x rays and lab studies. Special procedures e.g peritoneal lavage, x rays and lab studies. Assessment of the eyes,ears,nose,mouth,rectum and pelvis should not be neglected. Assessment of the eyes,ears,nose,mouth,rectum and pelvis should not be neglected.

D- Definitive care phase: in which all the patient's injuries are managed ; includes comprehensive management of fractures stabilization and any necessary operative intervention and preparation for transfer to a higher level medical care. in which all the patient's injuries are managed ; includes comprehensive management of fractures stabilization and any necessary operative intervention and preparation for transfer to a higher level medical care.

E- Triage : sorting of patient's based on need for treatment based on the A B C priorities. sorting of patient's based on need for treatment based on the A B C priorities. Two types of situation usually exist: Two types of situation usually exist: 1-Number of patients and severity of their injuries do not exceed the ability of the facility to render care. In this case, patients with life threatening problems and those sustaining multiple system injuries are treated first. 1-Number of patients and severity of their injuries do not exceed the ability of the facility to render care. In this case, patients with life threatening problems and those sustaining multiple system injuries are treated first. 2-Number of patients and severity of their injuries exceed the capability of the facility and staff. In this case,those patients with the greatest chance of survival,with the least expenditure of time, equipment, supplies and personnel are managed 1st. 2-Number of patients and severity of their injuries exceed the capability of the facility and staff. In this case,those patients with the greatest chance of survival,with the least expenditure of time, equipment, supplies and personnel are managed 1st.

II- Priority Plan –Treatment and Management A-1ry Survey : A-1ry Survey : 1-Airway and cervical spine:- 1-Airway and cervical spine:- -chin lift or jaw thrust -chin lift or jaw thrust -clear airway from foreign bodies -clear airway from foreign bodies -oropharyngeal airway -oropharyngeal airway -orotracheal or naso-tracheal intubation -orotracheal or naso-tracheal intubation -cricothyroidectomy -cricothyroidectomy -Maintain the cervical spine in a neutral position with manual immobilization as necessary when establishing an airway -Maintain the cervical spine in a neutral position with manual immobilization as necessary when establishing an airway

2-Breathing control:- 2-Breathing control:- -expose the chest -expose the chest -determine the rate and depth of respiration -determine the rate and depth of respiration inspect and palpate for unilateral and bilateral chest movement and signs of injury inspect and palpate for unilateral and bilateral chest movement and signs of injury -ausculate the chest bilaterally -ausculate the chest bilaterally -alleviate tension pneumothorax -alleviate tension pneumothorax -seal open pneumothorax -seal open pneumothorax

3-Circulatory and hemorrhage control: 3-Circulatory and hemorrhage control: -pulse: quality,rate and regularity -pulse: quality,rate and regularity -colour of skin,capillary blanch test -colour of skin,capillary blanch test -hamorrhage -hamorrhage -I.V. catheters and obtain blood for cross matching and haematologic and chemical analysis and arterial blood gases -I.V. catheters and obtain blood for cross matching and haematologic and chemical analysis and arterial blood gases -initiate Ringer lactate solution and blood transfusion. -apply the pneumatic antishock garment if necessary -initiate Ringer lactate solution and blood transfusion. -apply the pneumatic antishock garment if necessary -apply direct pressure to bleeding site -apply direct pressure to bleeding site -E.C.G Monitor -E.C.G Monitor -insert urinary catheter and N.G. tube unless contraindicated. -insert urinary catheter and N.G. tube unless contraindicated.

4-Disability – Brief neurological example : 4-Disability – Brief neurological example : determine the level of consciousness ; alert, response to vocal stimulation,response to painful stimulation and unresponsive. determine the level of consciousness ; alert, response to vocal stimulation,response to painful stimulation and unresponsive. assess the pupils for size, equality and reaction assess the pupils for size, equality and reaction 5-Exposure: 5-Exposure: completely undress the patient completely undress the patient

B- 2ry Survey and Management : 1-Head and face: inspection,palpation,re-evaluate pupils and cranial nerve function.Maintain airway and haemorrhage control. 1-Head and face: inspection,palpation,re-evaluate pupils and cranial nerve function.Maintain airway and haemorrhage control. 2-Neck: inspection,palpation,auscultation, X-ray spine.Maintain adequate immobilization of spine. 2-Neck: inspection,palpation,auscultation, X-ray spine.Maintain adequate immobilization of spine. 3-Chest: inspection, palpation,auscultation,percussion,pleural decompression,thoracentesis,pericardiocentesis and chest X-ray. 3-Chest: inspection, palpation,auscultation,percussion,pleural decompression,thoracentesis,pericardiocentesis and chest X-ray.

4-Abdomen: inspection, percussion, auscultation, palpation and peritoneal lavage if needed. 4-Abdomen: inspection, percussion, auscultation, palpation and peritoneal lavage if needed. 5-Perineal and rectal examination: anal sphincter tone, rectal blood,bowel wall integrity, prostate position,blood at urinary meatus,scrotal haematome. 5-Perineal and rectal examination: anal sphincter tone, rectal blood,bowel wall integrity, prostate position,blood at urinary meatus,scrotal haematome. 6-Back: bony deformity and evidence of penetrating or blunt trauma 6-Back: bony deformity and evidence of penetrating or blunt trauma 7-Extrimities: deformity, expanding haematoma, tenderness, cripitation, abnormal movements,splint for # 7-Extrimities: deformity, expanding haematoma, tenderness, cripitation, abnormal movements,splint for # 8-Neurologic: senseromotor – paralysis or paresis. 8-Neurologic: senseromotor – paralysis or paresis.

C-Stabilization and transport: outline rational for patient transfer outline rational for patient transfer transfer procedures transfer procedures patient's needs during transfer patient's needs during transfer

III-History A-Patient: allergies,medications,past illness, last meal, events related to injury. A-Patient: allergies,medications,past illness, last meal, events related to injury. B-Mechanism of injury: injury types can be classified according to the direction and amount of energy force B-Mechanism of injury: injury types can be classified according to the direction and amount of energy force 1-Blunt trauma : falls,automobile,motorcycle.The direction of impact determine the pattern of injury in the affected body cavities: front, side, rear impact, ejection from a vehicle. 1-Blunt trauma : falls,automobile,motorcycle.The direction of impact determine the pattern of injury in the affected body cavities: front, side, rear impact, ejection from a vehicle.

2-Penetrating trauma: 2-Penetrating trauma: The region of the body →specific organ injury The region of the body →specific organ injury The transfer of energy determine the injury itself. The transfer of energy determine the injury itself. The velocity of the missile and its mass→amount of injury The velocity of the missile and its mass→amount of injury The distance from the source of impact The distance from the source of impact

3-Burns:Thermal injury to skin,smoke inhalation and heat injury to lung. 3-Burns:Thermal injury to skin,smoke inhalation and heat injury to lung. Carbon monoxide inhalation and effects of any chemicals involoved Carbon monoxide inhalation and effects of any chemicals involoved 4-Hypothermia and cold injuries 4-Hypothermia and cold injuries 5-Hazardous environment: 5-Hazardous environment: chemicals, toxins and radiation chemicals, toxins and radiation

IV. Records & Legal Considerations