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{{Adult top}} [[Trauma (peds)]].''
==Background==
*The emergency clinician plays a critical role in coordinating a multi-disciplinary team to stabilize, resuscitate, and manage multiple trauma patients
*A structured assessment, namely the ABCDE method, can be used to systematically assess the trauma patient to quickly identify and prioritize injuries, simplifying the thought process in a chaotic environment
*Multiple trauma (i.e. polytrauma) is defined as any trauma associated with two or more injuries, of which, one injury is classified as life threatening
**The two most common mechanisms of multiple trauma are blunt and penetrating trauma
*The ABCDE method is used to assess these trauma patients: airway and cervical stabilization, breathing, circulation, disability, and exposure/environmental control
*General Approach to Multiple Trauma Patients 
**Pre-hospital and Triage
**Primary Survey
**Secondary Survey
**Laboratory and Radiographic Evaluation
**Disposition

{{Locations of Possible Life-Threatening Bleeding}}
{{Lethal triad trauma}}

==Primary Survey<ref>Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300</ref><ref>American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81</ref><ref>Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.</ref>==
*The goal of the primary survey is to immediately identify and manage life-threatening injuries
*There are five components of ABCDE: airway and cervical stabilization, breathing, circulation, disability, exposure and environmental control
*As critical conditions are encountered, initiate treatment without delay before continuing to the next step of the assessment
**Often multidisciplinary team involved who can address treatment while primary survey can continue
*After the primary survey, evaluate whether the patient needs to be transferred to a facility that can provide definitive treatment not available at the initial hospital
**Specifically if not a level 1 trauma center
*Continually reassess components of the primary survey

===Airway and cervical spine stabilization (A)===
*Clinical Presentation 
**Patients can present with poor respiratory effort, altered mental status, inability to phonate, hypoxia, tachypnea, bradypnea, etc.
**Look for signs of airway obstruction: blood, hematoma, edema, vomitus, facial or neck trauma, foreign bodies 
*Diagnosis and Evaluation 
**Assess airway patency, phonation, and ability to protect airway
***If a patient can clearly phonate and protect their airway, move to “B” or Breathing, but continually reevaluate
***If airway not patent or patient cannot phonate or protect airway, consider intubation
**If there is any concern for a cervical spine (c-spine) injury base on history or exam, take care to limit c-spine movement and place c-collar
***If intubation is warranted, remove the front of the cervical collar and have second person hold manual in-line stabilization
***Front of cervical collar significantly decreases mouth opening<ref>Goutcher CM, Lochhead V. Reduction in mouth opening with semi-rigid cervical collars. Br J Anaesth. 2005;95(3):344-348. doi:10.1093/bja/aei190</ref>
**If time permits, perform a neurologic examination prior to intubation and sedation
***The need for an emergent airway always takes priority and need not be delayed 
*Treatment
**Although not a definitive airway, a supraglottic airway may be useful when a patient has significant facial trauma or is difficult to intubate or ventilate
***These devices are contraindicated in awake patients and those with inability to open the mouth
**Avoid nasal airway if suspected basilar skull fracture
**Suction the airway of blood or emesis, and remove foreign bodies and dentures before laryngoscopy
**Video laryngoscopy with rapid sequence intubation (RSI) is the recommended first line approach to minimize cervical spine motion and provide superior laryngeal views
**A cricothyrotomy or another surgical airway may be necessary if endotracheal intubation fails or there is significant facial trauma or airway obstruction
**Use capnography, auscultation and post-intubation CXR to confirm tube placement
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Indications for intubation in trauma patient'''
|-
| A GCS equal to or less than 8 in trauma patients (inability to protect airway)
|-
| Failure to oxygenate
|-
| Failure to ventilate
|-
| Expected clinical course
|-
| Impending airway compromise (i.e. expanding hematoma)
|}

===Breathing (B)===
*Clinical Presentation
**Awake patients may complain of difficulty breathing
**The mechanisms of injury, such as penetrating chest trauma or blunt force trauma to the chest, may signal impending respiratory failure
**Deviated trachea, flail chest, sucking chest wounds, asymmetric breath sounds, chest wall crepitus, etc.
**If patient is adequately ventilating and oxygenating, then proceed to “C” or circulation
*Diagnosis and Evaluation 
**Ventilation
***Assess mental status, chest wall rise, respiratory rate and check end-tidal CO2 or blood gas
***If poor ventilation identified, consider naloxone and check glucose
***If persistent altered mental status, consider head CT, send toxicology workup, and have a second provider obtain collateral history for exposure to toxins and identify co-morbidities
***Intubate if unable to identify or reverse cause of hypoventilation and the patient is retaining significant CO2
**Oxygenation
***If there is respiratory distress or hypoxia, consider flail chest, pulmonary contusion, pneumothorax or massive hemothorax
***If unequal breath sounds, and you identify pneumothorax, hemothorax or hemopneumothorax, perform a tube thoracostomy
**Use the Extended Focused Assessment with Sonography for Trauma ([[eFAST]]) to assess for pneumothorax and hemothorax
***Presence of B-lines may be a sign of lung contusion
***Lung sliding for detection of pneumothorax by absence of lung sliding
*Treatment
**For suspected pneumothorax/hemothorax, perform needle decompression with 14-gauge needle or tube thoracostomy at the fourth or fifth intercostal space along the mid or anterior axillary line
**If asymmetric breath sounds or lung sliding only on one side (generally on the right) immediately following intubation, the endotracheal tube may be positioned in either mainstem bronchus
***Measure depth on chest x-ray and reposition tube above the carina 
**Treat toxidromes appropriately when present

===Circulation (C)===
*Clinical Presentation
**Assess the patient’s level of consciousness, skin perfusion, capillary refill, blood pressure, heart rate, pulse pressure and quality of pulse
**If the patient has good peripheral pulses, normal mental status, and adequate peripheral perfusion without obvious signs of shock, then proceed to “D” or Disability
**Signs of shock include tachycardia, hypotension, altered mental status, rapid and thready pulse, and pale skin
**Do not transport unstable patients to the CT scanner
**Classes of [[hemorrhagic shock]] shown in table below
*Diagnosis and Evaluation
**In penetrating trauma, may use [[eFAST]] to assess for pneumothorax, free fluid in the abdomen, and cardiac tamponade 
**The [[FAST]] exam has a high specificity, but poor sensitivity for identifying clinically important hemorrhage
**Serial [[FAST]] exams should be performed if initial [[FAST]] was negative in an unstable patient
**Look for hemorrhage before considering other causes of shock (e.g., neurogenic)
**For hemorrhagic shock, locate the hemorrhage using physical exam, x-rays, [[eFAST]], CT imaging
**For non-hemorrhagic shock, consider [[tension pneumothorax]], [[cardiac tamponade]], [[cardiogenic shock]], [[neurogenic shock]], [[septic shock]], or hypovolemic shock from insensible fluid losses
*Treatment
**Identify the culprit source of hemorrhage and if possible, obtain control (may need interventional radiology, embolization, etc). 
**Establish a minimum of 2 large bore IVs 16 gauge or larger
***Consider central venous or intraosseous access if peripheral IVs cannot be obtained quickly
**If hemorrhagic or unclear source of shock, infuse blood products as soon as possible
***No more than 1 liter of balanced crystalloid solution is recommended
****More fluid may contribute to dilutional coagulopathy
****Balanced crystalloid over normal saline is recommended to avoid non-anion gap metabolic acidosis and renal insufficiency
****There is no advantage of giving colloids over crystalloid
***If further resuscitation required, consider 2:1:1 or 1:1:1 infusion of packed red blood cells to platelets to plasma
**[[Massive transfusion protocol]] (MTP) can be initiated when a patient is suspected to require more than 10 units of pRBC in the first 24 hours of admission OR more than 4 units of pRBC in one hour
***MTP should follow the 2:1:1 or 1:1:1 ratio discussed above
**If the patient is male or not of childbearing age, and requires emergent blood transfusion, prior to type and screen, O positive blood should be administered. 
**For women who might be of childbearing age, administer O negative blood to prevent formation of Rho antibodies
**Consider [[tranexamic acid]] (TXA) as a 1g bolus over 10 minutes, ideally administered within 1 hour of injury, although benefit lasts up to 3 hours
***Then infuse 1g over 8 hours if hemorrhage not controlled
**Consider permissive hypotension, with a MAP goal of 50mmHg, unless there is concern for traumatic brain or spinal cord injury, in which the MAP goal is 80mmHg
**Ensure adequate tissue perfusion, identified by mental status, vital signs, physical exam, urine output, lactate, and base excess
**Avoid hypothermia from infusion of fluids
***Use fluid warmers for infusions and external warming measures
**Reverse known coagulopathies
***For example, if there is a history of warfarin use or liver disease, consider PCC, FFP and vitamin K
***Give platelets if thrombocytopenic and patient continues to hemorrhage
***If indicated, consider administration of the reversal agents for thrombin and Xa inhibitors
****PCC can be used for Xa inhibitors if the reversal agent is unavailable
****Dialysis should be considered in patients on direct thrombin inhibitors with severe hemorrhage.
**Consider Resuscitative Endovascular Occlusion of the Aorta (REBOA) if readily available and indicated (ie. pelvic hemorrhage)

===Disability (D)===
*Clinical Presentation 
**Establish the patient’s level of consciousness and assess for neurologic deficits
**The [[Glasgow Coma Scale]] (GCS) is a 15-point scale that determines the patient’s level of consciousness
**GCS of 15 does not exclude the possibility of a traumatic brain injury
**The GCS motor score best correlates with patient outcomes
*Diagnosis and Evaluation 
**Altered mental status can occur from traumatic or non-traumatic causes
**If there is a decrease in GCS, always assume there is a central nervous system injury until proven otherwise
**Perform pupillary exam and brief motor exam of extremities as part of disability assessment
**Perform appropriate CTs, generally non-contrast head and c-spine
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Traumatic'''
| align="center" style="background:#f0f0f0;"|'''Non-traumatic'''
|-
| Epidural hematoma, subdural hematoma, subarachnoid hemorrhage, cerebral contusion||Intoxication
|-
| Diffuse axonal injury||Hypoglycemia
|-
| Poor cerebral perfusion secondary to shock||Electrolyte disturbances
|-
| ||Mental health conditions
|-
| ||Previous stroke or intracranial injury
|}
*Treatment
**If GCS <8, consider intubation to protect airway
**Reverse any obvious cause of altered mental status, i.e., D50 for hypoglycemia, fluid/blood product resuscitation for hypoperfusion, oxygen for hypoxia, ventilation for hypercarbia
**Consult a neurosurgeon when a brain or spinal cord injury is identified
**If elevated intracranial pressure suspected, elevate the head of the bed, infuse mannitol or hypertonic saline, hyperventilate (pCO2 goal 35 mmHg)

===Exposure and Environmental Control (E)===
*Clinical Presentation
**Completely disrobe patient to assess all anatomical areas for injury
**Hypothermia can be present on arrival or quickly develop in the emergency department  and is a preventable, potentially lethal complication
*Diagnosis and Evaluation
**Look for signs of penetrating trauma, burns, ecchymosis (Grey-Turner, Cullen’s sign), foreign bodies (do not remove until sure it is not penetrating a vessel), open fractures, etc.
**Logroll patients with c-spine stabilization and check back, axilla, groin and buttocks as these areas are often overlooked
**All patients should be removed from long backboards to prevent decubitus ulcers and aspiration pneumonia
**Continually monitor patient’s temperature
*Treatment
**Place blankets or external warming devices over patients to prevent hypothermia
**Use warmed crystalloid fluids and blood products if warming transfuser available
***Can microwave crystalloid fluids but not blood products
**Decontaminate patient if exposed to toxic chemicals

==Secondary Survey<ref>Gross, Eric A, and Marc L Martel. “Multiple Trauma.” Rosen’s Emergency Medicine-Concepts and Clinical Practice, 9th ed., vol. 1, Elsevier, 2018, pp 287-300</ref><ref>American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81</ref><ref>Cameron, P., Knapp, B., “Trauma in Adults.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition (Kindle Locations 80405-80406). McGraw-Hill Education. Kindle Edition.</ref>==
*After the primary survey, the clinician can obtain pertinent medical history and perform a more detailed and complete physical exam to find injuries not observed on the primary survey
*Providers can refer to the AMPLE pneumonic for a pertinent history
*Continually reassess the components of the primary survey
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''AMPLE in the Secondary Survey'''
|-
| Allergies
|-
| Medications
|-
| Past Medical History and Pregnancy
|-
| Last meal
|-
| Events and environment surrounding the trauma
|}

==Differential Diagnosis==
{{Head trauma DDX}}
{{Blunt neck trauma DDX}}
{{Thoracic trauma DDX}}
{{Abdominal trauma DDX}}
{{Lower GU trauma DDX}}
{{Extremity trauma DDX}}

==Evaluation==
===Laboratory Evaluation===
*Clinical assessment and presentation should guide which diagnostic tests to order
*Lab testing can provide a baseline assessment of metabolic derangements to guide resuscitation (e.g., base deficit and lactate)
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Laboratory Test'''
| align="center" style="background:#f0f0f0;"|'''Clinical Importance'''
|-
| Complete blood count||Hemoglobin and hematocrit (but note that value may be falsely reassuring, due to time necessary to equilibrate); thrombocytopenia
|-
| Electrolyte panel||Potassium in CKD, often elevated in crush injuries; sodium in head injury or altered mental status
|-
| Liver function tests and lipase||Determine blunt injury to these organs, underlying liver disease, or shock liver in setting of hypoperfusion
|-
| PT/INR and PTT||Determine developing or underlying coagulopathies; provide clues to anti-coagulation use and need for reversal such as INR and coumadin
|-
| Pregnancy test in women||May change medication management; may need to consult OBGYN
|-
| Blood type and screen or type and cross depending on injury severity||Prevent transfusion reactions; prevent Rho antibody formation in women of childbearing age
|-
| Urine studies||Gross hematuria or microscopic hematuria > 20-50 RBC in urine suggests urinary tract injury; toxicology screen may indentify cause of AMS
|-
| Lactate, arterial blood gas, base excess, anion gap||Assess tissue perfusion and help guide fluid resuscitation; assess pH
|-
| Troponin||Myocardial damage if concern for cardiac contusion
|}

===Radiographic Evaluation===
*Radiographic evaluation of the multiple trauma patient is crucial in identifying acute injuries that may not be elucidated on physical exam
*Chest X-rays and pelvic X-rays are standard exams for multiple trauma patients
*[[eFAST]] should be performed as part of the primary survey
**[[eFAST]] is not appropriate (sensitivity is low) to assess for retroperitoneal fluid
*Ultrasound can help to examine the inferior vena cava during the secondary survey to assess volume status
*Although operator dependent, ultrasound is superior to chest X-ray to screen for hemothorax, pneumothorax and tamponade
*Perform CT scans based on clinical judgment after completion of the primary and secondary survey
*If c-spine injury is suspected, apply decision rules such as National Emergency X-Radiography Utilization Study ([[NEXUS]]) criteria or [[Canadian cervical spine rule]] (CCR) to help determine if a CT C-spine is indicated

{{Hemorrhagic shock classes}}

==Management==
===Initial evaluation objectives===
#Rapidly identify life-threatening injuries
#Initiate supportive therapy
#Organize definitive therapy 

===Specific Treatments===
*[[Massive transfusion protocol]]

===Reassessment===
*Continually reassess all multiple trauma patients as their disposition is fluid and their clinical status can change rapidly

==Disposition==
*Depends on underlying injury
**Decide whether to observe in the emergency department, admit to inpatient, transfer to a tertiary care facility with resources that the current facility does not have, or redline to the OR

==Complications==
*[[Hypothermia]] 
*[[Acidosis]]
*(Dilutional) [[coagulopathy]]
*[[Hypocalcemia]]

==See Also==
*[[Trauma sedation]]
*[[Trauma in pregnancy]]
*[[Trauma center levels]]
*[[Hemorrhagic shock]]
*[[Gun shot wounds]]

==External Links==

==References==
<references/>

[[Category:Trauma]]