Multiple Injuries Polytrauma is defined as multisystem trauma or injury to two or more body systems that can imperil vital signs. The magnitude of injury is related to the energy transferred during the event and the area of tissue involved. Trauma deaths follow a trimodal distribution in the first minutes, golden hour, and after days/weeks due to various injuries. Blast injuries include primary injuries from direct pressure effects, secondary from projectiles, tertiary from structural collapse, and quaternary from exacerbated conditions. Management prioritizes the airway, breathing, circulation, disability, and exposure during primary survey and resuscitation while avoiding diagnostic delays.

1. Multiple Injuries

2. Polytrauma --
Multisystem trauma
Terminology:
• Injury = the result of harmful event that arises from the
release of specific forms of energy.
• Trauma = defined as the morbid condition of body
produced by external violence.
• “polytrauma” = Multisystem trauma = injury of two or
more systems, one or the combination imperil vital signs.

3. Pathophysiology of Trauma
• A major trauma is characterized by a series
of complex pathophysiological reactions,
some directly as a result of the event itself,
others as part of a compensatory response.

4. • The main features are triggered by:
hypoxia
shock
neurohumoral responses

5. INJURY BIOMECHANICS AND ACCIDENT
PREVENTION
The magnitude of an injury is related to
energy transferred to the victim during the
event,
the volume/area of tissue involved and
the time taken for the interaction.

6. Trauma deaths have a trimodal distribution
• First peak
–Within minutes of injury
–Due to major neurological or vascular injury
–Medical treatment can rarely improve
outcome

7. • Second peak
–Occurs during the 'golden hour'
–Due to intracranial haematoma, major
thoracic or abdominal injury
–Primary focus of intervention for the
Advanced Trauma Life Support (ATLS)
methodology

8. • Third peak
–Occurs after days or weeks
–Due to sepsis and multiple organ failure

9. Types of Blast Injuries
• Primary
–Due to direct effect of pressure
• Secondary
–Due to effect of projectiles from explosion

10. • Tertiary
–Due to structural collapse and from persons
being thrown from the blast wind
• Quaternary
–Burns, inhalation injury, exacerbations of
chronic disease

12. Other Primary Blast Injuries
• Eye
– Globe rupture, serous retinitis, hyphema, lid
laceration, traumatic cataracts, injury to optic
nerve
– Signs and symptoms include eye pain, foreign
body sensation, blurred vision, decreased vision,
drainage

13. • Brain
–TBI due to barotrauma of gas embolism
–Signs and symptoms include headache,
fatigue, poor concentration, lethargy,
anxiety, and insomnia

16. Tertiary Blast Injuries
• Due to persons being thrown into fixed
objects by wind of explosions
• Also due to structural collapse and
fragmentation of building and vehicles
• Structural collapse may cause extensive blunt
trauma.

17. –Crush syndrome
• Damage to muscles and subsequent release
of myoglobin, urates, potassium, and
phosphates
• Oliguric renal failure
–Compartment syndrome
• Edematous muscle in an inelastic sheath
promotes local ischemia, further swelling,
increased compartment pressures,
decreased tissue perfusion, and further
ischemia

18. Quaternary Blast Injuries
• Explosion related injuries or illnesses not due to
primary, secondary, or tertiary injuries
– Exacerbations of preexisting conditions, such as
asthma, COPD, CAD, HTN, DM, etc.

20. Burns (chemical and thermal)
• White Phosphorous (WP) from munitions
causes extensive burns, hypocalcemia
and hyperphosphatemia
–Toxic inhalation
–Radiation exposure
–Asphyxiation (carbon monoxide and
cyanide)

21. Triage
• Pre-hospital triage
• At the scene of trauma
• On arrival at the receiving hospital

22. Managing a major trauma situation
1. Plan for eventuality
2. Set up the trauma team before the patient
arrive.
3. Organize lines of communication and
command.

23. Primary survey and resuscitation
• Airway with cervical spine protection
• Breathing and ventilation
• Circulation and control of bleeding
• Disability
• exposure

24. Adjuncts to the primary survey
• Full blood counts
• Coagulation studies
• Plasma chemistry
• Transfusion screening
• ECG

25. • Radiography
–Cervical spine
–Chest
–pelvis
• Urinary and gastric catheter

26. Secondary survey
• Head and face
• Neck
• Chest
• Abdomen and pelvis
• extremities

27. Treatment for Burns
• Cover burns to minimize heat and fluid loss
• WP burns require special management
–Copious lavage and removal or particles and
debris

28. –Rinse with 1% copper sulfate solution
• Combines with phosphorous particles and
impedes further combustion
–Cardiac monitor
• Hypokalemia and hyperphsophatemia common
–Use moistened face masks to protect from
phosphorous pentoxide gas exposure
–Avoid use of flammable anesthetic agents
and excessive oxygen

29. Definitive care and transfer
• Golden hour concept
• Transfer when haemodynamically and
cardiovascularly stable

30. Summary -Management
• Assessment and resuscitation are vital.
• Diagnostic delays must be avoided.
• Organ specific diagnosis is not required.

31. Guidelines for Admission
• High risk patients who require admission
–Significant burns
–Suspected air embolism
–Radiation

32. –Contamination
–Abnormal vital signs
–Abnormal lung examination findings
–Clinical or radiographic evidence of
pulmonary contusion or pneumothorax
–Abdominal pain or vomiting
–Penetrating injuries to the thorax,
abdomen, neck, or cranial cavity

33. Selected References
• Bailey & Love’s SHORT PRACTICE of SURGERY
26th EDITION
• www.trauma.org