The multiply injured or polytraumatised patient is at a greater risk of morbidity and mortality than patients with isolated injuries. This risk is greater than the sum of the risks of their individual injuries. A high index of suspicion is needed to recognise immediately life threatening injuries and promptly address them. The principles of management is captured with the ATLS protocol and every trauma surgeon should be conversant with this indispensable tool.

1. Principles of Management of the
Multiply Injured Patient
Dr. Chris Alumona
Orthopaedics & Traumatology
National Orthopaedic Hospital, Igbobi
Lagos, Nigeria
August 2021

2. Outline
• Introduction
– Definition
– Statement of Surgical importance
– Epidemiology
• Aetiology and Pattern
• Trimodal death pattern
• Trauma scoring system
• Principles of mgt
– Pre-hospital care
– Hospital phase
• The managing team
– ATLS:
• Primary Survey
• Secondary survey
• Definitive care
• Conclusion
• Refrences

3. Introduction
• Trauma: a form of injury caused by the
transfer of excessive energy to body tissues
from physical agents
• Multiply injured
– A significant/life threatening injury in two or more
organ systems
– At least two significant injuries in one system
– ISS >16, AIS >3

4. Statement of surgical Importance
• Risk of death in multiply injured > sum of risk
of mortality from individual injuries
• A complex mechanism at play
• An understanding of this mechanism and
measures of rapid assessment and
resuscitation is crucial to improve survival in
these patients

5. Epidemiology of Trauma
• Trauma represents about 10% of global
mortality and 16% global burden of disease
(Juca M etal)
• Yearly mortality in UPTH btw 2007-2012: 9.1% -
25.6% (Onyeanunam etal)
• M:F 2.5:1
• Trauma deaths: head injury (31%), multiple
injury (30%), fractures (13.1%), cervical spine
injury (13.1%), GSI (8.3%), burns (4.8%), others
(5%) (Solagberu etal)

6. Aetiology and Pattern
• Causes
– RTA
– Warfare, terror, banditary, assualts
– Industrial and domestic accidents
– Disasters
• Pattern of polytrauma
– Extremity trauma
– TBI
– Abdominal trauma
– Thoracic injuries
– Spinal column fractures
– Burns, near drowning

7. Trimodal death pattern
• First peak:
– Apnea from severe TBI, high C-spine injury, large
blood vessel rupture
• Second peak:
– epi & subdural hematomas, hemopneumothorax,
pelvic fractures
• Late peak(20%)
– Sepsis, Multiple organ system dysfunction

8. Trauma Scoring Systems
• Role
– Triage and classification
– Evaluation and monitoring
– Prognosis and family counseling
– Research and communication
• Classification
– Physiologic eg GCS
– Anatomic eg ISS
– Combined eg TRISS

9. Physiologic Anatomic Combined
Glasgow Coma Score (GCS) Abbreviated Injury Score
(AIS)
Trauma score- Injury
Severity score (TRISS)
Revised trauma score (RTS) Injury Severity Score (ISS) A Severity Classification of
Trauma (ASCOT)
Emergency trauma score New Injury severity Score
(NISS)
ICD based ISS
Systemic inflamatory
Response Syndrome score
(SIRS)
Anatomic Profile (AP)
Sequential Organ Failure
Assessment (SOFA)
Trauma Mortality
prediction Model (TMPM-
ICD9)
Acute physiology and
Chronic Health evaluation
(APCHE)

10. Principles of Managment
• Pre-Hospital care: Pre hospital trauma life support
(PHTLS)
– Stay and play vs Scoop and run vs Run and play
– Goals of Pre hospital care
• Minimize scene time
• Ensure safety of pt
• Prevent further injury during extraction and transport
• Secure airway, support ventilation and circulation
• Analgesia
• Alert receiving hospital
• Provide relevant information to receiving trauma team

11. Pre-Hospital care cont
• Awareness
– Scene safety
– Mechanism of injury
• Recognition
– ABC assesssment
• Management
– ABC/ C-ABC sequence
• Extrication and Immobilization
• Transfer to Hospital

13. Hospital phase
• Multidisciplinary trauma team:
– Team leader, Airway managers, trauma nurses,
orthopeadic surgeon, general surgeon, record
keeper, radiographer etc
• Advance planning prior to pts arrival:
– resuscitation area, airway equipments available and
operational, warm IVF, protocol to summon
additional medical assistance or expedite transfer to
a trauma centre
• ATLS protocol of management

14. ATLS
• James Styner (1976)
• American College of Surgeons Committee on
Trauma
• NICE guideline UK
• Basis
– Golden hour
– Some injury are more life threatening than others
– Life threatening injuries may be not be obvious
– Difficulty in following sequence in the stress of the
moment

15. Algorithm of ATLS initial Assesment and
Management

16. Stages of the ATLS
• Primary survey and simultaneous resuscitation
– ABCDE
– Adjunct to the primary survey
• Secondary survey
– Detailed history
– Head to toe examination
– Adjuncts to the secondary survey
• Definitive care: specialist trx of identified
injuries

17. • Immediately Life
threatening injuries
– Airway obstruction
– Tension pneumothorax
– Open pneumothorax
– Massive heamothorax
– Flail chest
– Cardiac tamponade
ATOM-FC
• Potentially Life
threatening injuries
– Aortic injury
– Thoracic injury
– Oesophageal perforation
– Muscular diaphragmatic
injury
– Pulmonary contusion
– Cardiac contusion
ATOM-PD

18. Primary survey and simultaneous resuscitation
• A: airway and cervical spine control
• AIRWAY OBSTRUCTION/C-SPINE protection
– Assess patency
– Airway obstruction:
• Unconscious: tongue,
• fluid: aspirate, secretions, blood,
• tracheal injury,
• foreign body
– Clear airway:
• manual removal of foreign bodies,
• suction,
• chin lift & jaw thrust

19. Airway mgt cont.
– Maintain patency:
• oropharyngeal and nasopharyngeal airways,
• supraglotic devices (laryngeal mask airway, intubating
laryngeal mask airway, laryngeal tube airway, intubating
laryngeal tube airway, double oesophageal airway, i-
gel)
• Definitive airway: Endotracheal tube, surgical airway
(needle/surgical cricothyroidotomy)
• Emergency tracheostomy is discouraged

20. Primary survey and simultaneous resuscitation
cont
• B: Breathing and Ventilation
– TENSION PNEUMOTHORAX, OPEN
PNEUMOTHORAX, MASSIVE HEMOTHORAX, FLAIL
CHEST
– Assess breathing: look, feel & listen
• Chest excursion, bruising, open wounds,
• tracheal position, percusion notes, subcutaneous
emphysema
• breath sounds,
– Needle decompresion, closed tube thoracostomy,
valved dressing,
– Assisted ventilation: reservior BMV with high flow
oxygen: all intubated pt, bilateral thoracostomy
drainage

21. Primary survey and simultaneous resuscitation
cont
• C: Circulation and Heamorrhage control
– Cardiac Tamponade, Catastrophic Beeding, Cardiovascular
Collapse/Shock
– Signs of shock:
• Level of consciousness
• Skin perfusion: pallor, cold claamy skin, delayed capillary refill
• Pulse: tachycardia, decreased pulse pressure, absent central pulses
• (Hypovolemia, Obstructive, Neurogenic, SEPTIC)
– Cardiac Tamponade:
• Becks triad: Distant hear sounds + hypotension + distended neck veins
• needle paracentesis, open thoracostomy
– Heamorrahge Control:
• Mechanical: pressure, touniquet
• Pharmacological: Traxenamic acid (not part of ATLS protocol)
• large bore cannulation for fluid, samples for grouping and
crossmatching PCV, PT, toxicology

22. Primary survey and simultaneous resuscitation
cont
• D: Disability and Neurologic status
– GCS
• 3-15
• Motor score correlates best with outcome
• Pitfalls: intoxication
– AVPU: alert (GCS>14), Responds to verbal stimulus (GCS >12),
responds to painful stimulus , unresponsive (GCS <8)
– Pupils size and reaction: raised ICP
– Signs of spinal cord injury: loss of movement, sensations and
reflexes, neurogenic shock, diaphragmatic injury, priapism,
urinary retension.
– Patients with suspected brain injury should be managed by a
neurosurgeon as soon as it is recognized

23. Primary survey and simultaneous resuscitation
cont
• E: Exposure and Environmental control
– Remove all clothing, jewelries etc
– Cover with warm blankets
– Warm IV fluids: fluid warmers, micro waves (not
for blood products)
– Maintain warm environment; “patients body
temperature is a higher priority than the comfort
of the healthcare providers” (ATLS 2018)

24. • Adjuncts to primary Survey
– Pulse oximetry
– ECG monitoring
• Dysarrythmias indicates blunt cardiac injury, hypothermia
• Pulseless elctrical activity (PEA) indicates cardiac tamponade,
tension pneumothorax, severe hypovolemia
– Urinary and gastric catheters
– Capnography
– ABG
– X-Rays: AP chest, AP pelvis
– FAST, eFAST and DPL

25. Classification of Shock

26. Patterns of Response to Fluid bolus

27. Damage Control Resuscitation
• Aims to combat the lethal triads
– Coagulopathy
– Hypothermia
– Acidosis
• Minimalistic crystalloid based resuscitation
• Early release of blood and blood products
• Permissive hypotension

28. Massive Transfusion Protocol
• A transfusion approach for critically injured pts
requiring large amounts of blood
• Coordinates activities of surgeons and blood bank
for shipment of blood components
• Various blood components administered in
specific ratio
• To restore blood volume and correct
coagulopathy
• Components: type O, type specific or biologicaly
compatible RBC

30. Secondary survey
• Starts only after Primary survey has been
completed, resuscitation underway and vital
signs are stable
• History: AMPLE
– Allergies
– Medications
– Past illness/pregnancy
– Last meal
– Events (RTA, GSI, Burns etc)
• Complete physical examination of all the
systems/regions

31. • Adjuncts to Secondary survey
– X-ray of spine and extremeties
– CT scan of the head, chest, abdomen, and spine
– Contrast urography
– Angiography
– Trans-esophageal uss
– Bronchoscopy
– Esophagoscopy etc

32. • Re-evaluation
– Should be done constantly
– Recognize deterioration
– For unrecognized injuries
• Analgesia
• Tetanus prophylaxis

33. Definitive Care/Transfer
• Life threatening injuries has been addressed
• Pt still needs specialist care for injuries identified
during the survey
• Damage control surgery/early total care
– Damage control craniotomy, thoracotomy, laparotomy,
fasciotomy, external fixation, suprabubic cystostomy etc
• Pt transfer
– For specialized investigations
– For specialized care not available in managing hospital

34. PREVENTION
• Primary
– Transport/traffic regulation
– Structural modification
– Education & public enlightenment
– Elimination of conflicts
• Secondary
– Speed limits
– Safety regulations
• Tertiary
– Trauma policies
– rehabilitation

35. Conclusion
• The incidence of multiple trauma is expected
to rise in the society.
• It is essential that every surgeon is trained on
the ATLS protocol to minimize the associated
morbidity and mortality.
• Governmental policies trauma care also
should be revised and updated continuously

36. References
• Juca Moscardi M.F, Meizoso J., Rattan R. (2020) Trauma Epidemiology. In: Nasr A., Saavedra Tomasich F., Collaco I.,
Abreu P., namias N., Marttoso A. (eds) The Trauma Golden Hour. Springer, Cham. https://doi.org/10.1007/978-3-
030-264437_2
• Onyeanunam Ngozi Ekeke, Kelechi Emmanuel Okonta. Trauma: a major cause of death among surgical in patients
of a nigerian Tertiary hospital. Pan african medical Journal. 2017;28:6. [doi:10.11604/pamj.2017.28.6.10690]
https://www.panafrican-med-journal.com/content/article/28/6/full
• Solagberu BA, Adekanye AO, Ofoegbu CP, Udoffa US, Abdur-Rahman LO, Taiwo JO. Epidemiology of Trauma
Deaths. West Afr J Med. 2003 Jun;22(2):177-81. doi:10.4314/wajm.v22i2.27944. PMID: 14529233
• Schwartz's Principles of Surgery, 11e Eds. F. Charles Brunicardi, et al. McGraw Hill,
2019, https://accesssurgery.mhmedical.com/content.aspx?bookid=2576&sectionid=208294867.
• Mark Karadsheh, Benjamin C. Taylor. Trauma scoring systems. Orthobullets
• Sharon H., Haren B., Ronald M., ATLS Students Course Manuel, 10th edition. Americal College of Surgeons. 2018
• Bashir Bin Yunus. Compendium for Surgical Tutorials
• Viva in Surgical Principles and Operative Surgery. Emeka Kesieme