Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter VIII: Multiple Injuries

Treatment and Management

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

1. Primary Survey:
   1. Airway and C-spine. Upper airway problems are not uncommon in the combat casualty arriving for definitive care. Initial attempts to establish a patent airway include the chin-lift, the jaw thrust maneuver, or simply the removal of foreign debris. Patients in whom blunt trauma has been a mechanism of injury, such as from a helicopter crash or blast displacement injury, should have a consideration for protection of the C-spine. Excessive movement of the C-spine can result in permanent injury. In any patient in whom a C-spine injury is suspected, a lateral C-spine X-ray should be taken. All seven vertebrae must be visually confirmed as normal. Pain, tenderness, swelling, and neurological exam are all unreliable indicators of C-spine injury.
   2. Breathing. Ventilatory exchange should be assessed by looking at the chest and listening with a stethoscope. Airway patency does not assure adequate ventilation. The three traumatic conditions that most often compromise ventilation are tension pneumothorax, open pneumothorax, and a large flail chest with pulmonary contusion. Ventilation may be accomplished with an oral or nasal airway and a bag valve device. Chemical injuries may create life-threatening breathing problems. Blast injuries can result in acute pulmonary dysfunction.
   3. Circulation. Adequate circulatory volume can be assessed by examining pulse, skin color, capillary refill, and blood pressure. If the radial pulse is palpable, the systolic pressure will be above 80mm of mercury. If the femoral or carotid pulse is palpable, the systolic pressure will be above 70mm of mercury. A quick and easy method of assessing the peripheral perfusion is the capillary blanch test, done on the hypothenar eminence, the thumb, or the toenail bed. In a normal volemic patient, the color returns to normal within two seconds. Extremity hemorrhage should be controlled by direct pressure. Tourniquets may be of value, but the use of clamps directly into the wound should not be employed. Pneumatic splints may be helpful in controlling bleeding as well. Occult bleeding into the major body cavities will result in shock if left unchecked, and bleeding around crush injuries and fractures will also contribute to hypovolemia. Blast injury can result in arrhythmias.
   4. Disability. A brief neurologic examination should be conducted to establish the level of consciousness and the status of the pupils. A more detailed neurologic examination will follow later in the secondary survey. Simply identifying the level of consciousness and the status of the pupils in the primary survey is sufficient.
   5. Expose. The patient should be completely undressed to facilitate thorough examination and assessment.
2. Resuscitation:
   1. Maintenance of airway, establishment of ventilatory mechanism, and resuscitation of circulating volume should be initiated when the problem is identified rather than after completion of the entire primary survey.
   2. Supplemental oxygen therapy should be instituted. Nasal cannulae provide the simplest method of providing this; however, rebreathing masks provide a higher level of inspired oxygen.
   3. Two large-bore IVs should be started and a Ringer's lactate infusion begun. Percutaneous IV sites have the lowest incidents of complications. Cutdowns may be employed in the antecubital fossa or in the lower extremities. Central line placement in the internal jugular or subclavian veins may also be employed and are of value for central venous pressure monitoring. Resuscitation may also include type-specific whole blood or low-titer type O blood. Hypovolemic shock is not treated by vasopressors, steroids, or sodium bicarbonate. Adequate resuscitation is assessed by following pulse blood pressure and urinary output. Careful electrocardiogram (ECG) monitoring may be indicated by clinical circumstances, such as blunt chest trauma.
   4. Placement of urinary and nasogastric catheters should now be considered. Urinary catheters are contraindicated in the presence of suspected urethral transection, and nasogastric tubes are contraindicated in the presence of cribriform plate fractures.
3. Secondary Survey:
   1. Head. The secondary survey begins with an evaluation of the head and proceeds downward. The scalp and bony structures of the head should be checked for evidence of blunt penetrating trauma. The eyes should be examined for chemical irritation, foreign bodies, and pupillary integrity.
   2. Maxillofacial trauma. Maxillofacial trauma is important because of its relationship to the airway, the central nervous system and the cervical spine. Maxillofacial trauma by itself can usually be managed at some later time. Patients with midface fractures may have fractures of the cribriform, plate and in these patients gastric intubation should be performed by the oral route.
   3. C-spine/neck. Patients with maxillofacial trauma produced by blunt injury should be presumed to have a C-spine fracture until proven otherwise. The absence of a neurologic deficit, pain, or deformity does not rule out a C-spine injury. A lateral C-spine X-ray is the only way to completely rule out a C-spine injury. Following blunt trauma to the head and neck, the C-spine should be mobilized utilizing sandbags and tape until such time as the injury has been ruled out. Penetrating wounds of the neck should not be explored in the emergency area with probes or fingers, but should be evaluated in the operating room. Arteriography may be indicated prior to exploration.
   4. Chest. Visual examination of the chest, both front and back. will identify most penetrating trauma. Sucking chest wounds should be covered with vaseline gauze or treated with chest tube insertion. Evaluation of ventilatory function is best performed utilizing the stethoscope. A check for the status of the neck veins may be helpful in making an assessment of cardiac tamponade.
   5. Abdomen. All penetrating abdominal traumata should be explored in the operating room. Blunt trauma to the abdomen requires special assessment. Close observation and frequent reevaluation are important in the management of blunt abdominal trauma. Patients with neurologic injury resulting in an impaired sensorium may present special difficulties in evaluating blunt abdominal trauma. Peritoneal lavage may be of assistance in these instances.
   6. Rectum. A complete rectal exam is important in all trauma patients: look at the perineum, examine sphincter tone, check the integrity of the rectal wall, check the location and mobility of the prostate and look at the examining finger for the presence of gross blood. This is especially important in blunt trauma.
   7. Fractures. Extremities should be examined for contusions or deformity. Palpation and examining for tenderness, crepitation, or abnormal movements along with shafts will help identify fractures. A special check for fractures of the pelvis in blunt trauma is particularly important, because the identification of a fractured pelvis usually indicates the need for significant blood volume replacement. Pulses should be examined in each of the extremities in which there is blunt or penetrating trauma.
   8. Neurologic An in-depth neurological examination should be conducted in which the physician looks for reflexes, evaluates motor and sensory function, and reevaluates the level of consciousness. The Glasgow Coma Scale is important in assessing the patient with head trauma.
4. Definitive Care. The definitive care of each injury will be discussed in subsequent chapters.

   Most combat casualties are young, healthy individuals; however, senior personnel and civilian combatants may provide the opportunity to care for individuals with preexisting medical problems and possible medication complications. An "AMPLE" history is important.

   A - Allergies

   M - Medication

   P - Past illnesses

   L - Last meal

   E - Events preceding the injury

   Reevaluation of the patient is an essential part of all patient assessment, whether for blunt or penetrating trauma. Many injuries may not be evident when the patient first presents. As the patient remains in the health care system and is transported from one location to another, injuries and altered physiology may be evident. Continuous monitoring of vital signs is essential.

   Meticulous recordkeeping is extremely important since more than one provider will be participating in the care of the patient along the evacuation chain. Precise records are essential in order to keep up with the patient's clinical status. As the patient is transported along the evacuation chain, all records of laboratory tests, treatments, and X-ray evaluations should accompany him.

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