Introductory Chapter: How to Contemplate the Hidden Threat in the Management of Multiple Trauma Patients?

1. Introduction

1.1 Case presentation

Time 05.30: after the motor-vehicle accident (MVA), a 28 year-old man has been transported to the emergency department (ED) by a taxi. The patient had been driving the vehicle himself, his seat belt was not fastened, and he smelt alcohol. He was on the ground next to the vehicle that had tumbled off the road at the time of the accident.

Time 05.52: the patient is taken to the ED. Conscious, trying to cooperate, agitated.

BP: 100/70 mmHg, pulse: 128 bpm, respiratory rate (RR): 30 bpm, arterial O₂ saturation (SaO₂, pulse oximetry): 96%.

Head – neck: there is skin abrasion in the right maxillary region. There is no cervical tenderness.

Resp: breath sounds are equal. No rales, no rhonchus. Crepitus and tenderness are detected on the right at the 10th rib level.

CVS: rhythmic, tachycardic.

Abdomen: cannot be reliably evaluated due to the patient’s agitation. Voluntary guarding and tenderness in the right upper quadrant are noted. Bedside abdominal ultrasonography was difficult to interpret because of overlying bowel gas and obesity.

Extremity: open, comminuted fracture 20 cm proximal to the ankle on the right tibia and fibula. There is no pulse in the dorsalis pedis. There is external bleeding from the wound.

At 06.00: a vascular access is opened to the patient from the left antecubital region with an 18 G, and 500 mL of normal saline is infused.

Tetanus vaccine 0.5 mL IM and antibiotic prophylaxis are administered.

Complete blood count, blood group, and blood alcohol level are ordered, and blood transfusion is prepared. His chest radiography and right tibia and fibula radiographies are ordered.

The right leg is irrigated with normal saline, bandaged, and splinted, and the patient was sent to radiology suit. His tachycardia is thought to be due to pain and agitation.

07.00: the patient returns from radiology. PA chest radiograph shows a right 10th rib fracture and a communited, displaced fracture in the right tibia and fibula.

BP: 90/50 mmHg, and heart rate: 130 bpm. Hemoglobin (Hb): 13.2 g/dL, and hematocrit (Htc): 38.0%. Orthopedic consultation is requested. The patient is evaluated, and hospitalization is planned for the operation. Vascular surgeon is being consulted, and angiography is planned.

Time 07.30: BP 80/40 mmHg, and heart rate: 125 bpm.

The patient’s general condition deteriorates. He looks pale, sweaty, and cold. He can barely cooperate. Fluid administration is continued. Hb: 6.2 g/dL; Htc 20.1%.

Considering that the patient had blood loss from an open fracture, three units of blood were administered. Transfusion is performed. Hb is 8.5 g, and Htc is 24.5%.

While the patient is waiting for angiography, he develops hypotension and bradycardia.

Time 09.00: respiratory and cardiac arrest are observed in the patient. Resuscitation (CPR) is commenced. The patient is unresponsive. In the postmortem evaluation, it was determined that the cause of death was intra-abdominal hemorrhage due to liver laceration.

2. Approach to multiple trauma

Trauma has long been the most common cause of death and disability in the productive age group, childhood, and young adults (1–40 years) in the world, including developed countries [1]. It is an enormous social problem that disables large masses and has a significant share in healthcare costs. For the physician, it refers to a wide range of patient groups, from life-threatening and disabling injuries to pathologies that can be corrected with minor interventions.

In the evaluation of all kinds of trauma cases, a standard approach system has been introduced and has been widely accepted all over the world, regardless of the external appearance of the patient. This approach is known as Advanced Trauma Life Support (ATLS), in which the patient’s care is characterized by two main parts: primary and secondary care.

In a patient with major blunt injury, the first hour is certainly the most decisive period for massive bleeding and shock [2]. Those inappreciable minutes can be used to identify the victim’s clinical condition and institute specific treatments. Trauma victims with certain criteria should be transferred to developed institutions also called as trauma centers in some countries: penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee, flail chest, two or more proximal long bone fractures, crushed, degloved, or mangled extremity, amputation proximal to wrist and ankle, pelvic fractures, open or depressed skull fracture, and paralysis [3].

In this approach to trauma, the team leader is a person experienced in resuscitation and is responsible for the clinical monitoring of the patient and intervention orders. In a trauma case, the emergency physician should try to rule out the patient by assuming the worst possible injury. Most of the time, treatment interventions have to be initiated in the ED before a definitive diagnosis is established. For example, in a trauma case where tension pneumothorax is suspected, needle thoracostomy is performed without waiting for a chest X-ray or blood transfusion can be initiated before the exact source of bleeding is identified.

The physician should recognize sources of life-threatening blood losses and resultant hypovolemia. Pericardial tamponade, commotio cordis, and a pneumothoraces are all difficult diagnoses to manage. These can present with hypotension associated with high readings of CVP. On the other hand, hemorrhage of thoracoabdominal viscera is most often accompanied by low blood pressure and a low levels of CVP. Emergent evaluation and treatment of thoracic trauma appears to be of vital importance, as is the utilization of the correct diagnostic strategy to evaluate the possibility of intraabdominal and retroperitoneal injury [4]. Abdominal trauma is present in approximately 25% of major trauma patients and is the leading cause of unrecognized fatal injury in children [5]. Innovative approaches such as REBOA is mostly used in most developed countries for a wide range of indications including major trauma or intraoperative bleeding.

Primary survey: it is essential to first evaluate the patient with the initials ABCDE (A: airway, B: Breathing, C: circulation, D: deficit, and E: exposure) and proceed to secondary survey if there is no pathological finding. If any pathology is detected in the primary examination, especially in the ABC (e.g., difficult breathing or tachycardia/hypotension), resuscitation procedures for the problem must be initiated before continuing the examination.

Secondary examination: a detailed physical examination should be performed (from head to toe), and pathological findings should be noted, should there be no problem in the primary examination or if an attempt has been made to solve the detected problems. If significant bleeding or neurovascular damage is detected in any extremity during the initial examination, immediate intervention should be carried out. Patients are placed on a trauma board and evaluated after a cervical collar is applied. The patient should be completely undressed before the examination, and foreign objects and contaminated clothing should be removed from the surrounding area. In a patient with suspected trauma, spinal injury should always be assumed until proven otherwise, and the patient should be immobilized. It should be shown that there is no significant injury through physical and radiological examination.

Clinicians should focus on the approach to the massively bleeding trauma patients and on the recent advances in this aspect of care. Ways to detect life-threatening, but “invisible” injuries should be instituted in this high-risk group of patients. Although the patient who has open fractures and is covered in blood and screaming and screaming due to external bleeding may seem to require urgent intervention, it should not be forgotten that the patient who has no signs of trauma and remains silent may be more urgent.

Hypocrates cited that “thou shalt leave the cutting of the stone to the skilled craftsman” which can be translated into the current clinical practice as “you shall leave the emergency treatment of multiple trauma victims to the appropriate team.” Proper experience can help prevent the major pitfalls in trauma care and provide the optimal care for this high risk group.