Multi system Trauma

• Multisystem trauma involves injuries affecting more than one body system or organ.

• Assessment and management of multisystem trauma require integration of knowledge from primary and secondary assessment, as well as understanding of bleeding, shock, and specific types of trauma (soft-tissue, chest, abdominal, musculoskeletal, head, neck, and spine).

• Effective care depends on rapid identification of life-threatening conditions and prioritization of interventions based on the severity and combination of injuries.

Standard

• Multisystem trauma involves injuries affecting multiple organ systems, requiring you to recognize and manage complex, potentially life-threatening conditions.

• Assessment is critical; you must rapidly identify the extent and severity of injuries through a systematic approach, prioritizing life-threatening conditions first.

• Basic emergency care includes airway management, breathing support, and circulation stabilization, often using techniques such as airway adjuncts, oxygen administration, and hemorrhage control.

• Safe and timely transportation is essential, ensuring the patient is moved to an appropriate medical facility while continuing necessary interventions and monitoring.

Core Concepts

• Balancing prompt transport with on-scene treatment involves quickly assessing which injuries require immediate intervention and which can be managed during transport, ensuring life-threatening conditions are addressed without unnecessary delay.

• Determining trauma severity and transport priority requires evaluating the patient’s condition using established criteria to decide urgency and the most suitable medical facility for care.

• Selecting critical interventions at the scene means prioritizing treatments that stabilize airway, breathing, and circulation, especially for multiple-trauma patients, before or during transport.

• Calculating a trauma score uses a standardized scoring system that quantifies injury severity, guiding decisions about treatment priorities and transport destination.

Learning Objectives

• Approaching multisystem trauma involves rapid assessment and prioritization of life-threatening conditions, focusing on airway, breathing, and circulation, while simultaneously identifying injuries across multiple body systems.

• Key treatment and transport decisions include determining the need for immediate transport to a trauma center versus on-scene interventions, based on the severity and type of injuries, available resources, and distance to definitive care.

• Estimating injury severity requires integrating physiologic factors (such as vital signs), anatomic injuries (specific body regions affected), mechanism of injury (how the trauma occurred), patient characteristics (age, comorbidities), and situational factors (environment, time since injury).

• Certain assessment findings, such as altered mental status, hypotension, or abnormal respiratory patterns, may indicate critical internal injuries that are not immediately visible but require urgent intervention.

• Effective management of multisystem trauma relies on coordinated teamwork, with clear communication and defined roles among prehospital and hospital providers to ensure rapid, efficient care.

• Principles of multisystem trauma management include early recognition of life threats, rapid stabilization, and prompt transport, applying these concepts to various trauma scenarios to optimize patient outcomes.

• Trauma scoring tools, such as the Glasgow Coma Scale or Revised Trauma Score, help quantify injury severity and guide triage and treatment decisions by providing objective measures to assess and monitor trauma patients.

Key Terms

• Trauma patients often present with multiple injuries, unlike medical patients who usually have a single complaint.

• Multisystem trauma occurs when more than one area of the body is injured, such as having both a head injury and a broken leg.

• Multisystem trauma is considered a serious condition due to the complexity and severity of injuries affecting multiple body systems.

Multisystem Trauma

• Multiple-trauma patients have more than one serious injury, while multisystem-trauma patients have injuries affecting more than one body system. For example, a gunshot wound to the chest (affecting cardiovascular and respiratory systems) and a fractured arm (musculoskeletal system) can make a patient both multiple-trauma and multisystem-trauma.

• Common multisystem injuries include pneumothorax, tension pneumothorax, cardiac tamponade, solid organ damage, and hollow organ damage. Pneumothorax: Diminished/absent lung sounds on one side, respiratory distress, elevated pulse, possible chest injury. Tension pneumothorax: Very labored breathing, absent lung sounds, distended neck veins, altered mental status, low blood pressure, narrowing pulse pressure, increased pulse/respirations, possible chest injury, tracheal deviation (late sign). Cardiac tamponade: Distended neck veins, low blood pressure, narrowing pulse pressure, increased pulse/respirations, penetrating chest injury. Solid organ damage: Profuse bleeding (shock), delayed pain/diagnosis due to organ capsule, pain may be referred (e.g., to shoulder). * Hollow organ damage: Spillage of contents into abdomen, causing severe and diffuse pain due to irritation.

• Critical decisions must balance the need for rapid transport with the time spent treating injuries at the scene. Life-threatening injuries (e.g., airway obstruction, shock) take priority over non-life-threatening injuries (e.g., limb fractures) when deciding on immediate interventions versus rapid transport.

• Teamwork, timing, and transport decisions are essential in multisystem trauma care. Effective crew coordination (teamwork), minimizing on-scene time (timing), and choosing the appropriate hospital (transport decision) are crucial, especially since field stabilization is rarely possible for severe trauma.

• Protocols guide which patients should be transported to designated trauma centers, and when EMS can bypass other hospitals to ensure the best outcome for the patient.

Determining Patient Severity

• Critical decisions at a trauma scene include determining patient priority/severity, whether to limit scene time, and selecting the most appropriate hospital and transport method. Delays or errors in these decisions can negatively impact patient outcomes and scene management.

• No universal guidelines exist for every trauma situation; decisions depend on patient condition, hospital proximity, available transport options (including air medical), local protocols, and medical direction. The context (urban, suburban, rural) and available resources influence your approach.

• Field triage guidelines categorize patients using Red (high risk) and Yellow (moderate risk) criteria:

  • Red Criteria (High Risk): Includes specific injury patterns (e.g., skull or pelvic fractures, penetrating injuries, suspected spinal injury, multiple long-bone fractures, mangled or amputated extremities, active severe bleeding), abnormal vital signs (e.g., respiratory rate <10 or >29, respiratory distress, SpO₂ <90%, hypotension by age group, HR > SBP), and altered mental status (unable to follow commands, motor GCS <6). Patients meeting any Red criteria require immediate transport to the highest-level trauma center.

  • Yellow Criteria (Moderate Risk): Focuses on mechanism of injury (e.g., high-risk vehicle crashes, ejection, significant intrusion, need for extrication, death in passenger compartment, unrestrained children, severe telemetry data, significant impact to bicyclists/pedestrians, falls from height >10 feet), and additional risk factors (burns with trauma, significant head impact in young children or elderly, suspected child abuse, anticoagulant use, pregnancy >20 weeks). Patients meeting Yellow but not Red criteria should be transported to the nearest trauma center.

• Assessment should proceed in sequence: First, evaluate mental status and vital signs; if stable, then assess anatomic injury patterns; if still not meeting criteria, consider mechanism of injury and EMT judgment.

• Certain injuries (e.g., head, chest, pelvis, multiple long-bone fractures, amputations, mangled extremities) require trauma center care due to the need for specialized surgical intervention and risk of significant internal bleeding.

• Always follow local EMS protocols, which may adapt national trauma triage guidelines to regional needs.

Box 34-1

• Penetrating injuries to the head, neck, torso, and extremities proximal to the elbow and knee are critical and require immediate attention.

• Signs of severe trauma include skull deformity or suspected skull fracture, suspected spinal injury with new motor or sensory loss, chest wall instability or suspected flail chest, and suspected pelvic fracture.

• Other high-risk injuries include suspected fractures of two or more long bones, crushed, degloved, mangled, or pulseless extremities, and amputations proximal to the wrist or ankle.

• Active bleeding that requires a tourniquet or continuous wound packing is a key indicator of severe trauma.

• Altered mental status, hypotension, or abnormal respiratory rates (either too slow or too fast) are critical physiologic findings that indicate high priority for rapid transport to a trauma center.

Box 34-2

• Altered mental status (Glasgow Coma Scale (GCS) < 14) is a key indicator of serious conditions such as head injury or hypoxia, presenting as unresponsiveness, confusion, anxiety, or restlessness.

• Vital signs criteria for trauma triage are age-based:

  • For ages 0–9 years: Systolic blood pressure (SBP) <

  • For ages 10–64 years: SBP < 90 mmHg or heart rate (HR) > SBP

  • For ages ≥ 65 years: SBP < 110 mmHg or HR > SBP

• Abnormal respiratory rates are significant:

  • RR < 10 or > 29 breaths/min in all patients indicates serious injury.

  • In infants, RR < 20 is extremely grave.

  • Rapid RR (> 29) often signals shock; slow RR (< 10) may indicate head injury or late-stage shock.

• Room-air pulse oximetry < 90% or need for respiratory support indicates critical respiratory compromise.

• Hypotension (SBP < 90 mmHg) is a definitive sign of shock, often due to internal bleeding or circulatory disturbance.

• Mechanism of Injury (MOI): While a significant MOI does not guarantee serious injury, it warrants caution and may influence the decision to transport a patient to a trauma center, especially in the absence of abnormal physiologic or anatomic findings.

• Vehicle telemetry can provide important crash data (speed, rollover, impact location, airbag deployment) to assist in assessing MOI and determining the need for trauma center transport.

Box 34-3

• High-risk mechanisms of injury (MOI) for trauma triage include: partial or complete ejection from a vehicle, significant intrusion into the vehicle ( inches at the occupant site or inches at any site), need for extrication, death in the passenger compartment, unrestrained or improperly restrained children (age 0–9), and vehicle telemetry data indicating severe injury.

• Other high-risk scenarios: rider separated from a transport vehicle (such as motorcycle, ATV, or horse) with significant impact, pedestrian or bicyclist thrown, run over, or with significant impact, and falls from heights greater than 10 feet (all ages).

• EMS judgment is crucial in determining severity, as patient response to trauma varies by age and medical condition; older adults and children may require different triage decisions, and special consideration is needed for patients on anticoagulants or who are pregnant.

• Certain patients, such as older adults on blood thinners with head injuries, are at high risk for serious complications (like intracranial bleeding) even if they appear stable, and often require transport to a higher-level trauma center.

Box 34-4

• EMS judgment is crucial in trauma triage, especially for specific populations such as young children (≤ 5 years) and older adults (≥ 65 years) who experience low-level falls with significant head impact.

• Key risk factors requiring special attention include anticoagulant use, suspicion of child abuse, special high-resource health care needs, pregnancy over 20 weeks, and burns combined with trauma.

• Children should be triaged preferentially to pediatric-capable centers to ensure appropriate care.

• If there is any concern about the severity of trauma, transport to a trauma center is recommended.

• Multisystem trauma often involves internal organs, and understanding the pathophysiology of these injuries is essential for recognizing critical signs and symptoms.

Managing the Multisystem-Trauma Patient

• Recognition of multiple injuries is crucial early in the assessment, as it guides the EMT to suspect involvement of multiple body systems and anticipate complications.

• The EMT must quickly identify which body systems are likely affected (such as respiratory, circulatory, or nervous systems) based on the mechanism of injury and initial findings.

• The first management decision is to prioritize life-threatening conditions, focusing on airway, breathing, and circulation (the ABCs) before addressing less critical injuries.

• Critical interventions at the scene are selected based on immediate threats to life, such as controlling severe bleeding, ensuring a patent airway, supporting breathing, and preventing shock.

• Actions to support affected body systems include providing oxygen, immobilizing fractures, and rapid transport to definitive care, with ongoing reassessment to adjust priorities as the patient’s condition evolves.

Approaching the Scene

• Immediate life threats in multisystem trauma must be addressed simultaneously: In this scenario, the patient had both a compromised airway (gurgling and snoring respirations) and severe external bleeding from a thigh wound. One rescuer managed the airway while the other controlled bleeding with a tourniquet.

• Airway management is critical: The patient’s airway was cleared of blood with suction, and an oropharyngeal airway was inserted to prevent obstruction by the tongue. Assisted ventilations with a bag–valve mask and high-concentration oxygen were provided due to shallow, labored breathing.

• Rapid control of severe bleeding is essential: A tourniquet was applied to the thigh wound because of significant blood loss and the need to free up rescuers for other critical interventions. Signs of shock (pale, sweaty skin; weak pulses) indicated the urgency.

• Prioritize rapid transport to a trauma center: The patient was assigned high priority for transport due to altered mental status, shock, and mechanism of injury (motorcycle collision). Protocols dictated bypassing a closer community hospital in favor of a trauma center for comprehensive care.

• Comprehensive trauma assessment identifies multiple injuries: Findings included a head hematoma, decreased breath sounds on the right (suggesting chest injury), a compound femur fracture, bilateral mandibular fractures, and nonbleeding lacerations. Ongoing assessments monitored for changes in condition.

• Spinal immobilization and fracture stabilization are important: The patient was immobilized on a long backboard with a cervical collar to protect the spine and stabilize the femur fracture, which also served as a splint and a surface for potential CPR.

• Vital signs and mental status must be monitored continuously: The patient’s pulse, blood pressure, respirations, and skin signs were repeatedly checked, showing persistent shock and some neurological improvement (responding to pain, opening eyes).

• Communication with the trauma center is vital: Early notification allowed the hospital to prepare for the patient’s arrival, and updates on vital signs and condition were provided en route.

• Definitive care requires hospital resources: The patient was found to have a cerebral contusion, bilateral mandibular fractures, right hemothorax, and a femur fracture, requiring surgery and extended care. Early interventions in the field contributed to survival and recovery.

Analysis of the Call

• Critical injuries require prioritization of immediate life threats such as significant external bleeding, shock, airway obstruction (from blood and the tongue), and inadequate ventilation.

• Primary assessment guides interventions: Bleeding was controlled, airway was cleared and maintained with suction and an artificial airway, and assisted ventilations with high-concentration oxygen were provided due to shallow, labored breathing.

• Rapid transport takes precedence over non-life-threatening treatments when time is critical, especially with airway compromise; non-bleeding lacerations and traction splinting were deferred to avoid delaying transport.

• Use of a backboard as a universal splint for the femur fracture was chosen over a traction splint in the field, as definitive splinting was more appropriate in the emergency department once the patient was stable.

• Postponing non-essential actions, like taking vital signs, is justified if it prevents delays in transport; vital signs were taken en route instead of on scene.

• Early communication with the hospital, even with incomplete information, allows staff to prepare for the incoming patient and mobilize the trauma team, improving the patient’s chances.

Think Like an EMT

• Criticality assessment is essential for trauma patients because it guides decisions about patient priority and transport destination.

• Patients with stable vital signs and isolated injuries (such as the 30-year-old with a suspected lower leg fracture, normal mental status, and stable vitals) can generally be transported to a local hospital.

• Patients with altered mental status or signs of neurological decline (such as the 8-year-old with confusion, decreasing mental status, and sluggish pupil response after a significant fall) should be transported to a trauma center due to the potential for serious head injury.

• Pregnant trauma patients with concerning symptoms (such as the 32-year-old woman, 30 weeks pregnant, with head trauma, shoulder pain, and brisk vaginal bleeding) require transport to a trauma center because of the risk to both mother and fetus, and the need for specialized care.

• Key factors influencing transport decisions include mechanism of injury, changes in mental status, abnormal vital signs, and special patient populations (children, pregnant women).

General Principles of Multisystem-Trauma Management

• Preparation and role assignment before arrival is crucial; you and your team should clarify individual responsibilities, such as manual head immobilization and ventilation, to ensure efficient care for multisystem-trauma patients.

• Primary assessment priorities are airway, breathing, circulation, and bleeding; interventions at the scene should be limited to life-saving actions like cervical spine stabilization, airway management (suctioning, airway adjuncts, sealing sucking chest wounds), ventilation, high-concentration oxygen administration, bleeding control, and spinal motion restriction if it does not delay transport.

• Scene safety is paramount; be aware of specific dangers associated with blunt trauma (e.g., power lines, fuel leaks, sharp objects, traffic) and penetrating trauma (e.g., weapons, hostile assailants, crowds), and adjust your approach accordingly.

• Airway management flexibility is necessary; if standard ventilation methods fail, try alternative devices or maneuvers, and use the head tilt–chin lift if the jaw-thrust is ineffective, even with suspected spinal injury, as a last resort.

• Urgent or emergency moves may be required to quickly extricate critical patients from dangerous environments, prioritizing rapid transport over perfect immobilization.

• Adapt your assessment if the patient is trapped or inaccessible, and plan to complete a full examination after extrication.

• The main goal is rapid transport to definitive care, treating only immediate life threats at the scene to avoid unnecessary delays.

• Pediatric trauma care follows the same principles but requires additional emotional support, consideration of family dynamics, and, when possible, keeping family members together during transport.

• Children’s skeletal flexibility means significant internal injuries can occur without obvious external signs, so maintain a high index of suspicion for internal trauma.

• Pediatric patients may compensate for shock longer but can deteriorate suddenly; monitor closely for signs of decompensation.

• Maintain focus and composure when treating pediatric patients, using your training to provide the best care despite emotional challenges.

Trauma Scoring

• Trauma scoring systems are used to objectively assess the severity of trauma patients' injuries by assigning numerical values to specific patient characteristics.

• Calculating a trauma score helps determine whether a patient should be transported directly to a trauma center or to a local hospital for stabilization, based on the severity of their condition.

• Trauma scores also enable trauma centers to compare outcomes among patients with similar injury severity, supporting quality improvement and research in trauma care.

• The Revised Trauma Score (RTS) is a widely used system that evaluates three key patient characteristics: the Glasgow Coma Scale (GCS), systolic blood pressure, and respiratory rate.

• Earlier trauma scoring systems included additional characteristics, but these were found to be difficult to assess consistently in the field and were ultimately deemed unnecessary.

Point of View: Patient

• The Revised Trauma Score (RTS) is a tool used by EMTs to assess the severity of a trauma patient's condition and predict their likelihood of survival. It assigns points based on three key physiological parameters: Glasgow Coma Scale (GCS), systolic blood pressure (SBP), and respiratory rate (RR).

• Each parameter is scored from 0 to 4 points, with lower scores indicating more severe injury and a lower chance of survival. For the GCS: 13–15 = 4 points, 9–12 = 3, 6–8 = 2, 4–5 = 1, 3 = 0. For SBP: >89 mmHg = 4, 76–89 mmHg = 3, 50–75 mmHg = 2, 1–49 mmHg = 1, 0 = 0. For RR: 10–29/min = 4, >29/min = 3, 6–9/min = 2, 1–5/min = 1, 0 = 0.

• The total RTS is the sum of the points from all three parameters, with a lower total score reflecting greater injury severity. This score helps guide decisions about patient transport and care, such as choosing a hospital with specialized trauma capabilities.

• Immediate life threats, such as airway management and bleeding control, take priority over calculating the RTS. EMTs may be required to collect the necessary data for the RTS, but the actual calculation and use of the score may be performed by hospital staff, depending on local protocols.