THE MULTIPLY INJURED PATIENT

A patient injured in more than two body systems is defined as multiply injured.
This situation commonly occurs in road traffic accidents, falls from a height, blast injuries, etc. The approach to a patient with multiple injuries has to be systematic in order to identify all the injuries and prioritize their sequence of attention.

Resuscitation Required and Its Order

  • Airway: Position the head and with finger or suction, clear blood, mucus, and foreign bodies. Take care to avoid causing cervical injury and apply cervical collar or use the jaw lift manoeuvre. Use log rolling procedure if it is necessary to reposition the patient in any way.
  • Breathing: Check respiratory rate and air entry into the chest. If need be perform mouth to mouth respiration using a gauze or plastic sheet with hole inserted.
  • Circulation: Stop active bleeding and monitor pulse rate and blood pressure; fix a large intravenous cannula preferably in the antecubital area. Perform a cut down if need be.
  • Dysfunction of CNS: Assess neurological status, consciousness level, spinal cord, etc.
  • Drugs, including fluids: Use these to correct acid base and volume imbalance.
  • Exposure for examination: Disrobe the patient entirely and carry out a complete physical examination. Look for:
    • Chest injuries: For example, haemopneumothorax from whatever cause takes priority.
    • Head injuries: Require setting of baseline observations.
    • A patient in shock from non-obvious causes: This points towards the abdomen, suggesting visceral injury. It may be very unapparent and can be fatal.
    • Peripheral bone fracture: This may need stabilization initially and proper attention later.
  • After resuscitation and stabilization: Carry out frequent and more thorough examinations.
  • Give attention to:
    • Continued bleeding – Stopping it and transfusion; haemopneumothorax may need underwater seal drainage.
    • Persistent shock from unexplained source – May necessitate an exploratory laparotomy.
    • Fractures – Limb may need plaster of paris fixation; spine fractures need bed rest with fracture boards. X-rays of a patient with multiple injuries should be taken after adequate resuscitation. Exceptions are in the chest and cervical spine, which should be taken after initial resuscitation.
    • Acute gastric distension – Managed by nasogastric tube and suction of the same; the patient will require feeding to counter the catabolism associated with multiple injuries.
  • Some of the injuries may require referral for more specialized care. This referral is executed after adequate resuscitation