A 48-year-old female restrained car driver is involved in a motor vehicle accident. Her car slid off the road into a tree when it was traveling at 50 mph with air bag deployment. She did not lose consciousness. After a short extrication time, she is brought to the emergency department (ED). The patient is awake and alert, although somewhat confused. Her vital signs include a BP of 80/40 mm Hg, HR 120 bpm, sats 94% on an Fio2 of 100% via nonrebreather face mask.
What are the immediate goals for this patient?
In the ED, many things need to be coordinated at once. Primary survey of airway, breathing, and circulation according to advanced trauma life support (ATLS) algorithms should be the immediate priority.1 Establishment of adequate intravenous access, the collection of laboratory studies, and recognition of life-threatening injuries are paramount.
The primary survey reveals a patent airway but minimal breath sounds over the right hemithorax, with ecchymosis and crepitus on the right chest wall. She has a tense abdomen and pain upon palpation of her pelvis. A right open tibial fracture is noted. Plain chest radiography demonstrates an effusion in the right hemithorax. A tube thoracostomy is performed on the right, with return of air and 800 cc of bloody fluid without significant improvement in hemodynamics. Pelvic films show fractures of the pelvic ring and a right acetabular fracture. The pelvis is temporarily stabilized with a bedsheet. A FAST (focused assessment with sonography in trauma) examination shows free fluid in the abdomen, and the patient is taken to the operating room (OR) for an exploratory laparotomy. A splenectomy and hepatic debridement and surgical packing are performed, as well as external fixation of her tibial fracture. The abdomen is left open. After the OR, the patient is taken to the Interventional Radiology Suite, and two pelvic arterial injuries are coiled with hemodynamic stabilization. The patient is taken to the ICU sedated, endotracheally intubated, and mechanically ventilated.
What are the goals of care of this patient in the operating room?
The pendulum has shifted from surgical correction of all injuries fully to "damage control" of those immediate life-threatening injuries.2-4 The rapid control of hemorrhage and prevention of coagulopathy, hypothermia, and acidosis are the perioperative goals. This is achieved via limiting the operative time as much possible with rapid transport to the intensive care unit (ICU) for further optimization. Damage-control surgery is the mainstay of acute surgical trauma care.5,6 Polytrauma patients will often require multiple operations to deal with problems stemming from the initial traumatic insult.
Traumatic injury represents the leading cause of death nationally in those under 45 years of age and the fifth most common cause of death overall.7 In the multiple trauma patients, the leading cause of death is catastrophic brain injury. ...