Critically ill patients with traumatic injuries are often complex, encompassing a wide array of problems. Their care often starts before they arrive at the hospital, continues from the time they arrive in the emergency room, and will likely consist of days in the hospital with rehabilitation after. A series of specialists is often required, including emergency medicine, trauma surgery, orthopedic surgery, neurosurgery, anesthesia, and facial surgery among others. This chapter will focus on the initial care of the critically ill patient with multisystem trauma in the emergency room.
Care of the multisystem trauma patient usually begins in the prehospital setting. Protocols are in place for emergency providers who initiate care. They are in contact with physicians at the receiving hospital to coordinate care and allow for adequate preparation of the emergency room resources and personnel. The initial management goals are to prevent further injury, initiate resuscitation, and to transport to the nearest appropriate facility, ideally a trauma center. Treatment provided includes the essential components of resuscitation including maintenance of the airway, hemorrhage control, immobilization of the cervical spine, and stabilization of fractures. In addition, prehospital personnel obtain background information including mechanism of injury, associated events, and past medical history to facilitate quicker diagnosis and treatment.1 The quality of prehospital care has been shown to impact patient outcome.2
The accurate triage of the multitrauma patient is essential to providing appropriate timely care and avoiding morbidity, mortality, and the overutilization of resources. Many trauma systems over-, under-, or mistriage patients. The impact of undertriaging can be great, with delayed or even missed injuries and interventions. The overtriage of patients can lead to significant burden on the hospital and systemwide resources and personnel.3 The American College of Surgeons Committee on Trauma guidelines states that priority has been given to decrease undertriage to prevent morbidity and mortality from delayed definitive care.4 An undertriage rate of 5–10% is generally thought of as acceptable.5
The trauma resuscitation team is made up of physicians, nurses, respiratory therapists, radiographic technologists, lab technicians, and other allied health personnel. Most trauma centers have a multitiered activation system, and the severity of the injured patient—in addition to the hospital level—will determine who responds to the trauma activation. In Level I and II trauma centers, the full trauma team needs to respond within 15 minutes for the highest level of activation and within 30 minutes at Level III or IV centers. Minimum criteria for full trauma team activation include confirmed blood pressure <90 mm Hg at any time; gunshot wounds to the neck, chest, or abdomen or extremities proximal to the elbow or knee; Glasgow Coma Scale (GCS) score of <9 with mechanism attributed to trauma; transfer patients from other hospitals receiving blood to maintain vital signs; intubated patients from the scene or patients who have respiratory compromise or are in need of an emergent airway; and emergency physician's discretion.4
The Eastern Association of Trauma has published guidelines with Level 2 evidence for both prehospital and in-hospital triage. For adult prehospital triage, they state that a combination of physiologic and anatomic parameters along with mechanism of injury (MOI), comorbidities, and demographics provides better triage than any smaller combination, and physiologic parameters are more ...