Multisystem Trauma

Multiple trauma vs. multisystem trauma

Multiple trauma means more than one serious injury, regardless of body system; a fractured arm and a fractured leg together are multiple trauma within a single system. Multisystem trauma means injury that affects more than one body system, and it is more dangerous because the physiologic reserve of several organ systems is compromised at the same time. The more systems involved, the less reserve the patient has to compensate for shock, and the more likely it becomes that field stabilization is impossible. For these patients, definitive care in the form of surgery is the actual treatment.

The core tension: treat vs. transport

Every decision in multisystem trauma balances the time spent treating against the time lost by delaying transport. An isolated musculoskeletal injury that cannot kill the patient in the next 10 minutes never takes precedence over a threat to the airway or breathing. When time is limited, interventions that address immediate life threats always come before interventions that only improve comfort.

The phrase "the well-packaged corpse" captures the failure to avoid. The goal is never to arrive at the hospital with a perfectly splinted, perfectly immobilized patient who died en route because too much scene time was spent achieving that perfection. For the truly critical patient, definitive care beats field perfection.

Field triage: the 2021 red and yellow criteria

The trauma destination decision follows the 2021 National Guideline for the Field Triage of Injured Patients (American College of Surgeons Committee on Trauma, with NAEMSP and federal partners). It replaced the 2011 scheme, which checked physiologic, then anatomic, then mechanism criteria in four numbered steps. The 2021 guideline has two tiers. Red criteria mean a high risk of serious injury: take the patient to the highest-level trauma center available within the regional trauma system. Yellow criteria mean a moderate risk: if no red criterion is met, take the patient to a trauma center, which need not be the highest level.

Red: injury patterns. A penetrating injury to the head, neck, torso or an extremity proximal to the elbow or knee; a skull deformity or suspected skull fracture; a suspected spinal injury with new motor or sensory loss; chest wall instability, deformity or a suspected flail chest; a suspected pelvic fracture; suspected fractures of two or more proximal long bones; a crushed, degloved, mangled or pulseless extremity; an amputation proximal to the wrist or ankle; and active bleeding that needs a tourniquet or wound packing with continuous pressure.

Table 34.1Field triage: the 2021 red and yellow criteria

Yellow: mechanism of injury. A high-risk crash: partial or complete ejection; intrusion, including the roof, of more than 12 in at the occupant site or more than 18 in at any site, or a need for extrication of an entrapped patient; a death in the same passenger compartment; a child aged 0–9 unrestrained or in an unsecured child safety seat; or vehicle telemetry consistent with severe injury. A rider separated from a motorcycle, ATV, horse or other transport with significant impact. A pedestrian or cyclist thrown, run over or struck with significant impact. A fall from more than 10 ft (3 m), at any age.

Yellow: EMS judgment. Consider the risk factors that make the same forces more dangerous: a low-level fall with significant head impact in a child aged 5 or under or an adult aged 65 or over; anticoagulant use; suspected child abuse; special, high-resource health care needs; pregnancy beyond 20 weeks; and burns together with trauma. Injured children should go preferentially to pediatric-capable trauma centers. A yellow criterion alone does not guarantee injury; it justifies a more cautious destination when harder evidence is absent.

Your regional protocol decides the actual destinations and how far you may travel to reach one. On the exam, red means highest-level trauma center, yellow means a trauma center, and the vital-sign thresholds above are the ones to know.

Special populations & pathophysiology of internal injuries

Age changes the thresholds. For age 65 and over, the field triage guideline uses a systolic blood pressure (BP) below 110, rather than below 90, as a red criterion, because a "normal-looking" reading of 100 mmHg may be significant relative hypotension in an older adult; a heart rate greater than the systolic pressure is a red criterion at any age from 10 up. Children present the opposite problem. Their bodies compensate more effectively and for longer, then decompensate suddenly and severely, so a "stable-looking" pediatric trauma patient can crash with little warning.

The internal injuries of multisystem trauma share a common physiology. In a tension pneumothorax, the compressed vena cava reduces venous return, which in turn reduces cardiac output, and shock follows. Cardiac tamponade produces similar findings, namely jugular venous distention (JVD), low BP and a narrowing pulse pressure, but it does so by external compression of the heart rather than collapse of a lung; breath sounds therefore remain bilateral, unlike the one-sided absence of a tension pneumothorax. A solid organ injury can be masked by the organ's capsule, which delays diagnosis, while a hollow organ injury causes diffuse pain as the spilled contents irritate the peritoneum.