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1116 PART 10: The Surgical Patient

• Fischer SA, Avery RK; the AST Infectious Disease Community • Cervical spine protection is crucial during airway assessment and
of Practice. Screening of donor and recipient prior to solid organ
transplantation. Am J Transplant. 2009;9:S7-S18. manipulation.
• Gries CJ, White DB, Truog RD, Dubois J, Cosio CC, Dhanani S, • When several personnel are involved, a trauma team leader is
et al. An official American Thoracic Society/International Society important to coordinate management in the multiply injured patient.
for Heart and Lung Transplantation/Society of Critical Care • Safe effective techniques for airway control, chest decompres-
Medicine/Association of Organ and Procurement Organizations/ sion, and the establishment of intravenous access are key skills in
United Network of Organ Sharing Statement: ethical and policy management of multiple trauma.
considerations in organ donation after circulatory determination • After immediately life-threatening abnormalities have been cor-
of death. Am J Respir Crit Care Med. 2013;188(1):103-109. rected, systematic anatomic assessment is required to identify and
• Halpern SD, Shaked A, Hasz RD, et al. Informing candidates for manage other injuries.
solid-organ transplantation about donor risk factors. N Engl J Med. • Repeated assessment is necessary to identify changes in the
2008;26;358:2832-2837. patient’s status and institute appropriate treatment.
• Joseph B, Aziz H, Pandit V, Kulvatunyou N, Sadoun M, Tang A,
et al. Levothyroxine therapy before brain death declaration
increases the number of solid organ donations. J Trauma Acute
Care Surg. 2014;76(5):1301-1305. Although the institution of trauma systems has altered the pattern
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• Lytle FT, Afessa B, Keegan MT. Progression of organ failure of mortality distribution following multiple injuries, it is still useful
2,3
in patients approaching brain stem death. Am J Transplant. to consider the trimodal distribution pattern. The first peak of this
2009;9(6):1446-1450. trimodal distribution represents deaths occurring at the scene and
• Mascia L, Pasero D, Slutsky AS, et al. Effect of a lung protec- results from such injuries as cardiac rupture or disruption of the major
intrathoracic vessels, and severe brain injury that is incompatible with
tive strategy for organ donors on eligibility and availability of survival. Death from such injuries occurs within minutes of the trau-
lungs for transplantation: a randomized controlled trial. JAMA. matic event and medical intervention is usually futile. The second peak
2010;304:2620-2627. in mortality following multiple injuries occurs minutes to a few hours
• Shemie SD, Ross H, Pagliarello J, et al. Organ donor management after the event. Mortality during this phase is related to injuries that
in Canada: recommendations of the forum on medical manage- are immediately life-threatening, such as airway compromise, tension
ment to optimize donor organ potential. CMAJ. 2006;174:S13-S32. pneumothorax, and cardiac tamponade. However, simple appropri-
• Tuttle-Newhall JE, Krishnan SM, Levy MF, et al. Organ donation ate resuscitative measures can significantly affect the outcome during
and utilization in the United States, 1998-2007. Am J Transplant. this phase. The third peak occurs as a result of complications of the
3
2009;9:879-893. injury, such as sepsis or multiorgan failure. However, mortality in this
• Venkateswaran RV, Steeds RP, Quinn DW, et al. The haemo- third phase can also be significantly altered by the type of intervention
dynamic effects of adjunctive hormone therapy in potential during the second phase. The intensivist dealing with the multiple
heart donors: a prospective randomized double blind factorially trauma patient is very likely to be involved in the institution of resus-
designed controlled trial. Eur Heart J. 2009;30:1771-1780. citative measures during the second phase as well as the management
during the third phase of the complications of the injury or complica-
• Wijdicks EFM, Varelas PN, Gronseth GS, et al. Evidence-based tions arising from inadequate treatment. Many of the chapters in this
guideline update: determining brain death in adults: Report of the text deal with the complications of trauma, such as sepsis and multiple
Quality Standards Subcommittee of the American Academy of organ failure. This chapter will emphasize treatment priorities during
Neurology. Neurology 2010;74;1911-1918. the second peak of the trimodal distribution of trauma-related mortality.
Blunt trauma from motor vehicle collision is the most frequent cause of
injuries in general. This type of impact usually results in injuries to many
different parts of the body simultaneously. Such a patient may present
REFERENCES with head and neck injuries as well as abdominal and extremity injuries.
Complete references available online at www.mhprofessional.com/hall When faced with multisystem injury, the intensivist must prioritize
treatment according to the threat to the patient’s survival. Prioritization
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of assessment and intervention requires a coordinated team approach.
Where personnel are available from different specialties, it is of para-
CHAPTER Priorities in Multisystem mount importance that the entire resuscitative effort be coordinated
through an identified team leader. This very simple decision should be
117 Trauma made prior to institution of therapy and can be critical to the outcome
in the patient with multisystem trauma. The team leader, who may be
Jameel Ali an intensivist, must be completely familiar with a wide variety of injuries
and the relative threat they pose to life in order to prioritize intervention
and direct personnel appropriately.
The description of the order of priorities follows a sequence based
KEY POINTS on one primary physician conducting the entire resuscitation. However,
• Therapeutic intervention in the multiply injured patient must be as frequently happens in most trauma centers, when many physicians
prioritized to maximize survival. and paramedical personnel are available, assessment and management
of several abnormalities occur simultaneously. For example, while the
• The degree of life threat posed by the alteration in physiology from airway is being assessed and managed, intravenous access could be
each injury determines the order of priority. established by different personnel.
• Immediate priority is given to airway control and to maintenance of Certain fundamental concepts underlie the approach to resuscita-
ventilation, oxygenation, and perfusion. tion of the multiply injured patient. The most important of these is that
immediately life-threatening abnormalities should be treated as they are

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