Principles of treatment and indications for surgery in severe multiple trauma.

Despite major advances, pitfalls in diagnosis and emergency treatment influence the survival chances of multitraumatized patients considerably. Diagnosis of traumatic shock cannot be made by blood pressure, pulse rate and shock index. Immediate shock therapy is indicated in all cases with severe trauma of two body regions, combined injury of one body cavity and long bone fractures and in all cases with one major thoracic or pelvic injury. In a consecutive series of 418 multitrauma patients, extremity injuries were present in 90%, severe head injuries in 65%, major thoracic trauma in 50% and abdominal or pelvic injuries in 40%. The most frequent pattern of multitrauma was long bone fractures with associated head trauma and one thoracic, abdominal or pelvic injury. Priorities of treatment are based on a 4-stage-schedule: Stage 1 includes intubation and hyperventilation for cerebral trauma, volume replacement by central venous catheter, emergency x-ray of cervical spine, chest, abdomen, pelvis and diagnostic peritoneal lavage. In 25% of admitted cases, diagnosis of abdominal hemorrhage was missed by the referring surgeon despite hemorrhagic shock, falsely attributed to cerebral trauma. At Stage 2, emergency surgery of internal and external bleeding is indicated. Wide open fractures are stabilized by external fixation. Stage 3 is concerned with stabilization of vital systems and further diagnostic evaluation, its duration varying from 2 hours to 2 days. At Stage 4, internal fixation of fractures and other non-emergency-operations are indicated. Operating time can be reduced considerably by 2 surgical teams operating simultaneously or overlapping. Early shock diagnosis, immediate intubation, ventilator treatment and the "4-stages-schedule" are considered the most successful steps in the management of multitrauma, as well as volume replacement with Fox' hypertonic saline solution and blood constituents instead of colloids. This has reduced mortality due to respiratory failure from 31% to 20%.