PREHOSPITAL CARE OF THE PATIENT WITH MULT IPLE TRAUMA

Adequate prehospital care of the severely traumatised patient is impor tant to prevent or attenuate early as well as late life threatening co mplications, such as tissue hypoxia, ischemia/reperfusion injury and f inally multiple organ failure. A mismatch of oxygen supply and oxygen demand is a hallmark in the pathophysiology of multiple trauma. Oxygen supply may be diminished by the following factors: shock-related decr ease of cardiac output, anemia and hypoxia. On the other hand, oxygen demand may be increased by pain, panic, and agitation. Hence, it is a central point in prehospital care to reduce this supply-demand imbalan ce by identification and prompt reversal of the underlying causes. Mos t often, shock is caused by hypovolaemia and tissue injury (''traumati c-hemorrhagic shock''). However, shock may also be a result of central nervous system injury (neurogenic shock as a special form of distribu tive shock) or circulatory obstruction, e.g tension pneumothorax or ca rdiac tamponade (obstructive shock). Volume resuscitation by means of crystalloid or colloid solutions is an essential part in the therapy o f the traumatic-haemorrhagic shock. In addition, catecholamines may be necessary in order to achieve an adaequate arterial pressure. However , if bleeding cannot be controlled in the prehospital setting, only mo derate volume support and permissive hypotension as well as rapid tran sportation into the next hospital may be preferable. This may be the c ase in penetrating thoracic or abdominal injuries as well as in trauma tic amputations of the proximal limb. On the contrary in patients with severe head injury, hypotension must be avoided by all means. Obstruc tive shock has to be treated urgently by insertion of a chest drain or drainage of the pericardium, respectively. Under all circumstances, i t is an essential part of prehospital therapy to provide sufficient an algesia as soon as possible. Prehospital anesthesia, combined with art ificial ventilation may be necessary for optimal patient management. F urthermore, ventilatory support is indicated when respiratory failure, loss of consciousness, or severe shock are present. Additional oxygen should be given whenever possible, even in the absence of an overt hy poxic state. Important additional measures are cervical spine immobili sation and reposition as well as splinting of long bone fractures or l uxations, in order to avoid secondary injury of the spinal cord or ong oing tissue and vascular damage.