From the trauma surgeon's viewpoint: multiple injuries--which cavity to open first?
Trauma patients with multiple complex problems pose critical management challenges. Clinical decisions are rarely straightforward. One of the biggest challenges in the care of the severely injured patient is how to deal with the issue of competing injuries; the process involved in the decision of what the trauma team should do first and then the next step. The ultimate goal is to transform a very complex situation into a simple problem by following straightforward algorithms to achieve a good outcome. The dilemma is that common algorithms used for "single body area" injury are usually not applicable for multisystem or multi-cavitary injuries. The first 5 or 10 minutes of trauma resuscitation are critical for the patient's outcome. The goal of nursing and the trauma surgical team during that short time frame is to address injuries and clinical situations that are life threatening. We routinely use the "ABCs" resuscitation strategy to achieve that goal; whenever that sequence is changed, a bad outcome ensues. It is proposed that the trauma team addressing complex problems in patients with multiple injuries can follow the same principles. Several challenging scenarios are common in clinical practice. For discussion purposes these will be divided according to the mechanism of injury either penetrating or blunt.