[Timing in the treatment of multiple injuries]

Combined injuries occur in a great number. More than half of the deaths in accidents are caused by combined injuries. In more than 70 per cent of these, brain injury is the decisive lethal factor. Shock, respiratory disturbances, signs of fat embolism, coagulation disturbances have to be assessed first. The primary shock therapy begins with the filling up of the volume by colloid solutions. If internal bleedings are the cause of the shock, they must be treated first. Respiratory insufficiencies are mainly due to thorax injuries. Although systematic treatment cannot remove the fact of a fat embolism, it can keep its pathophysiological consequences within certain limits. Among the coagulation disturbances, special attention should be paid to the consumption coagulopathy. As regards the brain, attention should be paid to the increase in intracranial pressure as well as to increase in body temperature, decrease in oxygen saturation, and the like, the combination of which often has a deleterious effect. In the timing, the shock therapy is followed by an orientating examination (including state of consciousness, possible internal haemorrhages, bone fractures, etc.), provisional immobilisation, pain relieving and, when required, sedation. Intracranial complications must be looked for in all their phases. Osteosynthesis is not carried out as part of the primary treatment but usually only one week later. Open brain injuries have no priority but intracranial haematomas have an absolute priority. Surgical treatment of liquor fistulas should only be carried out in the acute phase when extensive impression fractures are present at the same time.