POLYTRAUMA

EARLY MANAGEMENT

MTLS HSB OCT 2009

 POLYTRAUMA

Definition :
A clinical syndrome where a
patient sustained serious injuries
involving ≥2 major organ &
physiological systems
 Polytrauma
•
• Patients are usually hemodynamically
unstable with life-threatening conditions


• This patient requires immediate

resuscitation, stabilization, lifesaving
intervention & prompt & accurate
investigations by multidisciplinary team
•
Trauma Death - Trimodal Distribution

70
60
50
40
Line 1
30
20
10
0
seconds 30 min 1 hours 4hours 8 hours day 5 week
The Second Death Peak occurs within minutes
to several hours after injury
Main focus of Trauma Life Support is in this
peak
üReferred to as the “Golden Hour”
ü
The Third Peak of Death occurs several days - weeks
after initial injury.
Causes: Sepsis, Organ Failure.

ü
 THE FIRST PERSON
TO ASSESS THE
PATIENT CAN AFFECT
THE FINAL OUTCOME
 Approach to trauma
victims
• Slightly different from non-trauma
patients
• Treatment start before definitive
diagnosis being made
•
• Primary survey + Resuscitation
• Then secondary survey
•
Components of Trauma Care
in polytrauma patients :
1) Triage & scene assessment
2) Primary Survey
3) Secondary Survey
4) Re-evaluation.
5) Definitive Care
6) Rehabilitation
 Initial Assessment
Injury
Transfer
Primary Survey
Optimize patient
Adjuncts
status
Resuscitation
Reevaluation
Reevaluation
Secondary Survey
Adjuncts
PRIMARY SURVEY
Definition :
The preliminary assessment of a patient, which
is conducted in a systematic manner with the
objective of identifying life threatening
conditions & managing them as soon as they
are found
 PRIMARY SURVEY
1) Rapid examination to determine the
 patient’s condition
1)
2) Decide on critical interventions

ü Should not take >2 minutes

ü Should not be interrupted… unless there is
airway obstruction or cardiac arrest
 Primary survey &
resuscitation of vital
functions are done
simultaneously
If a life threatening problem is
identified during this rapid primary
survey it must be CORRECTED
IMMEDIATELY rather than waiting
until the end of the survey
(eg a tension pneumothorax must be treated once
suspected)
PRIMARY SURVEY
IMMEDIATE ASSESSMENT ( DR ABCDE)
D - Danger
R – Response - AVPU
A - AIRWAY & CERVICAL SPINE CONTROL
B - BREATHING & VENTILATION
C - CIRCULATORY FUNCTION & HEMORRHAGE
CONTROL
D - DISABILITY & NEUROLOGICAL STATUS
E - EXPOSURE & UNDRESS COMPLETELY
PRIMARY SURVEY - FIRST LOOK

1 . SCENE ASSESSMENT
2 . POSITION OR POSTURE
3 . STATE OF CONSCIOUSNESS ( AVPU or GCS )
4 . BEHAVIOUR
5 . OBVIOUS INJURIES OR DEFORMITIES
Check Response
PRIMARY SURVEY - AIRWAY
General Inspection
ØLook , Listen & Feel .
PRIMARY SURVEY - AIRWAY
1)
2)GENERAL INSPECTION
3)Open, clear & maintain
üGentle chin lift
üJaw thrust
üSuction
üRemoval of foreign bodies
üOropharyngeal airway
AIRWAY PRIMARY SURVEY

•
 Airway Obstruction
 Causes:


ü Tongue falling back

ü Secretions & foreign matter in the mouth


ü Deformity & injury to the airway

 (maxillofacial injuries)
ü Swelling & inflammation of the airway
 (burns , toxic substances)
ü Laryngospasm
PRIMARY SURVEY - AIRWAY

MANAGEMENT OF LIFE THREATENING CONDITIONS

1.BLOOD/SECRETIONS – suction & removal of FB

2.FLOPPY TONGUE – chin lift, jaw thrust, oropharyngeal

a/w

3.MAXILLOFACIAL INJURY – reduction, intubation,

surgical a/w

OPEN, CLEAR & MAINTAIN AIRWAY

 Protection of the C-spine
ü Assume that the C-spine is damaged in any injury above the
clavicle (neck pain, numbness, LOC, polytrauma)
ü
ü Note any injury to the neck (eg. bruising, deformity, JVP,
tracheal shift, surgical emphysema)
ü
ü Neck collar must be rigid & of the correct size
ü Sandbags or head immobiliser
ü Examination of the neck with manual in-line immobilization
ü C-spine Xray : AP & Lateral view (open mouth view)
ü

 PROTECTION OF THE C-SPINE

Any injury above the

clavicle
Unconscious

polytrauma
Neck pain

Localizing signs
PROTECTION OF THE C - SPINE
PROTECTION OF THE C - SPINE
PRIMARY SURVEY - BREATHING

CHEST EXAMINATION
üLook for injuries
(bruising, abrasion or laceration wound, selt-belt sign)
üObserve chest movement, rate & pattern
ü
Management
üRescue breaths
üAdministration of High Flow O2
PRIMARY SURVEY - BREATHING

CHEST EXAMINATION (con’t)

üChest expansion, percussion, apex beat
üChest spring test – rib tenderness

Conscious patient – tender

Unconscious – Laxity of rib cage
üAUSCULTATION
Apex site
Air entry
Quality of heart sound - muffled
PRIMARY SURVEY - BREATHING
LIFE THREATENING CONDITIONS DIAGNOSED &


TREATED IMMEDIATELY:


 1) AIRWAY OBSTRUCTION
 2) TENSION PNEUMOTHORAX
 3) OPEN PNEUMOTHORAX / CHEST WOUND
 4) MASSIVE HEMOTHORAX
 5) FLAIL CHEST
 6) CARDIAC TAMPONADE


 ATOM FC
 1° survey : ATOM FC


 1) AIRWAY OBSTRUCTION
 2) OPEN PNEUMOTHORAX / CHEST WOUND
 3) TENSION PNEUMOTHORAX
 4) MASSIVE HEMOTHORAX
 5) FLAIL CHEST
 6) CARDIAC TAMPONADE


üPhysical examination
ü CXR
ü FAST ultrasound

OPEN PNEUMOTHORAX
PATHOPHYSIOLOGY
* Chest wall defect
* Collapsed lung
* Ball valve defect

Implanted object eg knife - natural seal

DO NOT REMOVE THE OBJECT
 OPEN PNEUMOTHORAX

Seal at 3 corners using sterile occlusive dressing

Insert chest tube
Definitive surgical repair
Apply
Apply occlusive
occlusive dressing
dressing to
to
open
open wounds
wounds
OPEN PNEUMOTHORAX
Large defects / open wounds (diameter of wound > than
trachea) causing ‘sucking’ chest wounds.
Equilibration between intrathoracic & atmospheric pressure
resulting in impairment of effective ventilation
EARLY MANAGEMENT :
1. Ensure an airway
2. Close the chest wall defect by any means
3. Administer 100% Oxygen
4. Insert a large-bore IV line
5. Monitor cardiac function
6. Rapidly transport patient to appropriate hospital
OPEN PNEUMOTHORAX

MANAGEMENT :
1 . Cover defect with sterile
occlusive dressing .
2 . Chest tube insertion .
3 . Definitive surgical closure .
TENSION PNEUMOTHORAX
ØAir enters pleural space – then No
exit
ØCollapse of affected lung
ØImpaired venous return
ØImpaired ventilation of unaffected
lung

Causes
qChest wall or parenchyma injury
qPositive pressure ventilation
Tension Pneumothorax Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
 Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
The mediastinum is
pushed to
the unaffected side
 TENSION PNEUMOTHORAX
üOne-way valve mechanism
üAir trapped in pleural space, Lung collapse
üIncrease intra-pleural pressure
üMediastinal shift

üNeedle decompression
üFollowed by chest tube
TENSION PNEUMOTHORAX
qSIGNS
1 . Tracheal Deviation
2 . Respiratory Distress
•Absence of breath sounds -
Unilateral
•Distended Neck Veins
•Cyanosis – Late
qDIAGNOSIS - Clinically , NOT Radiological
qMANAGEMENT
•Needle Thoracocentesis
•Chest Tube Insertion
 2nd Intercostal space

NEEDLE Mid Clavicular Line

THORACOCENTESIS
Needle Decompression
MASSIVE HAEMOTHORAX
qMore than 1500 ml of blood lost into the
chest cavity OR drain 1 . 5 L stat OR 600
ml / 6H ( 600 ml / H for 1 hour OR 100 ml / H for 6H
OR 200 ml / H for 3H by chest tube .
qpenetrating injuries that disrupt the
systemic / pulmonary vasculature .
qSigns :
1 . Dyspnoea
2 . Hypoxia
3 . Flat / distended neck veins
4 . Dullness and absence of breath sounds
üFluid/blood transfusion
üChest tube insertion
üAuto- transfusion
üMassive heamothorax – thoracotomy
FLAIL CHEST
qWhen a segment of chest wall does not
have bony continuity with the rest of
the thoracic cage ( e . g . multiple rib
fractures )

EFFECT
qSevere disruption of normal chest wall movement.
Ø‘paradoxical motion’
Ø Severe lung/pulmonary contusion which lead to
hypoxia
 FLAIL CHEST

MANAGEMENT
qAdequate ventilation &
Oxygen
qVolume restoration
qAnalgesia
CARDIAC TAMPONADE
COMMON CAUSES
Penetrating OR Blunt injury

CHARACTERISTIC
•BECK ’ S TRIAD
- Elevated JVP
- Muffled Heart Sounds
- hypotension
Narrowed Pulse Pressure
 PERICARDIAL
TAMPONADE

üBlood enters pericardial

space
üReduced expansion of
ventricle
üInadequate filling of
ventricle
üCardiac output reduced
CARDIAC TAMPONADE
qDIAGNOSTIC FACTORS
•Site of penetrating injury
•Raised JVP despite blood loss
•Signs of impaired cardiac performance :
- poor peripheral perfusion
- decreased urine output
- anxious , obtunded patient
- low volume with paradoxical pulse
- distant or absent heart sounds
•Globular enlarged cardiac silhouette on CXR
 CARDIAC TAMPONADE
In trauma , as little of 150 ml – 200 ml
of blood in pericardium can caused sign
of cardiac tamponade

qMANAGEMENT
- PERICARDIOCENTESIS
- OPEN THORACOTOMY
CARDIAC TAMPONADE
 Primary survey

ü Airway üCIRCULATION
ü Breathing


ATOM CF

PRIMARY SURVEY ( CONT ’ D )

CIRCULATION
qGENERAL ASSESSMENT
•skin color & temperature
•PR , BP
•capillary refill
•identify exsanguinations hemorrhage
•
DON ’ T WAIT UNTIL THE BP FALLS TO
SUSPECT SHOCK AND BEGIN TREATMENT
Class of hypovolaemia Class Class Class Class
I II III IV
Blood Loss: <15 15-30 30-40 >40
% Circulating volume

Blood Loss: <750 750-1500 1500-2000 >2000

Volume (mls in adults)

Pulse Normal 100-120 bpm 120 bpm Weak >120 bpm

Very weak

Blood Pressure: Normal Normal Low Very Low

Systolic
Blood Pressure: Normal High Low Very Low
Diastolic
Capillary Refill Normal Slow Slow Absent
Mental State Alert Anxious Confused Lethargic
Respiratory Rate Normal Normal Tachy- Tachy-
pnoeic pnoeic
Urine Output >30 mls/hr 20-30 mls/hr 5-20 mls/hr <5 mls/hr
1° survey : CIRCULATION
ü Pulse – rate & character. Blood pressure
ü Inspect, palpate & auscultate abdomen
ü Pelvic spring, perineum, limbs
ü
ü Stop external bleeding by direct compression, elevation,
pressure point
ü 2 large bore IV cannulae – give fluids/blood
ü
ü Pelvic Xray
ü DPL
ü FAST ultrasound
 Fluid in peritoneum & pericardial space


PELVIC SPRING TEST should it be performed?
1° survey : Disability
•
• AVPU/GCS
•
• Pupillary signs
•
• Log roll : Spinal tenderness, rectal examination
•
•
DISABILITY IN NEUROLOGY
qBrief examination carried out to
ascertain the state of consciousness .
A - A lert
V - Response to V erbal command
P - Response to P ain
U - U nresponsive

* All Head Injury Patients Should Be Given

High Oxygen Concentration *
 1° survey :
EXPOSURE/ENVIRONMENT


 Undress patient completely for exposure

 Thorough examination so as not to miss any
injury
 Pelvis, Groin, Genitalia, Back


 Keep patient warm – blanket, warm fluids
 Reassessment


Reevaluate ABCDE – traumatic injury is a dynamic
process
Reevaluate vital signs


 RE-EVALUATE!
 RE-EVALUATE !
 RE-EVALUATE !
 Adjunct to Primary Survey
 Primary survey Xrays:
• Lateral cervical spine
• CXR
• PelviC Xray
•
 FAST US
• Focused assessment eith sonography in trauma
• For detection of fluid (BLOOD) in peritoneal &
pericardial space


 Dxt, Crossmatch , CBD, ECG, ABG

SECONDARY SURVEY
qHISTORY
- Past Med . History / Allergies
- Mechanism of Injury
- Patient ’ s Condition at the Field
- Other Relevant Details

qPHYSICAL EXAMINATION
- Head & Neck
- Chest
- Abdomen
- Muscular - skeletal
- Neurological
 Secondary Survey
ü Detailed assessment from head to toe – to
detect HIDDEN life threatening causes
ü
ü Examine all orifices – ENT, PR, vagina,
perineum
ü Re-examine



PAT MED
POTENTIALLY LIFE THREATENING INJURIES
ASSESSED DURING THE SECONDARY SURVEY
1 . Pulmonary contusion
2 . Myocardial contusion
3 . Aortic ( Great vessel ) disruption
4 . Traumatic diaphragmatic hernia
5 . Tracheal - bronchial disruption
6 . Esophageal disruption
 Secondary Survey

PATMED
ü
ü P - Pulmonary contusion
ü A - Aortic dissection
ü T - Tracheo-broncho fistula
ü
ü M - Myocardial contusion
ü E - Esophageal perforation
ü D - Diaphragmatic disruption
RE-EVALUATION

Because of the dynamic state of the

physiological systems, the condition may
change within a short period of time. Hence,
after each primary survey a complete RE-
EVALUATION of all the vital systems must be
carried out.
 Lethal triad


Avoid -


1) Hypothermia (core temp < 35° C)

2) Acidosis
3) Coagulopathy


Temperature measurement & control

Adequate warm fluids & blood products, blanket

ABG, PT/APTT

Do not delay definitive management (surgery)


 Lethal triad
•
• Hypothermia occurs mainly during resuscitation
• Complication of hypothermia – bleeding (DIC),
dysrhytmias, renal & hepatic failure
•
• Coagulopathy – dilutional coagulopathy (DIC) &
hypothermia induced coagulopathy (Rx is rewarming)
•
• Acidosis - shock
 Summary
 Polytrauma - serious injuries involving ≥2 major
organ & physiological systems

 PRIMARY SURVEY – rapid systematic assessment to
identify & promptly treat life threatening
conditions



ATOM CF


 Summary
Adjunct to primary survey – FAST US,
primary survey X-rays

Secondary Survey – complete detailed
assessment from head to toe – to detect
HIDDEN life threatening causes

PAT MED


 Re-evaluate

Always Work in A Team
THANK YOU