Approach to patients with polytrauma
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1) The document discusses the approach to managing polytrauma patients, beginning with the primary survey (ABCDEs) and simultaneous resuscitation to address life-threatening injuries first. 2) It outlines the assessment of airway, breathing, circulation, disability and exposure/environment, as well as triage considerations for multiple casualties. 3) Initial fluid resuscitation, hemorrhage control including blood replacement, and management of injuries like tension pneumothorax are covered.
Approach to patients with polytrauma
- 1. Approach to Polytrauma Patients Dr. Awaneesh Katiyar M.Ch. Senior Resident Trauma Surgery and Critical Care AIIMS, Rishikesh, UK, India
- 2. Objectives • The concepts and principles of the primary and secondary patient assessments. • Establish management priorities in a trauma situation. • Initiate primary and secondary management necessary for the emergency management of acute life threatening conditions in a timely manner.
- 3. Distribution of global injury mortality
- 4. The Need • More than nine people die every minute from injuries or violence • 5.8 million people of all ages and economic groups die every year • The burden of injury is even more significant, accounting for 18% of the world’s total diseases.
- 6. History
- 7. ATLS and Trauma Systems • As mentioned earlier, Advanced Trauma Life Support (ATLS) was developed in 1976 following a plane crash in which several children were critically injured.
- 8. The Concept • Treat the greatest threat to life first. • Never allow the lack of definitive diagnosis to impede the application of an indicated treatment. • A detailed history is not essential to begin the evaluation of a patient with acute injuries.
- 9. Initial assessment includes the following elements: • Preparation • Triage • Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries • Adjuncts to the primary survey and resuscitation
- 10. Initial assessment includes the following elements: • Consideration of the need for patient transfer • Secondary survey (head-to-toe evaluation and patient history) • Adjuncts to the secondary survey • Continued post-resuscitation monitoring and reevaluation • Definitive care
- 11. Preparation • Preparation for trauma patients occurs in two different clinical settings: • in the field and • in the hospital. • During the prehospital phase, events are coordinated with the clinicians at the receiving hospital. • During the hospital phase, preparations are made to facilitate rapid trauma patient resuscitation.
- 12. Triage • Multiple Casualties • Multiple-casualty incidents are those in which the number of patients and the severity of their injuries do not exceed the capability of the facility to render care. • In such cases, patients with life-threatening problems and those sustaining multiple-system injuries are treated first.
- 13. Triage • Mass Casualties • In mass-casualty events, the number of patients and the severity of their injuries does exceed the capability of the facility and staff. • In such cases, patients having the greatest chance of survival and requiring the least expenditure of time, equipment, supplies etc.
- 14. Primary Survey with Simultaneous Resuscitation Airway maintenance with restriction of cervical spine motion Breathing and ventilation Circulation with hemorrhage control Disability(assessment of neurologic status) Exposure/Environmental control
- 15. 10-second assessment Clinicians can quickly assess A, B, C, and D in a trauma patient by identifying themselves, asking the patient for his or her name, and asking what happened
- 16. Airway
- 17. Airway • First assess the airway to ascertain patency • Begin measures to establish a patent airway while restricting cervical spine motion • Initially, the jaw-thrust or chin-lift maneuver often suffices as an initial intervention • GCS score of 8 or lower usually require the placement of a definitive airway • Establish an airway surgically if intubation is contraindicated or cannot be accomplished
- 18. Problem Recognition • Maxillofacial Trauma • Neck Trauma • Laryngeal Trauma 1. Hoarseness 2. Subcutaneous emphysema 3. Palpable fracture
- 19. Predicting Difficult Airway Management • L = Look Externally • E = Evaluate the 3-3-2 Rule • M = Mallampati • O = Obstruction • N = Neck Mobility:
- 20. DEFINITIVE AIRWAYS • There are three types of definitive airways: • Orotracheal tube • Nasotracheal tube • Surgical airway (cricothyroidotomy and tracheostomy).
- 21. Surgical Airway Needle Cricothyroidotomy Surgical Cricothyroidotomy
- 23. Life-threatening injuries • Airway obstruction • Tracheobronchial tree injury • Tension pneumothorax • Open pneumothorax • Massive hemothorax • Cardiac tamponade
- 24. Potentially life-threatening injuries • Simple pneumothorax • Hemothorax • Flail chest • Pulmonary contusion • Blunt cardiac injury • Traumatic aortic disruption • Traumatic diaphragmatic injury, • Blunt esophageal rupture.
- 25. Significant Chest Injuries • Subcutaneous emphysema, • Thoracic crush injuries, • Sternal, rib, and clavicular fractures
- 26. Airway Problems • Airway Obstruction • Laryngeal injury • Posterior dislocation of the clavicular head • Tracheobronchial Tree Injury • Incomplete expansion of the lung and continued large air leak after placement of a chest tube suggests a tracheobronchial injury, and placement of more than one chest tube may be necessary to overcome the significant air leak.
- 27. Breathing Problems • Tension Pneumothorax • Tension pneumothorax develops when a “one-way valve” air leak occurs from the lung or through the chest wall
- 28. Breathing Problems • Open Pneumothorax • Large defects of the chest wall that remain open can result in an open pneumothorax, or sucking chest wound.
- 29. Breathing Problems • Open Pneumothorax • For initial management of an open pneumothorax, promptly close the defect with a sterile dressing large enough to overlap the wound’s edges with seal on three side.
- 30. Breathing Problems • Massive Hemothorax • This condition results from the rapid accumulation of more than 1500 mL of blood or one-third or more of the patient’s blood volume in the chest cavity.
- 31. Breathing Problems • Cardiac Tamponade Cardiac tamponade can result from penetrating or blunt injuries that cause the pericardium to fill with blood from the heart, great vessels, or pericardial vessels
- 32. Potentially Life-Threatening Injuries Simple Pneumothorax : Pneumothorax results from air entering the potential space between the visceral and parietal pleura
- 33. Potentially Life-Threatening Injuries Flail Chest : Two or more adjacent ribs fractured in two or more places
- 34. Potentially Life-Threatening Injuries Traumatic Aortic Disruption: Traumatic aortic rupture is a common cause of sudden death after a vehicle collision or fall from a great height. Maintain a high index of suspicion prompted by a history of decelerating force and characteristic findings on chest x-ray films. Aortic Disruption
- 35. Potentially Life-Threatening Injuries Diaphragmatic Rupture. Blunt trauma produces large radial tears that lead to herniation, whereas penetrating trauma produces small perforations that can take time—sometimes even years—to develop into diaphragmatic hernias.
- 36. Other Manifestations of Chest Injuries • Subcutaneous emphysema, • Thoracic crush injuries, • Sternal, rib, and clavicular fractures • Upper ribs (1 to 3) • Middle ribs (4 to 9) • Lower ribs (10 to 12)
- 37. Circulation with hemorrhage control
- 39. Clinical Differentiation of Cause of Shock • Hemorrhagic Shock • Cardiogenic Shock • Cardiac Tamponade • Tension Pneumothorax • Neurogenic Shock • Septic Shock
- 41. Initial Fluid Therapy • Administer an initial, warmed fluid bolus of isotonic fluid. The usual dose is 1 liter for adults and 20 mL/kg for pediatric patients weighing less than 40 kilograms • The goal of resuscitation is to restore organ perfusion and tissue oxygenation.
- 43. Blood Replacement • Crossmatched, Type-Specific, and Type O Blood • Autotransfusion • Massive Transfusion • > 10 units of pRBCs within the first 24 hours of admission or more than 4 units in 1 hour
- 44. Abdominal and Pelvic Trauma • Inspection, Auscultation, Percussion, and Palpation • Pelvic Assessment • Urethral, Perineal, Rectal, Vaginal, and Gluteal Examination
- 45. Abdominal and Pelvic Trauma • ADJUNCTS TO PHYSICAL EXAMINATION • Gastric Tubes and Urinary Catheters • FAST • DPL • X-rays for Abdominal Trauma • Computed Tomography FAST : Focused Assessment with Sonography for Trauma
- 46. Pelvic Fractures and Associated Injuries AP Compression fracture Lateral compression fracture Vertical shear fracture
- 47. Pelvic Fractures and Associated Injuries A sheet, pelvic binder, or other device can produce sufficient temporary fixation for the unstable pelvis when applied at the level of the greater trochanters of the femur.
- 48. Disability The primary goal of treatment for patients with suspected traumatic brain injury is to prevent secondary brain injury.
- 49. Intra Cranial Pressure(ICP) • Elevation of intracranial pressure (ICP) can reduce cerebral perfusion and cause or exacerbate ischemia. • The normal ICP for patients in the resting state is approximately 10 mm Hg. • Pressures greater than 22 mm Hg, particularly if sustained and refractory to treatment, are associated with poor outcomes
- 53. CT Scans of Intracranial Hematomas A. Epidural hematoma. B. Subdural hematoma. C. Bilateral contusions with hemorrhage. D. Right intraparenchymal hemorrhage with right to left midline shift and associated biventricular hemorrhages.
- 55. CT scanning is the preferred method of imaging, although obtaining CT scans should not delay transfer of the patient who requires it.
- 56. Medical Therapies for Brain Injury • Hypovolemia in patients with TBI is harmful. • Correction of Anticoagulation • Hyperventilation acts by reducing PaCO2 and causing cerebral vasoconstriction. • Mannitol is used to reduce elevated ICP. The most common preparation is a 20% solution (20 g of mannitol per 100 ml of solution). • The goal in resuscitating the patient with brain injuries is to prevent secondary brain injury.
- 57. Spine and spinal cord trauma
- 58. Spine and Spinal Cord Trauma • Because spine injury can occur with both blunt and penetrating trauma, and with or without neurological deficits, it must be considered in all patients with multiple injuries. • These patients require limitation of spinal motion to protect the spine from further damage until spine injury has been ruled out.
- 59. Anatomy
- 61. Neurogenic Shock versus Spinal Shock • Neurogenic shock results in the loss of vasomotor tone and sympathetic innervation to the heart. • Injury to the cervical or upper thoracic spinal cord (T6 and above) can cause impairment of the descending sympathetic pathways. • Spinal shock refers to the flaccidity (loss of muscle tone) and loss of reflexes that occur immediately after spinal cord injury.
- 62. General management of spine and spinal cord trauma • Restricting spinal motion • Intravenous fluid • Medications • Transfer, if appropriate
- 64. Injuries to the musculoskeletal system are common in trauma patients. The delayed recognition and treatment of these injuries can result in life-threatening hemorrhage or limb loss.
- 65. Musculoskeletal injuries • The initial assessment of musculoskeletal trauma is intended to identify those injuries that pose a threat to life and/or limb. • Although uncommon, life-threatening musculoskeletal injuries must be promptly assessed and managed. • A staged approach to hemorrhage control is utilized by applying direct pressure, splints, and tourniquets.
- 66. Musculoskeletal injuries • Most extremity injuries are appropriately diagnosed and managed during the secondary survey. • A thorough history and careful physical examination, including completely undressing the patient, is essential to identify musculoskeletal injuries. • It is essential to recognize and manage arterial injuries, compartment syndrome, open fractures, crush injuries, and dislocations in a timely manner
- 67. Give extra attention to…. • PEDIATRIC TRAUMA • GERIATRIC TRAUMA • TRAUMA IN PREGNANCY AND INTIMATE PARTNER VIOLENCE
- 68. SCENARIO • You are summoned to a safe triage area at a shopping mall where 6 people are injured in a mass shooting. The shooter has killed himself. You quickly survey the situation and determine that the patients’ conditionsare as follows: • PATIENT A—A young male is screaming, “Please help me, my leg is killing me!” • PATIENT B—A young female has cyanosis and tachypnea and is breathing noisily. • PATIENT C—An older male is lying in a pool of blood with his left pant leg soaked in blood. • PATIENT D—A young male is lying facedown and not moving. • PATIENT E—A young male is swearing and shouting that someone should help him or he will call his lawyer. • PATIENT F—A teenage girl is lying on the ground crying and holding her abdomen