Approach for poly-trauma patient

Approach for poly-trauma patientDr. Hany VictorLecturer of Anesthesia and ICUETC Instructor

ObjectivesCase presentation on poly-trauma patient.Discussion on the caseApproach to poly-trauma patientRecommendationMCQ

CaseMale patient 28 years presented to the ER following a motor car accident 30 min ago complaining of chest pain, cut wound in the forehead with minimal bleeding and pain in the right forearm.By history the patient had a blunt trauma to the head and chest in the dashboard. Other previous medical history is irrelevant.

On examinationAirway: ClearCervical Spine immobilization after neck examination with no major abnormality Breathing: RR: 20/minEqual air entry bilateral with no adventitious sounds.Tenderness over the sternum.SpO2: 95% on room air.

Circulation: There is no major site of bleeding, vital signs include:HR: 100/min felt central and peripheral, equal on both sides. Blood pressure: 100/60 mmHg.Capillary refill time: 1.5 sec.Temp: 37.1CNeck veins not congestedThere is wound in the forehead 5X3 cm.

Disability GCS 15/15 No loss of cons, no nausea or vomiting, no bleeding per orifices, no transient amnesia and no fits.Pupils are equal bilateral and reactive to light.Blood sugar 140 mg/dl.ExposureNo major bleedingNo major deformity

Discussion on part one of the lectureTypes of assessment8Primary Survey and resuscitation

Identification of Life threatening conditions ACBCDE Approach

Secondary Survey

Detailed head to toe examinationMedical historyAll lab and radiology investigation orderedManagement Plan8Illinois EMSC9PURPOSE OF THE INITIAL ASSESSMENTIdentification of LIFE-THREATENING emergenciesAssess Change - Reassess

Initiation of LIFE-SAVING measures (CPR)

95 second RoundIllinois EMSC10Pt is conscious or notAirwayVentilationSigns of massive external hemorrhageThere is any deformitySkin color and temp with feeling pulse 10Illinois EMSC11Primary SurveyAirway/ Cervical Spine ControlBreathingCirculationDisability (neurological)Expose

11 Assessing AirwayIs the airway:Clear and safe?At risk?Obstructed?

12Illinois EMSC13AIRWAY INTERVENTIONSJaw thrust Vs Head tilt.Deliver Oxygen (mask with reservoir).Use Rigid suction.Secure airway.

135 Chest clues in the neckWoundsDistended neck veinsTracheal positionSurgical emphysemaLaryngeal crepitus

14Illinois EMSC15CERVICAL SPINE STABILIZATIONPlace hands on either side of the head cervical collar.flv

Maintain neck midline manual in line stabilization

15Breathing and ventilationAimsSupport if inadequateEliminate any immediately life threatening thoracic condition ..

16Breathing and ventilationInspectionRespiratory rate Effort of breathingSymmetryWounds & marks

PalpationTender points, equal expansion

PercussionNo abnormal noteAuscultationAll lung zones

17Illinois EMSC18BREATHING INTERVENTIONSIf breathing is absent, start ventilation using:Simple Adjuvants (Airways)Bag valve mask with reservoirLMAETT18Fatal Chest conditions?Tension pneumothoraxOpen chest traumaCardiac tamponadeFlail chestMassive hemothoraxIllinois EMSC1919Illinois EMSC20CIRCULATORY ASSESSMENTCarotid pulse (absent or present)Capillary refillSkin colorSkin temperatureSites of bleeding

2021CIRCULATORY INTERVENTIONSIf central pulse is absent, begin CPRApply direct pressure to open woundsIV access (2 wide bore cannulae14/16G).Fluids (colloids Vs crystalloids) 20ml/KgPeripheral Vs central line? 21Dysfunction of the CNSAimsRapid neurological assessmentAlert; Voice; Pain; UnresponsivePupilsMini-neurological assessmentGCS score / AVPU Pupils Lateralising signsBlood sugar

22If GCS 8 or less intubate if not already done so23

23Exposure and environmentAimsRemove clothing to allow examination of entire patientCare when removing tight trousersPrevent hypothermiaPatient dignityRemove spine board24Prevent hypothermiaCover overWarming devicesRoom temperatureWorse if spinal injury

Dont Forget The Back

Pause & check

Are all immediately life-threatening injuries identified?Is all monitoring in place?Investigations ordered?Analgesia?Relatives informed?Non-essential team members disbanded?26Ensure all monitoring in placeECG, BP, SpO2, etCO2, urine output

Tests:Chest and pelvic x-raysUltrasoundCTFBC, U&Es, BS, cross-match, pregnancy test, arterial blood gases The well practiced trauma team should aim to complete the primary survey in less than 10 minutesIllinois EMSC27

27RadiologyOnce the patient is stabilized the patient is sent to radiology for the survery:Cervical spine X-ray (AP and lateral view)Chest X- ray (Rib cage)Pelvis X-rayAbdomen and Pelvis U/SCT brain is ordered if there is suspicion of head traumaX-ray of extremities if fracture is suspected.Chest X-Ray

Part 2 casePatient returned form the radiology department complaining of severe chest pain and could not lay down on his back for suturing of the cut wound in the forehead Patient received the following medication:1500 cc of normal salinecefoperazone 1.5 gm IV Analgesia as Perfalgan 1gm IV followed by Pethedine 50 mg IM

Labs were send for urgent HbPatients Vital signs were:HR: 120/minBlood pressure 85-90/50-60 mmHg.CRT 2 secSpO2:92 % On Room air.

Patient still complains of severe chest pain and received another 50 mg pethedine over 100 cc Normal Saline over 30 min

What is the next stepWhat Labs to order?What other radiological investigations to ask for?What other medications to give?

Chest X-Ray

Double aortic knob signDiffuse enlargement of the aortaTracheal displacement to the rightPleural effusion Pericardial effusionCardiac enlargementLeft apical opacityFractured first or second ribsMediastinal wideningCT chest

Aortograghy

AortograghyFinal DiagnosisTraumatic aortic tear

THORACIC TRAUMA

Traumatic Aortic Rupture These are found in victims of high-speed motor vehicle crashes and falls from great heights, and 85% of these injuries are due to blunt trauma. The majority (80-90%) of the patients die at the scene of the accident from massive blood loss. Of the patients reaching hospital alive, only 20% will survive without operation.The mortality remains high even after surgery.In cases of aortic rupture, the clinical presentation depends upon the site of injury. Patients with injury to the intrapericardial portion of the ascending aorta will usually develop a cardiac tamponade.Extrapericardial ascending aortic injury produces a mediastinal haematoma and a haemothorax, usually on the right sideRapid deceleration is believed to be responsible for damage to the aorta that most commonly occurs in the region of ligamentum arteriosum, just distal to the origin of left subclavian artery.

Patients may show transient hypotension, which responds well to fluid therapy and further clinical signs may be absent. This may delay the diagnosis with catastrophic results should the aorta rupture completely. Thus a high index of suspicion should be kept in mind.Aortic disruption should always be suspected in patients with profound shock and who have no other external signs of blood loss and in whom mechanical causes of shock (tension pneumothorax and pericardial tamponade) have been excluded.Symptoms (if the patient is conscious) may include:Severe retrosternal pain Pain between the scapulaeHoarseness of voice (pressure from haematoma on the recurrent laryngeal nerve) Dysphagia Paraplegia or paraparesis Aortic dissection Vs ACS.The definitive investigation of choice is angiography or a CT angiogram of the aortic arch, the choice depending on local policy. Survival in patients who have their injury repaired surgically and who have remained haemodynamically stable during the repair is 90%.

Minimally invasive repair using aortic stenting techniques are also being used

MANAGEMENT OPEN PNEUMOTHORAXEnsure adequate airway100% oxygenSeal open woundLoad & GoIV access en routeNotify Medical Direction

Courtesy of David Effron, M.D.SEALING THE OPEN WOUNDAsherman chest seal is very effective

SEALING THE OPEN WOUNDYou can use impervious material taped on three sides

TENSION PNEUMOTHORAX

MANAGEMENTTENSION PNEUMOTHORAXEnsure adequate airway100% oxygenNeedle decompression if indicatedLoad & GoIV access en routeNotify Medical DirectionMCQWhich of the following is true in regards to a traumatic aortic rupture?A.There is a 50% survival rateB.Immediate defibrillation is indicatedC.Usually due to deceleration injury D.They are easily diagnosed in the pre-hospital setting

3. What is the MOST likely abnormality that would be seen on chest x-ray in a patient with traumatic rupture of the aorta after blunt injury?Obscuration of the aortic knob Deviation of esophagus to the leftFracture of the first or second ribApical capSuperior mediastinal widening3. Male patient with intracerebral hemorrhage and intra-abdominal bleeding, the optimum blood pressure for this patient should be maintained around:90 mmHg.100 mmHg.110 mmHg.70 mmHg.4. The initial management of a poly-trauma patient should include the following order:Conscious level, secure airway, assess circulation , control cervical spine, assist ventilation and exposure.Secure airway, control cervical spine, assess circulation, follow up conscious level and assist ventilation and exposure.Secure airway, control cervical spine, assist ventilation, assess circulation, follow up conscious level and exposure.control cervical spine , secure airway, assist ventilation, assess circulation, follow up conscious level and exposure.

5-Which of the following is the BEST screening test for detecting traumatic aortic injury in a stable patient? (A) Chest radiograph. (B) Computed tomography aortography. (C) Trans-thoracic echocardiography. (D) Test for unequal blood pressures in the upper extremities.. RecommendationsAll Trauma patients should be assessed using the universal AcBCDE approach.Management of Poly-trauma should include primary and secondary survey.Team work is standard in management of trauma patients.Routine investigation should be implemented as a protocol for our policy in Demerdash and ASUSH.High index of suspicion should be kept for aortic trauma in any posttraumatic chest pain.

QUESTIONS?

THANK YOU