Management Of Management Of Multiply Injured Multiply Injured

PatientsPatients By:By:Dr. Zuhair Al-SamarraeDr. Zuhair Al-SamarraeFRCS, FICS, CABS, DS, FRCS, FICS, CABS, DS,

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TraumaTrauma

• Trauma claims the life of millions every year.

• Mostly it affects young age group-the productive section of society.

• Visit Trauma.org and look at the instantly changing no.of mortality due to trauma.

TIME NOW

                  TRAUMA DEATHS

SINCE MIDNIGHT

                   

TIME OF ESSENCETIME OF ESSENCE

• What are areas where time is wasted?• Trimodal death and the Golden Hour• 3 peaks of death• 1st peak-seconds to minutes after injury-due to

brain lacerations,rupture aorta….• 2nd peak minutes to hours after injury-the peak of

avoidable death-the golden Hour• 3rd peak in ICU-due to sepsis, MOD…..• WHERE DO U PUT YOUR MONEY?

Time of essenceTime of essence

• Yes exactly• It is in the Golden Hour• So again where is waste of time usuallly

occur?• 1.in the field: Scoop and run • – not stay and play• 2.in hospital: be prepared • mobilize Trauma Team

prioritizationprioritization

• Triaging according to :

• Salvagability: Donot waste time on unsalvagable cases

• Severity of injury(ABCDE): Donot waste time on <life threatening injuries

Spicy PizzaSpicy Pizza

• Ensure your safety and yor team

• Triage multiple casualities

• Prioritize (ABCDE)&manage accordingly

• Notify the hospital

• Scoop and run

Spicy pizza in hospitalSpicy pizza in hospital

• Do Primary Survey-minutes only

• What is primary survey? ABCDE

Talk to the victim:a verbal response means

a patent airway and reasonable breathing.

If no verbal reponse then

The Pizza Indian spicy&v. hot

ABCDEABCDE

•Airway and C–spine immobilization

•Breathing•Circulation•Disability•Exposure / Environment

control

ABCDEABCDE

• Open the airway: chin lift& jaw thrust

• No head tilt

• No hyperextension

• No hyperflexion

• No rotation

• But maintain on-line immobilization• May need adjuncts

airwayairway

• Oro&nasopharyngeal airway• Suction• Removal of denture ,FB…• Ambu-bag• Endotracheal intubation, LMA• Cricothyrotomy• C-spine immobilization• In short: maintain the airway

Breathing Breathing

• 4 conditions need to be recognized-treated• Tension pneumothorax• Open pneumothrax• Flial chest• Massive hemothorax• The good news is--- • u need 2 tubes&1 needle and mask• Most life-threatening thoracic injuries can be

treated by airway control, needle/chest tube insertion

Thoracic injuriesThoracic injuries

• Inspect---close an open pneumoth.

• Palpate –flial chest: may need intubation?

• Percuss& auscultate

• needle for tension pneumoth ---tube for massive hemothorax +?

• Blood & R/L solution.

• Again u need 2 tubes,needle,and mask

Circulation -SHOCKCirculation -SHOCK

• Bleeding is the predominant cause of death.• Shock recognition:• pulse, skin color , level of conciousness.• Pulse : rate. Volume and regularity.• Bp -----late

• Anatomical vs physiological derangement• These changes occur with bleeding anywhere—

do I need to know the exact anatomical source?• Not really ….early management is the same.

Hemorragic shock-managementHemorragic shock-management

• Support circulation and stop bleeding.• Support circulation: 2 wide bore cannula• 2L warmed R/L , blood• Avoid hypothermia---risk of coagulopathy.• Stop bleeding:• stop external bleeding by direct pressure• How about torniquet ?• Only in bleeding amputated limb• Splint fracture e.g pelvic fracture

TRANSIENT RESPONSE---WHY?TRANSIENT RESPONSE---WHY?

• Ongoing bleed….or may be ..???

• Other causes of shock-- obstructive shock

• Obstructive e.g tension pneumothorax & tamponade (treated by pericardiocentesis)

• Keep an eye open to other possibilities?

• Neurogenic shock: IVF + - vasopressors.

• Periodic re-evaluation esp indeterioration

D - DisabilityD - Disability

• GCS or AVPU• GCS 3-15: 3 worst, and 15 best• What can cause abnormal GCS?• Of course brain injury, but what else?• Hypotension and hypoxia.• Any deterioration of GCS is due to brain

injury----check pulse-ox & vitals 1st .• Always assume spinal injury , so immobilize

spines--- cervical collar & backboard.

E ----Exposure & Environment E ----Exposure & Environment controlcontrol

• Exposure is nessary for proper assessment, and to avoid missing injuries

• Avoid unnecessary exposure

• Warmed IVF

• Warm blankets

• Raise room temperature.

• Any relation between E & C ?

Adjuncts to primary surveyAdjuncts to primary survey

• X-ray chest & pelvis - + C-spine

• Pulse-ox

• ECG monitoring

• NGT.

• Urinary catheter.

END OF PRIMARY SURVEYEND OF PRIMARY SURVEY

• WHAT NOW?

• Consider transfer( remember time) …next…?

• Secondary survey: head- toe examination

• Re-evaluate and re-evaluate…

• Re-evaluate ….

• Re-evaluate…

summarysummary

• Time of essssssence

• Triage according to salvagability

• Prioritize according to ABCDE

• Early Recognition,Early intervention,Early transfer-scoop and run

Remember Remember

• Never forget your ABC…what is ABC?

• Almond Board of California