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

0

10

20

30

40

50

60

70

seconds 30 min 1 hours 4hours 8 hours day 5 week

Line 1

The Second Death Peak occurs within minutes to several hours after injury

Main focus of Trauma Life Support is in this peak

Referred to as the “Golden Hour”

The Third Peak of Death occurs several days - weeks after initial injury.

Causes: Sepsis, Organ Failure.

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

Reevaluation

Resuscitation

Adjuncts

Primary Survey

Adjuncts

Secondary Survey

Reevaluation

Optimize patientstatus

Transfer

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

2) Decide on critical interventions Should not take >2 minutes 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

Look, Listen & Feel.

PRIMARY SURVEY - AIRWAY

1)GENERAL INSPECTION

2)Open, clear & maintain

Gentle chin lift

Jaw thrust

Suction

Removal of foreign bodies

Oropharyngeal airway

AIRWAY PRIMARY SURVEY

Airway Obstruction

Causes:

Tongue falling back Secretions & foreign matter in the mouth

Deformity & injury to the airway (maxillofacial injuries)

Swelling & inflammation of the airway (burns , toxic substances)

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

http://www.nda.ox.ac.uk/wfsa/html/u06/u06ap03b.htm

Protection of the C-spine Assume that the C-spine is damaged in any injury above the

clavicle (neck pain, numbness, LOC, polytrauma)

Note any injury to the neck (eg. bruising, deformity, JVP,

tracheal shift, surgical emphysema)

Neck collar must be rigid & of the correct size

Sandbags or head immobiliser

Examination of the neck with manual in-line immobilization

C-spine Xray : AP & Lateral view (open mouth view)

Any injury above the clavicle

Unconscious polytrauma Neck painLocalizing signs

PROTECTION OF THE C-SPINE

PR

OTEC

TIO

N O

F T

HE C

-SP

INE

PROTECTION OF THE C-SPINE

PRIMARY SURVEY - BREATHING

CHEST EXAMINATION

Look for injuries

(bruising, abrasion or laceration wound, selt-belt sign)

Observe chest movement, rate & pattern

Management

Rescue breaths

Administration of High Flow O2

PRIMARY SURVEY - BREATHING

CHEST EXAMINATION (con’t)

Chest expansion, percussion, apex beat

Chest spring test – rib tenderness

Conscious patient – tender

Unconscious – Laxity of rib cage

AUSCULTATION

Apex site

Air entry

Quality of heart sound - muffled

PRIMARY SURVEY - BREATHINGLIFE 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

Physical examination CXR 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 dressingInsert chest tubeDefinitive surgical repair

Apply occlusive dressing to open wounds

Apply occlusive dressing to open 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 Air enters pleural space – then No exit

Collapse of affected lung

Impaired venous return

Impaired ventilation of unaffected lung

Causes

Chest wall or parenchyma injury

Positive pressure ventilation

Tension Pneumothorax Each time we inhale,the lung collapses further. There

is no place for the air toescape..

Each time we inhale,the lung collapses further. There

is no place for the air toescape..

The mediastinum ispushed to

the unaffected side

TENSION PNEUMOTHORAX One-way valve mechanism

Air trapped in pleural space, Lung collapse

Increase intra-pleural pressure

Mediastinal shift

Needle decompression Followed by chest tube

TENSION PNEUMOTHORAX SIGNS

1. Tracheal Deviation

2. Respiratory Distress

• Absence of breath sounds - Unilateral

• Distended Neck Veins

• Cyanosis – Late

DIAGNOSIS - Clinically, NOT Radiological

MANAGEMENT

• Needle Thoracocentesis

• Chest Tube Insertion

NEEDLE THORACOCENTESIS

2nd Intercostal space

Mid Clavicular Line

Needle Decompression

MASSIVE HAEMOTHORAX More 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.

penetrating injuries that disrupt the systemic /pulmonary vasculature.

Signs:

1. Dyspnoea

2. Hypoxia

3. Flat / distended neck veins

4. Dullness and absence of breath sounds

Fluid/blood transfusion Chest tube insertion Auto- transfusion Massive heamothorax – thoracotomy

FLAIL CHEST When a segment of chest wall does not have bony continuity with the rest of the thoracic cage (e.g. multiple rib fractures)

EFFECT

Severe disruption of normal chest wall movement. ‘paradoxical motion’ Severe lung/pulmonary contusion which lead to

hypoxia

FLAIL CHEST

MANAGEMENT

Adequate ventilation & Oxygen

Volume restoration

Analgesia

CARDIAC TAMPONADE COMMON CAUSES

Penetrating OR Blunt injury

CHARACTERISTIC

• BECK’S TRIAD

- Elevated JVP

- Muffled Heart Sounds

- hypotension

Narrowed Pulse Pressure

PERICARDIAL TAMPONADE

Blood enters pericardial

space

Reduced expansion of

ventricle

Inadequate filling of

ventricle

Cardiac output reduced

CARDIAC TAMPONADE DIAGNOSTIC 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

MANAGEMENT

- PERICARDIOCENTESIS

- OPEN THORACOTOMY

CARDIAC TAMPONADE

Primary survey

Airway Breathing

ATOM CF

CIRCULATION

PRIMARY SURVEY (CONT’D)

CIRCULATION GENERAL 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

ClassI

ClassII

ClassIII

ClassIV

Blood Loss:% Circulating volume <15 15-30 30-40 >40

Blood Loss:Volume (mls in adults) <750 750-1500 1500-2000 >2000

Pulse Normal 100-120 bpm

120 bpm Weak

>120 bpm Very weak

Blood Pressure:Systolic Normal Normal Low Very Low

Blood Pressure:Diastolic Normal High Low Very Low

Capillary Refill Normal Slow Slow Absent

Mental State Alert Anxious Confused Lethargic

Respiratory Rate Normal Normal Tachy-pnoeic

Tachy-pnoeic

Urine Output >30 mls/hr

20-30 mls/hr 5-20 mls/hr <5 mls/hr

1° survey : CIRCULATION Pulse – rate & character. Blood pressure Inspect, palpate & auscultate abdomen Pelvic spring, perineum, limbs

Stop external bleeding by direct compression, elevation, pressure point

2 large bore IV cannulae – give fluids/blood

Pelvic Xray DPL 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

Brief examination carried out to ascertain the state of consciousness.

A - Alert

V - Response to Verbal command

P - Response to Pain

U - Unresponsive

* 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

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

PHYSICAL EXAMINATION- Head & Neck- Chest- Abdomen- Muscular-skeletal- Neurological

Secondary Survey

Detailed assessment from head to toe – to detect HIDDEN life threatening causes

Examine all orifices – ENT, PR, vagina, perineum

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

P - Pulmonary contusion A - Aortic dissection T - Tracheo-broncho fistula

M - Myocardial contusion E - Esophageal perforation 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 triadAvoid - 1) Hypothermia (core temp < 35° C)2) Acidosis3) Coagulopathy

Temperature measurement & controlAdequate warm fluids & blood products, blanketABG, PT/APTTDo 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