Approach to polytraumatized patient

1. POLYTRAUMA
By:
Dr. Mohammed Abdel Ghany Ismail
MD plastic and reconstructive surgery

2. Definition
• Injury to 2 or more organ systems leading
to a life threatening condition

3. World wide No.1 cause of death amongst the
younger age group (18-44 yrs).
Third most common cause of death in all age
group(cancer and atherosclerotic disease)

4. POLYTRAUMA / MULTIPLE
FRACTURES
Multiple fractures are purely orthopaedic problem
Polytrauma involvement of more than one system,
head/spinal injury, chest injury, abdominal or pelvic
injury.

5. Trauma related Death
Immediate: within minutes
1. Severe head injury
2. Brain stem injury
3. High cord injury
4. Heart and major vessel injury
5. Massive blood loss

6. Second peak of death / Early trauma
death
1. Intracranial bleed
2. Chest injury
3. Abdominal bleeding
4. Pelvic bleeding
5. Multiple limb injury

7. Third peak of death / Late death
• It occurs after several days or weeks due
– Sepsis
– Organ failure

8. Trauma Goals
1. Save a life
2. Save a limb
3. Save a joint
4. Restore function

9. Trauma System
Recently, many protocols were introduced for
management of multi injured patients including :
 ATLS → Advanced Trauma Life Support.
followed by:
 ATNC → Advanced Trauma Nursing Course.
and more recently:
 PHTLS → Pre-Hospital Trauma Life Support.

10. Advanced Trauma Life Support
(A.T.L.S.)
• In 1970s, James Styner (American orthopedic
surgeon)
an air crash
• the wife :death
• three children :serious injuries
A trauma management program
adopted by The American College of Surgeons and
developed the Advanced Trauma Life Support (ATLS)
protocol or EMST (Early Management of Severe Trauma)
as known in the UK.

11. Advanced Trauma Life Support (ATLS)
• Treat the lethal injuries first, then re-assess and
treat again
Primary Survey
identify what is fatal
and treat it.
Secondary Survey
proceed to discover all
other injuries.
Definitive Care
develop a definitive
management plan.

12. PRE-HOSPITAL PHASE
basic technician skills
1) Maintenance of Airway ( endotracheal intubation)
2) Cardiopulmonary resuscitation
3) Fluid replacement with isotonic solution
4) Reduction and splint of fractures
5) Perform primary survey of patient and report
findings to destination center

13. TRIAGE
• Triage is the sorting of patients based on the need
for treatment and the available resources to provide
that treatment
• Ideally must be followed right from the site of the
Accident

14. Triage
sift and sort
Sift
1. Identify those most severely injured.
then
2) identify and remove:
o the dead
o the slightly injured
o the uninjured

15. Triage
sift and sort
Sort
Categorize the most severely injured:
1. Serious wounds: resuscitation and immediate
action
2. Second priority: need surgery but can wait
3. Superficial wounds: ambulatory management
4. Severe wounds: supportive treatment

16. Category I: Resuscitation and
immediate action
• Patients who need urgent surgery – life-saving –
and have a good chance of recovery.
(E.g. Airway, Breathing, Circulation: tracheostomy,
haemothorax, haemorrhage abdominal injuries,
peripheral blood vessels)

17. Category II: Need surgery but can
wait
Patients who require surgery but not on an urgent basis.
A large number of patients will fall into this group:
1. non-haemorrhaging abdominal injuries
2. wounds of limbs with fractures
3. major soft tissue wounds
4. head wounds GCS > 8

18. Category III: Superficial wounds
(no surgery, ambulatory treatment)
Patients with wounds requiring little or no surgery.
large group
superficial wounds managed under local anesthesia
in the emergency room or with simple first aid
measures.

19. Category IV: Very severe wounds
(no surgery, supportive treatment)
• severe injuries
• unlikely to survive or would have a poor quality of
survival.
• those with multiple major injuries whose
management could be considered wasteful of scarce
resources in a mass casualty situation.

20. The Golden Hour
The Golden Hour is a theory stating that the best
chance of survival occurs when a seriously
injured patient has emergency management
within ONE hour of the injury.

21. Primary Survey
A-B-C-D-E
A. Airway with cervical spine control
B. Breathing and ventilation
C. Circulation –control external bleeding
D. Dysfunction of the central nervous system
E. Exposure (undress)/Environment(temp.)
Control

22. Primary Survey
• During the primary survey life threatening conditions are
identified and management is instituted
SIMULTANEOUSLY.
•Airway obstruction
•Tension pneumothorax
•Hemothorax
•Open thoracic injury and Flail chest
•Cardiac temponade
•Massive internal or External hemorrhage

23. Airway compromise
1) disturbed conscious level .
2) maxillo-facial or cervical trauma.
3) vomiting.
4) nasal or oral bleeding.

24. Airway
Assess
If the patient is conscious airway is maintained
SIGNS OF AIRWAY OBSTRUCTION
FEELLISTENLOOK
CREPITUS.
RACHEAL
DEVIATION.
HEMATOMA.
SPEECH? How are
you
HOARSENESS.
NOISY BREATHING
GURGLE.
STRIDOR
AGITATION
RIB RETRACTION
DEFORMITY
FOREIGN BODY

25. Cervical Spine
considered unstable until proved otherwise by radiology (at
least 3 views) esp. in:
*Altered level of consciousness.
*Blunt injury above the clavicle.
*Cervical bony abnormalities or tenderness.
*Maxillofacial trauma.
Stabilization of cervical spine:
- Backboard and rigid neck collar.
- Sand bags and fore head tape.
- If a collar is not available, manual immobilization

26. Airway (intubation)
Indications of endotracheal intubation in patients with major trauma:
1.Apnea (as part of CPR).
2.Respiratory insufficiency:
• PO2 < 60 mmHg (N= 80-100 mmHg)
• PCO2 > 45 mmHg (N= 35-45 mmHg)
3.Risk of aspiration (disturbed consciousness with repeated vomiting).
4.upper airway compromise(inhalation, maxillo- facial injuries).
5.Closed head injuries. (hyperventilation)

27. Breathing
• Having a patent airway is not necessarily
associated with normal respiration.
• Abnormal respiration after trauma may be :
a. Central:
e.g. severe head trauma→ respiratory centre
depression.
b. Peripheral (chest trauma)

28. chest trauma
Immediate life threatening:
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Cardiac tamponade
Potential life threatening
• Lung and cardiac contusion
• Aortic or diaphragmatic rupture
• Tracheo-bronchial injury

29. Assessment of breathing
OthersAuscultationPalpationInspection
• Auscultation
• Percussion
• Pulse
oximeter(unr
eliable)
• ABG
• Chest X ray
• air entry at
different
lung fields
on both
sides.
• surgical
emphysema.
• tenderness.
• fracture click.
• flail
segments.
• chest wall
bulge or
retraction.
• chest
expansion.
• chest wounds.
• respiratory rate
• tracheal shift.

30. ASSESS CIRCULATION
• PULSES and blood pressure
1. Compare radial and carotid pulses:(Rapid, low amplitude
with narrow pulse pressure
indicates SHOCK).
SKIN -Color
Temperature
Moisture
BRAIN - Level of consciousness.
KIDNEYS - Urine output

31. Assess circulation (Shock signs)
A. symptoms:
• thirst sensation. • air hunger • coldness.
• Restlessness (in early post-haemorrhagic state) then weakness & fainting.
B. Signs:
• With penetrating injuries obvious blood loss.
• With blunt trauma (potential haemorrhage )
Vital signs:
1) rapid weak "thready" or absent peripheral pulse.
2) low systolic BP (↓ blood volume→ ↓ VR→ ↓COP & ↓ ABP)
3) RR: deep rapid= air hunger due to:
* hypoxia (stimulationg RC).
* acidosis.
*↓ vagal inhibition on medullary centres* catecholamines action on CNS.
4) Temp: subnormal

32. Shock
• Systemic signs of shock:
• oliguria: (< 0.5-1 ml/kg/hour) due to:
- ↓ Renal Blood Flow
- ↑ ADH release.
• skin ( of extremities):
pale (skin capillary VC).
cold (skin arteriolar VC).
clammy (sweat secretion).
cyanosis is LATE( stagnant capillary circulation)
• Peripheral veins (esp neck): collapsed low CVP

33. CAUSES OF MAJOR BLEEDING(THE BIG FIVE)
TreatmentDiagnosisSource
Local pressurevisualEXTERNAL
Intercostal tubePrimary survey
and CXR
THORACIC
Conservative -surgicalpelvis X-rayPELVIC
Traction-fixation-splintclinical
examination. X-ray
LONG
BONES
Surgical laparotomyclinical
findings/exclusion
of
other/USG/CT/DPL
ABDOMEN

34. TREAT
A-Treat the cause (e.g. control haemorrhage): actively bleeding patients
 any delay in interference to control haemorrhage increases mortality
 a goal of systolic BP of 80 to 90 mmHg may be adequate
 profound haemodilution avoided(early transfusion of PRBCs).
• They cannot be resuscitated until control of ongoing haemorrhage by:
1- Stopping external haemorrhage (Position, Pressure, Packing).
2- Stopping internal "intracavitary" haemorrhage

35. TREAT
B- replacement of losses:
1- Insert 2 wide-bore I.V. lines.:
• short, wide-bore catheters allow rapid infusion of fluids.
•central venous catheters : high a resistance to allow rapid infusion+ monitoring
2- Insert Foley's urinary catheter.
3- Severe haemorrhage : blood or blood products (oxygen carrying
capacity of crystalloids and colloids is ZERO .blood loss= the ideal fluid is
blood ± Fresh frozen plasma (correct coagulopathy))
4- Correct metabolic acidosis:
• I.V. fluids to↑ tissue perfusion.
• If resistant (pH ˂ 7)= give NaHCO3 0.5-1 meq/kg over 5-10 min and evaluate arterial pH to assess the need
for increasing the dose

36. Initial Fluid Therapy
• Lactated Ringer is preferred
 For adult 1-2 liters bolus
 For child 20ml/kg bolus
3 FOR 1 Rule
replace each 1 ML of blood loss with 3 ML crystalloid fluid,
thus restore plasma volume lost into the interstitial & intracellular
space

37. Disability
causes :
head injury, shock , hypoxia and intoxication
Assess : AVPU method
 Alert and responsive .
 Vocal stimulus elicits response.
 Painful stimulus is needed to elicit a response
 Unresponsive
N.B.
50% of trauma death are due to head injuries GCS

38. Signs of Severe Head Injury
1. Unequal pupils
2. Unequal motor examination
3. An open head injury with exposed tissue
4. Neurological deterioration
5. Depressed skull fracture
These are signs of severe head injury irrespective of
GCS score

39. EXPOSURE /
ENVIRONMENTAL CONTROL
1) Patient should be undressed to facilitate
examination
2) Warm environment (room temp) should be
maintained
3) Intravenous fluid should be warm.
4) Early control of hemorrhage.

40. End point of resuscitation
Stable hemodynamics
1. Stable oxygen saturation
2. Stable pulse and blood pressure
3. Lactate level below 2 mmol / L
4. No coagulation disturbance
5. Normal temp
6. Urinary output > 1ml /kg/hr
7. No requirement of inotropic support

41. Summary of the primary
survey
A. Airway
• Airway opened,
• airway obstruction treated,
• definitive airway placed A definite airway is a cuffed tube in the trachea.
B. Breathing - Breathing assessed, treat threats.
• Every multiple injured pt should received supplement oxygen.
• Breathing not an airway
(A clear distinction between an adequate airway and adequate breathing).

42. Summary of the primary
survey(cont.)
C. Circulation –
 Control bleeding by direct pressure or operative
 Minimum of two large caliber IV(16G)
 Lactated Ringer is preferred (warm)
D. Disability - Neurologic status assessed
E. Exposure/environment - Patient fully undressed
protect from hypo or hyperthermia
Consider transfer - For higher level of care if necessary.
Adjuncts - Trauma radiographs, laboratory studies, urinary or gastric catheters,
consider blood transfusion

43. Secondary Survey
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