Akif Poly Trauma

7/31/2019 Akif Poly Trauma

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Initial Assessment andManagement of the Multiply

Injured Patient

Dr Akif Durrani



PRE HOSPITAL TRAUMA C ARE SYSTEM

Basic life support (BLS) system

Non invasive supportive care to trauma patients by

emergency medical technicians

Transport trauma patients rapidly to a medical carefacility

Paramedic Performed Advanced Trauma Life

Support (PARAALS) system

Perform invasive procedures such as intubationand intravenous fluid therapy, administer drugs

Physician Performed Advanced Life

Support(PHYSALS) systems



TRAUMA MORTALITY

• Early phase - immediate death severe brain injury, disruption of great vessels,

cardiac disruption

•

Second phase - minutes to hours subdural, epidural hematomas,

hemopneumothoraces, severe abdominalinjuries, multiple extremity injuries (bleeding)

• Third phase - delayed multisystem organ failure

sepsis





POLYTRAUMA P ATIENT

• Injury Severity Score >18

• Hemodynamic instability

• Coagulopathy

• Closed head injury

• Pulmonary injury

• Abdominal injury



INJURY SEVERITY SCORE

Def.: scale of anatomic injury

ISS is the sum of the squares of the three highest AIS categories

AIS (Abbreviated Injury Scale) – looks at six

categories: head and neck, face, chest, abdominal,extremities, and external (soft-tissue) injury

Maximum ISS is 75



PRINCIPLES OF RESUSCITATION

ATLS

• Phases of management

Primary Survey

Resuscitation

Secondary Survey

Definitive care

• Priorities in treatment

Airway

Breathing

Circulation/CNS

Digestive system

Excretory Tracts

Fractures



AIRWAY

• Establish and maintain an appropriate airway

obtain patency-jaw lift

oral or nasal airway

surgical airway

• Control of the cervical spine

• Lateral C-spine radiograph

not included in the initial radiographic evaluation in the revised

ATLS protocol



BREATHING

• Assess breathing and oxygenation

• Evaluation with Arterial Blood Gas (ABG)

• Etiology of decreased oxygenation has to

be determined Tension pneumothorax-decompress

Open pneumothorax-seal and chest tube

Flail chest, pulmonary contusion-chest tube

• Mechanical assistance with ventilation maybe required



INDICATIONS FOR INTUBATION

• Control of airway

• Prevent aspiration in unconscious patient

• Hyperventilation for increased intracranial pressure

• Combative Patient

• Obstruction from facial trauma and edema

• Prophylactic Intubation for impending indicationsabove



CIRCULATION

• Identifiable bleeding controlled with direct pressure

• Always try direct pressure first

• Avoid blind use of vascular clamps

• Tourniquets are rarely indicated except for traumatic amputations or when direct pressure will

not control hemorrhage



ASSESSMENT OF BLOOD PRESSURE

PERIPHERAL PERFUSION

Peripheral Pulse

radial

femoralcarotid

capillary refill > 2 secs

Systolic Blood Pressure

80 mm Hg

70 mm Hg60 mm Hg

Hypotensive



RESUSCITATION

• Two peripheral largebore IVs• BOLUS two liters of Ringers Lactate

If no response then

severe hemorrhage hasoccurred

immediate blood isneeded

• Monitor

Blood pressure Urinary output

Base deficit

InitialHematocrit/Hemoglobin -unreliable



TYPES OF SHOCK

• Hemorrhagic (hypovolemic)

• Cardiogenic-(e.g. pericardial tamponade)

• Neurogenic, spinal cord injury

hypotension without tachycardia Vasoconstrictive meds not administered until volume is

restored

• Septic-late sequela



BLOOD TRANSFUSION

• Crossed Matched

1 hour

• Type Specific

10 minutes

• Type O Rh neg

immediately

• Blood warmer-preventshypothermia, arrhythmias

• Blood filters-160 u macropore

• Coagulation status-Plateletsmonitored every 10 units

Platelets < 100,000-replace

If continued hemorrhage-replace

• Labile factors (fibrinogen)-

replace with FFP



M ANAGEMENT OF SHOCK

SUMMARY

• Direct control of bleeding sources

• Large bore IV access-Fluid replacement

• Monitor-urine output, CVP, pH, lactate level

• Blood replacement-indicated by clinical response



SECONDARY SURVEY

• Head

skull trauma

reevaluate pupillary size and reaction

blood/fluid at tympanic membranes and nares

facial and ethmoid fractures

• Cervical spine

swelling, crepitus, expanding hematoma



NEUROLOGICAL EXAM

• Glascow Coma

Score-GCS• Pupil exam-

intracranial pressure

• Motor and Sensory -

all extremities in alert

patient





SECONDARY SURVEY

• Rectal exam

tone, sensory, prostate injury if abnormal (i.e. high-riding prostate), do not pass foley-

consult Urology

• Extremity exam

palpate for crepitus, swelling, pain, instability, range of motion

• Neurological exam-document all findings



TRAUMA SEVERITY SCORES

• Physiologic Trauma Index-Kirkpatrick

and Youman

Glascow Coma Scale

• Anatomic Damage Abbreviated Injury Scale

(AIS)

Injury Severity Score(ISS)

• Biochemical Indices



EXPECTED BLOOD LOSSES

Pelvis/acetabulum - 8-10 units

Closed Femur - 2-3 units Closed Tibia - 1-2 units

Open fractures will bleed more!



ORTHOPAEDIC EMERGENCIES

• Open fractures

• Dislocations

• Compartment syndromes

• Cauda equina syndrome• Extremities with neurological or vascular compromise



ORTHOPAEDIC PRIORITIES

• Reduce and stabilize dislocations

• Fasciotomies in compromised limbs

• Proper debridement and irrigation

of open injuries

• Stabilization of long bone injuries• Secure fixation of intra-articular

fractures

• Proper splinting of other injuries



INDICATIONS FOR DAMAGE CONTROL SURGERY

Physiological Criteria

HYPOTHERMIA

COAGULOPATHY

ACIDOSIS

(LETHAL TRIAD)



P ATIENT STABILITY

• Adequacy of resuscitation Vital signs of resuscitation deceptive

Laboratory parameters—base deficit, lactic acidosis

• Anesthesia-agents-myocardial depressants

• Coagulopathy-dilution, DIC, thrombocytopenia

• As long as hemodynamic stability is maintained,there is no evidence that duration of the procedurealone results in pulmonary or other organ

dysfunction or worsens the prognosis of the patient• Must be ready to change plan as the patient status

dictates



DECISION M AKING

• General surgery, Anesthesia, Orthopaedics• Magnitude of the procedure can be tailored

to the patient’s condition • Timing and extent of operative intervention

based on physiologic criteria• “Too sick for an operation” not acceptable

given current knowledge

• May require damage control surgery as a temporizing and stabilizing measure



REASONABLE APPROACH

• Timing (when?)

• Titration (how much?)

• Temporization

(when necessary)

• Temptations (avoid)



INCOMPLETE RESUSCITATION

• Based on physiological assessment

• ICU - monitoring, resuscitation, rewarming,

correction of coagulopathy and base deficit

• Once patient is warm and oxygen delivery is

normalized reconsider further operative procedures



UNILATERAL FRACTURE PATTERNS

Careful immobilization of diaphyseal fractures is

first phase of fracture management

Periarticular fractures of large joints and open

reduction and internal fixation is not possible then

trans articular external fixation



BILATERAL FRACTURES

Incase of bilateral fractures simultaneous treatment

is ideal

Evaluation of injury severity with more severe

injuries being stabilized first

If patient vital sign deteriorate then second leg may

be temporarily stabilized



UPPER EXTREMITY INJURY

Secondary to the treatment of head ,trunk ,lower

extremity injuries.

Further imaging is done

Definitve treatment is carried out after stabilization

of patient.



LOWER EXTREMITY INJURY

Long bone fractures with severe head injury or

chest trauma require specially modified strategy

Expanded monitoring of respiratory function,

ventilation, circulatory hemodynamics is essential



PELVIC INJURIES



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Akif Poly Trauma

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