Management of patients with multiple trauma Prof. M K Alam MS; FRCS
ILO’s • Incidence of trauma • Causes and types of trauma • Timing and mode of death in trauma patients and its effect on trauma management. • Pre-hospital care and triage • Hospital care • Primary survey and initial management • Secondary survey • Pathophysiology of common injuries • Investigations during primary and secondary survey • A brief outline of management of major injuries.
Epidemiology • Trauma remains the most common cause of death between the ages of 1 and 44 years. • Affects a disproportionate number of young people- the burden to society in terms of lost productivity, premature death, and disability is considerable. • A major public health issue.
Arab News 16thFeb 2014 • 20 deaths daily on the Kingdom's roads. • Last year- 707 amputations due to RTA. • Accidents increased by 78% in the KSA recently • Affecting mostly young between 18 and 22 years • Around 30% of those injured are permanently disabled. • The state has spent SR21 billion treating such patients
Causes of trauma • RTA or MVA • Pedestrian trauma • Fall from height • Assault • Firearm injuries • Knife • Industrial accidents • Natural disasters • Explosions
Types of trauma • Blunt trauma results of an impact from blunt object • Penetrating trauma results from an object piercing the body • Assessment and diagnosis of blunt injuries are more difficult than of penetrating injuries • Multi-trauma- injury affecting simultaneously different organ and body system
Trimodal death in trauma • Immediate:Within seconds or minutes after injury- 50% of deaths due to injury to the aorta, heart, brainstem, or spinal cord or by acute respiratory distress. • Early:Within hours of injury- approximately 30% of deaths. Half of these deaths are caused by hemorrhage and the other half by central nervous system (CNS) injury. These patients can be saved by appropriate treatment (golden hour). • Late: peaks from days to weeks, mortality due to infection and multiple organ failure.
Improvement in mortality • Early deaths: Prevention and control program by legislation and behavior modification • Later deaths: • Trauma centers providing better care. • Better understanding of pathophysiology of multiple organ failure and brain injury
Pre-hospital care • Delivery to the hospital for definitive care as rapidly as possible- scoop and run • Only critical interventions at the scene • Airway established, hard collar, spine board, control any external hemorrhage • Infusion on way to the hospital
Triage • Definition: Prioritizing victims into categories based on their severity of injury, likelihood of survival, and urgency of care. • Goals: • Identify high-risk injured patients who would benefit from the resources available in a trauma center. • Limit the excessive transport of non-severely injured patients so that the trauma center is not overwhelmed.
Hospital care • ATLS approach • A well defined order • Primary survey- initial assessment and management • Treat the greatest threat to life • Immediate intervention as the threat to life is identified • Detailed history not essential • Re-evaluation of initial management • Secondary survey- a head to toe evaluation
Primary survey • A B C D E • Airway & cervical spine protection • Breathing • Circulation • Disability (neurologic assessment) • Exposure and Environmental control
Primary survey- a team approach • Simultaneous diagnosis and treatment by multiple providers • Reduces the time to assess and stabilize a multiple trauma patients • Team should be organized before patient arrival. • Leadership and unity of command are essential
Primary survey-one clinician Do not perform subsequent steps in the primary survey until after addressing life-threatening conditions in the earlier steps.
Airway & cervical spine • Verbal response: Salam! How are you? Airway is compromised if: • No response- unconscious , airway obstruction • Noisy breathing • Severe facial trauma • Oropharyngeal bleeding or foreign body • Patient agitated - hypoxia
Airway & Cervical spine • Adequacy of airway- completed within seconds • Open the front of the collar for airway manipulation • Maintain manual stabilization by an assistant • Oropharyngeal airway/ bag valve mask ventilation • Oxygen supplement + pulse oximetry • Rapid-sequence endotracheal intubation • Frequent reassessment for airway compromise
Difficult airway • Surgical airway when oral intubation cannot be accomplished: • Cricothyroidotomy –Surgical • Percutaneous needle technique- only temporary • Tracheostomy (laryngeal injury)
BREATHING Life threatening injuries to look for: • Tension pneumothorax • Open pneumothorax (open chest wound) • Flail chest with underlying pulmonary contusion • Massive hemothorax
BREATHING • Dyspnoea • Unilateral diminished chest expansion • Bruising/ abrasion • Distended neck vein • Trachea deviated to the opposite side • Percussion: dull - haemothorax Hyper resonant - Pneumothorax • Diminished/ absent breath sound
Tension pneumothoraxPathophysiology • Collapsed lung acts as a one-way valve • Each inhalation- additional air accumulate in the pleural space. • Normal negative intrapleural pressure becomes positive, depressing the ipsilateral hemidiaphragm, pushing the mediastinal structures into the contralateral chest • Contralateral lung is compressed, the heart is rotated about the superior and inferior vena cava, decreasing venous return and cardiac output while distending the neck veins
Tension pneumothoraxClinical features & treatment • Respiratory distress • Tracheal deviation away from the affected side • Lack of or decreased breath sounds • Distended neck veins or systemic hypotension • Subcutaneous emphysema, hyper resonance • Treatment: x-ray confirmation not required • Wide bore needle in 2ndinercost. space, mid clavicular • Chest tube in 5thintercost. space, ant. axillary line
Open pneumothorax or sucking chest woundPathophysiology • Full-thickness loss of the chest wall: free communication between the pleural space and the atmosphere. • Collapse of the lung on the injured side • If the diameter of the injury is greater than the narrowest portion of the upper airway, air will preferentially move through the injury • Impair ventilation on the contralateral side
Open pneumothoraxManagement • Complete occlusion of the injury may result in converting an open pneumothorax into a tension pneumothorax. • Initial treatment: occlusive dressing, which is taped on three sides over the wound • Dressing permits effective ventilation, while the untaped side allows accumulated air to escape from the pleura • Definitive treatment: wound closure and tube thoracostomy
Flail chest with pulmonary contusion Pathophysiology • Four or more ribs fractured in at least two locations • Paradoxical movement of free-floating segment may occasionally compromise ventilation. • More importantly, an underlying pulmonary contusion may compromise oxygenation or ventilation • Initial chest x-ray underestimates the degree of contusion. • The lesion evolve with time and fluid resuscitation.
Flail chest with pulmonary contusionManagement • Respiratory failure in these patients may not be immediate • Frequent re-evaluation is needed. • Intubation and mechanical ventilation is required
Massive hemothorax • Accumulation of >1.5L of blood • Disruption of large vessel • Flat neck vein • Dullness on percussion • No breath sound • Shock • Management:Chest tube in 5th space, fluid resuscitation. Thoracotomy if significant bleeding continues.
Circulation • Assessment of cardiovascular compromise and management • Is the patient in shock? • Any external bleeding source? • Any internal hemorrhage?
CirculationPathophysiology • Shock is secondary to hemorrhage in most trauma patients • Patient can be in shock before developing hypotension • Hypotension- a sign of decompensation (class III ) • 5 locations for major blood loss: Chest Abdomen Pelvis and retroperitoneum Multiple long bone fractures ( lower limb) External hemorrhage
Pathophysiology of blood loss • Responses are compensatory • Progressive vasoconstriction- skin, muscle, viscera • Tachycardia to preserve cardiac output • Increased peripheral resistance- catecholamines • Venous return preserved in early stage by reduced blood volume in venous system • Continued bleeding- shock develops • Inadequate tissue perfusion, metabolic acidosis
CirculationIndicators of shock in trauma patients • Tachycardia* • Agitation • Tachypnea • Sweating • Cool extremities • Weak peripheral pulse • Decreased pulse pressure • Hypotension • Oliguria
CirculationCardiogenic shock • Tension pneumothorax- most common cause, Pericardial tamponade(penetrating trauma), Myocardial contusion • Beck’s triad- hypotension, distended neck vein (raised CVP >15 cm H2O), muffled heart sound • CVP: Hemorrhagic <5 cmH2O • Dysrhythmias in contusion • Ultrasonography : helpful in diagnosis • Treatment: fluid resuscitation, pericardiocentesis
CirculationNeurogenic shock • Loss of sympathetic tone due to cord injury • Hypotension, warm well perfused limbs, diminished/absent motor function • Bradycardia • Management: IV fluid, vasopressor, corticosteroids
CirculationSeptic shock • Delayed arrival • Penetrating abdominal injuries • Early septic shock- normal circulating volume • Tachycardia • Warm skin • Systolic close to normal, • Wide pulse pressure
Circulation Initial management • External haemorrhage- compression dressing • IV access- two peripheral catheters • ECG monitoring • Blood sample- typing and lab. investigations • Initial resuscitation:1-2L of Ringer's lactate or NS • Packed red blood cells if no response • Foley’s catheter: urine output is .5 mL/kg/hour in adult
Circulation Initial management Search for any source of blood loss: • CXR, X-ray pelvis, FAST (focused abdominal sonography in trauma) • If fracture pelvis is found pneumatic antishock garment or a bed sheet wrapped around the pelvis may be applied
Evaluation of fluid resuscitation • BP and pulse rate • Urine output (0.5ml/kg/hour) • Mental status and skin color/temperature • CVP • Acid/base status