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POLYTRAUMA

POLYTRAUMA. SYED AMIR AHMAD MD Asst. Prof. in Emergency Medicine College of Medicine and Dentistry King Saud University. Objectives: Approach to Multiple Injure Patients.

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POLYTRAUMA

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  1. POLYTRAUMA SYED AMIR AHMAD MD Asst. Prof. in Emergency Medicine College of Medicine and Dentistry King Saud University

  2. Objectives: Approach to Multiple Injure Patients • Diagnose, initially manage and to knowwhen to immediately refer a patient with a condition that requires urgent specialist management. • Management as per ATLS protocol. • Knowledge about the in-line immobilization of cervical spine while managing the airway. • Function of spinal board as a transfer tool only. • Emergency orthopedic conditions that affect the patient life and its initial management; e.g. open book pelvis fracture, bilateral femur fractures, mangled extremity. • Importance of interpersonal and intrapersonal communication skills

  3. Polytrauma Multisystem trauma Terminology: • Injury = the result of harmful event that arises from the release of specific forms of energy. • “polytrauma” = Multisystem trauma = injury of two or more systems, one or the combination imperil vital signs.

  4. INTRODUCTION UK - > 18, 000 deaths annually. > 60, 000 hospital admission. > Costing 2.2 billion pounds. USA - > 120, 000 deaths annually. > 100 billion dollars.

  5. MECHANISMS OF INJURY Types of injury • Penetrating. • Non-penetrating blunt. • Blast. • Thermal. • Chemical. • Others - crush & barotrauma.

  6. TRIMODAL DISTRIBUTION OF DEATH Immediate death (50%) 0 to 1 hr Early death (30%) 1 to 3 hrs Late death ( 20%) 1 to 6 wks Golden Hour

  7. Trauma deaths First peak • Within minutes of injury • Due to major neurological or vascular injury • Medical treatment can rarely improve outcome Second peak • Occurs during the 'golden hour' • Due to intracranial haematoma, major thoracic or abdominal injury • Primary focus of intervention for the Advanced Trauma Life Support (ATLS) methodology Third peak • Occurs after days or weeks • Due to sepsis and multiple organ failure

  8. ADVANCED TRAUMA LIFE SUPPORT (ATLS) PHILOSOPHY Treat lethal injuries first Reassess Treat again/Transfer

  9. PREHOSPITAL RETRIEVAL & MANAGEMENT AIMS Access of the patient Smooth transfer APPROACHES Scoop & Run policy Stay & Play policy

  10. ATLS – COMPONENT STEPS Primary survey Identify what is killing the patient. Resuscitation Treat what is killing the patient. Secondary survey Proceed to identify other injuries. Definitive care Develop a definitive management plan.

  11. ORGANISATION OF TRAUMA CENTRES LEVEL 1 – REGIONAL TRAUMA CENTRES LEVEL 2 – COMMUNITY TRAUMA CENTRES LEVEL 3 – RURAL TRAUMA CENTRES

  12. THE TRAUMA TEAM comprised as per hospital policy for eg initially of 4 Doctors At least 1 Anaesthetist 1 Orthopaedician 1 General surgeon 5 Nurses 1 Radiographer MANAGEMENT IN HOSPITAL

  13. CAPTAIN OF THE TRAUMA TEAM Most experienced. Preferably a general surgeon. Takes all TRIAGE decisions. Should be familiar with each members’ skills. Prioritise procedures. Communicate with consultants & family members.

  14. Multiple casualties • several causalties at the same time. 1. Alarm ER services 2. Assess the scene - without puting your safety at risk. 3. Triage 'do the most for the most'

  15. Triage • Ability to walk • Airway • Respiratory rate • Pulse rate or capillary return

  16. 1. Make the area safe • protect yourself, the causalty and other road users. • Park your car safely, turn lights on, set hazard lights flashing. • Do not across a bussy motorway to reach other side • Set others to warn other comming drivers • Set up warning triangles or lights 200 metres in each direction. • Swich off ignition of any damaged vehicle. • Is anyone smoking?

  17. 2. Check all caulsalties • quick assess • no moving • apply life-saving treatment

  18. 3. Treat • in the position found • first life-threatening or potentialy serious injuries

  19. How to move unconscious casualty • do not move the casualty unless it is absolutely necessary • assume neck injury until proved otherwise • support head and neck with your hands, so he can breathe freelyApply a collar, if possible • There should be only 1 axis (head, neck, thorax)no moving to sides, no flexion, no extension. • with other 3-4 people1 support head (he is directing others), other one shoulders and chest, other one hips and abdomen, last one - legs.

  20. Skill Video Demonstations • Applying cervical collar • log rolling and spinal board • Inline Immobilization • spinal Clearance

  21. TRIAGE TRIAGE SIEVE– to separate dead & the walking from the injured TRIAGE SORT – to categorise the casualties according to local protocols. Cat 1 : critical & cannot wait. Cat 2 : urgent – can wait for 30 mins at most Cat 3 : less serious injuries. Cat 4 : expectant – survival not likely.

  22. How to triage? 1. Can the patient walk? Yes delayed No check for breathing 2. Is the patient breathing? No open the airway Are they breathing now? Yes IMMEDIATE No DEAD Yes count the rate <10 & > 30 / min – IMMEDIATE 10 – 30 /min – check circulation 3. Check the circulation Capillary refill> 2 sec-IMMEDIATE Capillary refill < 2 secs - urgent

  23. TRAUMA TEAM CALL-OUT CRITERION • Penetrating injuries • Two or more proximal bone fractures • Flail chest & pulmonary contusion • Evidence of high energy trauma - fall from > 6ft -changes in velocity of 32 kmph - 35 cm displacement of side wall of car - ejection of the patient - roll-over - death of another person in same car - blast injuries

  24. ATLS Primary survey & resuscitation follows ABCDE sequence Only radiographs permitted during this phase are - cross table lateral C- spine X-ray - AP supine chest X-ray - AP plain pelvic film FAST

  25. Assessment of the injured patient • Primary survey and resuscitation • A = Airway and cervical spine • B = Breathing • C = Circulation and haemorrhage control • D = Dysfunction of the central nervous system • E = Exposure • Adjunct to primary survey: Xrays , USG • Secondary survey • Definitive treatment • Consider Early Transfer

  26. Airway and cervical spine • Always assume that patient has cervical spine injury • If patient can talk then he is able to maintain own airway • If airway compromised initially attempt a chin lift and clear airway of foreign bodies, suction, adjuncts to open airways. • Remember to avoid causing harm NP tube, nasopharyngeal airway in base skull fracture • Give 100% Oxygen (face mask, bag valve) • Assist A&B including definitive airways (Intubate/cricothyroidotomy)

  27. ATLS- PRIMARY SURVEY A – Airway maintenance & Control of C.Spine If conscious- Ask the pt’s name If unconscious-Look for added sounds (stridor,cyanosis etc) If the pt does not respond to any questions- resuscitate.

  28. ATLS- PRIMARY SURVEYA-AIRWAY Sequence of events: chin lift Jaw thrust finger sweep suction Oropharyngeal/ orotrachial tube Cricothyroidotomy Trachiostomy

  29. ATLS- Primary SurveyB-Breathing& ventilation • Exposure • Inspection • Palpation • Movement • Auscultation The aim is to hunt out & treat the life threatening thoracic condns which include:

  30. ATLS- Primary SurveyB- Breathing & ventilation Tension pneumothorax C/F Respiratory distress Tracheal deviation Diminished breath sounds Distended neck veins needle decompression Immediate needle thoracocentesis thro’ 2nd intercostal space in mid clavicular line reqd.

  31. ATLS- Primary SurveyB- Breathing & ventilation Five life threatening thoracic conditions: • Tension Pneumothorax • Massive Pneumothorax • Open pneumothorax • Flail segment • Cardiac tamponade

  32. Breathing • If open chest wound seal with occlusive dressing • Definitive treatment for hemopneumothorax will include chest tube placement • https://chest Tube insertion

  33. ATLS- Primary SurveyB- Breathing & ventilation Suction pneumothorax: Sealing of the wound Tube thoracostomy https://youtu.be/qR3VcueqBgc Flail segment: Endotrachial intubation Mechanical ventilation

  34. ATLS- Primary SurveyB- Breathing & ventilation Cardiac tamponade(almost always seen with a penetrating wound) Beck’s triad: Hypotension distended neck veins Muffled heart sounds Pulsus paradoxus Treatment: needle pericardiocentes Thoracotomy & repair as def managemnt

  35. Circulation and haemorrhage control • Assess pulse, capillary return and state of neck veins • Identify exsanguinating haemorrhage and apply direct pressure • Place two large calibre intravenous cannulas Give intravenous fluids (crystalloid or colloid) • Attach patient to ECG monitor

  36. ATLS- Primary SurveyC-Circulation and hge control Adults- 2 lit of Ringer lact soln as initial fluid challenge Children- 20mg/kg of body wt Response to initial fluid challenge: • Immediate & sustained return of vital signs. • Transient response with later deterioration • No improvement.

  37. ATLS- Primary SurveyC-Circulation and hge control Tachycardiain a cold patient indicates shock Causes of shock following injury: • Hypovolemic • Cardiogenic • Neurogenic • Septic

  38. ATLS- Primary SurveyC-Circulation and hge control Assessment of blood loss External or obvious Internal or covert chest abdomen pelvis limbs Resuscitation Arrest bleeding Obtain vascular access

  39. ATLS- Primary SurveyC-Circulation and hge control Immediate responders-<20% blood loss Bleeding ceases spontaneously Transient responders- bleeding within body cavities Surgical intervention reqd. Non responders- >40% of blood vol lost require immediate surgery Continued IV fluids detrimental

  40. Classification of Hypovolaemic Shock and Physiologic Changes What is your fluid replacement regimen?

  41. ATLS- Primary SurveyC-Circulation and hge control Estimation of blood loss

  42. VIDEO: TESTING PELVIC STABILITY

  43. Fluid resuscitation - DEBATE Shock due to primary haemorrhage First Hit Ongoing bleeding 2O resuscitation regimen Coagulopathy Lethal Triad of Death Second Hit? Voluminous crystalloid ● dilutes coagulation factors ● causes hyperchloremic and lactate acidosis ● supplies inadequate O2 to under-perfused tissue Hypothermia Acidosis

  44. Current concepts Permissive hypotension Maintain systolic B.P. at 85 - 95 mm of Hg Turn off the tap and do not infuse too much of fluid and blood products

  45. Paradigm Shift in Resuscitation To DCR in 1990s HD Triage: Stable, Borderline, Unstable and In Extremis DAMAGE CONTROL RESUSCITATION Permissive hypotension and haemorrhage control Haemostatic resuscitation in ICU Damage Control Surgery Definitive fracture fixation after D5 C A B C D E

  46. Balanced Resuscitation 1. Fluid Replacement in Balanced Resuscitation ● Initial fluid replacement with up to 2L crystalloid Permissive hypotensionto achieve SBP to 80-90mmHg (radial pulse) until definitive control of bleeding is obtained ● Role of fluid challenge (250-500ml) tests to stratify responder, transient responder, non-responder 2. Haemostatic Resuscitation ● Early blood versus HBOC transfusion decreases MODS ● Packed RBC, FFP and Platelets in 1:1:1 ratio ● Cryoprecipitate, Tranexamic acid, Recombinant factor-VIIa ● Storage blood of < 2 weeks to minimise TRALI, MODS

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