APPROACH & MANAGEMENT OF POLYTRAUMA

Dr.K.R.Dharmendra., M.S[Gen.Surg].,D.N.B[Gen.Surg].,

AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT

OUTLINE

Concepts of trauma care Principles of trauma management ATLS Philosophy Damage control surgery Future directions

EPIDEMIOLOGY

Trauma—commonest cause of death between 1-40

By 2020, injuries—third leading cause of death

Definition of Polytrauma

2 or more body regions with SIRS

SIRS

2 out of 4 signsTachycardia >90 beats/minTachypnoea >20 breaths/minPyrexia >38 c[or hypothermia <36 c]WBC >12000/mcL or <4000/mcL

SEPSIS

SIRS with a proven infective source

MODSSevere Sepsis

CVSRSKidneyLiverCoagulation

METABOLIC RESPONSE TO TRAUMA

TWO PHASESEBB PHASE Role: conserve volume & energy

for recovery & repairFLOW PHASERole: mobilization of body

resources

EBB PHASE Lasts for 24-48 hrs Characterised by Hypovolaemia Decreased BMR Reduced cardiac output Hypothermia Lactic acidosis

FLOW PHASE Corresponds to SIRSTissue oedemaIncreased BMRIncreased cardiac outputLeucocytosis, Raised body temperatureIncreased oxygen consumptionIncreased gluconeogenesis Catabolic – 3-10 days Anabolic - weeks

METABOLIC RESPONSE TO TRAUMA

PHARMACOLOGICAL IMMUNOMODULATION

IMMUNO NUTRITION

IMMUNO SUPPRESSION

• Epidural anaesthesia• Statins• B blockers• Tranexamic acid

GRADES OF HAEMORRHAGE

REVISED TRAUMA SCORE

“WELL BEGUN IS HALF DONE”

• Initial assessment & management is critical in decreasing morbidity & mortality

• Aids recovery

THE GOLDEN HOUR

TRIMODAL DEATH DISTRIBUTION

TRIMODAL DEATH DISTRIBUTION

PRINCIPLES OF TRAUMA MANAGEMENT

• Organised team approach • Assumption of most serious injury• Treatment before diagnosis• Thorough examination• Frequent examination

TRIAGE• In French, triage

means “to sort”• Goals:• To identify the high

risk injured patients• To channelise the

transport of patients to appropriate centres

3 PHASES OF TRIAGE

• Pre hospital Triage • At the scene of trauma• On arrival at hospital

MULTIPLE CASUALTIES

• The number & severity < Facility of the center

• Priority is for life threatening injuries

MASS CASUALTIES

• The number & severity > Facility of the centre

• Priority is for best chance of survival, least expenditure

COMMUNICATION

• Co ordination between pre hospital & hospital care

• Timely preparation & mobilization of trauma team

• Hemodynamic instability is also informed

HAND OVER

• Ambulance driver to Trauma team leader verbally

MIST• Mechanism of Injury• Injuries suspected• Vital signs• Treatment en route to hospital

TRAUMA TEAM

• For better triage & care• Registrars from ED ICU

Surgery Radiology Anaesthesiology

• Theatre staff• Spokesperson

ROLES SPECIFIED• Team Leader—Registrar from ED or ICU Airway Doctor• Plans interventions & treatment in

consultation with Surgical Registrar [Traffic Controller & Information Collator]• Surgical Registrar—Circulation Doctor Procedure Doctor Secondary Survey

ATLS PHILOSOPHY

• Primary Survey & Resuscitation

• Secondary Survey

• Definitive Care

PRIMARY SURVEY

PRIMARY SURVEY• A—Airway Maintenance &

Cervical spine protection• B—Breathing & Ventilation• C--- Circulation & Haemorrhage

Control• D--- Disability: Neurological status• E--- Exposure & Environment

protection  

C-SPINE PROTECTION

   Assume a cervical spine injury in any patient with multisystem trauma, especially with an altered level of consciousness,

or a blunt or penetrating injury above the level of the clavicle

 

PHILADELPHIA COLLAR 

• 35

Airway Management

Aims• When is the airway potentially

threatened?• When is the airway compromised?• How do you treat and monitor?• What is a definitive airway?

Predisposing Conditions

• Coma• Aspiration• Maxillofacial trauma• Neck injury• Haematoma• Laryngeal injury• Thoracic inlet penetrating injury

Signs of Airway Obstruction : "Look"

• Agitation• Poor air movement• Rib retraction• Deformity• Foreign material

Signs of Airway Obstruction : "Listen"

 

• Speech? "How are you?" Hoarseness• Noisy breathing• Gurgle• Stridor

Signs of Airway Obstruction : "Feel"

 

• Fracture crepitus• Airway structures in neck• Tracheal deviation• Haematoma

AIRWAY RESUSCITATION

• Suction• Chin lift• Jaw Thrust• Oral airway• Definitive Airway

• POLY5-34

CHIN LIFT

JAW THRUST

When do you intubate the patient?

• This is the definitive airway• Brain injury with GCS <8• Severe multi system injury or

haemodynamic instability• Facial burns or inhalational injury• Inability to closely monitor during

ongoing resuscitation & investigation [ angio&CT]

• Uncooperative or combative behavior

Cricothyroidotomy

INDICATIONS• Trauma causing oral, pharyngeal

or nasal haemorrhage • Foreign body obstruction• Maxillo facial injuries

Technical considerations

• No surgical Cricothyroidotomy below 12 years

• A permanent tracheostomy within 24 hrs

• More than 2 days—higher risk of glottic stenosis

NEEDLE CRICOTHYROIDOTOMY

COMPLICATIONS

EARLY • Bleeding• False passage• Subcutaneous emphysema• Oesophageal perforation• Vocal cord injury

LATE

• Infection

• Glottic & Subglottic stenosis

• Tracheo oesophageal fistula

BREATHING & VENTILATION

Abnormal Breathing : Look• Cyanosis• Decline in mental state• Chest asymmetry• Tachypnoea• Distended neck veins• Paralysis• Chest wounds• Flial segment

Abnormal Breathing : Listen

• I can't breathe!

• Stridor, wheezing

• Decreased breath sounds

Abnormal Breathing : Feel

• Surgical emphysema

• Chest tenderness

• Trachea deviated

• Percussion & Auscultation

DEADLY DOZEN THREATS FROM CHEST INJURY

Immediately Life Threatening• Airway Obstruction• Tension Pneumothorax• Pericardial Tamponade • Open Pneumothorax

• Massive haemothorax

• Flial Chest

Potentially Life Threatening

• Aortic Injuries• Tracheo bronchial Injuries• Myocardial Contusion• Rupture of Diaphragm• Oesophageal injuries• Pulmonary Contusion

SEALING OF OPEN WOUND

Tension Pneumothorax

• Not a radiological diagnosis; only

clinical

• Put a needle in 2nd ICS in MCL

• Later ICD at 5th ICS in mid axillary

line

TENSION PNEUMOTHORAX

HAEMOTHORAX

• ICD INDICATIONS OF THORACOTOMY

• Initial 1500 ml• 200 ml for 3 consecutive hours

FLIAL CHEST• Rib fractured at 2

different places• Paradoxical chest

movements• Underlying lung

contusion• Positive pressure

ventilation• Rarely surgical

fixation is necessary

CIRCULATION & HAEMORRHAGE CONTROL

• Surgical Registrar & procedure nurse apply pressure bandage to open wounds

Signs:• Deteriorating conscious level• Pallor• Rapid , thready pulse

Is the heart beating?

• Is there serious external bleeding?

• Does patient have radial pulse?• Absent radial = systolic BP < 80• Does patient have carotid pulse?• Absent carotid = systolic BP < 60

Is patient perfusing?• Cool, pale, moist skin• Capillary refill > 2 sec• Restlessness, anxiety,

combativeness If internal hemorrhage, quickly

expose, palpate abdomen, pelvis, thighs

THE STRATEGY

• Primary Haemorrhage Control and timely surgical intervention rather than Overaggressive Fluid Resuscitation

[ Permissive Hypotension ]

THE PROCEDURES

• IV access by procedure doctor• 2 wide bore cannula - 14 G or 16 G• Scalp bleeding—running locked

sutures• Open fractures—direct pressure,

reduction& splinting• No blind clamping of vessels• Angiography & embolisation

CAUSES OF MAJOR BLEEDING MAJOR BLEEDING -THE BIG FIVE

•  EXTERNAL• THORACIC• PELVIC• LONG BONES• ABDOMEN

FLUID THERAPY

• Crystalloid fluid is preferred• Class 3 &4 shock—colloid

fluid advised• Bolus of 1 litre of RL given

3 RESPONDERS

• Rapid Response Be careful, these patients may still

require surgery and may become "unstable" again!

• Transient Response Stop the bleeding!• Minimal Response Remember the "Big 5"! Go to the operating theatre!

Investigations for tissue perfusion

Transfusion Guidelines

Transfusion Guidelines

• HCT < 21• Lesser HB trigger in

Asymptomatic patients• Higher HB trigger in severe CV

diseases

Why RL is preferred over NS

• RL gives a hypercoagulable state• NS causes hyperchloremic acidosis• Significant difference in HCT• NS decreases FVIIa & FVIIa- Tissue Factor

Complex• But in Head injury, RL may cause cerebral

oedema• In patients taking metformin, chance of

metabolic alkalosis is there if you use RL

METABOLIC ACIDOSIS

• Decreases Cardiac contractility• Decreases effectiveness of circulating

catecholamines• Inhibits propagation phase of

thrombin generation• Accelerates Fibrinogen degradation• Hyperchloremia causes renal

vasoconstriction- decrease in GFR

DISABILITY & NEUROLOGICAL EXAMINATION

• Level of Consciousness = Best brain perfusion sign

• Use AVPU initially• Check pupils• Eyes are the window of the CNS

Brief Neurologic Examination

• A–Alert• V –Responds to Vocal stimuli• P–Responds to Painful stimuli• U–Unresponsive      More detailed evaluation -during the Secondary Survey

Decreased LOC

• Brain injury• Hypoxia• Hypoglycemia• Shock• Never think drugs, alcohol, or

personality first

GCSEYE OPENINGEYE OPENING VERBALVERBAL MOTORMOTOR

Spontaneous 4Spontaneous 4 Oriented 5Oriented 5 Obeys 6 Obeys 6

Verbal 3Verbal 3 Confused 4Confused 4 Localises 5Localises 5

Pain 2Pain 2 Words 3Words 3 Withdraws 4Withdraws 4

None 1None 1 Sounds 2Sounds 2 Decorticate 3Decorticate 3

None 1None 1 Decerebrate 2Decerebrate 2

None 1None 1

DISABILITY INTERVENTIONS• Spinal cord injury

–High dose steroids if within 8 hours• ICPmonitor-Neurosurgical consultation• Elevated ICP

–Head of bed elevated–Mannitol–Hyperventilation–Emergent decompression

Exposure&Environmental protection

• Complete disrobing of patient

• Logroll to inspect back

• Rectal temperature

• Warm blankets/external warming

device to prevent hypothermia

Always Inspect the Back

PAUSE & CHECK

• Are all immediately life-threatening injuries identified?

• Is all monitoring in place?• Investigations ordered?• Analgesia?• Relatives informed?• Non-essential team 

members disbanded?

The well practiced trauma team should aim to complete the primary survey in less than 10 minutes

Adjuncts to Primary Survey

• ECG monitoring

• Urinary and Gastric Catheters

• Monitoring

• X-rays and Diagnostics Studies

Monitoring1. Ventilatory rate and ABG• Monitor the adequacy of respiration• Confirm the ETT location 2. Pulse oximetry Measure of oxygen saturation of Hb• Should not be placed distal to the

blood pressure cuff 3. Blood pressure

X-rays and Diagnostics Studies

• Chest x-ray AP• Pelvis AP• Lateral C-spine• DPL or FAST• Films can be taken in resuscitation area, usually with portable x-ray

• Should not interrupt the resuscitation process

INDICATIONS FOR ICU ADMISSION

Requirement for:• Airway protection and mechanical

ventilation• Cardiovascular resuscitation• Severe head injury• Organ support• Correct coagulopathy• Invasive monitoring

SECONDARY

SURVEY

SECONDARY SURVEY

• Does not begin until the primary

survey (ABCDEs) is completed

• Complete history

• Head-to-toe evaluation

• Reassessment of all vital signs

HISTORYA - AllergyM- current Medication P- Past illness and operationL- Last mealE- Event and Environment related to the injury

A Complete “Head to Toe’ examination

• HEENT: scalp, eyes, ears, face, throat • Neck: distended neck veins, trachea midline, posterior

midline deformity • Chest wall: flail segment, breath sounds• Abdomen: scaphoid or distended, tender• Pelvis: stable or unstable• Genitourinary: blood, bruising• Rectal: tone, blood• Back: spinal deformity, exit wounds• Extremities: deformity, pulses• Neurologic: GCS,feels all four/moves all four

LOG ROLLING• 4 Persons required• 1 - Spinal inline traction

[anaesthesiologist]• 2 -Torso• 3- Pelvis & Lower limb• 4- Detailed examination of back

EXAMINATION OF BACK• Examine entire spine• Any penetrating injury or exit

wound• Appropriate Dressing• Palpation of posterior chest

wall• Percussion & Auscultation of

post.chest

SECONDARY SURVEY

‘Tubes and fingers in every orifice’

Adjuncts to the Secondary Survey

• Further investigation for specific injuries after stabilising the patient

• x-ray spine and extremities• CT scan• contrast urography and angiography• Transesophageal ultrasound• Bronchoscopy• Esophagoscopy

RE-EVALUATION• Continuous monitoring of vital signs, Hct• urinary output: adult keep > 0.5 mL/kg/hr children keep > 1 mL/kg/hr• Arterial blood gas• Cardiac monitoring• Pulse oximetry• End tidal CO2• Relief of severe pain and anxiety IV opiates and anxiolytics

DPL

INDICATIONS FOR DPL

• Equivocal abdominal sign

• Unexplained hypotension

• Impaired mental status

• Paraplegia or spinal cord

injuries

CONTRAINDICATIONS FOR DPL

Absolute contraindication• existing indication for explore

laparotomyRelative contraindications• Previous abdominal operation• Morbid obesity• Advance cirrhosis• Coagulopathy

CRITERIA FOR POSITIVE DPL

> 10 ml of gross blood in blunt trauma • RBC count >100,000 /mm3 for blunt

trauma• RBC count >10,000/mm3 for

penetrating trauma• WBC count > 500/mm3• Amylase > 200u/ml• Smear show bacteria or enteric content

DPL

DPLAdvantages• Fast• Sensitive• Can be performed while resuscitation

ongoingDisadvantages• Invasive• Learning curve• Not Organ specific

FAST

FAST• Detect intra abdominal fluid• Rapid, noninvasive, accurate,

inexpensive, can repeat frequently• Indications same as DPL• Factors that compromise its utility

are obesity, presence of subcutaneous air, previous abdominal operation

FAST

ADVANTAGES OF FAST

• Fast

• Noninvasive

• Can be performed while

resuscitation ongoing

• Can be very sensitive

DISADVANTAGES OF FAST

• Operator dependent• Body habitus may limit

quality/sensitivity• Organ aspecific• Can’t detect Hollow viscous and retroperitoneal injuries

Trauma Management

CARRY HOME MESSAGE

• Organised Team Approach [There is no ‘I’ in TRAUMA]• Initial Assessment & Management is the key• Interferon –gamma, Epidural Anaesthesia &

Early enteral nutrition• Appropriate Triage according to resources• Communication is pivotal for better

preparation or Trauma Team

• ATLS Philosophy• Primary Survey in 10 min• C-Spine protection with

Philadelphia Collar• Needle Cricothyroidotomy – Ideal

in emergency situations where Intubation is not feasible

• Tension Pneumothorax is a clinical diagnosis; Immediate needling should be done

• Primary Operative Control of haemorrhage is preferred over Overaggressive Fluid Resuscitation – Permissive Hypotension

• No blind clamping of vessels• Angio embolisation is an important tool in

controlling haemorrhage • Fluid challenge of 1 L RL is preferred• Serum lactate level & mixed venous

saturation are the most indicators of tissue perfusion

• If HB<7 & HCT<21- Transfusion indicated

• Brief Neurological exam is enough initially• Rule out organic causes for decreased

consciousness before thinking of drugs, alcohol & personality

• Examination, Resuscitation & monitoring should go hand in hand

• Head to Foot Secondary Survey is important to find out the missed injuries; Done by Surgical Registrar

• “Tubes & Fingers in every orifice” –Theme of Secondary Survey

• DPL & FAST come in handy in equivocal abdominal signs & Unexplained Hypotension

• Damage Control Surgery is the weapon to tackle the “Triad of Death”

TRAUMA @ AHIH

• Trauma Team• Trauma Protocol• Training of Personnel• Learning of Procedures• In house/On call Consultants

July 20 1969

• “From inability to Let well alone;• from too much zeal for the new and

Contempt for what is old;• from putting knowledge before Wisdom,• science before Art,• and cleverness before Common sense,• from treating patients as cases,• and from making the cure of the disease

more grievous than the Endurance of the same,

• Good Lord, deliver us.” --Sir Robert Hutchison

A DharmendraPresentation