POLYTRAUMA

ObjectivesPrioritize and initiate assessment of the traumatized patientInitiate treatment of life-threatening traumatic injuryUtilize radiography in identifying significant traumatic injuryIdentify and respond to changes in status of the injured patientIdentify patients requiring transfer to a higher level of care

POLYTRAUMA

Defined as a clinical state following injury to the body leading to profound physiometabolic changes involving multisystem. ORPatient with anyone of the following combination of injuries

TWO MAJOR SYSTEM INJURY + ONE MAJOR LIMB INJURY.ONE MAJOR SYSTEM INJURY + TWO MAJOR LIMB INJURY.ONE MAJOR SYSTEM INJURY + ONE OPEN GRADE III SKELETAL INJURY.UNSTABLE PELVIS FRACTURE WITH ASSOCIATED VISCERAL INJURY.

Polytrauma is not synonym of multiple fractures.

Multiple fractures are purely orthopaedic problem as there is involvement of skeletal system alone.

StatisticsTrimodal death distribution

First peak instantly (brain, heart, large vessel injury)Second peak minutes to hours (golden hour)3rd peak weeks later of late complications and organ failure

If preventive measures are taken 70% deaths can be prevented, means 30% deaths are nonsalvagable deaths

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.

Platinum 10 minutes : Only 10 minutes of the Golden Hour may be used for on-scene activities

ATLS TREAT LETHAL INJURY FIRST, THEN REASSESS AND TREAT AGAIN

TRIAGE

Triage is the sorting of patients based on the need for treatment and the available resources to provide that treatment

Trauma Team

Case Study 1Unrestrained man ejected after his car collided with a large truckIncoherent and unable to clear secretionsFemur fracture, scalp laceration, chest and abdominal contusionsBP 90/60 mm Hg, HR 125/min, RR 35/minLethargic with cool, clammy skin

What does the primary survey indicate?

*Trauma ManagementPrimary assessmentInitial evaluation and resuscitationSecondary assessmentDiagnosis and treatment of other injuriesTertiary assessmentOngoing evaluation

*Primary AssessmentAirway maintenance with cervical spine precautionsBreathing: oxygenation and ventilation Circulation with hemorrhage control Disability: brief neurologic examination Exposure/environment: undress, avoid hypothermia

*Copyright 2012 Society of Critical Care Medicine Case Study 1Incoherent, unable to clear secretionsFemur fracture, scalp laceration, chest and abdominal contusionsBP 90/60 mm Hg, HR 125/min, RR 35/minNo eye opening to stimuli, lethargic, all extremities withdrawn to painCool, clammy skin

What does the primary survey indicate? What interventions are most important?

*Airway and Breathing IssuesEstablish airway patencyAirway control: intubation, adjunctive device, surgical airwayOxygenation and ventilationCervical spine stabilization

Airway InterventionsSupplemental oxygenSuction Chin lift/jaw thrust Oral/nasal airwaysDefinitive airwaysRSI for agitated patients with c-spine immobilizationETT for comatose patients (GCS

Flail Chest

Subcutaneous Emphysema

What would we do for this patient who is having difficulty breathing?

*Case Study 1Incoherent, unable to clear secretionsFemur fracture, scalp laceration, chest and abdominal contusionsBP 90/60 mm Hg, HR 125/min, RR 35/minNo eye opening to stimuli, lethargic, all extremities withdrawn to painCool, clammy skin

Is this patient in shock? What interventions are indicated?

*Shock in TraumaHemorrhagicChestAbdomenPelvisFemurNonhemorrhagicObstructive: tension pneumothorax, cardiac tamponadeNeurogenic: spinal cord injuryCardiac: blunt injury

C- CirculationHemorrhagic shock should be assumed in any hypotensive trauma patient Rapid assessment of hemodynamic statusLevel of consciousnessSkin colorPulses in four extremitiesBlood pressure and pulse pressure(narrow)

Haemorrhage

* Hemorrhage ClassificationBP 90/60 mm Hg, HR 125/min, RR 35/min

VariableClass IClass IIClass IIIClass IVSystolic BPNNHR, beats/min100>120>140RR, breaths/min14-2020-3030-40>35Mental statusanxiousagitatedconfusedlethargicBlood loss (mL)2,000Blood loss (%)40

Resuscitation

fluidOral or crystalloidCrystalloidCrystalloid and

bloodBlood and crystalloid

*Circulation IssuesLarge bore peripheral IV cannulas (2) or IO 2 L warmed lactated Ringer solution (>50 mL/kg)External hemorrhage controlDiagnostic studies for hemorrhage sourceRed blood cell transfusionTransfusion of other blood productsMonitoring

Pelvic Binders

*Case Study 1Incoherent, unable to clear secretionsFemur fracture, scalp laceration, chest and abdominal contusionsBP 90/60 mm Hg, HR 125/min, RR 35/minNo eye opening to stimuli, lethargic, all extremities withdrawn to painCool, clammy skin

How would you assess disability? What adverse effects occur from exposure?

**Glasgow Coma ScaleGCS = 7

ScoreEye Opening Best VerbalBest Motor1No ResponseNo Response No Response2To PainIncomprehen-sible Extensor3To SpeechInappropriate Flexor4SpontaneousDisoriented Withdraws to Pain 5Oriented Localizes Pain6Obeys Command

Always Inspect the Back and Perineum

Extradural Hematoma(EDH)

What disease process does this indicate?

*Case Study 1Patient is intubated and mechanically ventilated with 100% O2Coarse rhonchi bilaterally2 L lactated Ringer solution administered BP 104/78 mm Hg, HR 110/min, RR 18/min, SpO2 95%What are the next steps in assessment? Which laboratory and radiologic tests should be obtained?

*Secondary Assessment Detailed historyHead-to-toe physical examinationLaboratory studies Radiologic studiesOther interventions FASTDiagnostic peritoneal lavageNaso- or orogastric tubeAntibioticsTetanus status

*Case Study 2Man with liver and mesenteric lacerations from vehicular accidentBowel resected and abdomen packed to control bleeding Fluid resuscitation continuesAirway pressures and urine output after ICU admissionWhat are possible causes of airwaypressures and urine output?

*Tertiary Assessment Head injuryPulmonary injuryCardiac injuryAbdominal injuryMusculoskeletal injuryAdequacy of resuscitationTransfer

Golden Rules of TraumaAll trauma patients need oxygen until proven otherwise.

All trauma patients are bleeding until proven otherwise.

All trauma patients have a cervical spine injury until proven otherwise.

All unconscious/altered LOC trauma patients have a brain injury until proven otherwise.

ConclusionReadiness, hyper-vigilance, consistent organization and clear cut communication produces effective outcomesWe should all know our A, B, C, DsPractice makes perfect

The success of a trauma resuscitation is only as good as its team ANDA proficient trauma team cannot function without a well-skilled trauma nurse!

First comes first