Early management of Early management of polytraumapolytrauma
Purnendu SaxenaPurnendu Saxena
MS(Orth), DNB (Orth), MS(Orth), DNB (Orth),
D’Orth (UK), MCh Orth (UK),D’Orth (UK), MCh Orth (UK),
FRCS (Trauma and Orth)(UK)FRCS (Trauma and Orth)(UK)
Society for care in emergency Society for care in emergency
Why Why
Trauma care is need of our societyTrauma care is need of our society Mortality is highMortality is high Most of the victims are young and Most of the victims are young and
the resultant loss to the families are the resultant loss to the families are catastrophic catastrophic
Many of these deaths are Many of these deaths are preventable preventable
Society for care in emergency Society for care in emergency
Early care Early care
Requires a Requires a wider understandingwider understanding and and not a “specialist’s” approach not a “specialist’s” approach
Requires that Requires that life threatening prioritieslife threatening priorities are dealt urgentlyare dealt urgently
A A complete clinicalcomplete clinical assessment should assessment should not be neglected while priorities are not be neglected while priorities are being managed being managed
Surgical procedures are tailoredSurgical procedures are tailored as as per patient’s general condition per patient’s general condition
Society for care in emergency Society for care in emergency
Primary SurveyPrimary Survey– Identify life threatening conditions following Identify life threatening conditions following
‘ABCD’ ‘ABCD’ – Manage life threatening conditions Manage life threatening conditions – Start resuscitationStart resuscitation
Secondary survey Secondary survey – Assess everything “Head to toe” Assess everything “Head to toe”
Early definitive managementEarly definitive management– Damage control surgeries Damage control surgeries – Continued care in ICU Continued care in ICU
Final definitive management Final definitive management
Steps in trauma Steps in trauma managementmanagement
Society for care in emergency Society for care in emergency
PRIMARY SURVEYPRIMARY SURVEY
Priority is ABCDEPriority is ABCDE A- Airway and neckA- Airway and neck B- BreathingB- Breathing C- CirculationC- Circulation D- DisabilityD- Disability E- Environment controlE- Environment control This is not a formula to remember for This is not a formula to remember for
exam!exam!
Society for care in emergency Society for care in emergency
Why ABCDWhy ABCD
Your brain can work Your brain can work only if it can get only if it can get oxygenated blood oxygenated blood through circulationthrough circulation
The circulating blood is The circulating blood is useful only if it can get useful only if it can get oxygenated within oxygenated within breathing lungsbreathing lungs
A functional lung can A functional lung can be useful only if it get be useful only if it get air through a patent air through a patent airway airway
Society for care in emergency Society for care in emergency
fix the fix the AAirway first irway first fix the fix the BBreathing lungs next reathing lungs next fix the fix the CCirculation and irculation and then fix the then fix the DDisability (brain & isability (brain &
bones)bones)
Why ABCDWhy ABCD
Society for care in emergency Society for care in emergency
What is What is AAirwayirway
Society for care in emergency Society for care in emergency
What to seeWhat to see
Is there an obstructionIs there an obstruction Is there any impending obstructionIs there any impending obstruction
Society for care in emergency Society for care in emergency
Support it Support it (remember cervical spine)(remember cervical spine) Clean itClean it Assist Assist IntubateIntubate Surgical airway Surgical airway
What to doWhat to do
Society for care in emergency Society for care in emergency
Monitoring Monitoring
Put pulse oximeter Put pulse oximeter
Society for care in emergency Society for care in emergency
BreathingBreathing
Conduction of air is the function of Conduction of air is the function of AirwayAirway
Breathing is a process in which Breathing is a process in which gaseous exchange takes place gaseous exchange takes place
Breathing is the function of lungs and Breathing is the function of lungs and ribcage ribcage
Society for care in emergency Society for care in emergency
What to see and whyWhat to see and why
Trauma Clinicians Often Miss Trauma Clinicians Often Miss FracturesFractures
Tension pneumothoraxTension pneumothorax Cardiac temponadeCardiac temponade Open woundOpen wound Massive pneumothoraxMassive pneumothorax Flail chestFlail chest
Society for care in emergency Society for care in emergency
Tension pneumothoraxTension pneumothoraxUrgent decompressionUrgent decompression
Cardiac temponade Cardiac temponade Urgent decompressionUrgent decompression
Open wound Open wound Seal as a valveSeal as a valve
Massive pneumothoraxMassive pneumothoraxDrain it and put a chest tubeDrain it and put a chest tube
Flail chest Flail chest Ventilatory supportVentilatory support
What to doWhat to do
Society for care in emergency Society for care in emergency
Monitoring Monitoring
Put ECG leads Put ECG leads
Society for care in emergency Society for care in emergency
CirculationCirculation
Circulatory failure leads to reduced Circulatory failure leads to reduced tissue perfusion that is Shock tissue perfusion that is Shock
Hemorrhagic shockHemorrhagic shock -most likely-most likely Nonhemorrhagic Nonhemorrhagic
– Neurogenic shock Neurogenic shock – Septic shock Septic shock – Mechanical shock – pump failure Mechanical shock – pump failure
Society for care in emergency Society for care in emergency
What to seeWhat to see
PulsePulse Skin colour and temperature Skin colour and temperature Blood pressureBlood pressure Urine outputUrine output ConsciousnessConsciousness
Society for care in emergency Society for care in emergency
What to doWhat to do
Stop obvious bleedingStop obvious bleeding Restore volume rapidly (Fluid Restore volume rapidly (Fluid
challenge)challenge) See the responseSee the response
Society for care in emergency Society for care in emergency
Monitoring & Monitoring & interventions interventions
Two veinflons Two veinflons
Take blood sample Take blood sample
Start iv fluidsStart iv fluids
Blood pressure monitoringBlood pressure monitoring
ECG monitoring ECG monitoring
Society for care in emergency Society for care in emergency
Head injuryHead injury FracturesFractures
DisabilityDisability
Society for care in emergency Society for care in emergency
What to seeWhat to see
AVPUAVPU AAlertlert Respond to Respond to vvocal stimulusocal stimulus Respond to Respond to ppainful stimulusainful stimulus UUnresponsivenresponsive
Society for care in emergency Society for care in emergency
What to doWhat to do
Early management is restoration Early management is restoration of ABCof ABC
CommunicationCommunication
Society for care in emergency Society for care in emergency
EnvironmentEnvironment
Completely undressCompletely undress Hypothermia preventionHypothermia prevention
Society for care in emergency Society for care in emergency
Completion of primary Completion of primary surveysurvey At the end of primary surveyAt the end of primary survey
Get lateral view of C/SGet lateral view of C/SChest XrayChest XrayPelvic XrayPelvic XrayCathaterise / intubate / ryles tube if Cathaterise / intubate / ryles tube if
required required Start life saving maneuvers like intubation, Start life saving maneuvers like intubation,
decompressing tension pneumothorax, decompressing tension pneumothorax, and giving IV fluid and giving IV fluid
Consider need for transfer Consider need for transfer
Society for care in emergency Society for care in emergency
Secondary surveySecondary survey
Life threatening priorities are Life threatening priorities are identified and their management is identified and their management is started in primary survey started in primary survey
Secondary survey focuses on Secondary survey focuses on – History History – Head to toe exam & more complete Head to toe exam & more complete
investigationsinvestigations– Deciding priorities Deciding priorities
Society for care in emergency Society for care in emergency
HistoryHistory (AMPLE) (AMPLE)
AllergiesAllergies Medications currently takenMedications currently taken Past illnessPast illness Last mealLast meal Event leading to injury Event leading to injury
Society for care in emergency Society for care in emergency
Secondary survey – Total patient Secondary survey – Total patient evaluation evaluation – Head & skull, MaxillofacialHead & skull, Maxillofacial– Neck,Neck, Chest,AbdomenChest,Abdomen– PerineumPerineum– Musculoskeletal Musculoskeletal – Complete neurological examComplete neurological exam
Head to toe examination Head to toe examination
Society for care in emergency Society for care in emergency
At the end you should haveAt the end you should have All Xrays All Xrays CT / US/ laboratory investigationCT / US/ laboratory investigation Tubes and fingers in all orifices Tubes and fingers in all orifices
Complete investigationsComplete investigations
Society for care in emergency Society for care in emergency
Fixing prioritiesFixing priorities
Communication with all Communication with all subspecialties subspecialties
Priorities discussed Priorities discussed
Society for care in emergency Society for care in emergency
Early definitive care Early definitive care
There is a controversy -There is a controversy -– Is patient fit enough to undergo another Is patient fit enough to undergo another
trauma in the form of surgery ? (Don’t touch!)trauma in the form of surgery ? (Don’t touch!)– Will patient improve / survive without having Will patient improve / survive without having
done a surgery ? (Do it now!) done a surgery ? (Do it now!) Damage control surgeries are the middle Damage control surgeries are the middle
path ( Do the minimum!)path ( Do the minimum!) Continued care in ICUContinued care in ICU
Society for care in emergency Society for care in emergency
Definitive treatment Definitive treatment
Do whatever you like Do whatever you like
Society for care in emergency Society for care in emergency
SummarySummary
Primary survey Primary survey – Life threatening priorities managed (ABCD)Life threatening priorities managed (ABCD)
Secondary survey Secondary survey – Head to toe exam and all the injuries identified Head to toe exam and all the injuries identified
Early definitive careEarly definitive care– Damage control surgeries Damage control surgeries – Management in ICUManagement in ICU
Definitive management Definitive management
Thanks Thanks
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