Management Of Polytrauma

Polytrauma ?

• Single patient with multiple injuries ?

• Multiple patients with multiple injuries ?

Poly = Multi Trauma

• Head Injury

• Chest Injury

• Abdominal Injury

• Skeletal Injury : Limb + Pelvis

• Spine Injury

• Urogenital Injury

Key Factors

• Team Approach• Triage• Damage control Orthopaedics

• Pre Hosp Care• Primary Survery• Secondary Survey

• Pre hospital care: EMT

• A & E : Resuscitation

• Specific management

• Nutritional support

• Rehabilitation

Assessment

• Primary Survey

• Airway

• Breathing

• Circulation

• Disability: Head Injury

• Estimate ISS

Prim Survey & Resus : Simultaneous

? Find the cause of haemodynamic/resp instability

- Quick short relevant history- Mech of Injury- Level of consciousness- Any CPR instituted- Restore Volume, Ventillation, - Pharmacologic Support

Secondary Survey

• Head to toe evaluation

• History

• X rays: CXR, Pelvis, Cervical Spine

Mx Stages( Tscherne)

• Acute care: upto 3 hrs

• Primary Stabilization period : 1 hrs to 3 days

• Secondary Stabilisation 3 to 8 day

• Tertiary Stabilisation: > 8 days

Acute Care

• A,B,C, D• Chest drain Vs thoracotomy > 1.5 L• Laprotomy r/o pelvic injury• External immobilization:• Open fracure Mx• Perineal wound ??? Colostomy• C spine injury: Immobilize

Prim Stabilsation

• Adeq perfusion• Steroid ??? Spinal injury• Ix : MRI Vs CT• Pelvic stabilisation : Ex Fix• Limb stabilisation: Ex Fix Vs Nailing• Compartment Release• Open fracture Rx

• Second Look Debridement

• Flap Cover

• Closed Limb fracture :

LL> UL

Pelvis + LL

UL delayed

Secondary Stabilisation

• Intra articular resconstruction

• Complex spinal and limb fracrure treatment

• Definitive flaps

Teritiary Stabilization

• Amputation cover etc

• Reconstructive surgery

Damage control concept

• IL 6 > SIRS !!!!!!!

• Plan and stage Rx

• Evolved from abdominal injury studies

• Reduce the damage due to surgery

• Imp in Thoraic injury, ARDS, Long bone fracture

Airway

• Effort

• Excursion

• Effect

• Sounds

Obstruction : In Vs Out

Breathing

• Pneumothorax : Open, Tension , Flail

• Massive Haemothorax

• Asess ???

Should you wait for an X ray ???

When ICD ?

Circulation

• BP, HR , UO, Skin, Cyanosis• Volume replace ??? How • When blood ???

Thrombocytopaenia ??? Cardiac tamponade ? Becks Triad : Venous High Decrease Ar Pressure Muffled HS

Head Injury

• GCS

• ISS

• Coma ?

• Neurogenic Shock Vs Hypovolaemic shock

• Spinal shock

Abdomen

• Clinical signs

• USG Vs CT Vs DPL

• Laprotomy

Spine

• Immobilise

• Asso injuries

• Steroids

• X ray : MRI : CT

• Disloc/ Fracture : Reduction

Pelvis

• See for H hage Stability Dislocation HypothermiaAcidosisCoagulopathy

Limb Injury

• Open Vs Closed

• LL Vs UL

• Pul injury Vs No lung injury

• Vascular injuries

• Compartments

• Stabilisation