Polytrauma ppt
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APPROACH & MANAGEMENT OF POLYTRAUMA
Dr.K.R.Dharmendra., M.S[Gen.Surg].,D.N.B[Gen.Surg].,
AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT
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OUTLINE
Concepts of trauma care Principles of trauma management ATLS Philosophy Damage control surgery Future directions
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EPIDEMIOLOGY
Trauma—commonest cause of death between 1-40
By 2020, injuries—third leading cause of death
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Definition of Polytrauma
2 or more body regions with SIRS
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SIRS
2 out of 4 signsTachycardia >90 beats/minTachypnoea >20 breaths/minPyrexia >38 c[or hypothermia <36 c]WBC >12000/mcL or <4000/mcL
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SEPSIS
SIRS with a proven infective source
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MODSSevere Sepsis
CVSRSKidneyLiverCoagulation
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METABOLIC RESPONSE TO TRAUMA
TWO PHASESEBB PHASE Role: conserve volume & energy
for recovery & repairFLOW PHASERole: mobilization of body
resources
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EBB PHASE Lasts for 24-48 hrs Characterised by Hypovolaemia Decreased BMR Reduced cardiac output Hypothermia Lactic acidosis
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FLOW PHASE Corresponds to SIRSTissue oedemaIncreased BMRIncreased cardiac outputLeucocytosis, Raised body temperatureIncreased oxygen consumptionIncreased gluconeogenesis Catabolic – 3-10 days Anabolic - weeks
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METABOLIC RESPONSE TO TRAUMA
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PHARMACOLOGICAL IMMUNOMODULATION
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IMMUNO NUTRITION
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IMMUNO SUPPRESSION
• Epidural anaesthesia• Statins• B blockers• Tranexamic acid
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GRADES OF HAEMORRHAGE
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REVISED TRAUMA SCORE
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“WELL BEGUN IS HALF DONE”
• Initial assessment & management is critical in decreasing morbidity & mortality
• Aids recovery
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THE GOLDEN HOUR
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TRIMODAL DEATH DISTRIBUTION
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TRIMODAL DEATH DISTRIBUTION
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PRINCIPLES OF TRAUMA MANAGEMENT
• Organised team approach • Assumption of most serious injury• Treatment before diagnosis• Thorough examination• Frequent examination
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TRIAGE• In French, triage
means “to sort”• Goals:• To identify the high
risk injured patients• To channelise the
transport of patients to appropriate centres
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3 PHASES OF TRIAGE
• Pre hospital Triage • At the scene of trauma• On arrival at hospital
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MULTIPLE CASUALTIES
• The number & severity < Facility of the center
• Priority is for life threatening injuries
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MASS CASUALTIES
• The number & severity > Facility of the centre
• Priority is for best chance of survival, least expenditure
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COMMUNICATION
• Co ordination between pre hospital & hospital care
• Timely preparation & mobilization of trauma team
• Hemodynamic instability is also informed
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HAND OVER
• Ambulance driver to Trauma team leader verbally
MIST• Mechanism of Injury• Injuries suspected• Vital signs• Treatment en route to hospital
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TRAUMA TEAM
• For better triage & care• Registrars from ED ICU
Surgery Radiology Anaesthesiology
• Theatre staff• Spokesperson
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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
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ATLS PHILOSOPHY
• Primary Survey & Resuscitation
• Secondary Survey
• Definitive Care
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PRIMARY SURVEY
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PRIMARY SURVEY• A—Airway Maintenance &
Cervical spine protection• B—Breathing & Ventilation• C--- Circulation & Haemorrhage
Control• D--- Disability: Neurological status• E--- Exposure & Environment
protection
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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
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PHILADELPHIA COLLAR
• 35
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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?
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Predisposing Conditions
• Coma• Aspiration• Maxillofacial trauma• Neck injury• Haematoma• Laryngeal injury• Thoracic inlet penetrating injury
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Signs of Airway Obstruction : "Look"
• Agitation• Poor air movement• Rib retraction• Deformity• Foreign material
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Signs of Airway Obstruction : "Listen"
• Speech? "How are you?" Hoarseness• Noisy breathing• Gurgle• Stridor
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Signs of Airway Obstruction : "Feel"
• Fracture crepitus• Airway structures in neck• Tracheal deviation• Haematoma
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AIRWAY RESUSCITATION
• Suction• Chin lift• Jaw Thrust• Oral airway• Definitive Airway
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• POLY5-34
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CHIN LIFT
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JAW THRUST
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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
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Cricothyroidotomy
INDICATIONS• Trauma causing oral, pharyngeal
or nasal haemorrhage • Foreign body obstruction• Maxillo facial injuries
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Technical considerations
• No surgical Cricothyroidotomy below 12 years
• A permanent tracheostomy within 24 hrs
• More than 2 days—higher risk of glottic stenosis
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NEEDLE CRICOTHYROIDOTOMY
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COMPLICATIONS
EARLY • Bleeding• False passage• Subcutaneous emphysema• Oesophageal perforation• Vocal cord injury
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LATE
• Infection
• Glottic & Subglottic stenosis
• Tracheo oesophageal fistula
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BREATHING & VENTILATION
Abnormal Breathing : Look• Cyanosis• Decline in mental state• Chest asymmetry• Tachypnoea• Distended neck veins• Paralysis• Chest wounds• Flial segment
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Abnormal Breathing : Listen
• I can't breathe!
• Stridor, wheezing
• Decreased breath sounds
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Abnormal Breathing : Feel
• Surgical emphysema
• Chest tenderness
• Trachea deviated
• Percussion & Auscultation
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DEADLY DOZEN THREATS FROM CHEST INJURY
Immediately Life Threatening• Airway Obstruction• Tension Pneumothorax• Pericardial Tamponade • Open Pneumothorax
• Massive haemothorax
• Flial Chest
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Potentially Life Threatening
• Aortic Injuries• Tracheo bronchial Injuries• Myocardial Contusion• Rupture of Diaphragm• Oesophageal injuries• Pulmonary Contusion
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SEALING OF OPEN WOUND
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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
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TENSION PNEUMOTHORAX
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HAEMOTHORAX
• ICD INDICATIONS OF THORACOTOMY
• Initial 1500 ml• 200 ml for 3 consecutive hours
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FLIAL CHEST• Rib fractured at 2
different places• Paradoxical chest
movements• Underlying lung
contusion• Positive pressure
ventilation• Rarely surgical
fixation is necessary
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CIRCULATION & HAEMORRHAGE CONTROL
• Surgical Registrar & procedure nurse apply pressure bandage to open wounds
Signs:• Deteriorating conscious level• Pallor• Rapid , thready pulse
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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
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Is patient perfusing?• Cool, pale, moist skin• Capillary refill > 2 sec• Restlessness, anxiety,
combativeness If internal hemorrhage, quickly
expose, palpate abdomen, pelvis, thighs
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THE STRATEGY
• Primary Haemorrhage Control and timely surgical intervention rather than Overaggressive Fluid Resuscitation
[ Permissive Hypotension ]
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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
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CAUSES OF MAJOR BLEEDING MAJOR BLEEDING -THE BIG FIVE
• EXTERNAL• THORACIC• PELVIC• LONG BONES• ABDOMEN
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FLUID THERAPY
• Crystalloid fluid is preferred• Class 3 &4 shock—colloid
fluid advised• Bolus of 1 litre of RL given
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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!
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Investigations for tissue perfusion
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Transfusion Guidelines
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Transfusion Guidelines
• HCT < 21• Lesser HB trigger in
Asymptomatic patients• Higher HB trigger in severe CV
diseases
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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
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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
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DISABILITY & NEUROLOGICAL EXAMINATION
• Level of Consciousness = Best brain perfusion sign
• Use AVPU initially• Check pupils• Eyes are the window of the CNS
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Brief Neurologic Examination
• A–Alert• V –Responds to Vocal stimuli• P–Responds to Painful stimuli• U–Unresponsive More detailed evaluation -during the Secondary Survey
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Decreased LOC
• Brain injury• Hypoxia• Hypoglycemia• Shock• Never think drugs, alcohol, or
personality first
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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
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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
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Exposure&Environmental protection
• Complete disrobing of patient
• Logroll to inspect back
• Rectal temperature
• Warm blankets/external warming
device to prevent hypothermia
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Always Inspect the Back
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PAUSE & CHECK
• Are all immediately life-threatening injuries identified?
• Is all monitoring in place?• Investigations ordered?• Analgesia?• Relatives informed?• Non-essential team
members disbanded?
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The well practiced trauma team should aim to complete the primary survey in less than 10 minutes
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Adjuncts to Primary Survey
• ECG monitoring
• Urinary and Gastric Catheters
• Monitoring
• X-rays and Diagnostics Studies
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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
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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
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INDICATIONS FOR ICU ADMISSION
Requirement for:• Airway protection and mechanical
ventilation• Cardiovascular resuscitation• Severe head injury• Organ support• Correct coagulopathy• Invasive monitoring
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SECONDARY
SURVEY
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SECONDARY SURVEY
• Does not begin until the primary
survey (ABCDEs) is completed
• Complete history
• Head-to-toe evaluation
• Reassessment of all vital signs
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HISTORYA - AllergyM- current Medication P- Past illness and operationL- Last mealE- Event and Environment related to the injury
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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
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LOG ROLLING• 4 Persons required• 1 - Spinal inline traction
[anaesthesiologist]• 2 -Torso• 3- Pelvis & Lower limb• 4- Detailed examination of back
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EXAMINATION OF BACK• Examine entire spine• Any penetrating injury or exit
wound• Appropriate Dressing• Palpation of posterior chest
wall• Percussion & Auscultation of
post.chest
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SECONDARY SURVEY
‘Tubes and fingers in every orifice’
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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
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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
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DPL
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INDICATIONS FOR DPL
• Equivocal abdominal sign
• Unexplained hypotension
• Impaired mental status
• Paraplegia or spinal cord
injuries
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CONTRAINDICATIONS FOR DPL
Absolute contraindication• existing indication for explore
laparotomyRelative contraindications• Previous abdominal operation• Morbid obesity• Advance cirrhosis• Coagulopathy
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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
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DPL
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DPLAdvantages• Fast• Sensitive• Can be performed while resuscitation
ongoingDisadvantages• Invasive• Learning curve• Not Organ specific
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FAST
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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
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FAST
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ADVANTAGES OF FAST
• Fast
• Noninvasive
• Can be performed while
resuscitation ongoing
• Can be very sensitive
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DISADVANTAGES OF FAST
• Operator dependent• Body habitus may limit
quality/sensitivity• Organ aspecific• Can’t detect Hollow viscous and retroperitoneal injuries
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Trauma Management
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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
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• 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
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• 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
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• 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”
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TRAUMA @ AHIH
• Trauma Team• Trauma Protocol• Training of Personnel• Learning of Procedures• In house/On call Consultants
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July 20 1969
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• “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
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A DharmendraPresentation