What is polytrauma Multiple traumatic injuries to a victum. Overview of ATLS P rim a ry S u rvey (A B C D E 's ) R e su scita tion S e co nd a ry S u rvey D a ta / Info rm a tio n / R e spo n se to T h era py D e fin itive C a re Types of assessment 1. Primary Survey and resuscitation • Identification of Life threatening conditions • AcBCDE Approach 2. Secondary Survey • • • • Detailed head to toe examination Medical history All lab and radiology investigation ordered Management Plan 4 PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergencies Assess – Change - Reassess Initiation of LIFE-SAVING measures (CPR) Illinois EMSC 5 5 second Round •Pt is conscious or not •Airway •Ventilation •Signs of massive external hemorrhage •There is any deformity •Skin color and temp with feeling pulse Illinois EMSC 6 Primary Survey Airway/ Cervical Spine Control Breathing Circulation Disability (neurological) Expose Illinois EMSC 7 Assessing Airway Is the airway: Clear and safe? At risk? Obstructed? AIRWAY INTERVENTIONS Jaw thrust Vs Head tilt. Deliver Oxygen (mask with reservoir). Use Rigid suction. Secure airway. Illinois EMSC 9 5 Chest clues in the neck Wounds Distended neck veins Tracheal position Surgical emphysema Laryngeal crepitus CERVICAL SPINE STABILIZATION Place hands on either side of the head cervical collar.flv Maintain neck midline “manual in line stabilization” Illinois EMSC 11 Breathing and ventilation Aims Support if inadequate Eliminate any immediately life threatening thoracic condition ….. Breathing and ventilation Inspection Respiratory rate Effort of breathing Symmetry Wounds & marks Palpation Percussion Auscultation All lung zones BREATHING INTERVENTIONS If breathing is absent, start ventilation using: Simple Adjuvants (Airways) Bag valve mask with reservoir LMA ETT Illinois EMSC 14 Surgical Airway Cricothyroidotomy (tracheostomy) Indication Unable to intubate(sever maxillo-facial injury) Contraindication Transection of the airway Fatal Chest conditions? Tension pneumothorax Open chest trauma Cardiac tamponade Flail chest Massive hemothorax Illinois EMSC 16 Tension Pneumothorax Signs and Symptoms Chest pain, respiratory distress, tachycardia, hypotension, tracheal deviation, absent breath sounds, neck vein distention. Immediate decompression Needle thoracostomy Chest tube insertion MANAGEMENT OPEN PNEUMOTHORAX Ensure adequate airway 100% oxygen Seal open wound Load & Go IV access en route Notify Medical Direction Courtesy of David Effron, M.D. Open pneumothorax >2/3 of the tracheal diameter 3 sided wound dressing Chest tube insertion SEALING THE OPEN WOUND Asherman chest seal is very effective SEALING THE OPEN WOUND You can use impervious material taped on three sides Cardiac temponade Penetrating injury Becks Triad 1) Elevated central venous pressure (distended neck veins) 2) Muffled heart sounds 3) low blood pressure FAST scan /ECHO Pericardiocentesis Flail Chest > 2 ribs fractured in 2 or more places usually on the same or opposite side of the chest. Paradoxical chest wall movement. Adequate ventilation/ inadequate ventilation Chest tube insertion Massive heamothorax >1500 cc or 1/3 of the blood volume in the lung cavity I/V resuscitation Chest tube insertion Thoracotomy > 1500 cc immediately 200 cc/h for 2-4 hours CIRCULATORY ASSESSMENT Carotid pulse (absent or present) Capillary refill Skin color Skin temperature Sites of bleeding Illinois EMSC 25 CIRCULATORY INTERVENTIONS If central pulse is absent, begin CPR Apply direct pressure to open wounds. IV access (2 wide bore cannulae14/16G). Fluids (colloids Vs crystalloids) 20ml/Kg Peripheral Vs central line? 26 Hemorrhagic Shock Most common cause of shock in trauma External vs Internal hemorrhag Blood volume = 7% of BW Rx : Volume replacement Shock classification Classification Type 1 - 15% blood loss - p<100 - BP Normal - PP Normal - RR 14-20 - Urine output > 30cc/h - Mental status : Slightly anxious Classification Type 2 - 15-30% blood loss - p>100 - BP Normal - PP Decreased - RR 20-30 - Urine output 20-30cc/h - Mental status : Mildly anxious Classification Type 3 - 30-40% blood loss - p>120 - BP Decreased - PP Decreased - RR 30-40 - Urine output > 5-15cc/h - Mental status : Confused Classification Type 4 - >40% blood loss - p>140 - BP Decreased - PP Decreased - RR >35 - Urine output Nil - Mental status : Confused/ Lerthargic Fluid Replacement Class 1-2 : Crystalloid Class 3-4 : Crystalloid , Blood Initial Fluid Therapy - 1 to 2 L for adult - 20cc/kg for children “3-for-1 Rule” - 1cc blood loss = 3 cc crystalloid replacement Response to Fluid resuscitation Rapid response - < 20% blood loss - Cross match and surgical consult Transient response - 20-40% blood loss - Ongoing blood loss - Blood transfusion, Surgical Intervention No response - Immediate operative intervention Neurogenic Shock Isolated intracranial injuries do not cause shock. Loss of sympathetic tone: Spinal cord injury Hypotension without tachycardia Initially treated as Hypovolemia DDx for non responder Dysfunction of the CNS Aims Rapid neurological assessment • Alert; Voice; Pain; Unresponsive • Pupils Mini-neurological assessment • GCS score / AVPU • Pupils • Lateralising signs • Blood sugar Factors affecting level of consciousness Oxygenation Ventilation Perfusion Hypoglycemia Alcohol Trauma Head injury severity GCS Mild 13-15 Moderate 9-12 Severe <8 Head injury Types Skull Fractures Intracranial Bleed - Epidural Hematoma - Subdural hematoma - Intracerebral Bleed - Sub arrachnoid hemorrhage - Diffuse brain injury Epidural hematoma Subdural Hematoma Intracerebral Bleed 42 Management Mild Hi(GCS 13-15) - Neuro-observation - CT scan if LOC >5 mins Amnesia Severe headache Focal neurological deficit Moderate (GCS 9-13) - CT brain - Admit and observe neurosigns/ FU CT in 12-24 hrs Severe head injury Prompt diagnosis & treatment Do not delay patient’s transfer to obtain CT scan!!! Inform the Neurosurgery team and Neurology team on call as required. Intubate if indicted by the ABG’s and clinical signs. Transfer patient to OR or ICU ASAP. Exposure and environment Aims Remove clothing to allow examination of entire patient Care when removing tight trousers Prevent hypothermia Patient dignity Remove spine board Don’t Forget 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 Illinois EMSC 49 Adjuncts Once the patient is stabilized the patient is sent to radiology for the survey: Cervical spine X-ray (AP and lateral view) Chest X- ray (Rib cage) Pelvis X-ray Abdomen and Pelvis U/S CT brain is ordered if there is suspicion of head trauma X-ray of extremities if fracture is suspected. Don’t forget medical aspects of trauma Judicious fluid management Adequate and appropriate antibiotic coverage. Proper pain management. Continued vitals monitoring. Secondary Survey Not to begin until primary survey is complete History (AMPLE) - Allergies - Medications - Past illnesses/ Pregnanacy - Last meal - Events Head-to-toe examination GCS X-rays Specialized diagnostic tests (CT,MRI,Endoscopy) Abdominal trauma Mechanism of injury - Blunt - Penetrating History and Physical examination - inspection, palpation, percussion and auscultation - Evaluation of penetrating wound - Pelvic stability - Penile, perineal and gluetal examination - vaginal and rectal examination Diagnostic Studies DPL: diagnostic peritoneal lavage FAST CT scan Abdomen/Pelvis Urethrography, Cystography MRI/MRA Recommendations All Trauma patients should be assessed using the universal AcBCDE approach. Management of Poly-trauma should include primary and secondary survey. Team work is standard in management of trauma patient. High index of suspicion should be kept for aortic trauma in any posttraumatic chest pain. QUESTIONS? THANK YOU