Approach for poly-trauma patient

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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)
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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
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Primary Survey
Airway/
Cervical Spine Control
Breathing
Circulation
Disability (neurological)
Expose
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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.
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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”
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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
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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
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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
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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?
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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
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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
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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
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