POLYTRAUMA PATIENTS

1. Approach to Polytrauma Patients
Dr. Awaneesh Katiyar
M.Ch. Senior Resident
Trauma Surgery and Critical Care
AIIMS, Rishikesh, UK, India

2. Objectives
• The concepts and principles of the primary and secondary patient
assessments.
• Establish management priorities in a trauma situation.
• Initiate primary and secondary management necessary for the
emergency management of acute life threatening conditions in a
timely manner.

3. Distribution of global injury mortality

4. The Need
• More than nine people die every minute from injuries or violence
• 5.8 million people of all ages and economic groups die every year
• The burden of injury is even more significant, accounting for 18% of
the world’s total diseases.

5. Tri-modal Death Distribution

6. History

7. ATLS and Trauma Systems
• As mentioned earlier, Advanced Trauma Life Support (ATLS) was
developed in 1976 following a plane crash in which several children
were critically injured.

8. The Concept
• Treat the greatest threat to life first.
• Never allow the lack of definitive diagnosis to impede the application
of an indicated treatment.
• A detailed history is not essential to begin the evaluation of a patient
with acute injuries.

9. Initial assessment includes the following
elements:
• Preparation
• Triage
• Primary survey (ABCDEs) with immediate resuscitation of patients
with life-threatening injuries
• Adjuncts to the primary survey and resuscitation

10. Initial assessment includes the following
elements:
• Consideration of the need for patient transfer
• Secondary survey (head-to-toe evaluation and patient history)
• Adjuncts to the secondary survey
• Continued post-resuscitation monitoring and reevaluation
• Definitive care

11. Preparation
• Preparation for trauma patients occurs in two different clinical settings:
• in the field and
• in the hospital.
• During the prehospital phase, events are coordinated with the clinicians at
the receiving hospital.
• During the hospital phase, preparations are made to facilitate rapid trauma
patient resuscitation.

12. Triage
• Multiple Casualties
• Multiple-casualty incidents are those in which the number of
patients and the severity of their injuries do not exceed the
capability of the facility to render care.
• In such cases, patients with life-threatening problems and those
sustaining multiple-system injuries are treated first.

13. Triage
• Mass Casualties
• In mass-casualty events, the number of patients and the severity
of their injuries does exceed the capability of the facility and staff.
• In such cases, patients having the greatest chance of survival and
requiring the least expenditure of time, equipment, supplies etc.

14. Primary Survey with Simultaneous Resuscitation
Airway maintenance with restriction of cervical spine motion
Breathing and ventilation
Circulation with hemorrhage control
Disability(assessment of neurologic status)
Exposure/Environmental control

15. 10-second assessment
Clinicians can quickly assess A, B, C, and D in a trauma patient by
identifying themselves, asking the patient for his or her name, and
asking what happened

16. Airway

17. Airway
• First assess the airway to ascertain patency
• Begin measures to establish a patent airway while restricting cervical spine
motion
• Initially, the jaw-thrust or chin-lift maneuver often suffices as an initial
intervention
• GCS score of 8 or lower usually require the placement of a definitive airway
• Establish an airway surgically if intubation is contraindicated or cannot be
accomplished

18. Problem Recognition
• Maxillofacial Trauma
• Neck Trauma
• Laryngeal Trauma
1. Hoarseness
2. Subcutaneous emphysema
3. Palpable fracture

19. Predicting Difficult Airway Management
• L = Look Externally
• E = Evaluate the 3-3-2 Rule
• M = Mallampati
• O = Obstruction
• N = Neck Mobility:

20. DEFINITIVE AIRWAYS
• There are three types of definitive airways:
• Orotracheal tube
• Nasotracheal tube
• Surgical airway (cricothyroidotomy and tracheostomy).

21. Surgical Airway
Needle Cricothyroidotomy Surgical Cricothyroidotomy

22. Breathing and ventilation

23. Life-threatening injuries
• Airway obstruction
• Tracheobronchial tree injury
• Tension pneumothorax
• Open pneumothorax
• Massive hemothorax
• Cardiac tamponade

24. Potentially life-threatening injuries
• Simple pneumothorax
• Hemothorax
• Flail chest
• Pulmonary contusion
• Blunt cardiac injury
• Traumatic aortic disruption
• Traumatic diaphragmatic injury,
• Blunt esophageal rupture.

25. Significant Chest Injuries
• Subcutaneous emphysema,
• Thoracic crush injuries,
• Sternal, rib, and clavicular fractures

26. Airway Problems
• Airway Obstruction
• Laryngeal injury
• Posterior dislocation of the clavicular head
• Tracheobronchial Tree Injury
• Incomplete expansion of the lung and continued large air leak after
placement of a chest tube suggests a tracheobronchial injury, and placement
of more than one chest tube may be necessary to overcome the significant air
leak.

27. Breathing Problems
• Tension Pneumothorax
• Tension pneumothorax develops when a
“one-way valve” air leak occurs from the
lung or through the chest wall

28. Breathing Problems
• Open Pneumothorax
• Large defects of the chest wall that
remain open can result in an open
pneumothorax, or sucking chest wound.

29. Breathing Problems
• Open Pneumothorax
• For initial management of an open
pneumothorax, promptly close the defect
with a sterile dressing large enough to
overlap the wound’s edges with seal on
three side.

30. Breathing Problems
• Massive Hemothorax
• This condition results from the rapid
accumulation of more than 1500 mL of
blood or one-third or more of the
patient’s blood volume in the chest
cavity.

31. Breathing Problems
• Cardiac Tamponade
Cardiac tamponade can result from penetrating or blunt injuries that cause the pericardium to fill with blood
from the heart, great vessels, or pericardial vessels

32. Potentially Life-Threatening Injuries
Simple Pneumothorax : Pneumothorax results from air entering the potential space between the visceral and parietal pleura

33. Potentially Life-Threatening Injuries
Flail Chest : Two or more adjacent ribs fractured in two or more places

34. Potentially Life-Threatening Injuries
Traumatic Aortic Disruption:
Traumatic aortic rupture is a common cause
of sudden death after a vehicle collision or fall
from a great height. Maintain a high index of
suspicion prompted by a history of
decelerating force and characteristic findings
on chest x-ray films.
Aortic Disruption

35. Potentially Life-Threatening Injuries
Diaphragmatic Rupture.
Blunt trauma produces large radial tears that
lead to herniation, whereas penetrating
trauma produces small perforations that can
take time—sometimes even years—to
develop into diaphragmatic hernias.

36. Other Manifestations of Chest Injuries
• Subcutaneous emphysema,
• Thoracic crush injuries,
• Sternal, rib, and clavicular fractures
• Upper ribs (1 to 3)
• Middle ribs (4 to 9)
• Lower ribs (10 to 12)

37. Circulation with hemorrhage control

38. Basic Cardiac Physiology

39. Clinical Differentiation of Cause of Shock
• Hemorrhagic Shock
• Cardiogenic Shock
• Cardiac Tamponade
• Tension Pneumothorax
• Neurogenic Shock
• Septic Shock

40. Hemorrhagic Shock

41. Initial Fluid Therapy
• Administer an initial, warmed fluid bolus of isotonic fluid. The usual
dose is 1 liter for adults and 20 mL/kg for pediatric patients weighing
less than 40 kilograms
• The goal of resuscitation is to restore organ perfusion and tissue
oxygenation.

42. Initial Fluid Therapy

43. Blood Replacement
• Crossmatched, Type-Specific, and Type O Blood
• Autotransfusion
• Massive Transfusion
• > 10 units of pRBCs within the first 24 hours of admission or more than 4 units
in 1 hour

44. Abdominal and Pelvic Trauma
• Inspection, Auscultation, Percussion, and Palpation
• Pelvic Assessment
• Urethral, Perineal, Rectal, Vaginal, and Gluteal Examination

45. Abdominal and Pelvic Trauma
• ADJUNCTS TO PHYSICAL EXAMINATION
• Gastric Tubes and Urinary Catheters
• FAST
• DPL
• X-rays for Abdominal Trauma
• Computed Tomography FAST : Focused Assessment with Sonography for Trauma

46. Pelvic Fractures and Associated Injuries
AP Compression fracture Lateral compression fracture Vertical shear fracture

47. Pelvic Fractures and Associated Injuries
A sheet, pelvic binder, or other device can produce sufficient temporary fixation for
the unstable pelvis when applied at the level of the greater trochanters of the femur.

48. Disability
The primary goal of treatment for patients with suspected traumatic brain
injury is to prevent secondary brain injury.

49. Intra Cranial Pressure(ICP)
• Elevation of intracranial pressure (ICP) can reduce cerebral perfusion
and cause or exacerbate ischemia.
• The normal ICP for patients in the resting state is approximately 10
mm Hg.
• Pressures greater than 22 mm Hg, particularly if sustained and
refractory to treatment, are associated with poor outcomes

50. Monro–Kellie Doctrine

53. CT Scans of Intracranial Hematomas
A. Epidural hematoma.
B. Subdural hematoma.
C. Bilateral contusions with hemorrhage.
D. Right intraparenchymal hemorrhage with
right to left midline shift and associated
biventricular hemorrhages.

55. CT scanning is the preferred method of
imaging, although obtaining CT scans
should not delay transfer of the patient
who requires it.

56. Medical Therapies for Brain Injury
• Hypovolemia in patients with TBI is harmful.
• Correction of Anticoagulation
• Hyperventilation acts by reducing PaCO2 and causing cerebral
vasoconstriction.
• Mannitol is used to reduce elevated ICP. The most common preparation is a
20% solution (20 g of mannitol per 100 ml of solution).
• The goal in resuscitating the patient with brain injuries is to prevent
secondary brain injury.

57. Spine and spinal cord
trauma

58. Spine and Spinal Cord Trauma
• Because spine injury can occur with both blunt and penetrating
trauma, and with or without neurological deficits, it must be
considered in all patients with multiple injuries.
• These patients require limitation of spinal motion to protect the spine
from further damage until spine injury has been ruled out.

59. Anatomy

61. Neurogenic Shock versus Spinal Shock
• Neurogenic shock results in the loss of vasomotor tone and
sympathetic innervation to the heart.
• Injury to the cervical or upper thoracic spinal cord (T6 and above) can
cause impairment of the descending sympathetic pathways.
• Spinal shock refers to the flaccidity (loss of muscle tone) and loss of
reflexes that occur immediately after spinal cord injury.

62. General management of spine and spinal cord trauma
• Restricting spinal motion
• Intravenous fluid
• Medications
• Transfer, if appropriate

63. MUSCULOSKELETAL TRAUMA

64. Injuries to the musculoskeletal system are common in
trauma patients. The delayed recognition and treatment of
these injuries can result in life-threatening hemorrhage or
limb loss.

65. Musculoskeletal injuries
• The initial assessment of musculoskeletal trauma is intended to
identify those injuries that pose a threat to life and/or limb.
• Although uncommon, life-threatening musculoskeletal injuries must
be promptly assessed and managed.
• A staged approach to hemorrhage control is utilized by applying direct
pressure, splints, and tourniquets.

66. Musculoskeletal injuries
• Most extremity injuries are appropriately diagnosed and managed during
the secondary survey.
• A thorough history and careful physical examination, including completely
undressing the patient, is essential to identify musculoskeletal injuries.
• It is essential to recognize and manage arterial injuries, compartment
syndrome, open fractures, crush injuries, and dislocations in a timely
manner

67. Give extra attention to….
• PEDIATRIC TRAUMA
• GERIATRIC TRAUMA
• TRAUMA IN PREGNANCY AND INTIMATE PARTNER VIOLENCE

68. SCENARIO
• You are summoned to a safe triage area at a shopping mall where 6 people are injured in a mass
shooting. The shooter has killed himself. You quickly survey the situation and determine that the
patients’ conditionsare as follows:
• PATIENT A—A young male is screaming, “Please help me, my leg is killing me!”
• PATIENT B—A young female has cyanosis and tachypnea and is breathing noisily.
• PATIENT C—An older male is lying in a pool of blood with his left pant leg soaked in blood.
• PATIENT D—A young male is lying facedown and not moving.
• PATIENT E—A young male is swearing and shouting that someone should help him or he will call
his lawyer.
• PATIENT F—A teenage girl is lying on the ground crying and holding her abdomen