1.
APPROACH & MANAGEMENT OF
POLYTRAUMA
Dr.K.R.Dharmendra.,
M.S[Gen.Surg].,D.N.B[Gen.Surg].,
AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT

2.
OUTLINE
 Concepts of trauma care
 Principles of trauma management
 ATLS Philosophy
 Damage control surgery
 Future directions

3.
EPIDEMIOLOGY
 Trauma—commonest cause of
death between 1-40
 By 2020, injuries—third leading
cause of death

4.
Definition of Polytrauma
 2 or more body regions with SIRS

5.
SIRS
 2 out of 4 signs
Tachycardia >90 beats/min
Tachypnoea >20 breaths/min
Pyrexia >38 c[or hypothermia <36 c]
WBC >12000/mcL or <4000/mcL

6.
SEPSIS
SIRS with a proven infective
source

7.
MODS
Severe Sepsis
CVS
RS
Kidney
Liver
Coagulation

8.
METABOLIC RESPONSE TO
TRAUMA
TWO PHASES
EBB PHASE
Role: conserve volume & energy
for recovery & repair
FLOW PHASE
Role: mobilization of body
resources

9.
EBB PHASE
 Lasts for 24-48 hrs
 Characterised by
 Hypovolaemia
 Decreased BMR
 Reduced cardiac output
 Hypothermia
 Lactic acidosis

10.
FLOW PHASE
Corresponds to SIRS
Tissue oedema
Increased BMR
Increased cardiac output
Leucocytosis, Raised body temperature
Increased oxygen consumption
Increased gluconeogenesis
 Catabolic – 3-10 days
 Anabolic - weeks

11.
METABOLIC RESPONSE TO TRAUMA

12.
PHARMACOLOGICAL
IMMUNOMODULATION

13.
IMMUNO NUTRITION

14.
IMMUNO
SUPPRESSION
• Epidural anaesthesia
• Statins
• B blockers
• Tranexamic acid

15.
GRADES OF HAEMORRHAGE

16.
REVISED TRAUMA SCORE

17.
“WELL BEGUN IS HALF
DONE”
• Initial assessment & management
is critical in decreasing morbidity
& mortality
• Aids recovery

18.
THE GOLDEN HOUR

19.
TRIMODAL DEATH
DISTRIBUTION

20.
TRIMODAL DEATH
DISTRIBUTION

21.
PRINCIPLES OF TRAUMA
MANAGEMENT
• Organised team approach
• Assumption of most serious injury
• Treatment before diagnosis
• Thorough examination
• Frequent examination

22.
TRIAGE
• In French, triage
means “to sort”
• Goals:
• To identify the high
risk injured patients
• To channelise the
transport of
patients to
appropriate centres

23.
3 PHASES OF
TRIAGE
• Pre hospital Triage
• At the scene of trauma
• On arrival at hospital

24.
MULTIPLE CASUALTIES
• The number &
severity <
Facility of the
center
• Priority is for
life threatening
injuries

25.
MASS CASUALTIES
• The number &
severity >
Facility of the
centre
• Priority is for
best chance of
survival, least
expenditure

26.
COMMUNICATION
• Co ordination between pre
hospital & hospital care
• Timely preparation & mobilization
of trauma team
• Hemodynamic instability is also
informed

27.
HAND OVER
• Ambulance driver to Trauma
team leader verbally
MIST
• Mechanism of Injury
• Injuries suspected
• Vital signs
• Treatment en route to hospital

28.
TRAUMA TEAM
• For better triage & care
• Registrars from
ED
ICU
Surgery
Radiology
Anaesthesiology
• Theatre staff
• Spokesperson

29.
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

30.
ATLS PHILOSOPHY
• Primary Survey & Resuscitation
• Secondary Survey
• Definitive Care

31.
PRIMARY
SURVEY

32.
PRIMARY SURVEY
• A—Airway Maintenance &
Cervical spine protection
• B—Breathing & Ventilation
• C--- Circulation & Haemorrhage
Control
• D--- Disability: Neurological status
• E--- Exposure & Environment
protection

33.
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

34.
PHILADELPHIA COLLAR
• 35

35.
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?

36.
Predisposing Conditions
• Coma
• Aspiration
• Maxillofacial trauma
• Neck injury
• Haematoma
• Laryngeal injury
• Thoracic inlet penetrating injury

37.
Signs of Airway Obstruction :
"Look"
• Agitation
• Poor air movement
• Rib retraction
• Deformity
• Foreign material

38.
Signs of Airway Obstruction :
"Listen"
• Speech? "How are you?"
Hoarseness
• Noisy breathing
• Gurgle
• Stridor

39.
Signs of Airway Obstruction :
"Feel"
• Fracture crepitus
• Airway structures in neck
• Tracheal deviation
• Haematoma

40.
AIRWAY RESUSCITATION
• Suction
• Chin lift
• Jaw Thrust
• Oral airway
• Definitive Airway

41.
• POLY5-34

42.
CHIN LIFT

43.
JAW THRUST

44.
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

45.
Cricothyroidotomy
INDICATIONS
• Trauma causing oral, pharyngeal
or nasal haemorrhage
• Foreign body obstruction
• Maxillo facial injuries

46.
Technical considerations
• No surgical Cricothyroidotomy
below 12 years
• A permanent tracheostomy within
24 hrs
• More than 2 days—higher risk of
glottic stenosis

47.
NEEDLE CRICOTHYROIDOTOMY

48.
COMPLICATIONS
EARLY
• Bleeding
• False passage
• Subcutaneous emphysema
• Oesophageal perforation
• Vocal cord injury

49.
LATE
• Infection
• Glottic & Subglottic stenosis
• Tracheo oesophageal fistula

50.
BREATHING & VENTILATION
Abnormal Breathing : Look
• Cyanosis
• Decline in mental state
• Chest asymmetry
• Tachypnoea
• Distended neck veins
• Paralysis
• Chest wounds
• Flial segment

51.
Abnormal Breathing : Listen
• I can't breathe!
• Stridor, wheezing
• Decreased breath sounds

52.
Abnormal Breathing : Feel
• Surgical emphysema
• Chest tenderness
• Trachea deviated
• Percussion & Auscultation

53.
DEADLY DOZEN THREATS FROM
CHEST INJURY
Immediately Life Threatening
• Airway Obstruction
• Tension Pneumothorax
• Pericardial Tamponade
• Open Pneumothorax
• Massive haemothorax
• Flial Chest

54.
Potentially Life Threatening
• Aortic Injuries
• Tracheo bronchial Injuries
• Myocardial Contusion
• Rupture of Diaphragm
• Oesophageal injuries
• Pulmonary Contusion

55.
SEALING OF OPEN WOUND

56.
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

57.
TENSION PNEUMOTHORAX

58.
HAEMOTHORAX
• ICD
INDICATIONS OF THORACOTOMY
• Initial 1500 ml
• 200 ml for 3 consecutive hours

59.
FLIAL CHEST
• Rib fractured at 2
different places
• Paradoxical chest
movements
• Underlying lung
contusion
• Positive pressure
ventilation
• Rarely surgical
fixation is necessary

60.
CIRCULATION & HAEMORRHAGE
CONTROL
• Surgical Registrar & procedure
nurse apply pressure bandage to
open wounds
Signs:
• Deteriorating conscious level
• Pallor
• Rapid , thready pulse

61.
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

62.
Is patient perfusing?
• Cool, pale, moist skin
• Capillary refill > 2 sec
• Restlessness, anxiety,
combativeness
If internal hemorrhage, quickly
expose, palpate abdomen, pelvis,
thighs

63.
THE STRATEGY
• Primary Haemorrhage Control and
timely surgical intervention rather
than Overaggressive Fluid
Resuscitation
[ Permissive Hypotension ]

64.
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

65.
CAUSES OF MAJOR BLEEDING
MAJOR BLEEDING -THE BIG FIVE
• EXTERNAL
• THORACIC
• PELVIC
• LONG BONES
• ABDOMEN

66.
FLUID THERAPY
• Crystalloid fluid is preferred
• Class 3 &4 shock—colloid
fluid advised
• Bolus of 1 litre of RL given

67.
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!

68.
Investigations for tissue perfusion

69.
Transfusion Guidelines

70.
Transfusion Guidelines
• HCT < 21
• Lesser HB trigger in
Asymptomatic patients
• Higher HB trigger in severe CV
diseases

71.
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

72.
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

73.
DISABILITY & NEUROLOGICAL
EXAMINATION
• Level of Consciousness = Best
brain perfusion sign
• Use AVPU initially
• Check pupils
• Eyes are the window of the CNS

74.
Brief Neurologic Examination
• A–Alert
• V –Responds to Vocal stimuli
• P–Responds to Painful stimuli
• U–Unresponsive
More detailed evaluation
-during the Secondary Survey

75.
Decreased LOC
• Brain injury
• Hypoxia
• Hypoglycemia
• Shock
• Never think drugs, alcohol, or
personality first

76.
GCS
EYE OPENING
EYE OPENING VERBAL
VERBAL MOTOR
MOTOR
Spontaneous 4
Spontaneous 4 Oriented 5
Oriented 5 Obeys 6
Obeys 6
Verbal 3
Verbal 3 Confused 4
Confused 4 Localises 5
Localises 5
Pain 2
Pain 2 Words 3
Words 3 Withdraws 4
Withdraws 4
None 1
None 1 Sounds 2
Sounds 2 Decorticate 3
Decorticate 3
None 1
None 1 Decerebrate 2
Decerebrate 2
None 1
None 1

77.
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

78.
Exposure&Environmental protection
• Complete disrobing of patient
• Logroll to inspect back
• Rectal temperature
• Warm blankets/external warming
device to prevent hypothermia

79.
Always Inspect the Back

80.
PAUSE & CHECK
• Are all immediately life-
threatening injuries
identified?
• Is all monitoring in place?
• Investigations ordered?
• Analgesia?
• Relatives informed?
• Non-essential team
members disbanded?

81.
The well practiced
trauma team
should aim to
complete the
primary survey in
less than 10
minutes

82.
Adjuncts to Primary Survey
• ECG monitoring
• Urinary and Gastric Catheters
• Monitoring
• X-rays and Diagnostics Studies

83.
Monitoring
1. 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

84.
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

85.
INDICATIONS FOR ICU
ADMISSION
Requirement for:
• Airway protection and mechanical
ventilation
• Cardiovascular resuscitation
• Severe head injury
• Organ support
• Correct coagulopathy
• Invasive monitoring

86.
SECONDARY
SURVEY

87.
SECONDARY SURVEY
• Does not begin until the primary
survey (ABCDEs) is completed
• Complete history
• Head-to-toe evaluation
• Reassessment of all vital signs

88.
HISTORY
A - Allergy
M- current Medication
P- Past illness and operation
L- Last meal
E- Event and Environment
related to the injury

89.
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
•

90.
LOG ROLLING
• 4 Persons required
• 1 - Spinal inline traction
[anaesthesiologist]
• 2 -Torso
• 3- Pelvis & Lower limb
• 4- Detailed examination of back

91.
EXAMINATION OF BACK
• Examine entire spine
• Any penetrating injury or exit
wound
• Appropriate Dressing
• Palpation of posterior chest
wall
• Percussion & Auscultation of
post.chest

92.
SECONDARY SURVEY
‘Tubes and fingers in
every orifice’

93.
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

94.
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

95.
DPL

96.
INDICATIONS FOR DPL
• Equivocal abdominal sign
• Unexplained hypotension
• Impaired mental status
• Paraplegia or spinal cord
injuries

97.
CONTRAINDICATIONS FOR DPL
Absolute contraindication
• existing indication for explore
laparotomy
Relative contraindications
• Previous abdominal operation
• Morbid obesity
• Advance cirrhosis
• Coagulopathy

98.
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

99.
DPL

100.
DPL
Advantages
• Fast
• Sensitive
• Can be performed while resuscitation
ongoing
Disadvantages
• Invasive
• Learning curve
• Not Organ specific

101.
FAST

102.
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

103.
FAST

104.
ADVANTAGES OF FAST
• Fast
• Noninvasive
• Can be performed while
resuscitation ongoing
• Can be very sensitive

105.
DISADVANTAGES OF FAST
• Operator dependent
• Body habitus may limit
quality/sensitivity
• Organ aspecific
• Can’t detect Hollow viscous
and retroperitoneal injuries

106.
Trauma Management

107.
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

108.
• 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

109.
• 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

110.
• 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”

111.
TRAUMA @ AHIH
• Trauma Team
• Trauma Protocol
• Training of Personnel
• Learning of Procedures
• In house/On call Consultants

112.
July 20 1969

113.
• “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

114.
A
Dharmendra
Presentation