Decision Making in Polytrauama

1. Decision making in Polytrauma
DR Chandrakant Sabale

2. As per WHO and CDC more than
nine people die every minute from
injuries or violence, and 5.8 million
people of all ages and economic
groups die every year from
unintentional injuries and violence.
Distribution of global injury mortality by cause

3. TRIMODAL DEATH DISTRIBUTION
Timing distribution of trauma deaths compared with
the historical trimodal distribution.
1ST Peak: occurs within seconds to minutes of injury.
During this early period, deaths result from apnea due
to severe brain or high spinal cord injury or rupture of
the heart, aorta, or other large blood vessels.
2nd Peak : occurs within minutes to several hours
following injury. Deaths that occur during this period
are usually due to subdural and epidural hematomas,
hemopneumothorax, ruptured spleen, lacerations
of the liver, pelvic fractures, and/or multiple injuries
associated with significant blood loss.
3rd Peak : occurs several days to weeks after the
initial injury, is most often due to sepsis and multiple
organ system dysfunctions.

4. Initial assessment
• Preparation
• Triage
• Primary survey (ABCDEs) with immediate
• resuscitation of patients with life-threatening injuries
• Adjuncts to the primary survey and resuscitation
• Consideration of the need for patient transfer
• Secondary survey (head-to-toe evaluation and patient history)
• Adjuncts to the secondary survey
• Continued postresuscitation monitoring and reevaluation
• Definitive care

5. Preparation
• Prehospital Phase During this phase,
personnel emphasize airway maintenance, control of
external bleeding and shock, immobilization of the
patient, and immediate transport to the closest
appropriate facility, preferably a verified trauma center.

6. FIELD
TRIAGE
DECISION
SCHEME:

7. Hospital phase
Critical aspects of hospital preparation include :
• A resuscitation area is available for trauma
patients.
• Properly functioning airway equipment is
organized, tested, and strategically placed to
be easily accessible.
• Warmed i.v. crystalloid solutions are
immediately available for infusion, as are
appropriate monitoring devices.
• A protocol to summon additional medical
assistance is in place, as well as a means to
ensure prompt responses by laboratory and
radiology personnel.
• Transfer agreements with verified trauma
centers are established and operational.
Trauma team members are trained to use standard
precautions

8. TRIAGE
A Multiple Casualties
• No of severity & pt do not exceed the
ability of the facility.
B Mass Casualties DISASTER
• No & severity of pt. EXCEED the
capability of the facility & staff.

9. Primary survey
• Airway maintenance with restriction
of cervical spine motion
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability(assessment of neurologic
status)
• Exposure/Environmental control
• Clinicians can quickly assess A, B, C, and D in a
trauma patient (10-second assessment) by
identifying themselves, asking the patient for his
or her name, and asking what happened

10. • Priorities for the care of Adult ,
Pediatrics & Pregnancy women are
all the same.
• During the primary survey life
threatening conditions are identified
and management is instituted
SIMULTANEOUSLY.

11. Airway Maintenance with
RESTRICTION OF CERVICAL SPINE MOTION
• Protection of the spine & spinal
cord is the important management
principle.
• Neurological exam alone does
not exclude a cervical spine injury.
• Always assume a cervical spine
injury in any pt with multi-system
trauma, especially with an altered
level of consciousness or blunt
injury above the clavicle.

12. Indication For Definite Airway
• Unconscious
• Severe maxillo-facial fracture
• Risk for aspiration : Bleeding/ vomiting
• Risk for obstruction : neck
hematoma/laryngeal, tracheal injury/
stridor
• Apnea : Neuromuscular
paralysis/unconscious
• Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
• Severe closed head injury need for
hyperventilation

13. Breathing and Ventilation
• Airway patency alone does not ensure adequate
ventilation.
• Adequate gas exchange is required to maximize
oxygenation and carbon dioxide elimination.
• Ventilation requires adequate function of the lungs,
chest wall, and diaphragm; therefore, clinicians must
rapidly examine and evaluate each component.
• To adequately assess jugular venous distention,
position of the trachea, and chest wall excursion,
expose
the patient’s neck and chest.

14. Circulation with Haemorrhage Control
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin colour
c. Pulse.
2. Bleeding
Rapid, external blood loss is managed by direct manual pressure on the wound.
Tourniquets are effective in massive exsanguination from an extremity but carry a risk of ischemic injury
.
Use a tourniquet only when direct pressure is not effective and the patient’s life is threatened.
• Identify and Treat Shock
• 2 Large bore IV’s or central venous access
• Warm IVF : Normal Saline vs. Ringers Lactate
• Emergency release blood
• risk for coagulopathy : Tranexamic acid

15. Disability (Neurologic Evaluation)
• A rapid neurologic evaluation establishes
the patient’s level of consciousness and
pupillary size and reaction; identifies the
presence of lateralizing signs; and
determines spinal cord injury level, if present.
• Primary brain injury results from the structural
effect of the injury to the brain. Prevention of
secondary brain injury by maintaining
adequate oxygenation and perfusion are the
main goals of initial management.

16. Exposure and Environmental Control
• Completely Undress
Must occur when patient hits the
door
• Don’t miss injuries
Roll the patient
Look in creases/ back of
head/neck
• Keep Warm
Hypothermia leads to
coagulopathy and increasedblood
loss

17. ADJUNCT TO PRIMARY SURVEY &
RESUSCITATION
• continuous electrocardiography
• pulse oximetry, carbon dioxide (CO2) monitoring,
and assessment of ventilatory rate, and ABG
measurement.
• urinary catheters can be placed to monitor urine
output and assess for hematuria.
• Gastric catheters decompress distention and
assess for evidence of blood.
• Other helpful tests : include blood lactate, x-ray
examinations (e.g., chest and pelvis), FAST,
extended focused assessment with sonography for
trauma (eFAST), and DPL. eFAST

18. Special population
• Patient populations that warrant special
consideration during initial assessment are
children, pregnant women, older adults, obese
patients, and athletes.
• Priorities for the care of these patients are the
same as for all trauma patients, but these
individuals may have physiologic responses that
do not follow expected patterns and anatomic
differences that require special equipment or
consideration

19. Secondary Survey
• History
A Allergies
M Medications
P Past illness, pregnancy
L Last Meal
E Events /environments relating to injury

20. Mechanism of injury

21. Dashboard

22. Physical Exam
• Physical Exam
Head and Neck
Chest
Abdomen
Pelvis
Genital/Rectal
Extremities
Back

23. ADJUNCT TO THE SECONDARY SURVEY
• additional x-ray examinations of the
spine and extremities; CT scans of the
head, chest, abdomen, and spine;
contrast urography and angiography;
transesophageal ultrasound;
bronchoscopy; esophagoscopy; and
other diagnostic procedures may be
performed as per required.

24. RE-EVALUATION
• Trauma patients must be reevaluated
constantly to ensure that new findings
are not overlooked and to discover any
deterioration in previously noted findings.
• Adult urine output 0.5ml/kg/hr
• Pediatric urine output 1mg/kg/hr
• Pain relief --

25. Definite care
• Whenever the patient’s treatment needs exceed
the capability of the receiving institution, transfer
is considered.
• This decision requires a detailed assessment of
the patient’s injuries and knowledge of the
capabilities of the institution, including equipment,
resources, and personnel