In a tertiary care institute of northern India, the emergency department receives an average of 6–7 patients with poly trauma every day. Of these patients, some come directly and many are referred from other hospitals from the region. Various problems are faced in the management of patients with poly trauma. This presentation aimed to elicit various complaints, suggestions and possible solutions in the management of patients with poly trauma.

1. Management
Strategies -
Poly trauma
patient
DR.Fiaz Maqbool Fazili
Acute Care,Trauma & MAS Surgeon,
Dept ofSurgery,
King Fahd hospital Medinah al munawarh

2. How much trauma poses as a
problem/disease?
Large number of people ,mostly youngsters die from a
(preventable cause-. Trauma)
if prompt &proper managements ARE instituted ,
many of them can be saved with an acceptable quality of life.
#For Hajis no age is a bar;
1.Traffic accidents are the leading cause of
death in males 16 to 36 years as stated in
a briefing on the Country Cooperation
Strategy for the World Health Organization
(WHO) and Saudi Arabia.
2.MV A ccidents are the fifth leading
cause of death in Saudi Arabia.

3.  Every year.RTA cost Saudi Arabia’s economy SR26 billion.
a year,; which is 4.0 per cent of the gross domestic product
(GDP)- a big loss
 by 2020 =SR55 billion ($14.98 billion) a year (Arab news)
 1/3 of all beds in government hospitals are occupied by
road accident victims.( Hon,ble Minister says -Lot of
Pressure on MOH hospitals)
 Saher” system for the automatic detection of traffic violations, will have
a positive impact on public health facilities in the country,”Honble
Minister Of Health -----Arab news

4. WHAT DOES THIS DATA
TELL… US?
What Message it has for Us……..?Road ahead ..

5. CAN WE IMPROVISE OUR CARE?
Strategy to Save lives/reduce morbidity/cost
1. Recognise Trauma as a disease?
1. Causes of trauma.
2. preventive aspect
1. with law enforcing agencies &mediia
2. Treatment part_medical
3. Timing of Death resulting from trauma.
2. RECOGNIZE OUR PT (HAJI)& special circumstances;
3. Error reporting –honest;Common errors in the current trauma
management—self appraisal for improvisation; voluntary [-not
for punishment) NO BLAME_NO NAME_ NO SHAME
4. Review Last year,s trauma Management during Hajj - strategies
& Statistics.
5. Audit THE REPORT---RECOGNISE GRAY AREAS -PUT New
POLICIES on basis of Recommendations

6. Trauma Deaths Occurs….three modes#
<1 hour 1-3 hours 4 to 6 weeks
“The Trimodal Distribution”
Golden hour
First few hours can highly influence
the outcome.
Because of the time factor and the
complexity of the injury it is best
managed by fixed guide lines##
Period of preventable deaths

7. Immediate Deaths
instantaneous death or within few minutes –
non salvageable injury; to major organs/ vessels /brain,,heart ,
 Loss of Airway
 Brain Stem Laceration
 High C-Spine Lesion
 Aortic/Heart Rupture
These are almost non salvageable conditions-
No point n bringing these
victims to hospital

8. A specialist medical retrieval service performing( life saving interventions,critical care,
inter hospital transport & rescue at the accident scene.(Hospital on wings/wheels)
1st Airborne ing ...
y.
The first 10 minutes is
now being called the
"Platinum 10“ –are re a
key determining factor in
whether or not the
wounded .is
salvageble..impt than
the Golden Hour after a
traumatic injur

9. Golden Hour
 Time is a critical factor for
the patient with a
significant MOI-the
morbidity and mortality can
be reduced with timely
interventions
 Barring the need for extrication,
the rule of the “Golden hour”
and the “Platinum 10 minutes”
will apply
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.

10. Early Deaths (1-3 hours)
 Epidural/ SubduraHematoma
 Hemo/Pneumothorax
 Intra-abdominal Bleeding
 Pelvic Fractures
 Internal ; hemorrhage
 chest /abdomen
 #Femur/Multiple long bone
Why do these
patients die?-
delay In
transport/inter
vention
## During this phase Mort/Morb are reducible by timely interventions+avoidance
of secondary injury due to hypoxia ;hemaorraghe;or any process due to
inadequate perfusion;
One-fifth to one-third of
all early deaths may be
preventable-JAMA 1985

11. Late (2-4 weeks)
Deaths occurring in HDU ;icu and wards-
 Sepsis
 Multiple Organ System Failure
How can these deaths be
avoided?
if our initial management has been
satisfactory.

12. Multiple Trauma ––Strategical
PLAN (essential components are..
-Preparedness to receive trauma victims (Trauma
hospital /unit,leader,etc)##well defined-protocol
Triage on scene-pre hospital care-rapid
transportation
Primary survey (ABCs) ._pre/inside hosp
Resuscitation & Timely interventions by
Trauma team.
Secondary survey ( Head – to – Toe ) Rapid
Trauma assessment.
 Definitive Care management

13. What We need ….
PREPARE PROTOCOLS
for
1. Pre-Hospital phase
2.Hospital Management
3. Rehabilitation & counseling

14. Pre Hospital Phase- Accident
Scene #Triage =Platinum10
CONTROL OF Revealed
hemorrhage .
Immobilization of the patient
/splinting fractures
1.Minimize
scene time.
2.Quickly
perform a
rapid
trauma
assesment.
3.#Identify
high risk pts.
4.Perform
life-saving
procedures
If life-threat
is present,
5.Transport
to the
appropriate
facility
If you can’t correct it:
Do no more harm
O2
Ventilate/intubate
Perfusion-iv fluids
Stabilize & Transfer-
Collar/hard board

15. Safe transport and "packaging as per availability
This slide demonstrates the immobilization and transport of an injured
Modern concept of transport
Towards In- hospital care

18. IN Hospital Preparation-TRAUMA BAY
 In Hospital Phase:Check list
 ALL EQUIPMENT (Laryngoscope
,tubes, suction,warmed fluids etc;
).
AVAILABLE_VISIBLE_TESTED
/enough quantity;###
 Checked after every pt
reception/shift; .
 Lab – X ray /USG machine Stand by
 Scene Safety & Personal
Protection
 -Infection control-measures
 Universal precautions-Wearing
gloves, masks, gowns

19. -What am I going to do first?
- What’s next?

20.  Team leader determines
priorities according to
situation of pt.
 Every member knows his
job.
 Most efficient method of
improving patient survival.;
Systematic, coordinated team
approach to AT ER

22.  Follow ATLS
guidelines
1. Detailed history/thorough
physical exam is not
 Follow:A B C DE ###
 Lack of definitive Diagnosis
should not impede definitive
treatment to save life
@Immediate Goal of ER staff on arrival of
Victim?
Thoroughly assess the pt on admission so that
life threatening injuries can be corrected

23. III
Tasks for ER Staff & Interventions
 (Resuscitation +Assessment
 + Monitoring-
 (ALL GOING SIMULTANEOUSLY.)
 Tubes in-O2 ,Iv lines;
IFC.NGT/
 Monitors – for
(HR/Ecg;Pulse
oximetry;)###
 Data collection is rt
 Brief history(AMPLE –accident
details-relevant exam
 Assess responses to treatment
–Documentation

25. 2% of abd injuries(children) compression aganst spine;direct blow (handle
bar;Sports;fight

26. Steering wheel Injury- Prevention
by Use (Proper) Seat Belt
 Seat belts certainly
prevent much greater trauma
 The introduction of seatbelts
reduced mortality following
severe motor vehicle
accidents from about 5.6% to
3.4%.
 Major head and face injuries
and major vascular injuries to
the chest if no seat belt
 if improperly placed can
produce some trauma to
NO SEAT BELT

27. STEERING-WHEEL INJURY,
A DECELERATIVE IMPACT
FORCE
MULTIPLE CONTUSIONS OF
HEART WITH OBVIOUS
SUBEPICARDIAL
EXTRAVASTIONS OF BLOOD
NO SEAT
BELT

28. VARIABLE DEGREES
OF SHOCK OR IN
EXTREMIS
DECREASED ARTERIAL
AND PULSE PRESSURES
OFTEN EXIST BUT NOT
PATHOGNOMONIC
NECK VEINS DISTENDED
HEART SOUNDS DISTANT
CVPRESSURE
ELEVATED
(PATHOGNOMONIC)
#Needs Drainage

29. After inspection for foreign bodies .
Any patient with a possible cervical
spine injury should have their
neck immobilised in a neutral
position by Cx collar to prevent
further damage.
 No excessive movement of the
cervical spine-hyperextension
/hyperflexion, or rotation.###
 Chin lift or jaw thrust maneuvers are
recommended.-Collar apllied
Always -A-airway with C-spine
control

30. Common Errors during
Trauma management-
self criticism serves as
future guideline
Unintentional errors in medicine are not
uncommon-but we need to minimize them
Still continuing Mistakes like
Inappropriate inter-hospital
transfer of unstable pts=3.1%
Unstable pt sent to Ct
scan=3.1%?

31. This is a clear example of a
patient in whom airway
management requires a so-
called "surgical airway".
This patient's face hit the
dashboard in a motor vehicle
accident.
The most experienced
anesthesiologist or emergency
physician would have a difficult
time recognizing the anatomical
landmarks in intubating this
patient
Common ERRORS -Airway
management-
 This is a clear example
of a patient in whom
airway management
requires a so-called
"surgical airway".
 The most experienced
anesthesiologist or
emergency physician
would have a difficult
time recognizing the
anatomical landmarks in
intubating this patient
What this pt needs-nxt

32. Surgical Airway -Crico- thyroidotomy
Don’t waste time by
repeated attempts.
only way to attain an
adequate airway
in this patient
was with a
Surgical
cricothyroidotomy

33. Do not,….put NGT
 Patient who has evidence of a
Basilar skull fracture with ,
“Raccoon eyes" sign.
 .

What you should not attempt here is ?
WHAt is wrong in this picture?
Passing NG tube through the nose.
can go through injured cribiform
plate, and pass into the brain.
Place tube through the mouth

34. B-Breathing
 Expose the patient's
chest, quickly to assess
rapidly;
 Recognise & treat life-
threatening conditions
##
 Tension pneumothorax
 Open pneumothorax
 Flail chest
 Hemothorax;
 Cardiac tamponade.
 #Need ICT Drainage

35. C- CIRCULATION
 Hypovolaemia due to Hemorrhage is the
predominant cause of post injury deaths
.
 Notice the indirect informants of circulation status
within seconds
 Level of consciousness
 Skin color
 Pulse –rate,character,volume.
 Capillary refilling
 BP
 BP-unreliable indicator
Tachycardia is the predominant sign of blood loss##

36.  All Types of SHOCK
may be present
 Hypovolaemic shock
commonest
 The presence of a
"normal" blood
pressure does not
exclude significant
intra-abdominal
bleeding,##
 Injury to hollow viscera
especially with short
prehospital times,
SHOCK in Trauma

37. `
Class 1
0-15%
Class 2
15-30%
Class 3
30-40%
Class 4
>40%
Amount
loss
750 ml 750-1500 1500-
2000 ml
>2000ml
Syst.B.P. >110 >100 <90 <90
Pulse R <100 >100 >120 >140
Resp.R 16 16-20 21-26 >26
Mental S anxious agitated confuse lethargic
Treatment R/L R/L R/L,FCM
blood
R/L,PCM,F
CM blood

38. Fluid resuscitation in Trauma-crystalloids vs
colloids. What , How < Where; (Which size )
 Insert Two large-bore
short (14) IV's
peripherally,
 Shock therapy -Give
One-two liters of
balanced salt solution,
either Ringer's Lactate
or Normal saline,(warm)
during the first few
minutes.
Based on 3:1 rule when using
crystalloids
DO NOT OVER INFUSE?

39. Observe Response to Shock
therapy (fluid challenge )
1. Responder;A sustained improvement in
the signs of shock will hopefully be seen, and this suggests
blood loss is less than 25% of the blood volume.
2. Transient Responder-If the improvement is
short lived, this indicates continuing haemorrhage that
requires control.
1. Surgical intervention may be required and further blood
transfusion necessary.
3. Refractory -If no improvement in the
condition of the patient is seen-Blood loss is greater
than 40%

40. Q.How we Evaluate our
resuscitation?
--vital signs are
impt but poor
indicators
Urine output- is
Sensitive index
Adult-50ml/hour(0.5ml/hr)
Child- 1ml/kg hour
<1year -2ml/kg/hour

41. If blood is needed –how much time it needs
Type of blood Time required for preparation
 Full crossmatch 30-45 minutes
ABO Compatible 10 minutes
Uncrossmatched O
Rhesus Negative Available Immediately

42. Errors due to Over-resuscitation with
fluids
CAUTIOUS IN GIVING LOT OF iv
FLUIDS(Crystalloids- esp with lung
and head injuries
Over-resuscitation is a consequence
of aggressive fluid management in
the face of hypotension.—can lead
Compartment
syndrome/hemodilution sequences
The pulmonary consequences ##of
(fatal in polytrauma pts).###esp s
A new
protocol
was
instituted
in 2003
,clear
guidelines
to limiting
fluids,
beginning
inotropic
agents, &
rapid
control of
bleeding.

43. D- DISABILITY
Consider early intubation
Establish the patient’s level of consciousness
& pupillary sign & reaction .
 Simple way to detect the level of
consciousness is
the (AVPU) method :
A - Alert
V - Responds to vocal stimuli
P - Responds to painful stimuli
U - Unresponsive
 The Glasgow Coma Scale is more
detailed neurological evaluation that is
quick and simple
 Head injury ; Decreased Oxygenation;
Shock
 .
Early Dx/Mangement of severe Head injury is important to
prevent secondary injury to brain

44. E - EXPOSURE
 PT completely undressed
to see underlying injuries
with precautions –privacy
(esp;female pt) .
 Cover the patient to
prevent
HYPOTHERMIA#/
* Warm- blankets;
* I.V Fluid;
* Warm environment
For Privacy..

45. Did you forget the back
 Turn the casualty over
when you can do it safely
 LOOK for injuries-
Palpate ribs, spine, sacrum
for tenderness and
irregularities ##
 Dress the wound with an
occlusive dressing

46. Use of Log rolling to inspect back
?Spinal injury
 The patient must be log
rolled (figure 8) and the
entire spine examined for
deformities or injuries.##
 The rest of the back
should also be
examined at this point to
exclude other injuries.

47. Seat Belt Sign
www.emedicine.com
An external
sign(Seat belt) like
this signifies
serious injury
inside;##

48. Small bowel;duodenum;colon –all can b injured

49. Rupture urethra signs-
The three signs are
1. Perineal hematoma
2. Scrotal hematoma,
3. Blood at the
urethral meatus. #
 Possible membranous
urethral disruption in the
male with blunt pelvic
trauma.
the abnormal position or
absence of a prostate,
or a "high-riding
prostate" is another
clinical signs;
DO NOT ATTEMPT
CATHETER
What you should not attempt here is ?

50. Grey Turner Sign-don’t underestimate
this discolration =-ecchymoses
-
Flank ecchymosed from internal bleeding

51. Evisceration Injuries -
pt should GO TO OR
Extrusion of abdominal contents secondary
to abdominal trauma
Entrance
Wound

52. Ancillary aids-Lab & xrays
 BLOOD:
 URINE exam.(preg test)
Cbc;CHEM:
 AMYLASE.
 ABG
 *for Grouping, Drug level, etc)
 Initial Hb/Hct may be
misleading due to
hemoconcentration or hemodilution,
Repeat Hb/hct is recommended
 Pregnancy test –blood
 3 impt Xrays-
Cx;Chest;Pelvis#
 FAST/DPL/CT SCAN free air under the diaphragm,-
Plan=OR

53. 1. The patient should be
repeatedly reassessed,
particularly if clinical signs
change.
2. Any immediately life
threatening condition
diagnosed should be rectified
without delay.
3. Any external bleeding should
be stopped by using direct
pressure.
4. Penetrating wounds and
impalements must be left for
formal surgical exploration

54.  Will depend on the nature/severity injuries
detected during the preceding examination.
 The highest priority is given to those that are
potentially life threatening.


55. .
Unduly long initial op procedures done
on unstable pts=(7.8%)
ERRORS Damage control
surgery principles not
followed
@
Policy of Permissive
Hypotension
## ?whether we can do
conservative management
for solid organs-For hajis
.
The principles of damage control
surgery are:
Control hemorrhage
Prevention contamination
Avoid further injury
Surgical priorities - Damage control versus early total care
Definitive surgical repair is delayed until
the patient is stable and adequately
resuscitated

56. Lethal triad –”prevention is the KEY
Lethal triad
Coagulopathy
Hypothermia
Acidosis
Most of POLY Trauma Deaths due to unawareness of ….

57. Prevention is better
than cure
Follow safety standards
Driving too fast
Tougher Police
enforcement for violators
inexperience of complex traffic conditions
STOP Road rage

58.  WHAT CAN MAKE DIFFERENCE?
 The The Lancet Editorial concludes: "But the
individual solution lies with what is perhaps
one of the hardest things to change -
Human Behaviour
 Road accidents disproportionately affect
young people. Being taught about road safety
from a very young age must become a
priority, with adults setting a good example at
all times.“

59. ?
COULD WE HAVE DONE BETTER
Every time ask yourself before you
are asked –Q;How to improvise?
Ans ; by SELF AUDITING /CRITICISM
How many ERRORS occurred today in our ER set up during …….. Management ?
1-Airway management
2.Hemorrhage control
3-Inappropriate Mx of unstable patients
4-Complications of procedures
5-Inadequate prophylaxis
6-Missed or delayed diagnoses
7-Over-resuscitation with fluids;
8-Transfer errors-Other poor coordination decisions

60. In All cases it is essential to ensure that those
treating the patient are safe to carry out the
work. And follow principle
DO NO MORE
HARM?

61. THANKS FOR YOUR ATTENTION
Dr. Fiaz Maqbool Fazili