1. The document discusses the approach and management of polytrauma patients. It outlines the concepts of trauma care including the ATLS philosophy and damage control surgery.
2. Polytrauma is defined as two or more body regions with signs of systemic inflammatory response syndrome (SIRS). The metabolic response to trauma occurs in two phases - the ebb phase which conserves energy and the flow phase which mobilizes resources.
3. Management principles include organized team approach, treatment before diagnosis, and frequent re-examination. The primary and secondary surveys follow the ATLS protocol to address airway, breathing, circulation, disability, and exposure.
8. METABOLIC RESPONSE TO
TRAUMA
TWO PHASES
ďśEBB PHASE
ďśRole: conserve volume & energy
for recovery & repair
ďśFLOW PHASE
ďśRole: mobilization of body
resources
22. PRINCIPLES OF TRAUMA
MANAGEMENT
⢠Organised team approach
⢠Assumption of most serious injury
⢠Treatment before diagnosis
⢠Thorough examination
⢠Frequent examination
23. TRIAGE
⢠In French, triage
means âto sortâ
⢠Goals:
⢠To identify the high
risk injured patients
⢠To channelise the
transport of
patients to
appropriate centres
24. 3 PHASES OF
TRIAGE
⢠Pre hospital Triage
⢠At the scene of trauma
⢠On arrival at hospital
25. MULTIPLE CASUALTIES
⢠The number &
severity <
Facility of the
center
⢠Priority is for
life threatening
injuries
26. MASS CASUALTIES
⢠The number &
severity >
Facility of the
centre
⢠Priority is for
best chance of
survival, least
expenditure
27. COMMUNICATION
⢠Co ordination between pre
hospital & hospital care
⢠Timely preparation & mobilization
of trauma team
⢠Hemodynamic instability is also
informed
28. HAND OVER
⢠Ambulance driver to Trauma
team leader verbally
MIST
⢠Mechanism of Injury
⢠Injuries suspected
⢠Vital signs
⢠Treatment en route to hospital
29. TRAUMA TEAM
⢠For better triage & care
⢠Registrars from
ED
ICU
Surgery
Radiology
Anaesthesiology
⢠Theatre staff
⢠Spokesperson
30. ROLES SPECIFIED
⢠Team LeaderâRegistrar from ED or ICU
Airway Doctor
⢠Plans interventions & treatment in
consultation with Surgical Registrar
[Traffic Controller & Information Collator]
⢠Surgical RegistrarâCirculation Doctor
Procedure Doctor
Secondary Survey
34. 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
37. 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?
46. 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
47. Cricothyroidotomy
INDICATIONS
⢠Trauma causing oral, pharyngeal
or nasal haemorrhage
⢠Foreign body obstruction
⢠Maxillo facial injuries
48. Technical considerations
⢠No surgical Cricothyroidotomy
below 12 years
⢠A permanent tracheostomy within
24 hrs
⢠More than 2 daysâhigher risk of
glottic stenosis
58. 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
60. HAEMOTHORAX
⢠ICD
INDICATIONS OF THORACOTOMY
⢠Initial 1500 ml
⢠200 ml for 3 consecutive hours
61. FLIAL CHEST
⢠Rib fractured at 2
different places
⢠Paradoxical chest
movements
⢠Underlying lung
contusion
⢠Positive pressure
ventilation
⢠Rarely surgical
fixation is necessary
62. CIRCULATION & HAEMORRHAGE
CONTROL
⢠Surgical Registrar & procedure
nurse apply pressure bandage to
open wounds
Signs:
⢠Deteriorating conscious level
⢠Pallor
⢠Rapid , thready pulse
63. 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
65. THE STRATEGY
⢠Primary Haemorrhage Control and
timely surgical intervention rather
than Overaggressive Fluid
Resuscitation
[ Permissive Hypotension ]
66. THE PROCEDURES
⢠IV access by procedure doctor
⢠2 wide bore cannula - 14 G or 16 G
⢠Scalp bleedingârunning locked
sutures
⢠Open fracturesâdirect pressure,
reduction& splinting
⢠No blind clamping of vessels
⢠Angiography & embolisation
67. CAUSES OF MAJOR BLEEDING
MAJOR BLEEDING -THE BIG FIVE
⢠EXTERNAL
⢠THORACIC
⢠PELVIC
⢠LONG BONES
⢠ABDOMEN
68. FLUID THERAPY
⢠Crystalloid fluid is preferred
⢠Class 3 &4 shockâcolloid
fluid advised
⢠Bolus of 1 litre of RL given
69. 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!
72. Transfusion Guidelines
⢠HCT < 21
⢠Lesser HB trigger in
Asymptomatic patients
⢠Higher HB trigger in severe CV
diseases
73. 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
74. 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
75. DISABILITY & NEUROLOGICAL
EXAMINATION
⢠Level of Consciousness = Best
brain perfusion sign
⢠Use AVPU initially
⢠Check pupils
⢠Eyes are the window of the CNS
76. Brief Neurologic Examination
⢠AâAlert
⢠V âResponds to Vocal stimuli
⢠PâResponds to Painful stimuli
⢠UâUnresponsive
More detailed evaluation
-during the Secondary Survey
77. Decreased LOC
⢠Brain injury
⢠Hypoxia
⢠Hypoglycemia
⢠Shock
⢠Never think drugs, alcohol, or
personality first
79. DISABILITY INTERVENTIONS
⢠Spinal cord injury
âHigh dose steroids if within 8 hours
⢠ICPmonitor-Neurosurgical consultation
⢠Elevated ICP
âHead of bed elevated
âMannitol
âHyperventilation
âEmergent decompression
80. Exposure&Environmental protection
⢠Complete disrobing of patient
⢠Logroll to inspect back
⢠Rectal temperature
⢠Warm blankets/external warming
device to prevent hypothermia
82. PAUSE & CHECK
⢠Are all immediately life-threatening
injuries
identified?
⢠Is all monitoring in place?
⢠Investigations ordered?
⢠Analgesia?
⢠Relatives informed?
⢠Non-essential team
members disbanded?
83. The well practiced
trauma team
should aim to
complete the
primary survey in
less than 10
minutes
84. Adjuncts to Primary Survey
⢠ECG monitoring
⢠Urinary and Gastric Catheters
⢠Monitoring
⢠X-rays and Diagnostics Studies
85. 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
86. 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
87. INDICATIONS FOR ICU
ADMISSION
Requirement for:
⢠Airway protection and mechanical
ventilation
⢠Cardiovascular resuscitation
⢠Severe head injury
⢠Organ support
⢠Correct coagulopathy
⢠Invasive monitoring
89. SECONDARY SURVEY
⢠Does not begin until the primary
survey (ABCDEs) is completed
⢠Complete history
⢠Head-to-toe evaluation
⢠Reassessment of all vital signs
90. HISTORY
A - Allergy
M- current Medication
P- Past illness and operation
L- Last meal
E- Event and Environment
related to the injury
91. A Complete âHead to Toeâ
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
⢠Neurologic: GCS,feels all four/moves all four
92. LOG ROLLING
⢠4 Persons required
⢠1 - Spinal inline traction
[anaesthesiologist]
⢠2 -Torso
⢠3- Pelvis & Lower limb
⢠4- Detailed examination of back
93.
94. EXAMINATION OF BACK
⢠Examine entire spine
⢠Any penetrating injury or exit
wound
⢠Appropriate Dressing
⢠Palpation of posterior chest
wall
⢠Percussion & Auscultation of
post.chest
96. 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
97. 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
103. DPL
Advantages
⢠Fast
⢠Sensitive
⢠Can be performed while resuscitation
ongoing
Disadvantages
⢠Invasive
⢠Learning curve
⢠Not Organ specific
105. 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
107. ADVANTAGES OF FAST
⢠Fast
⢠Noninvasive
⢠Can be performed while
resuscitation ongoing
⢠Can be very sensitive
108. DISADVANTAGES OF FAST
⢠Operator dependent
⢠Body habitus may limit
quality/sensitivity
⢠Organ aspecific
⢠Canât detect Hollow viscous
and retroperitoneal injuries
110. CARRY HOME MESSAGE
⢠Organised Team Approach
[There is no âIâ in TRAUMA]
⢠Initial Assessment & Management is the key
⢠Interferon âgamma, Epidural Anaesthesia &
Early enteral nutrition
⢠Appropriate Triage according to resources
⢠Communication is pivotal for better
preparation or Trauma Team
111. ⢠ATLS Philosophy
⢠Primary Survey in 10 min
⢠C-Spine protection with
Philadelphia Collar
⢠Needle Cricothyroidotomy â Ideal
in emergency situations where
Intubation is not feasible
⢠Tension Pneumothorax is a clinical
diagnosis; Immediate needling
should be done
112. ⢠Primary Operative Control of haemorrhage
is preferred over Overaggressive Fluid
Resuscitation â 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
113. ⢠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
⢠âTubes & Fingers in every orificeâ âTheme of
Secondary Survey
⢠DPL & FAST come in handy in equivocal abdominal
signs & Unexplained Hypotension
⢠Damage Control Surgery is the weapon to tackle
the âTriad of Deathâ
114. TRAUMA @ AHIH
⢠Trauma Team
⢠Trauma Protocol
⢠Training of Personnel
⢠Learning of Procedures
⢠In house/On call Consultants
116. ⢠âFrom 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.â
--Sir Robert Hutchison