APPROACH & MANAGEMENT OF

POLYTRAUMA

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M.S[[Link]].,D.N.B[[Link]].,
AL HAYAT INTERNATIONAL
 OUTLINE
❖ Concepts of trauma care
❖ Principles of trauma management
❖ ATLS Philosophy
❖ Damage control surgery
❖ Future directions
 EPIDEMIOLOGY
❖ Trauma—commonest cause of
death between 1-40

❖
By 2020, injuries—third
leading cause of death
Definition of Polytrauma

❖ 2 or more body regions with SIRS

 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
 SEPSIS
❖SIRS with a proven infective
source
 MODS
Severe Sepsis
❖CVS
❖RS
❖Kidney
❖Liver
❖Coagulation
 METABOLIC RESPONSE TO
TRAUMA
TWO PHASES
❖EBB PHASE
❖Role: conserve volume & energy
for recovery & repair
❖FLOW PHASE
❖Role: mobilization of body
resources
 EBB PHASE
❖ Lasts for 24-48 hrs
❖ Characterised by
❖ Hypovolaemia
❖ Decreased BMR
❖ Reduced cardiac output
❖ Hypothermia
❖ Lactic acidosis
 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
METABOLIC RESPONSE TO TRAUMA
 PHARMACOLOGICAL
IMMUNOMODULATIO
N
IMMUNO
NUTRITION
 IMMUNO
SUPPRESSION
• Epidural anaesthesia
• Statins
• B blockers
• Tranexamic acid
GRADES OF HAEMORRHAGE
REVISED TRAUMA SCORE
 “WELL BEGUN IS
HALF DONE”

• Initial assessment & management

is critical in decreasing morbidity
& mortality
• Aids recovery
THE GOLDEN HOUR
TRIMODAL DEATH
DISTRIBUTION
TRIMODAL DEATH
DISTRIBUTION
 PRINCIPLES OF TRAUMA
MANAGEMENT

• Organised team approach

• Assumption of most serious injury
• Treatment before diagnosis
• Thorough examination
• Frequent examination
TRIAGE
• In French, triage
means “to sort”
• Goals:
• To identify the high
risk injured patients
• To channelise the
transport of
patients to
appropriate centres
 3 PHASES OF
TRIAGE
• Pre hospital Triage
• At the scene of trauma
• On arrival at hospital
MULTIPLE CASUALTIES
• The number
& severity <
Facility of the
center
• Priority is for
life threatening
injuries
MASS CASUALTIES
• The number
& severity >
Facility of the
centre
• Priority is for
best chance of
survival, least
expenditure
 COMMUNICATIO
•N
Co ordination between pre
hospital & hospital care
• Timely preparation & mobilization
of trauma team
• Hemodynamic instability is also
informed
 HAND OVER
• Ambulance driver to
Trauma team leader verbally
MIST
• Mechanism of Injury
• Injuries suspected
• Vital signs
• Treatment en route to
 TRAUMA
TEAM
• For better triage & care
• Registrars from
ED
ICU
Surgery
Radiology
Anaesthesiolog
y
• Theatre staff
 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
 ATLS PHILOSOPHY

• Primary Survey & Resuscitation

• Secondary Survey

• Definitive Care
PRIMARY
SURVEY
 PRIMARY SURVEY
• A—Airway Maintenance
& Cervical spine
protection
• B—Breathing & Ventilation
• C--- Circulation & Haemorrhage
Control
• D--- Disability: Neurological
status
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
PHILADELPHIA COLLAR
• 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?
Predisposing Conditions
• Coma
• Aspiration
• Maxillofacial trauma
• Neck injury
• Haematoma
• Laryngeal injury
• Thoracic inlet penetrating injury
 Signs of Airway Obstruction :
"Look"

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

• Speech? "How are you?"

Hoarseness
• Noisy breathing
• Gurgle
• Stridor
Signs of Airway Obstruction :
"Feel"

• Fracture crepitus
• Airway structures in neck
• Tracheal deviation
• Haematoma
AIRWAY RESUSCITATION

• Suction
• Chin lift
• Jaw Thrust
• Oral airway
• Definitive Airway
• POLY5-34
CHIN
LIFT
JAW THRUST
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]
 Cricothyroidotomy

INDICATIONS
• Trauma causing oral, pharyngeal
or nasal haemorrhage
• Foreign body obstruction
• Maxillo facial injuries
 Technical considerations

• No surgical Cricothyroidotomy
below 12 years
• A permanent tracheostomy within
24 hrs
• More than 2 days—higher risk of
glottic stenosis
NEEDLE CRICOTHYROIDOTOMY
 COMPLICATIONS
EARLY
• Bleeding
• False passage
• Subcutaneous emphysema
• Oesophageal perforation
• Vocal cord injury
 LATE

• Infection

• Glottic & Subglottic stenosis

• Tracheo oesophageal fistula

BREATHING & VENTILATION

Abnormal Breathing : Look

• Cyanosis
• Decline in mental state
• Chest asymmetry
• Tachypnoea
• Distended neck veins
• Paralysis
• Chest wounds
• Flial segment
Abnormal Breathing : Listen

• I can't breathe!

• Stridor, wheezing

• Decreased breath sounds

Abnormal Breathing : Feel

• Surgical emphysema

• Chest tenderness

• Trachea deviated

• Percussion & Auscultation

DEADLY DOZEN THREATS FROM
CHEST INJURY
Immediately Life
Threatening
• Airway Obstruction
• Tension Pneumothorax
• Pericardial Tamponade
• Open Pneumothorax
• Massive haemothorax
Potentially Life Threatening

• Aortic Injuries
• Tracheo bronchial Injuries
• Myocardial Contusion
• Rupture of Diaphragm
• Oesophageal injuries
• Pulmonary Contusion
SEALING OF OPEN WOUND
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
TENSION PNEUMOTHORAX
 HAEMOTHORAX
• ICD
INDICATIONS OF THORACOTOMY

• Initial 1500 ml
• 200 ml for 3 consecutive hours
 FLIAL CHEST
• Rib fractured at 2
different places
• Paradoxical chest
movements
• Underlying lung
contusion
• Positive pressure
ventilation
• Rarely surgical
fixation is necessary
CIRCULATION & HAEMORRHAGE
CONTROL
• Surgical Registrar & procedure
nurse apply pressure bandage to
open wounds
Signs:
• Deteriorating conscious level
• Pallor
• Rapid , thready pulse
 Is the heart beating?
• Is there serious external
bleeding?
• Does patienthave radial pulse?
• Absent radial = systolic BP < 80
• Does patient have carotid
• pulse? Absent carotid = systolic
 Is patient perfusing?
• Cool, pale, moist skin
• Capillary refill > 2
• sec
Restlessness, anxiety,
combativeness
If internal hemorrhage, quickly
expose, palpate abdomen, pelvis,
 THE STRATEGY

• Primary Haemorrhage Control and

timely surgical intervention rather
than Overaggressive Fluid
Resuscitation
[ Permissive Hypotension ]
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
CAUSES OF MAJOR BLEEDING
MAJOR BLEEDING -THE BIG FIVE

• EXTERNAL
• THORACIC
• PELVIC
• LONG BONES
• ABDOMEN
 FLUID THERAPY

• Crystalloid fluid is
preferred
• Class 3 &4 shock—colloid
fluid advised
• Bolus of 1 litre of RL
given
 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!
Investigations for tissue perfusion
Transfusion Guidelines
Transfusion Guidelines
• HCT < 21
• Lesser HB trigger in
Asymptomatic patients
• Higher HB trigger in severe CV
diseases
 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
METABOLIC ACIDOSIS
• Decreases Cardiac contractility
• Decreases effectiveness of circulating
catecholamines
• Inhibits propagation phase of
thrombin generation
• Accelerates Fibrinogen
degradation
• Hyperchloremia causes renal
 DISABILITY & NEUROLOGICAL
EXAMINATION

• Level of Consciousness =
Best brain perfusion sign
• Use AVPU
• initially Check
• pupils
Eyes are the
window
Brief Neurologic Examination

• A–Alert
• V –Responds to Vocal stimuli
• P–Responds to Painful stimuli
• U–Unresponsive
More detailed evaluation
-during the Secondary Survey
 Decreased LOC
• Brain injury
• Hypoxia
• Hypoglycemia
• Shock
• Never think drugs, alcohol,
or personality first
 GCS
EYE OPENING VERBAL MOTOR
Spontaneous 4 Oriented 5 Obeys 6
Verbal 3 Confused 4 Localises 5
Pain 2 Words 3 Withdraws 4
None 1 Sounds 2 Decorticate 3
None 1 Decerebrate 2
None 1
DISABILITY INTERVENTIONS
• Spinal cord injury

– High dose steroids if within 8 hours

• ICPmonitor-Neurosurgical consultation
• Elevated ICP

– Head of bed elevated

– Mannitol
Exposure&Environmental protection

• Complete disrobing of patient

• Logroll to inspect back

• Rectal temperature

• Warm blankets/external warming

device to prevent hypothermia
Always Inspect the Back
PAUSE & CHECK

• Are all immediately life-

threatening injuries
identified?
• Is all monitoring in place?
• Investigations ordered?
• Analgesia?
• Relatives informed?
• Non-essential team
members disbanded?
The well practiced
trauma team
should aim to
complete the
primary survey in
less than 10
minutes
Adjuncts to Primary Survey

• ECG monitoring

• Urinary and Gastric Catheters

• Monitoring

• X-rays and Diagnostics Studies

 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
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
 INDICATIONS FOR ICU
ADMISSION
Requirement for:
• Airway protection and mechanical
ventilation
• Cardiovascular
• resuscitation Severe head
• injury
• Organ support
• Correct coagulopathy
SECONDARY
SURVEY
SECONDARY SURVEY

• Does not begin until the primary

survey (ABCDEs) is completed
• Complete history

• Head-to-toe evaluation

• Reassessment of all vital signs

 HISTORY
A - Allergy
M- current Medication
P- Past illness and operation
L- Last meal
E- Event and Environment
related to the injury
 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
• Neurologic: GCS,feels all
 LOG ROLLING
• 4 Persons required
•
1 - Spinal inline
traction
[anaesthesiologist]
• 2 -Torso
• 3- Pelvis & Lower limb
• 4- Detailed examination
EXAMINATION OF BACK
• Examine entire spine
• Any penetrating injury or exit
wound
• Appropriate Dressing
• Palpation of posterior chest
wall
• Percussion & Auscultation of
[Link]
SECONDARY SURVEY

‘Tubes and fingers in

every orifice’
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
 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
DPL
INDICATIONS FOR DPL
• Equivocal abdominal sign

• Unexplained hypotension

• Impaired mental status

• Paraplegia or spinal cord

injuries
CONTRAINDICATIONS FOR DPL
Absolute contraindication
• existing indication for explore
laparotomy
Relative contraindications
• Previous abdominal
operation
• Morbid obesity
• Advance cirrhosis
• Coagulopathy
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
DPL
 DPL
Advantages
• Fast
• Sensitive
• Can be performed while resuscitation
ongoing
Disadvantages
• Invasive
• Learning curve
• Not Organ specific
FAST
 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
FAST
ADVANTAGES OF FAST

• Fast

• Noninvasive

• Can be performed while

resuscitation ongoing
• Can be very sensitive
DISADVANTAGES OF FAST
• Operator dependent
• Body habitus may limit
quality/sensitivity
• Organ aspecific
• Can’t detect Hollow viscous
and retroperitoneal injuries
Trauma Management
 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
• 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
• 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
• 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”
 TRAUMA @ AHIH
• Trauma Team
• Trauma Protocol
• Training of Personnel
• Learning of Procedures
• In house/On call Consultants
July 20 1969
• “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
 A
Dharmendra
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