Polytrauma management
SEQUENCE FOLLOWED
In Trauma (According to ATLS)
• ABCD (Airway Breathing Circulation Disability Exposure
& environment control)
• In ACLS/BLS
• CAB (Circulation Airway Breathing)
ATLS PROTOCOL
Composed of
o Primary survey
• Secondary survey
Primary survey
Aimed at detecting & simultaneously treating immediately life-threatening injury
• Sequence followed
o A-Airway maintenance with cervical spine protection
B -Breathing that includes ventilation and oxygenation
C-Circulation with hemorrhage control
o D-Disability (brief neurological examination)
0 E-Exposure with environment control
Secondary survey
Consists of head to toe systematic assessment of with
special emphasis to
o Abdominal
o Pelvic and
o Thoracic areas
Complete inspection of body surface to find all injuries
and neurological examination
Tertiary survey (not included in ATLS-Recently used)
• It is a comprehensive patient evaluation after initial resuscitation (after 24 hours)
• It Includes
• Thorough physical examination
o Combined with targeted radiography imaging include
› X-rav
› USG or CT based on examination findings
• Main advantage of tertiary survey is it decreases delays in
Dx of potentially life-threatening injury
PRIMARY SURVEY
[Link] MAINTENANCE WITH CERVICAL SPINE PROTECTION
Cervical spine > airway
In all trauma patients - Cervical spine injury should be Suspected
Cervical spine immobilization should be done
• Assess the patency of airway- by eliciting verbal response
Ability to speak suggestive of Adequate airway protection
If patient not able to speak - suspect Mental status depression or obstruction of airway
Indications for Airway management
~other indication for airway management
-noisy breathing
- Facial trauma
- GCS <8
Stepwise progression in compromised airway
1. Clear the airway -By suctioning of secretion of blood
2. Chin lift /Jaw thrust
3. Insertion of oropharyngeal or nasopharyngeal airway
• Definitive airwav of choice in most of trauma patient's
Oral endotracheal intubation with cuffed ET tube
ATLS I0' edition recommends - Video laryngoscope
for intubation
IN PATIENTS OF SEVERE MAXILLOFACIAL INJURIES
Needle cricothyroidotomy
Emergency airway of choice
Performed quickly
• High flow 02 given via 4-6 mm tube
o Disadvantage
Co2 retention within 20-30 mins
Avoided in children <12 years due to the risk of
Subglottic stenosis
•tracheostomy- Definitive airway of choice
[Link] (VENTILATION + OXYGENATION)
Assess Breathing-By visualizing chest moments
Assess rate & depth-by Percussion and Auscultation
• O2 saturation
Limited respiratory efforts / dyspnea - Patient requires
Ventilation & further assessment
CAUSES OF VENTILATION PROBLEM
[Link] pneumothorax
o clinical diagnosis on the basis of suspicion
Wide bore needle in 2nd I/C space in MCL
Note
According to ATLS 10th edition - Recent evidences
support insertion of needle in 5th I/C space slightly
anterior to MAL in Adults
2. Massive hemothorax
• ICD insertion (28-32 F)
3. Massive pulmonary contusion
• For Severe pulmonary contusion - Aggressive
mechanical ventilation is performed
Acc. to 11 edition of Schwartz - Anterior Axillary line for
ICD insertion
3. CIRCULATION WITH HEMORRHAGE CONTROL.
• Assess circulation - Primary goal is to look for shock
• MC cause of shock in trauma - Bleeding (Hypovolemic shock)
Assess vitals
• PR> 100/ min or BP < 100 mmHg
Unstable vitals -Suggestive of Shock
• Mx of shock
• Put two Large bore IV canula (Green 18 G)
. Send blood to cross match
o 1-2 liters or warm Isotonic Crystalloid solution (old
edition)
Note
• ATLS10th edition
1 liter of warm crystalloid solution in adults
20 ml/ kg warm crystalloid solution in children < 40 kg
Rapid screening - To identify causes of life-threatening
blood loss
5 major locations that cause Exsanguination leading to
Shock
1. External blood loss (on the floor at the site of accident)
2. Chest
2 Abdomen
4. Retroperitoneum (pelvicfracture)
5. Multiple long bone fracture
During initial physical examination
Identify source of external bleeding - Direct pressure over the site of bleeding
o Identify Long bone fracture - Splinting should be done
Investigations done
o CXR- to evaluate Thoracic blood loss
o X-Ray Pelvis -to identify Pelvic fracture
FAST- for evaluation of Abdomen
o CECT is not done in 1° survey
Two most important X-ray in trauma patient
• CXR (PA)
o Xray pelvis (AP view)
• In non-responding pts. With ongoing signs of shock
- Manage ongoing bleeding
-blood transfusion
In Trauma transfusion, ratio to be followed is
• Packed cell: Plasma: Platelets ®1:1:1
Best Indicator of tissue perfusion in trauma-urine output
• Best indicator to determine fluid requirement-CVP
Acc. To ATLS manual 10th edition - Pediatric mass
transfusion Protocol p
o Initial 20 ml/kg bolus of warm isotonic crystalloid
o Followed by 10-20 ml/kg of Packed cell
10-20 ml /kg of Plasma
Ratio of 1:1:1
- 10-20 ml /kg of Platelets
CRASH-2 TRIAL
Recommends use of Tranexamic acid in hypotensive trauma patients
o 1 gm IV over 10 minutes followed by 1 gm over 8hours
o Advantages
Reduces the risk of mortality from bleeding in both blunt and penetrating trauma
Indications for Tranexamic Acid
All trauma patients aents have suspected
hemorrhage including SBP < 110 mmHg or PR >
110/min
o Administrated within 3 hours of injury
4. DISABILITY (BRIEF NEUROLOGICAL
EXAMINATION)
Assess GCS
Assess pupils
o Size
Equality
Reaction
Components of GCS
Maximum GCS score - 15 (E4 V5 M6)
Minimum GCSscore-3 (E1 V1 M1)
-Bestindicator of outcome - Motor response
On the basis of GCS score
13-15- Mild head injury
9-12 - Moderate head injury
<8 -› Severe head injury
Not testable
VNT
Reporting of nontestable components
Any element that cannot be tested should be marked as
NT
• It is no longer recommended to assign point to NT
elements
GCS-P
P pupil reactivity score
No-of N/R pupils
Both N/R-2 ,OneN/R-1 , Neither-N/R-0
Minimum-15
Maximum-1
GCS PACT
GCS
P-Pupils
A-AGE
CT -CT findings
[Link]/ ENVIRONMENTAL CONTROL
All clothing of patients should be removed - for adequate examination
Core body temperature should be obtained
• Keep the patient warm
Environmental control is done by
o Warm blankets
Increasing room temperature
Heated IV fluid administration
Bodv warmers
1) Acc. To ATLS 10th edition - Life threatening injuries
during primary survey are
3) SECONDARY SURVEY
Obtain AMPLE history from pt./ Relatives
A-Allergies
M-Medications
P-Pastillness/pregnancy
Last meal
E-Events related to injury
4) Apart from ample history we must perform
Systemic assessment from head to toe
Complete inspection of body surface
^ To Find all injuries
Neurological examination
STEPS OF SECONDARY SURVEY
Examination of 1) Head & face-R/O fracture & laceration ,2) Neck-R/O neck injuries ,3) Chest-R/O rib
fracture
4-Abdomen
o R/O abdominal
o Pain
o Tenderness
• Bruising
o NG tube insertion
In case of facial trauma - orogastric tube insertion
o Check meatus - if no blood at meatus. Foley's
catheterization is done
5) Back Aka Log roll
5 people are required for supporting
1- for head
3- for Body
1- for examination of back , ideal - 5 ,-› Minimum -4
• While back examination DRE is done
6) Extremities - for Tenderness, Crepitus and Deformity,
Abnormal movements -R/O Fractures
7) Neurological examination
• Repeat GCS
Re-Evaluate pupils
Look for localizing and lateralizing signs
Look for signs of spinal cord injury