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Initial Assessment and Management of the Multiply Injured Patient

Dr Akif Durrani

PRE HOSPITAL TRAUMA CARE SYSTEM


Basic life support (BLS) system Non invasive supportive care to trauma patients by emergency medical technicians Transport trauma patients rapidly to a medical care facility Paramedic Performed Advanced Trauma Life Support (PARAALS) system Perform invasive procedures such as intubation and intravenous fluid therapy, administer drugs Physician Performed Advanced Life Support(PHYSALS) systems

TRAUMA MORTALITY

Early phase - immediate death

severe brain injury, disruption of great vessels, cardiac disruption


subdural, epidural hematomas, hemopneumothoraces, severe abdominal injuries, multiple extremity injuries (bleeding) multisystem organ failure sepsis

Second phase - minutes to hours

Third phase - delayed


MULTIDISCIPLINARY TRAUMA TEAM


Trauma Surgeon TEAM LEADER Anesthesia Musculoskeletal traumatologist Neurosurgeon Vascular/CT surgeon Urology, Gynecology

Interventional radiology Intensivist Hospital Staff-Nursing, PT, OT, Speech, Admin. Legal/Security Social work Ministry

POLYTRAUMA PATIENT

Injury Severity Score >18 Hemodynamic instability Coagulopathy Closed head injury Pulmonary injury Abdominal injury

INJURY SEVERITY SCORE


Def.: scale of anatomic injury ISS is the sum of the squares of the three highest AIS categories AIS (Abbreviated Injury Scale) looks at six categories: head and neck, face, chest, abdominal, extremities, and external (soft-tissue) injury Maximum ISS is 75

PRINCIPLES OF RESUSCITATION ATLS

Phases of management

Priorities in treatment
Airway Breathing Circulation/CNS Digestive system Excretory Tracts Fractures

Primary Survey Resuscitation Secondary Survey Definitive care

AIRWAY

Establish and maintain an appropriate airway


obtain patency-jaw lift oral or nasal airway surgical airway

Control of the cervical spine Lateral C-spine radiograph

not included in the initial radiographic evaluation in the revised ATLS protocol

BREATHING

Assess breathing and oxygenation Evaluation with Arterial Blood Gas (ABG) Etiology of decreased oxygenation has to be determined

Tension pneumothorax-decompress Open pneumothorax-seal and chest tube Flail chest, pulmonary contusion-chest tube

Mechanical assistance with ventilation may be required

INDICATIONS FOR INTUBATION

Control of airway Prevent aspiration in unconscious patient Hyperventilation for increased intracranial pressure Combative Patient Obstruction from facial trauma and edema Prophylactic Intubation for impending indications above

CIRCULATION

Identifiable bleeding controlled with direct pressure Always try direct pressure first Avoid blind use of vascular clamps Tourniquets are rarely indicated except for traumatic amputations or when direct pressure will not control hemorrhage

ASSESSMENT OF BLOOD PRESSURE PERIPHERAL PERFUSION


Peripheral radial femoral

Pulse

Systolic

carotid

Blood Pressure 80 mm Hg 70 mm Hg 60 mm Hg
Hypotensive

capillary

refill > 2 secs

RESUSCITATION
Two peripheral large bore IVs BOLUS two liters of Ringers Lactate

If no response then severe hemorrhage has occurred immediate blood is needed

Monitor

Blood pressure
Urinary output Base deficit Initial Hematocrit/Hemoglobin unreliable

TYPES OF SHOCK

Hemorrhagic (hypovolemic) Cardiogenic-(e.g. pericardial tamponade) Neurogenic, spinal cord injury


hypotension without tachycardia Vasoconstrictive meds not administered until volume is restored

Septic-late sequela

BLOOD TRANSFUSION

Crossed Matched

1 hour 10 minutes immediately

Type Specific

Type O Rh neg

Blood warmer-prevents hypothermia, arrhythmias Blood filters-160 u macropore Coagulation status-Platelets monitored every 10 units

Platelets < 100,000-replace If continued hemorrhage-replace

Labile factors (fibrinogen)replace with FFP

MANAGEMENT OF SHOCK SUMMARY


Direct control of bleeding sources Large bore IV access-Fluid replacement Monitor-urine output, CVP, pH, lactate level Blood replacement-indicated by clinical response

SECONDARY SURVEY

Head
skull trauma reevaluate pupillary size and reaction blood/fluid at tympanic membranes and nares facial and ethmoid fractures

Cervical spine

swelling, crepitus, expanding hematoma

NEUROLOGICAL EXAM

Glascow Coma Score-GCS Pupil examintracranial pressure Motor and Sensory all extremities in alert patient

SECONDARY SURVEY

Chest-reevaluate for

crepitus, fractures, flail segments,open wounds

Abdomen-inspect,

auscultate, palpate
seat belt injury-spinal or intraabodominal injury

Pelvis-exam for

tenderness, instability

SECONDARY SURVEY

Rectal exam

tone, sensory, prostate injury if abnormal (i.e. high-riding prostate), do not pass foleyconsult Urology palpate for crepitus, swelling, pain, instability, range of motion

Extremity exam

Neurological exam-document all findings

TRAUMA SEVERITY SCORES

Physiologic

Trauma Index-Kirkpatrick and Youman Glascow Coma Scale Abbreviated Injury Scale (AIS) Injury Severity Score (ISS)

Anatomic Damage

Biochemical Indices

EXPECTED BLOOD LOSSES

Pelvis/acetabulum - 8-10 units Closed Femur - 2-3 units Closed Tibia - 1-2 units Open fractures will bleed more!

ORTHOPAEDIC EMERGENCIES

Open fractures Dislocations Compartment syndromes Cauda equina syndrome Extremities with neurological or vascular compromise

ORTHOPAEDIC PRIORITIES
Reduce and stabilize dislocations Fasciotomies in compromised limbs Proper debridement and irrigation of open injuries Stabilization of long bone injuries Secure fixation of intra-articular fractures Proper splinting of other injuries

INDICATIONS FOR DAMAGE CONTROL SURGERY


Physiological Criteria HYPOTHERMIA COAGULOPATHY ACIDOSIS

(LETHAL TRIAD)

PATIENT STABILITY

Adequacy of resuscitation

Vital signs of resuscitation deceptive Laboratory parametersbase deficit, lactic acidosis

Anesthesia-agents-myocardial depressants Coagulopathy-dilution, DIC, thrombocytopenia As long as hemodynamic stability is maintained, there is no evidence that duration of the procedure alone results in pulmonary or other organ dysfunction or worsens the prognosis of the patient
Must be ready to change plan as the patient status dictates

DECISION MAKING

General surgery, Anesthesia, Orthopaedics Magnitude of the procedure can be tailored to the patients condition Timing and extent of operative intervention based on physiologic criteria Too sick for an operation not acceptable given current knowledge May require damage control surgery as a temporizing and stabilizing measure

REASONABLE APPROACH

Timing (when?) Titration (how much?) Temporization (when necessary) Temptations (avoid)

INCOMPLETE RESUSCITATION

Based on physiological assessment ICU - monitoring, resuscitation, rewarming, correction of coagulopathy and base deficit Once patient is warm and oxygen delivery is normalized reconsider further operative procedures

UNILATERAL FRACTURE PATTERNS

Careful immobilization of diaphyseal fractures is first phase of fracture management

Periarticular fractures of large joints and open reduction and internal fixation is not possible then trans articular external fixation

BILATERAL FRACTURES

Incase of bilateral fractures simultaneous treatment is ideal Evaluation of injury severity with more severe injuries being stabilized first If patient vital sign deteriorate then second leg may be temporarily stabilized

UPPER EXTREMITY INJURY

Secondary to the treatment of head ,trunk ,lower extremity injuries. Further imaging is done

Definitve treatment is carried out after stabilization of patient.

LOWER EXTREMITY INJURY

Long bone fractures with severe head injury or chest trauma require specially modified strategy

Expanded monitoring of respiratory function, ventilation, circulatory hemodynamics is essential

PELVIC INJURIES

MANAGEMENT OF PELVIC INJURIES

Type A operative treatment is not required usually. Type B adequate stabilization is obtained by osteosynthesis of pelvic ring only. Type C anterior and posterior osteosynthesis for adequate stability.