2 Early Management of Polytrauma 1

Early management of Early management of polytraumapolytrauma

Purnendu SaxenaPurnendu Saxena

MS(Orth), DNB (Orth), MS(Orth), DNB (Orth),

D’Orth (UK), MCh Orth (UK),D’Orth (UK), MCh Orth (UK),

FRCS (Trauma and Orth)(UK)FRCS (Trauma and Orth)(UK)

Society for care in emergency Society for care in emergency

Why Why

Trauma care is need of our societyTrauma care is need of our society Mortality is highMortality is high Most of the victims are young and Most of the victims are young and

the resultant loss to the families are the resultant loss to the families are catastrophic catastrophic

Many of these deaths are Many of these deaths are preventable preventable


Early care Early care

Requires a Requires a wider understandingwider understanding and and not a “specialist’s” approach not a “specialist’s” approach

Requires that Requires that life threatening prioritieslife threatening priorities are dealt urgentlyare dealt urgently

A A complete clinicalcomplete clinical assessment should assessment should not be neglected while priorities are not be neglected while priorities are being managed being managed

Surgical procedures are tailoredSurgical procedures are tailored as as per patient’s general condition per patient’s general condition


Primary SurveyPrimary Survey– Identify life threatening conditions following Identify life threatening conditions following

‘ABCD’ ‘ABCD’ – Manage life threatening conditions Manage life threatening conditions – Start resuscitationStart resuscitation

Secondary survey Secondary survey – Assess everything “Head to toe” Assess everything “Head to toe”

Early definitive managementEarly definitive management– Damage control surgeries Damage control surgeries – Continued care in ICU Continued care in ICU

Final definitive management Final definitive management

Steps in trauma Steps in trauma managementmanagement


PRIMARY SURVEYPRIMARY SURVEY

Priority is ABCDEPriority is ABCDE A- Airway and neckA- Airway and neck B- BreathingB- Breathing C- CirculationC- Circulation D- DisabilityD- Disability E- Environment controlE- Environment control This is not a formula to remember for This is not a formula to remember for

exam!exam!


Why ABCDWhy ABCD

Your brain can work Your brain can work only if it can get only if it can get oxygenated blood oxygenated blood through circulationthrough circulation

The circulating blood is The circulating blood is useful only if it can get useful only if it can get oxygenated within oxygenated within breathing lungsbreathing lungs

A functional lung can A functional lung can be useful only if it get be useful only if it get air through a patent air through a patent airway airway


fix the fix the AAirway first irway first fix the fix the BBreathing lungs next reathing lungs next fix the fix the CCirculation and irculation and then fix the then fix the DDisability (brain & isability (brain &

bones)bones)

Why ABCDWhy ABCD


What is What is AAirwayirway


What to seeWhat to see

Is there an obstructionIs there an obstruction Is there any impending obstructionIs there any impending obstruction


Support it Support it (remember cervical spine)(remember cervical spine) Clean itClean it Assist Assist IntubateIntubate Surgical airway Surgical airway

What to doWhat to do


Monitoring Monitoring

Put pulse oximeter Put pulse oximeter


BreathingBreathing

Conduction of air is the function of Conduction of air is the function of AirwayAirway

Breathing is a process in which Breathing is a process in which gaseous exchange takes place gaseous exchange takes place

Breathing is the function of lungs and Breathing is the function of lungs and ribcage ribcage


What to see and whyWhat to see and why

Trauma Clinicians Often Miss Trauma Clinicians Often Miss FracturesFractures

Tension pneumothoraxTension pneumothorax Cardiac temponadeCardiac temponade Open woundOpen wound Massive pneumothoraxMassive pneumothorax Flail chestFlail chest


Tension pneumothoraxTension pneumothoraxUrgent decompressionUrgent decompression

Cardiac temponade Cardiac temponade Urgent decompressionUrgent decompression

Open wound Open wound Seal as a valveSeal as a valve

Massive pneumothoraxMassive pneumothoraxDrain it and put a chest tubeDrain it and put a chest tube

Flail chest Flail chest Ventilatory supportVentilatory support



Monitoring Monitoring

Put ECG leads Put ECG leads


CirculationCirculation

Circulatory failure leads to reduced Circulatory failure leads to reduced tissue perfusion that is Shock tissue perfusion that is Shock

Hemorrhagic shockHemorrhagic shock -most likely-most likely Nonhemorrhagic Nonhemorrhagic

– Neurogenic shock Neurogenic shock – Septic shock Septic shock – Mechanical shock – pump failure Mechanical shock – pump failure



PulsePulse Skin colour and temperature Skin colour and temperature Blood pressureBlood pressure Urine outputUrine output ConsciousnessConsciousness



Stop obvious bleedingStop obvious bleeding Restore volume rapidly (Fluid Restore volume rapidly (Fluid

challenge)challenge) See the responseSee the response


Monitoring & Monitoring & interventions interventions

Two veinflons Two veinflons

Take blood sample Take blood sample

Start iv fluidsStart iv fluids

Blood pressure monitoringBlood pressure monitoring

ECG monitoring ECG monitoring


Head injuryHead injury FracturesFractures

DisabilityDisability



AVPUAVPU AAlertlert Respond to Respond to vvocal stimulusocal stimulus Respond to Respond to ppainful stimulusainful stimulus UUnresponsivenresponsive



Early management is restoration Early management is restoration of ABCof ABC

CommunicationCommunication


EnvironmentEnvironment

Completely undressCompletely undress Hypothermia preventionHypothermia prevention


Completion of primary Completion of primary surveysurvey At the end of primary surveyAt the end of primary survey

Get lateral view of C/SGet lateral view of C/SChest XrayChest XrayPelvic XrayPelvic XrayCathaterise / intubate / ryles tube if Cathaterise / intubate / ryles tube if

required required Start life saving maneuvers like intubation, Start life saving maneuvers like intubation,

decompressing tension pneumothorax, decompressing tension pneumothorax, and giving IV fluid and giving IV fluid

Consider need for transfer Consider need for transfer


Secondary surveySecondary survey

Life threatening priorities are Life threatening priorities are identified and their management is identified and their management is started in primary survey started in primary survey

Secondary survey focuses on Secondary survey focuses on – History History – Head to toe exam & more complete Head to toe exam & more complete

investigationsinvestigations– Deciding priorities Deciding priorities


HistoryHistory (AMPLE) (AMPLE)

AllergiesAllergies Medications currently takenMedications currently taken Past illnessPast illness Last mealLast meal Event leading to injury Event leading to injury


Secondary survey – Total patient Secondary survey – Total patient evaluation evaluation – Head & skull, MaxillofacialHead & skull, Maxillofacial– Neck,Neck, Chest,AbdomenChest,Abdomen– PerineumPerineum– Musculoskeletal Musculoskeletal – Complete neurological examComplete neurological exam

Head to toe examination Head to toe examination


At the end you should haveAt the end you should have All Xrays All Xrays CT / US/ laboratory investigationCT / US/ laboratory investigation Tubes and fingers in all orifices Tubes and fingers in all orifices

Complete investigationsComplete investigations


Fixing prioritiesFixing priorities

Communication with all Communication with all subspecialties subspecialties

Priorities discussed Priorities discussed


Early definitive care Early definitive care

There is a controversy -There is a controversy -– Is patient fit enough to undergo another Is patient fit enough to undergo another

trauma in the form of surgery ? (Don’t touch!)trauma in the form of surgery ? (Don’t touch!)– Will patient improve / survive without having Will patient improve / survive without having

done a surgery ? (Do it now!) done a surgery ? (Do it now!) Damage control surgeries are the middle Damage control surgeries are the middle

path ( Do the minimum!)path ( Do the minimum!) Continued care in ICUContinued care in ICU


Definitive treatment Definitive treatment

Do whatever you like Do whatever you like


SummarySummary

Primary survey Primary survey – Life threatening priorities managed (ABCD)Life threatening priorities managed (ABCD)

Secondary survey Secondary survey – Head to toe exam and all the injuries identified Head to toe exam and all the injuries identified

Early definitive careEarly definitive care– Damage control surgeries Damage control surgeries – Management in ICUManagement in ICU

Definitive management Definitive management

Thanks Thanks

Documents

2 Early Management of Polytrauma 1