Evaluation and Management of Polytrauma

8/3/2019 Evaluation and Management of Polytrauma

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Dr Sujata Sahu, MS(ENT)

NSCH, Talcher


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Polytrauma:

yThe occurrence of injuries to more thanone body system

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EPID

EMIOLOGY

y Trauma-Major health problem

y Leading cause of death- (1-45)Yrs Age

y Fifth leading cause of death- All age group

yAlcohol- Significant contributor to trauma

fatalities

ySevere head injuries: >50% trauma deaths

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First Things First

Is the victim breathing?

If not, Provide airway.

Is there a pulse or heartbeat?If not, Close chest compression

Is there external bleeding?

I

f so, Apply enough external pressure.Is there any injury to spine?

If so, Protect the neck and spine.

Splint obvious fractures.

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ATLS(Advanced Trauma Life Support)

y Developed by ACS.

yA systematic and concise training for the early

care of trauma patients.

y Best current approach to severely injured

patients.

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Steps ofATLS:1. Primary Survey

Identify and treat immediate life threatening

condition.2. Resuscitation

3. Secondary Survey

Comprehensive physical examination toestablish treatment priorities.

4. Definitive Management

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Primary SurveyStandard of Care

Airway

Breathing

Circulation

Disability

Exposure

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Airway Maintenance

Chin lift or jaw thrust

Cleaning of patients mouth

Immobilization of cervical spine

Asses the airway

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Breathing

Degree of chest expansion

Breath sounds

Tachypnea

Crepitus from rib fracture

Subcutaneous emphysema

Presence of penetrating wound

Chest injury- second highest case fatality rate.

Tension Pneumothorax, Open Pneumothorax, Flail

chest- Most life threatening pul. Injuries.

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Circulation1. Haemorrhage

To be controlled by local pressure2. Vascular access and resuscitation

Crystalloid solution to manage shock Adult- 2 Ltrs of RL or NS

Child- Initial vol. 20ml/kg

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3. Monitoring

ECG- Continuous Cardiac Monitoring

BP Measurements

Pulse Oximetry- Adequate oxygen saturation

Temperature


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Neurological DisabilityCareful history, complete physical and

neurological examination with GCS score and

urgent head CT scan.Motor component of the GCS score is the most

accurate.

Assessment of pupil size and reaction to light.

Neurological dysfunction is assessed by

conscious level, pupils and posture.

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Glasgow Coma Scale Score(GCS)Parameter Score

Best Motor Response

Obeys Command 6

Localise purposeful movement towards the stimulus 5

Withdraws from painful stimulus 4

Abnormal flexion 3

Extension 2

No movement 1

Verbal Response

Oriented 5

Confused 4

Recognizable words produced(verbalizes) 3

Vocalizes 2

None 1 13


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Glasgow Coma Scale Score(GCS)Contd.Parameter Score

Eye Openning

Spontaneous 4

To command 3

To pain 2

None 1

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GCS Score range is 3-15. If less than 8, patient has

serious damage with raised intracranial

pressure.(More than 20mm of Hg)


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Exposure:All the clothing should be removed at once from theseriously injured patient avoiding unnecessarymovement.

Resuscitation: Hypovolemic shock-IV RL soln, blood

transfusion

Neurogenic shock(Due to spinal cordinjury)-IV crystalloid solution, CVP monitoring

Cardiac compressive shock- Urgentdecompresion


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Laboratory Studies-Full blood count

- Blood grouping and cross matching

- Serum electrolytes-Coagulation parameters

-Blood alcohol levels

Imaging Studies

- Plain X-ray films, CT scan of head, lateral x-ray

and CT scan of cervical spine, sonography for

blunt trauma abdomen and chest


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Acute extradural haematoma on the right side, and acute

traumatic subarachnoid haemorrhage on the left side


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Fractured ribs in back

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CT Scan showing injury to liver

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CT scan of Thorax showing hydropneumothorax

and surgical emphysema

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CT scan of abdomen showing injury to kidney

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Treatment

Head Injury:

Depends on GCS following resuscitation.

y

Mild(GCS 14-15)-admitted with through andfrequent neurological obsevation.

y GCS of 13 or less- should have CT scanimmediately

y

Acute lesion on CT scan or diffused cerebraloedema-Transfer to Neuro surgical unit

y Bolus dose of 1gm/kg ofIV Mannitol(20%)

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Neck & Abdo

minal

Injury

Control of the airway with early intubation

Venous injuries- ligation

Laryngeal and tracheal injurieswith airwayobstruction- tracheostomy

Diagnostic peritoneal lavage- to detect presence

of blood.Diagnostic laproscopy

Exploratory laparotomy

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Thoracic InjuriesMajority due to automobile accident

First priority- provide an airway and restore

circulationy Chest wall- Rib fractures-heal without

treatment/internal fixation.

y Trachea, bronchus- immediate primary repair

y Thoracotomy- for management of injuries tolung, heart, pericardium and great vessels.

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Documents

Evaluation and Management of Polytrauma