Management of

polytrauma patients at

POF Hospital

Dr.Monsif IqbalPGT SU-II

Summary Case Presentation

• Miss XYZ,a young lady 0f 23

• RTA blunt trauma abdomen

• Patient received in A & E

• Patient then shifted to ITC

Case presentati

on

Primary Survey

• Pulse….122• BP……..80/55• GCS……15/15• Irritable• pallor• Cold & Clammy

•Grade 3 shock

Case Presentation

FAST performed

Frank blood in abdominal cavity

Shattered Spleen

FAST

Management

Resuscitation

Exploratory Laparotomy

• I/V cannulae • Blood grouping & cross match• Restoration of intra vascular volume• catheterization• antibiotic • Blood transfusion

Case PresentationResuscitation

Cont. Case Presentation

Patient rushed to OT collapsed on OT table

Successful CPR doneblood transfusion

Patient reverted back

management

EXPLORATORY LAPAROTOMY

Findings of exploratory laparotomy Case Presentation

• Splenic injury ….grade 5• Renal injury…….grade 4• Lt colon crushed• Abdominal cavity full of blood• Retroperitoneal hematoma

Findings of exploratory laparotomyDefinitive surgical treatment Case Presentation

• Splenetomy• Nephrectomy

Lt• Sigmoid

Colostomy

• Mechanicl vent for 2 days• Drain output gradually reduced• Pneumovac given• Patient went into DIC with deranged

PT & APTT• FFPs and platelets transfused• 7 blood transfusions done gradually • Stoma started working on 2nd POD

Post op recovery

management

• Patient gradually reovered• Urine output remained satistory• Wound….healthy• Stitches out on 11th POD• Patient discharged home on 13th

POD

Cont…..manageme

nt

Diagnosis

Management of polytrauma patients

Resuscitation &

definitive management

• Primary survey• Resuscitation• Secondary

survey• Definitive

management

Componenets ATLS

•A..airway & cervical spine care

•B…Breathing & ventilation

•C…circulation & hemorrhage control

•D…Deformity & disability

•E…exposure & environmental cond

Primary survey ATLS

• ECG• Urinary & Gastric catheters• ABGs• Pulse oximetry• X-rays & Diagnostic studies

Adjuncts to primary survey ATLS

•History Blunt ? Penetrating ? Burn or cold

injuries

•Examination Head & neck Chest Abdomen Extremities spine

Secondary survey ATLS

• Detailed X-rays• CT scan• Angiography• USG• Transportation

Adjuncts to secondary survey

ATLS

Abdominal trauma

Blunt Abdominal trauma

Penetrating Abdominal trauma

Laparotomy

• FAST examines four areas for free fluid:– Morrison’s

Pouch– Perisplenic – Pelvis – +/-Pericardium

Focused Assessment with Sonography in Trauma FAST

Morrison’s pouch

• As a decision making tool for identifying the need for laparotomy in hypotensive patients (Systolic BP < 90), FAST has:

• a sensitivity of 92%, • specificity of 96% • Accuracy 93%

• How good is FAST?

How good is FAST? FAST

DPL

• Spleen• Kidney• Liver• Intestine• Diaphragm• Pancreas

Specific injuriesPolytrau

ma

Spleen

Liver

• Push• Plug• Pack• pringle

Liver injuriesmanagem

ent

Kidney

Grades of renal injury

Pancreas

Intestine

Damage control surgery

Colon

Diaphragmatic injury

Statistics of trauma in POF HOspital from

jan 2010- jan2011

• Head injury….212• Blunt abdominal injury….67• Penetrating abdominal injury….17• Thoracic injury……27• Orthopedic inj…..89• Polytrauma …..56• Mortality…..24

statistics polytrauma

ortho

Managementof Abdominal trauma

Blunt abdominal trauma

Conservative

management

Operative manageme

nt

34 33

• Total…..57• Positive……30• Inconclusive…..11• Negative……16

FAST done….polytraum

a

Head injury

Mortality

Take home message

‘Multidisciplinary approach required for management of polytrauma patient involving general surgeon,urlogist,orthpedic surgeon,anesthetist,radiologist etc’