Polytrauma

1. POLYTRAUMA
MODERATOR – DR C V MUDGAL
PRESENTER – DR AKSHAY PALEKAR

2. OBJECTIVES: APPROACH TO MULTIPLE INJURY PATIENTS
• Diagnose, initially manage and know when to immediately
refer a patient with a condition that requires urgent
specialist management
• Management as per ATLS protocol
• Knowledge about in-line immobilization of cervical spine
while managing the airway
• Function of spinal board as a transfer tool.
• Emergency orthopaedic conditions that affect the patient
life and its initial management; e.g. open book pelvis
fracture, bilateral femur fractures.
• Importance of interpersonal communication skills

3. DEFINITION
• Poly trauma syndrome multiple injuries
exceeding a defined severity (ISS MORE
THAN17) with sequential systemic reactions
that may lead to dysfunction or failure of remote
organs and vital systems, which have not
themselves been directly injured.

4. POLYTRAUMA
• Worldwide No-1 Cause of death amongst the younger age
group (18-45years).
• Third most common cause of death in all age group.

5. CRITERIA OF POLYTRAUMA INCLUDE ANY ONE OF THE
FOLLOWING COMBINATION INJURY
• Two major system injury + one major limb injury
• One major system injury + two major limb injuries
• One major system injury + one open grade 3 skeletal injury
• Unstable pelvis fracture with associated visceral injury

6. POLYTRAUMA VS MULTIPLE FRACTURES
• Polytrauma is not a synonym for multiple fractures.
• Multiple fractures are purely orthopaedic problem as
there is a involvement of skeletal system alone.
• While in polytrauma there is a involvement of more
than one system like associated head, spinal injury,
chest injury, abdominal injury or pelvic injury.
• Polytrauma is a multisystem injury and needs
management by team of surgeons and physicians,
orthopaedic surgeon is one of the team member of
trauma unit.

7. AETIOLOGY OF POLYTRAUMA
• RTA
• Fall from height(blunt or penetrating
injury)
• Assault,
• Aeroplane crashes, train derailment,
• Blast,
• Thermal, chemical injuries.

8. TRIMODAL DISTRIBUTION OF DEATH
Immediate death
(45%)
0 to 1 hr
Early death
(10%)
1 to 3 hrs
Late death
( 45%)
1 to 6 wks
Golden
Hour

9. Immediate: Devastating injury
Early: shock, hypoxia or
head injury
Delayed: sepsis, ARDS,MOF
Trauma Deaths

10. FIRST PEAK OF DEATH. Within minutes…
First peak of Death or immediate trauma death
• Within minutes of injury.
• Due to major neurological or vascular injury.
• Medical treatment can rarely improve outcome.
–Severe head injury.
–Brainstem injury.
–High cord injury.
–Heart, Aorta injury.
–Massive blood loss.

11. SECOND PEAK OF DEATH
SECOND PEAK of Death or early trauma death
• Occurs during the 'golden hour'.
• Golden hour is the period of time immediately
after traumatic injury during which there is a
highest likelihood that prompt medical and
surgical treatment will prevent death.
• Due to intracranial haematoma, major thoracic or
abdominal injury.
– Intracranial bleed.
– Thoracic injury .
– Abdominal bleeding.
– pelvic bleeding.
– multiple limb injury

12. THIRD PEAK OF DEATH
Third peak Of death or late death
• Occurs after days or weeks.
• Due to sepsis and multiple organ
failure.
–Sepsis.
–Multiple organ failure.

13. SCORING SYSTEMS
PHYSIOLOGIC ANATOMIC COMBINED
1 Revised trauma score
ABBREVIATED INJURY
SCALE TRISS
2 APACHE
INJURY SEVERITY
SCORE ASCOT
3 SOFA
NEW INJURY
SEVERITY SCORE ICISS
4
EMERGENCY TRAUMA
SCORE ANATOMIC PROFILE
5 PATI
6 ICISS
7 TMPM -ICD9

14. SCORING SYSTEMS
• Glasgow coma scale .
• Abbreviated injury scale.
• Injury severity score .
• New injury severity score.

15. GLASGOW COMA SCALE
•Summation of best motor, verbal,
eye response.
•Observer dependent.
•Predictive of mortality.

16. ABBREVIATED INJURY SCALE

17. ABBREVIATED INJURY SCALE
Each area scored from 0 to 6

18. ABBREVIATED INJURY SCALE
Each area scored from 0 to 6
• Examples:-
Femur fracture -> Serious, AIS = 3
Pulmonary contusion -> serious, AIS = 3
Flail chest -> severe, AIS = 4

19. INJURY SEVERITY SCORE

20. INJURY SEVERITY SCORE
• Calculated from AIS
• Highest AIS value from each individual anatomical area.
1. HEAD
2. NECK
3. FACE
4. CHEST
5. ABDOMEN AND PELVIS
6. SPINE
7. UPPER EXTREMITIES
8. LOWER EXTREMITIES
9. EXTERNAL
• 3 highest AIS value ( from different anatomic area )
– Squared
– Summed

22. • Highest score 75
– AIS of 5 in 3 anatomic areas
– AIS of 6 in any anatomic areas is 5
– AIS > or = 18 is POLYTRAUMA.
• DISADVANTAGES
– Injuries within the same anatomic system only counted once.
• INJURY SEVERITY SCORE
– Defines polytrauma - ISS > 18
– Correlates with :
• Mortality
• Morbidity

23. NEW INJURY SEVERITY SCORE
• Three highest values regardless of anatomical
regions are utilised.
• May be a better predictor of morbidity and
mortality.

24. PATHOPHYSIOLOGY
• Major trauma induces an intense immuno-
inflammatory response.
• The magnitude of this response depends on the initial
trauma load, the painful stimuli, the systemic and local
release of pro-inflammatory cytokines, age, sex as well
as the genetic makeup of the patient.

26. IMMUNOLOGICAL RESPONSE
• PRO-INFLAMMATORY PHASE
• IL-1, IL-6, TNF - alpha.
• Hypothalamus - pyrexia.
• Hepatic acute phase protein.
• SIRS
• MODS
• COUNTER REGULATORY PHASE
• IL -1 Receptor antagonist (IL- 1Ra) &
TNF Soluble receptors (TNF -sR-55 and
75)
• Prevent excessive pro-inflammatory
activities
• Restore the homeostasis
Compensatory anti-inflammatory
response syndrome(CARS).

29. HOST DEFENCE RESPONSE DURING POLYTRAUMA
TWO HIT THEORY
Primary insult
Trauma organ injury,
tissue injury, fractures
Secondary insult
Ischaemic/ Reperfusion injury,
interventional load,surgery
Hyper-inflammation
SIRS, MOF Hypo-inflammation
CARS
MARS

33. PHYSIOLOGIC RESPONSE TO TRAUMA
• Systemic inflammatory response (SIRS).
• compensatory anti-inflammatory response (CARS)

34. SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME (SIRS)
• A generalised response to trauma characterised by increasing cytokines,
complement , hormones .
• Clinical features
–Two or more of the following
• FEVER -Temperature more than 38°C or less than 36°C
• TACHYCARDIA-Heart rate more than 90 bpm
• HYPERVENTILATION -Respiratory rate more than 20 bpm
• LEUKOCYTOSIS -WBC more than 12,000 Cells per cubic MM, less than 4000
cells per cubic MM or more than 10% immature band forms

35. QUANTIFYING OF SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME
• SIRS SCORE
• Four variables, each scored 0 or 1.
–HR >90
–WBC <4000 or >12000 .
–RR >20 or PaCO2 <33mmhg.
–Temperature <36 or <38^c
• Total score = sum of four variables 0 to 4
• Score > 2 indicative of systemic inflammatory response
syndrome.

36. SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME (SIRS)
• Predictive of-
–Acute respiratory Distress syndrome.
–Disseminated intravascular Coagulopathy.
–Acute renal failure.
–Shock.
–Multisystem organ failure

37. COMPENSATORY ANTI-INFLAMMATORY RESPONSE
SYNDROME (CARS)
• A syndrome In which anti-inflammatory mediators
release Compensate for the systemic inflammatory
Response Leading to state of immune
suppression/immune paralysis.

38. MANAGEMENT OF POLYTRAUMA

39. BASICS OF TRAUMA ASSESSMENT
■ Preparation
– Team Assembly
– Equipment Check
■ Triage
– Sort patients by level of acuity (SATS)
■ Primary Survey
– Designed to identify injuries that are immediately life threatening and
to treat them as they are identified
■ Resuscitation
– Rapid procedures and treatment to treat injuries found in primary
survey before completing the secondary survey
■ Secondary Survey
– Full History and Physical Exam to evaluate for other traumatic injuries
■ Monitoring and Evaluation, Secondary adjuncts
■ Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another facility
39

40. STAGING OF THE PATIENT’S MANAGEMENT PERIODS
• 1. Acute “reanimation” period (1 to 3 hours)
• 2. Primary “stabilization” period (1 to 48 hours)
• 3. Secondary “regeneration” period (2 to 10 days)
• 4. Tertiary “reconstruction and rehabilitation” period (weeks)

41. ACUTE “REANIMATION” PERIOD
• This phase covers the time from
admission to the control of the
acute life-threatening conditions.
• Rapid systematic assessment is
performed to immediately
identify potentially life-
threatening conditions.

42. PRIMARY “STABILIZATION” PERIOD
• This phase begins when any acute life-threatening
situation has been treated and there is complete
stability of the patient’s respiratory, hemodynamic, and
neurologic systems.
• Fractures can be temporarily stabilized with external
fixation and the compartments released where
appropriate. The primary period lasts about 48 hours.

43. SECONDARY “REGENERATION” PERIOD
• In this phase the general condition of the patient is stabilized
and monitored.
• Regularly re-evaluate the constantly evolving clinical picture to
avoid any harmful impact from intensive care treatment or any
problems associated with complex operative procedures.
• Physiologic and intensive care scoring systems may be employed
to monitor clinical progress.

44. TERTIARY “RECONSTRUCTION AND
REHABILITATION” PERIOD
• This final rehabilitation period is when any necessary
surgical procedures, including final reconstructive measures
should be undertaken.

45. MULTIPLE CASUALTIES
• Several causalities at the same time.
1. Alarm ER services
2. Assess the scene - without putting your safety
at risk
3. Triage 'do the most for the most'

46. TRIAGE
• Ability to walk
• Airway
• Respiratory rate
• Pulse rate or capillary return

48. HOW TO
TRIAGE?
1. Can the patient walk?
Yes delayed
No check for breathing
2. Is the patient breathing?
No open the airway
Are they breathing now?
Yes IMMEDIATE
No DEAD
Yes count the rate
<10 & > 30 / min – IMMEDIATE
10 – 30 /min – check circulation
3. Check the circulation
Capillary refill> 2 sec- IMMEDIATE
Capillary refill < 2 secs - urgent

50. HOW TO MOVE UNCONSCIOUS CASUALTY
• Do not move the casualty unless it is absolutely
necessary
• Assume neck injury until proved otherwise
–support head and neck with your hands, so he
can breathe freely,Apply a collar, if possible
–There should be only 1 axis (head, neck,
thorax) no moving to sides, no flexion, no
extension.
–Move with help of 3-4 other people
1 support head (he is directing others), other
one shoulders and chest, other one hips and
abdomen, last one - legs.

51. TRAUMA TEAM CALL-OUT CRITERION
• Penetrating injuries
• Two or more proximal bone fractures
• Flail chest & pulmonary contusion
• Evidence of high energy trauma
- fall from > 6ft
-changes in velocity of 32 kmph
- ejection of the patient
- roll-over
- death of another person in same car
- blast injuries

52. ‘TREAT LETHAL INJURY FIRST, THEN
REASSESS AND TREAT AGAIN’

53. ATLS – COMPONENT STEPS
Primary survey
Identify what is killing the patient.
Resuscitation
Treat what is killing the patient.
Secondary survey
Proceed to identify other injuries.
Definitive care
Develop a definitive management plan.

54. ASSESSMENT OF THE INJURED PATIENT
• Primary survey and resuscitation
–A = Airway maintenance and control of cervical spine.
–B = Breathing And ventilation.
–C = Circulation and haemorrhage control.
–D = disability/Dysfunction of the central nervous system
–E = Exposure And environment control.
–F = fracture stabilisation and foleys catheterisation
• Adjunct to primary survey: Xrays , USG [EFAST]
• Secondary survey .
• Definitive treatment.

55. ATLS- Primary Survey
Airway and Protection of Spinal Cord

56. PRIMARY SURVEY
■Key Principles
– When you find a problem during the primary
survey, FIX IT.
– If the patient gets worse, restart from the
beginning of the primary survey
– Some critical patients in the Emergency
Department may not progress beyond the
primary survey
56

57. AIRWAY AND PROTECTION OF SPINAL CORD
■ Why first in the algorithm ?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ
damage,ischaehemic injury.
■ Airway Assessment
– Vital Signs = RR, O2 sat
– Mental Status = Agitation, Somnolent, Coma
– Airway Patency = Secretions, Stridor, Obstruction
– Traumatic Injury above the clavicles
– Ventilation Status = Accessory muscle use, Retractions, Wheezing
■ Clinical Pearls
– Patients who are speaking normally generally do not have a need for
immediate airway management
– Hoarse or weak voice may indicate a subtle tracheal or laryngeal injury
– Noisy respirations frequently indicates an obstructed respiratory 57

58. AIRWAY INTERVENTIONS
■ Maintenance of Airway Patency
– Suction of Secretions
– Chin Lift/Jaw thrust
– Nasopharyngeal Airway
– Definitive Airway
■ Airway Support
– Oxygen
– NRBM (100%)
– Bag Valve Mask
– Definitive Airway
■ Definitive Airway
– Endotracheal Intubation
■ In-line cervical stabilization
– Surgical Crichothyroidotomy
58

59. ATLS- PRIMARY SURVEY
A-AIRWAY
Sequence of events: chin lift
Jaw thrust
finger sweep
suction
Oropharyngeal/ orotracheal tube
Cricothyroidotomy
Tracheostomy

60. PROTECTION OF SPINAL CORD
•General Principle: Protect the entire
spinal cord until injury has been
excluded by radiography or clinical
physical exam in patients with
potential spinal cord injury.
•Spinal Protection
•Rigid Cervical Spinal Collar =
Cervical Spine
•Long rigid spinal board or
immobilization on flat surface such
as stretcher = T/L Spine
60

61. •Etiology of Spinal Cord Injury.
•Road Traffic Accidents (47%)
•High energy falls (23%)
•Clinical Pearls
•Treatment (Immobilization) before diagnosis
•Return head to neutral position
•Do not apply traction
•Diagnosis of spinal cord injury should not
precede resuscitation
•Motor vehicle crashes and falls are most
commonly associated with spinal cord injuries
•Main focus = Prevention of further injury

62. C-SPINE IMMOBILIZATION
■ Return head to neutral position
■ Maintain in-line stabilization
■ Correct size collar application
■ Blocks/tape
■ Sandbags
62

63. AIRWAY AND CERVICAL SPINE
• The assessment of the airways should be performed first.
• Obstruction due to facial fractures, foreign bodies, or mandible
fractures, laryngeal or tracheal injuries, Aspiration should be
identified as soon as possible
• In patient with severe head injuries (GCS >8) or who are
unconsciousness definitive management is usually required.
• During the initial assessment the immobilisation of the cervical
spine should be accomplished and maintained to avoid further
spinal cord injuries injuries.

64. ATLS- PRIMARY SURVEY
B- BREATHING & VENTILATION

65. BREATHING AND VENTILATION
■ General Principle: Adequate gas exchange is required to maximize
patient oxygenation and carbon dioxide elimination
■ Breathing/Ventilation Assessment:
– Exposure of chest
– General Inspection
■Tracheal Deviation
■Accessory Muscle Use
■Retractions
■Absence of spontaneous breathing
■Paradoxical chest wall movement
– Auscultation to assess for gas exchange
■Equal Bilaterally
■Diminished or Absent breath sounds
– Palpation
■Deviated Trachea
■Broken ribs
■Injuries to chest wall 65

66. ATLS- PRIMARY SURVEY
B- BREATHING & VENTILATION
• Injuries of the lung, chest wall
and diaphragm may
compromises gas exchange.
• Clinical and possibly bedside
radiographic (CXR) evaluation.
• The aim is to find out & treat
the life threatening thoracic
conditions.

67. ATLS- PRIMARY SURVEY
B- BREATHING & VENTILATION
Five life threatening thoracic
conditions:
1. Tension Pneumothorax.
2. Massive Pneumothorax.
3. Open pneumothorax.
4. Flail chest.
5. Cardiac tamponade.

68. ■ Life Threatening Injuries
–Tension Pneumothorax
■Air trapping in the pleural space between the lung
and chest wall
■Sufficient pressure builds up and pressure to
compress the lungs and shift the mediastinum
■Physical exam
–Absent breath sounds
–Air hunger
–Distended neck veins
–Tracheal shift
■Treatment
–Needle Decompression
■2nd Intercostal space, Midclavicular line
–Tube Thoracostomy
■5th Intercostal space, Anterior axillary line
68

69. ■ Hemothorax
– Blood collecting in the pleural space and is
common after penetrating and blunt chest
trauma
– Source of bleeding = Lung, Chest wall (intercostal
arteries), heart, great vessels (Aorta), Diaphragm
– Physical Exam
■Absent or diminished breath sounds
■Dullness to percussion over chest
■Hemodynamic instability
– Treatment = Large Caliber Tube Thoracostomy
■10-20% of cases will require Thoracostomy for
control of bleeding
69

70. ■Flail Chest
– Direct injury to the chest resulting in
an unstable segment of the chest wall
that moves separately from remainder
of thoracic cage
– Typically results from two or more
fractures on 2 or more ribs
– Typically accompanied by a pulmonary
contusion
– Physical exam = paradoxical
movement of chest segment
– Treatment = improve abnormalities in
gas exchange
■Early intubation for patients with
respiratory distress
■Avoidance of overaggressive fluid
resuscitation
70

71. ■Open Pneumothorax
–Sucking Chest Wound
–Large defect of chest wall
■Leads to rapid equilibration of
atmospheric and intrathoracic
pressure
■Impairs oxygenation and ventilation
–Initial Treatment
■Three sided occlusive dressing
■Provides a flutter valve effect
■Chest tube placement remote to
site of wound
■Avoid complete dressing, will create
a tension pneumothorax 71

72. Needle Thoracostomy
■ Needle Thoracostomy
– Midclavicular line
– 14 gauge Angiocath
– Over the 2nd rib
– Rush of air is heard
72

73. Tube Thoracostomy
■Insertion site
– 5th intercostal space,
– Anterior axillary line
■ Sterile prep, anesthesia with lidocaine
■ 2-3 cm incision along rib margin with #10 blade
■ Dissect through subcutaneous tissues to rib margin
■ Puncture the pleura over the rib
■ Advance chest tube with clamp and direct posteriorly
and apically
■ Observe for fogging of chest tube, blood output
■ Suture the tube in place
■ Complications of Chest Tube Placement
– Injury to intercostal nerve, artery, vein
– Injury to lung
– Injury to mediastinum
– Infection
– Allergic reaction to lidocaine
– Inappropriate placement of chest tube
73

74. ATLS- Primary Survey
B- Breathing & ventilation
Cardiac tamponade
(almost always seen with a penetrating wound
ABNORMAL FLUID COLLECTION IN PERICARDIAL SAC
COMPRESSING THE HEART AND AND LEADING TO A
DECREASE IN CO AND FURTHUR LEADING TO SHOCK.
Beck’s triad: Hypotension.
Distended neck veins.
Muffled heart sounds.
Pulsus paradoxus is characteristic feature of cardiac
tamponade
Treatment:
Needle pericardiocentesis in subxiphoid window,
Thoracotomy & repair as definitive managemnt.

75. ATLS- Primary Survey
C- Circulation and haemorrhage control

76. CIRCULATION AND HAEMORRHAGE CONTROL
• Assess pulse, capillary return and state of neck veins.
• Identify exsanguinating haemorrhage and apply direct
pressure.
• Place two large calibre intravenous cannulas
Give intravenous fluids (crystalloid or colloid).
• Attach patient to ECG monitor.
• At the place of injury occurance , tourniquet can be applied
to minimise the bleed.

77. ATLS- Primary Survey
C- Circulation and haemorrhage control
Adults- 2 litres of Ringer lactate solution as initial
fluid Challenge.
Children- 20mg/kg of body weight.
Response to initial fluid challenge:
• Immediate & sustained return of vital signs.
• Transient response with later deterioration
• No improvement.

78. ATLS- Primary Survey
C- Circulation and haemorrhage control
Tachycardia in a cold patient indicates shock
Causes of shock following injury:
1. Hypovolemic
2. Cardiogenic
3. Neurogenic
4. Septic

79. ATLS- Primary Survey
C- Circulation and haemorrhage control
Assessment of blood loss
External or obvious
Internal or covert
chest
abdomen
pelvis
limbs
Resuscitation
Arrest bleeding
Obtain vascular access

80. HEMORRHAGIC SHOCK
Class 1 Class 2 Class 3 Class 4
Blood loss (mL) Up to 750 750-1500 1500-2000 >2000
Blood loss (% of
volume)
Up to 15% 15-40% 30-50% >40%
Heart rate <100 >100 >129 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure
(mmHg)
Normal Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output
(mL/hr)
>30 20-30 5-15 Negligible
Mental status Slightly anxious Mildly anxious Confused Lethargic

81. OTHER TYPES OF SHOCK
• CARDIO-GENIC: heart failure, acute MI, pericardial
tamponade
• NEUROGENIC: Due to spinal cord injury that causes
distribution sympathetic outflow to heart and blood
vessels characterised bye hypertension, bradycardia,
warm skin, spinal cord injury, closed head injury
• SEPTIC (rare early in trauma)

82. 1. Fluid Replacement in Balanced Resuscitation
● Initial fluid replacement with up to 2L crystalloid
Permissive hypotension to achieve SBP to 80-90mmHg
(radial pulse) until definitive control of bleeding is obtained
● Role of fluid challenge (250-500ml) tests to stratify responder,
transient responder, non-responder
BALANCED
RESUSCITATION

83. ATLS- Primary Survey
C- Circulation and haemorrhage control
Immediate responders-<20% blood loss
=Bleeding ceases
spontaneously
Transient responders- Bleeding within body cavities.
=Surgical intervention required.
Non responders- >40% of blood vol lost
require immediate surgery
=Continued IV fluids.

84. ATLS- Primary Survey
C- Circulation and haemorrhage control
2.Haemostatic Resuscitation
● Early blood transfusion decreases MODS.
● Packed RBC, FFP and Platelets in 1:1:1 ratio.
● Cryoprecipitate, Tranexamic acid, Recombinant factor-VIIa .
● Storage blood of < 2 weeks to minimise TRALI, MODS.

85. ATLS- Primary Survey
D- Disability limitations
Assess level of consciousness using AVPU method
A = alert
V = responding to voice
P = responding to pain
U = unresponsive Pupil size and reaction
GCS
Assess pupil size, equality and responsiveness

86. • Fully undress patients to look for other injuries
• Avoid hypothermia
Hypothermia Prevention and Treatment Strategies
● Limit casualties’ exposure
● Warm IV fluids and blood products before transfusion by inline warmer
● Use forced air warming devices before and after surgery
● Use carbon polymer heating mattress
ATLS- Primary Survey
E – EXPOSURE AND ENVIRONMENT CONTROL

87. ATLS-PRIMARY SURVEY
F- FRACTURE MANAGEMENT
1. Minor
2. Moderate open Fracture of digits
undisplaced long bone or pelvis Fracture
3. Serious closed long bone Fractures
multiple hand/foot Fractures
4. Severe life threatening open long bone Fracture
pelvis # with displacement
dislocation of major joints
multiple amputations of digits
amputation of limbs
multiple closed long bone #s

88. GUSTILO ANDERSON CLASSIFICATION FOR
OPEN FRACTURERS
.

89. SECONDARY SURVEY (ATLS)
• Comprises of head to toe examination of the stable
patient.
• Requires:-
– Detailed history
– Thorough examination
– KEEP MONITORING the vital signs
– monitoring devices
-pulse oximeter
-rectal thermometer
• Detailed radiographic procedures
-C.T., USG, M.R.I.

90. SECONDARY SURVEY (ATLS)
HEAD
• Glasgow coma scale
• Reaction and size of pupils
• Plantar response
• Signs of rhinorrhoea,otorrhoea

91. SECONDARY SURVEY (ATLS)
NECK
• Subcut emphysema
• Cervical spine fractures
(specially C1,C2,C7)
• Penetrating neck
injuries

92. SECONDARY SURVEY (ATLS)
THORAX
Search for potentially life threatening injuries
• Pulmonary complication
• Myocardial contusion
• Aortic tear
• Diaphragmatic tear
• Oesophageal tear
• Tracheobronchial tear
• Early thoracotomy if initial
haemorrhage > 1500 ml

93. SECONDARY SURVEY (ATLS)
ABDOMEN
• Fingers and tubes in every orifice
• Nasogastric and Urinary catheter for diagnosis
and treatment
• Rectal examination.
• Wounds coverage
• Eviscerated bowels packed by warm wet
mops

94. SECONDARY SURVEY (ATLS) PELVIS
Clinical assessment
X-ray
stabilize pelvis with fixator/clamps
If urethral injury is suspected—high up prostate in PR
blood in meatus
Trial catheter perineal haematoma
With gentle manipulation
ascending Fine catheter
urethrogram
Lots of lubricants
In OT
suprapubic cystotomy

95. SECONDARY SURVEY (ATLS)
ABDOMEN
For rigid and distended abdomen
• Four quadrant tap
• Diagnostic peritoneal lavage
• Ultrasound E FAST
• Laparoscopic examination
Consider rapid surgical exploration
Any deterioration

96. SECONDARY SURVEY (ATLS)
Spinal injury
Thorough sensory and motor examination
• Prevent further damage in unstable fractures
• Log rolling for full neurological examination-
4 people required
• Use a long spine board for transportation

97. LOG ROLL METHOD
• Turn the patient in ONE
PIECE moving the
spine.Requires 4 persons
1. Maintain in line
immobilisation head and
neck.
2. Shoulder and pelvis.
3. Pelvis and legs.
4. Direct and move the spinal
board.

98. SECONDARY SURVEY (ATLS)
EXTREMITIES
• Full assessment of limbs for assessment of
injury
• Always look for distal pulse & neuro-status
• Carefully look for skin & soft tissue viability
• Look out for impending Compartment
syndrome

99. COMPLICATIONS
• A.R.D.S.
• Fat embolism
• D.I.C.
• Crush syndrome
• Multisystem organ failure (M.S.O.F.)

100. ACUTE RESPIRATORY DISTRESS SYNDROME
• Tachypnoea
• Dyspnoea
• Bilateral infiltrates in C XR
Treated with mechanical ventilation CPAP with
or without PEEP
Glucocorticoids
Inhaled nitric oxide

101. FAT EMBOLISM
• Around 72 hours
• Tachycardia
• Tachypnoea
• Dyspnoea
• Chest pain
• Petechial haemorrhage
Treated with ----- HYDRATION
mechanical ventilation
------anticoagulants
------fixation of fractures

102. DISSEMINATED INTRAVASCULAR COAGULATION
• Follows severe blood loss and sepsis
• Restlessness , confusion,neurological dysfunction,skin
infercation,oligurea
• Excessive bleeding
• Prolonged PT,PTT,TT,hypofibrinogenemia
Treatment– prevention and early correction and shock

103. CRUSH SYNDROME
• When a limb remains compressed for many hours
• Compartment syndrome and further ischaemia
• Cardiac arrest due to metabolic changes in blood
• Renal failure
Treatment
• Prevention-ensure high urine flow during extrication
• IV Crystalloids,Forced mannitol alkaline diuresis
• Fasciotomy and excision of devitalised muscles
• Amputation

104. MULTI-SYSTEMIC ORGAN FAILURE
Progressive and sequential dysfunction of
physiological systems
Hypermetabolic state
It is invariably preceded by a condition known as
Systemic Inflammatory Response Syndrome
(SIRS)
Characterised by two or more of the following
• Temperature >38º C or < 36ºC
• Tachycardia >90 /min
• Respiratory rate >20/min
• WBC count >12,000/cmm or <4,000/cmm

105. Treatment : Key word is PREVENTION
• Prompt stabilisation of fracture
• Treatment of shock
• Prevention of hypoxia
• Excision of all dirty and dead tissue
• Early diagnosis and treatment of infection
• Nutritional support

106. END POINT OF RESUSCITATION
• Stable hemodynamics.
• Stable oxygen saturation.
• Lactate level below 2 mmol per litre.
• No coagulation disturbances.
• Normal temperature.
• Urine output more than 1ml /kg/ hour.
• No requirement of Inotrophic support.

109. ORTHOPAEDIC MANAGEMENT
• Facilitating overall patient care,
• Control bleeding,
• Decreasing additional soft tissue injury,
• Avoiding further activation of the systemic inflammatory
response,
• Removal of DEVITALISED TISSUE,
• Prevention of ischemia / reperfusion injury,
• Pain relief.

110. When do we fix the fracture in the polytrauma
patient?
ETC vs DCO

111. THE 24 -72HR PERIOD AFTER THE INITIAL INJURY
APPEARS TO BE THE MOST AT RISK TIME.
• DAMAGE CONTROL
ORTHOPAEDICS
Decrease the chance of a second hit.
• EARLY TOTAL CARE
Stabilise fracture and bleeding
prior to the 24 - 72 hour high - risk
period.

114. INDICATION FOR EARLY TOTAL CARE
• Stable hemodynamics,
• No need for vasoactive/inotrophic stimulation,
• No hypxemia, no hypercapna,
• Lactate <2mmol/L.
• Normal coagulation,
• Normothermia,
• Urinary output >1mL/kg/h,

115. DAMAGE CONTROL
• The term damage control was
initially described by the US Navy as
the capacity of the ship to absorb
damage and maintain mission
integrity.
• In the polytraumatized patient, this
concept of surgical treatment intends
to control but not to definitively
repair the trauma-induced injuries
early after trauma. After restoration
of normal physiology (core
temperature, coagulation,
hemodynamics,

116. INDICATION FOR “DAMAGE CONTROL” SURGERY
1.PHYSIOLOGIC CRITERIA
–Blunt trauma: hypothermia,
coagulopathy, shock / blood loss, soft
tissue injury = Focus vicious cycles.
–Penetrating trauma : hypothermia
coagulopathy, acidosis = “Lethal
Triad”

117. INDICATION FOR “DAMAGE CONTROL” SURGERY
2.Complex pattern of severe injuries -
expecting major blood loss and a
prolonged reconstructive procedure
in a physiologically unstable patient.

118. DAMAGE CONTROL ORTHOPAEDICS
• Approach to treating polytrauma patients with the goal of
minimising the impact of “SECOND HIT”

119. DAMAGE CONTROL ORTHOPAEDICS
• INITIAL PRIORITIES - COMPONENTS
–Resuscitative surgery for Rapid Hemorrhage control
–Soft tissue management
–Restoration of normal physiologic parameters
–Provisional fracture stabilisation
• Definitive treatment delayed until physiology improved.

120. DAMAGE CONTROL ORTHOPAEDICS
• AN APPROACH THAT
–Contains and stabilises orthopaedic injuries so that patients overall
physiology can improve,
–Avoid worsening of patients condition by major procedure,
• Early rapid fracture stabilisation by external fixation avoiding prolonged
operative times preventing the onset of LETHAL TRIAD.
A. Coagulopathy,
B. Acidosis ,
C. Hypothermia.

121. DAMAGE CONTROL ORTHOPAEDICS
• Definitive open reduction and internal fixation is delayed until
the inflammatory response and the tissue Edema have
decreased and the patient is in stable clinical condition.
• Applied in polytrauma patients with Pelvic and long bone
fractures to avoid the SECOND HIT of an extensive and definitive
procedure and minimise initial morbidity and mortality.

122. DCO -A CURRENT CONCEPT
• STOP ON GOING DAMAGE
–Release compartments,
–Reduce dislocations,
–Deride the open wounds,
–Stabilise long bones/Pelvis,
–Control haemorrhage
–Fluid resuscitation
–CXR - ICD if necessary
–Lateral cervical spine x-ray
–X-ray pelvis AP
–FAST / DPL

123. DCO -A CURRENT CONCEPT
• STABILISE LONG BONES
–Initial early external fixation.
–Early temporary stabilization of unstable fractures and the
control of hemorrhage.

124. DCO -A CURRENT CONCEPT
• STABILISE PHYSIOLOGY
–Resusciataion of the patient in the ICU and optimisation of
their condition.
–Re-evaluate,
–Monitor vitals

125. DCO -A CURRENT CONCEPT
• DEFINITIVE STABILIZATION
–Staged intramedullary fixation,
–Minimal Invasive plate osteosynthesis

126. THE APPLICATION OF DCO IN THE MULTIPLE INJURED PATIENTS

127. DAMAGE CONTROL ORTHOPAEDIC STUDY.
• The practice of delaying definitive surgery in DCO attempts
to reduce the biologic load of surgical trauma on the already
traumatized patient.
• This hypothesis was assessed in a prospective randomized
study by means of measuring pro-inflammatory cytokines.
• Clinically stable patients with an ISS >16 and a femoral shaft
fracture were randomized to ETC (primary intramedullary
nailing of the femur within 24 hours) and DCO (initial
temporary stabilization of the femur with external fixator
and subsequent intramedullary nailing).

128. • A sustained inflammatory response (higher levels of IL-6) was
measured after primary (<24 hours) intramedullary femoral
instrumentation, but not after initial external fixation or after
secondary conversion to an intramedullary implant.
• DCO surgery appears to minimize the additional surgical
impact induced by the acute stabilization of the femur
,conversion of the external fixator to a nail should be done
within the first 2 weeks as this minimizes the risk of developing
deep sepsis.

129. • The sequence of fracture treatment in multiply injured
patients with multifocal injuries to an extremity is a crucial
part of the management concept. Some parts of the body
are prone to pro-gressive soft tissue damage because of
their anatomy.
• Therefore, the recommended sequence of treatment is
– Tibia,
– Femur,
– Pelvis,
– Spine, and
– Upper extremity.

130. MANAGEMENT OF UNILATERAL FRACTURE PATTERNS
In these cases it is recommended that careful
immobilization of diaphyseal fractures is the first
phase of fracture management.
If there are periarticular fractures of the large
joints and urgent open reduction and fixation is
impossible trans-articular external fixation (TEF)
should be performed.
In any case with a concomitant vascular injury or
any evidence of a developing compartment
syndrome, fasciotomies should be undertaken.

131. • In bilateral fractures, simultaneous
treatment is ideal.
• This is particularly true in bilateral
tibial fractures where both legs are
surgically cleaned and draped at
the same time. However, the
operative procedure is performed
sequentially because of the
problems inherent in the use of
fluoroscopy.
MANAGEMENT OF BILATERAL FRACTURE PATTERNS

132. • If the vital signs of the patient
deteriorate during the operation the
second leg may be temporarily
stabilized using an external fixator.
• The defini- tive osteosynthesis then
may be delayed until the general status
of the patient is stabilized again.
• The priorities in the treatment of
bilateral fracture patterns follow the
evaluation of the injury severity with
more severe injuries being treated first.

133. • The management of upper extremity
fractures in multiply injured patients is
usually undertaken secondary to the
treatment of injuries of the head, trunk, or
lower extremity.
• If there is a closed fracture of the upper
extremity without any associated injury,
such as vascular or nerve damage or
compartment syndrome, proximal fractures
of the shoulder girdle, proximal humerus,
and humeral shaft can be stabilized by a
shoulder body bandage.
UPPER EXTREMITY INJURIES

134. • External fixation is an
alternative.
• Primary management of
fractures of the forearm, wrist,
and hand is often with a cast
but temporary external fixation
may be used.

135. PELVIC FRACTURE – AO CLASSIFICATION

137. • type A injuries include stable
fractures such as fractures of
the pelvic rim, avulsion fractures
and undisplaced anterior pelvic
ring fractures. The posterior rim
is not injured at all.
• Treatment
– type A injuries operative
treatment is generally not
required
PELVIS FRACTURE- TYPE A

138. • comprise fractures with only partially intact
posterior structures and rota- tional dislocations
may be possible. Sometimes, this injury may
initially be an internal rotation dislocation
resulting in marked bone compression and
stabilization of the pelvis.
• However these injuries are associated with a high
risk of intra-abdominal dam- age. If the injury
results in an open book type of fracture with both
alae being externally rotated urogenital lesions
and hemor- rhagic complications are much more
common
• Treatment
– type B injuries adequate stabilization is obtained by
osteosynthesis of the ante- rior pelvic ring only.
PELVIS FRACTURE- TYPE B

139. • pelvis shows
translational instability
of the dorsal pelvic ring,
because the stabilizing
structures are all divided.
• Treatment
– Type C injuries require
anterior and posterior
osteosynthesis to gain
adequate stability.
PELVIS FRACTURE- TYPE C

140. • Pelvic injuries associated with any other injury to local
pelvic organs are called complex pelvic injuries.
• These injuries com- prise about 10% of pelvic injuries and
they are associated with a significantly higher mortality of
between 30% and 60% in comparison with simple pelvic
injuries.
• Therapeutic goal is
– intensive shock treatment,
– early stabilization of the pelvic ring, and
– potential operative hemorrhage control and packing rather than
a single treatment option.
COMPLEX PELVIC INJURIES

141. • In general, operative treatment of unstable spine injuries
in multiply injured patients is mandatory,
• Spinal fractures associated with neurologic dysfunction
are usually stabilized at the same time as the spinal cord
is decompressed.
• In multiply injured patients in particular closed reduction
may be difficult because of co-existing extremity injuries.
• In these cases correct axial and rotational alignment
should be obtained intraoperatively.
• If there is interposition of a bone fragment or an
intervertebral disc, open reduction is indicated to avoid
spinal cord compression.
SPINE FRACTURES

142. THANK YOU…..