Polytrauma- Assessment and management
till discharge
(ATLS Recent guideline)
Presenter: Dr. Bokinala Naveen
Moderator: Dr Saurabh Taneja

• Preparation
• Triage
• Primary survey
• Need for patient transfer
• Secondary survey
• Adjuncts
• Continued post resuscitation monitoring and evaluation
• Definitive care

Definition
• The term ‘polytrauma’ was first used by Tscherne et al., in 1966 for
patients that demonstrated a combination of at least 2 ‘severe injuries
of the head, chest or abdomen’, or ‘one of them in association with an
extremity injury’.
• Trentz in 1999 defined Polytrauma is a syndrome of multiple injuries
exceeding a defined severity (Injury Severity Score [ISS] >17) with
sequential systemic reactions that can lead to dysfunction or failure of
remote organs and vital systems, which have not themselves been
directly injured.
• Oestern, Hans-Jörg; Trentz, Otmar; Uranues, Selman (2014). General Trauma Care and Related Aspects || Polytrauma: Pathophysiology, Priorities, and
Management. , 10.1007/978-3-540-88124-7(Chapter 5), 69–76. doi:10.1007/978-3-540-88124-7_5

Injury severity score
Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care.
The Journal of Trauma. 1974 Mar;14(3):187-196. PMID: 4814394.

Trimodal distribution of trauma deaths (ATLS 10th ed)
First Peak
• Within minutes
• Apnea due to TBI or
high spinal cord injury
or rupture of the
heart, aorta or other
large blood vessels.
• Very few of these
patients survive
Second Peak
• Minutes to hours
• Injuries like SDH/EDH,
hemopneumothorax,
ruptured spleen,
lacerations of the
liver, pelvic fractures,
and/or injuries
associated with
significant blood loss.
Third peak
• Days to weeks
• Sepsis and Multiple
organ system
dysfunctions.

Gunst M, Ghaemmaghami V, Gruszecki A, et al. Changing epidemiology of trauma deaths leads to a bimodal
distribution. Proc (Baylor Univ Med Cent), 2010;23(4):349–354

Pre Hospital set up and levels of Trauma centres
• The prehospital set up is to
notify the receiving hospital
before personnel transport
the patient from the scene.
• This allows for mobilization
of the hospital’s trauma team
members so that all
necessary personnel and
resources are present in the
emergency department (ED)
at the time of the patient’s
arrival.
• Scoop and run
• Multiple vs mass casualty

Pre Hospital phase – admit to Level 1 trauma set up
1. GCS <13
2. Systolic BP <90
3. RR <10 or >29 / needs ventilator support
Anatomical injury
1. Penetrating trauma : head, neck, torso and extremities proximal to elbow/knee
2. Flial chest, pelvic fractures
3. 2 or more proximal long bone fractures
4. Proximal amputation (Wrist/Ankle)
5. Crushed, degloved, mangled, pulseless extremity
6. Depressed skull fractures
7. Paralysis

Based on the mechanism of injury & high-energy impact –
Transfer to Level 2 trauma setup
Falls
• Adults > 20 feet or 6 meters (2 stories)
• Children >10 feet or 3 meters (2-3 times the height of child)
High risk motor vehicle crash
• Intrusion, including roof >12 inches from occupant side
• Ejection (partial or complete from the vehicle)
• Death in same passenger compartment
• Vehicle telemetry data consistent with injury
Auto vs pedestrian/bicyclist thrown, run over with significant impact (>32kmph)
Motor cycle crash >32kmph

Special patient or system considerations
Older adults
• Risk of injury/death more in age >55 years
• Systolic BP <110mmHg in age >55 years
• Low impact mechanism (ground-level fall)
Patients on anticoagulation are at high risk for bleed after injury
Children preferably to a pediatric capable trauma center
Burns with trauma to a trauma center or else burns facility
Pregnant >20 weeks

Primary Survey
Rapid examination to identify and treat life threatening conditions
• A – Airway maintenance with C-spine protection
• B – Breathing and ventilation
• C – Circulation with hemorrhage control
• D – Disability and neurological status
• E – Exposure/ Environmental control
10 second assessment : Ask the patient to identify himself, name and
what happened

A-Airway
• Check for airway patency and suction the accumulated secretions/ blood
• Inspect for foreign bodies; identify facial, mandibular, and/or tracheal/laryngeal
fractures causing airway obstruction.
• Hoarseness, subcutaneous emphysema, palpable fracture suggests laryngeal
trauma
• Patients with facial burns and those with potential inhalation injury are at risk for
insidious respiratory compromise.
• For this reason, consider preemptive intubation
in burn patients.

• Patients with severe head injuries who have an altered level of
consciousness or GCS score of 8 or lower usually require the placement
of a definitive cuffed airway
• Initially, the jaw-thrust or chin-lift maneuver often suffices as an initial
intervention.
• If the patient is unconscious and has no gag reflex, the placement of an
oropharyngeal airway can be helpful temporarily.
• Establish a patent airway while restricting cervical spine motion.
• Use Cervical collar when necessary

Canadian C-spine rule
To be more selective in use of radiography in alert and stable
trauma patients.
Design: Prospective cohort study conducted from October 1996 to April
1999, sample of 8924 adults (mean age, 37 years) with blunt trauma to the
head/neck, stable vital signs, and a GCS of 15.
151 patients had (1.7%) had C-spine injury.
The resultant model and final Canadian C-Spine Rule comprises 3 main
questions:
(1) is there any high-risk factor present that mandates radiography
(2) is there any low-risk factor present that allows safe assessment of range
of motion
(3) is the patient able to actively rotate neck 45 degrees to the left and
right?
By cross-validation, this rule had 100% sensitivity (95% confidence interval
[CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying
151 clinically important C-spine injuries. The potential radiography ordering
rate would be 58.2%.
The Canadian C-Spine rule of radiography in alert and stable trauma patients. JAMA
2001;286:1841–1848.

NEXUS STUDY
Cervical-spine radiography does not need to be performed on
selected blunt trauma patients who are awake, alert, non
intoxicated, do not complain of midline neck pain, and have no
tenderness over the bony cervical spine.
• Study population:1000 patients in the UCLA Emergency Medicine
Center with a chief complaint of blunt trauma, for whom cervical-
spine films were ordered and for whom prospective data
questionnaires were completed.
• Results:
• 27 patients with cervical-spine fracture were among the 974
patients. All 27 patients with fracture had at least one of the
following four characteristics: midline neck tenderness, evidence of
intoxication, altered level of alertness, or a severely painful injury
elsewhere. Three hundred fifty-three of 947 (37.3%) patients without
cervical-spine fracture had none of these findings.
• Conclusion: Cervical-spine radiology may not be necessary in
patients without spinous tenderness in the neck, intoxication,
altered level of alertness, or other severely painful injury.
Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine eadiography in blunt trauma: a prospective study. Ann Emerg Med. 1992
Dec;21(12):1454- 60

Burns
• Risk for upper airway obstruction increases with burn size and depth, burns to the head and
face, inhalation injury, associated trauma, and burns inside the mouth causing edema and pose
a greater risk for airway compromise
• Pharyngeal thermal injuries can produce marked upper airway edema, and early protection of
the airway is critical.
• The clinical manifestations of inhalation injury may be subtle and frequently do not appear in
the first 24 hours.
• If the provider waits for x-ray evidence of pulmonary injury or changes in blood gas
determinations, airway edema can preclude intubation, and a surgical airway may be required.

• Examine the patient’s oropharynx for signs of inflammation, mucosal injury, soot in
the pharynx, and edema, taking care not to injure the area further.
• A carboxyhemoglobin level greater than 10% in a patient who was involved in a fire
also suggests inhalation injury.
• Transfer to a burn center is indicated for patients suspected of experiencing
inhalation injury; however, if the transport time is prolonged, intubate the patient
before transport.
• Circumferential burns of the neck can lead to swelling of the tissues around the
airway; therefore, early intubation is also indicated for full thickness circumferential
neck burns

American Burn Life Support (ABLS) indications for early intubation include:
• Signs of airway obstruction (hoarseness, stridor, accessory respiratory muscle use,
sternal retraction)
• Extent of the burn (total body surface area burn > 40%–50%)
• Extensive and deep facial burns
• Burns inside the mouth
• Significant edema or risk for edema
• Difficulty swallowing
• Signs of respiratory compromise: inability to clear secretions, respiratory fatigue, poor
oxygenation or ventilation
• Decreased level of consciousness where airway protective reflexes are impaired
• Anticipated patient transfer of large burn with airway issue without qualified personnel to
intubate en route

Breathing
Look
• Rate and depth of
respiration
• See for engorged neck
veins
• Tracheal deviation
• U/L and B/L chest
movements
• Use of accessory muscles
Listen
• Chest bilaterally
• Hoarseness
• Dysphonia
Feel
• Chest for dullness
(hemothorax) or hyper-
resonance(pneumothorax)
• Crepitus(Emphysema)
• Deformity

Tension pneumothorax
• Tension pneumothorax develops when a “one-way valve” air leak
occurs from the lung or through the chest Wall.
• Air is forced into the pleural space with no means of escape,
eventually collapsing the affected lung.
• Chest pain, Air hunger, Tachypnea, Respiratory distress,
Tachycardia, Hypotension, Tracheal deviation away from the side
of the injury, Unilateral absence of breath sounds, Elevated
hemithorax without respiratory movement, Neck vein distention
Cyanosis (late manifestation)

• The mediastinum is displaced to the opposite side,
decreasing venous return and compressing the
opposite lung.
• Shock results from marked decrease in venous return,
causing a reduction in cardiac output
• A simple pneumothorax can be converted to a tension
pneumothorax when a patient is intubated and
positive pressure ventilation is provided before
decompressing the pneumothorax with a chest tube.
• Needle decompression (5th ICS anterior to MAL)
converts tension pneumothorax to a simple
pneumothorax and ICD to be placed as early as
possible
• Tension pneumothorax can be managed initially
by rapidly applying the finger decompression
technique.

Flail chest
• When a segment of the chest wall does not have bony continuity with the rest of the thoracic cage.
• This condition usually results from trauma associated with multiple rib fractures (i.e., 2 or more
adjacent ribs fractured in 2 or more places), although it can also occur when there is a costochondral
separation of a single rib from the thorax
• Decreased respiratory effort, combined with contusion and atelectasis, may limit movement of the
chest wall
• Definitive treatment is oxygen therapy, adequate ventilation, and cautious fluid resuscitation.
• Analgesia with IV narcotics or local anesthetic administration
• Options for administering local anesthetics include intermittent intercostal nerve block(s) and
transcutaneous intrapleural, extrapleural, or epidural anesthesia.

Open Pneumothorax
• Large injuries to the chest wall that remain open results in an open
pneumothorax(sucking chest wound).
• Equilibration between intrathoracic pressure and atmospheric
pressure is immediate.
• Air tends to follow the path of least resistance, when the opening in
the chest wall is approximately two-thirds the diameter of the
trachea or greater, air passes preferentially through the chest wall
defect with each inspiration.
• Effective ventilation is impaired, leading to hypoxia and hypercarbia.
• The clinical signs and symptoms are pain, difficulty breathing,
tachypnea, decreased breath sounds on the affected side, and noisy
movement of air through the chest wall injury.

• Close the defect with a sterile dressing large enough to overlap the
wound’s edges.
• Any occlusive dressing (e.g. plastic wrap or petrolatum gauze) may
be used as temporary measure to enable rapid assessment to
continue.
• Tape it securely on only three sides to provide a flutter-valve effect
• As the patient breathes in, the dressing occludes the wound,
preventing air from entering. During exhalation, the open end of
the dressing allows air to escape from the pleural space.
• Taping all four edges of the dressing can cause air to accumulate in
the thoracic cavity, resulting in a tension pneumothorax unless a
chest tube is in place.
• Place a chest tube remote from the wound as soon as possible.
Subsequent definitive surgical closure of the wound is frequently
required.

Circulation- Shock
• Any injured patient who is cool to the touch and is tachycardic should be
considered to be in shock until proven otherwise
• Identify the probable cause of shock and adjust treatment accordingly
• Check peripheral pulses, heart rate, BP, pulse pressure, capillary refill, cyanosis
• Most injured patients have hypovolemic shock due to blood loss
• Shock may be either hemorrhagic or non hemorrhagic
• 2 large bore peripheral IV’s (at least 18 gauge) and control bleeding

Focused Assessment with Sonography for Trauma
(FAST & eFAST)

Look for blood : 4 places other than floor
A. The chest
B. The abdomen
C. The pelvis and retroperitoneum
D. Major long bones and soft tissues.
• C
• B
• D`2

Hemorrhagic shock
• Hemorrhage is the most common cause of shock in trauma patients.
• The trauma patient’s response to blood loss is made more complex by fluid shifts among
the fluid compartments in the body, particularly in the extracellular fluid compartment.
• Soft tissue injury, even without severe hemorrhage, can result in shifts of fluid to the
extracellular compartment.
• The response to blood loss must be considered in the context of these fluid shifts. Also
consider the changes associated with severe, prolonged shock and the pathophysiologic
results of resuscitation and reperfusion.
Hemorr hagic Shock

Initial Resuscitation

Cardiogenic Shock
• Cardiac injury, cardiac tamponade, an air embolus, or, rarely, myocardial infarction may cause
• Suspect a blunt cardiac injury when the mechanism of injury to the thorax involves rapid
deceleration.
• All patients with blunt thoracic trauma need continuous electrocardiographic (ECG)
monitoring to detect injury patterns and dysrhythmias.
• The shock state may be secondary to myocardial infarction in the elderly and other high-risk
patients, such as those with cocaine intoxication.
• Cardiac enzyme levels may assist in diagnosing and treating injured patients in the
emergency department (ED), as acute myocardial ischemia may be the precipitating event.

Cardiac Tamponade
• Cardiac tamponade is most commonly encountered in penetrating thoracic trauma, it can also result
from blunt injury to the thorax.
• Tachycardia, muffled heart sounds, and dilated, engorged neck veins with hypotension and insufficient
response to fluid therapy suggest cardiac tamponade –becks traid (Dilated RA, RV)
• Absence of these classic findings does not exclude.
• Tension pneumothorax can mimic cardiac tamponade, with findings of distended neck veins and
hypotension in both. However, absent breath sounds and hyper-resonant percussion are not present
with tamponade.
• Echocardiography can be used , FAST to identify pericardial fluid,
• Cardiac tamponade is best managed by formal
operative intervention, as pericardiocentesis is
at best only a temporizing maneuver
• Tension pneumothorax

Neurogenic Shock
• Isolated intracranial injuries do not cause shock unless the brainstem is injured.
• Cervical and upper thoracic spinal cord injuries can produce hypotension due to loss of
sympathetic tone
• The classic presentation of neurogenic shock is hypotension without tachycardia or
cutaneous vasoconstriction.
• A narrowed pulse pressure is not seen in neurogenic shock.
• The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation
suggests either continuing hemorrhage or neurogenic shock.
• Advanced techniques for monitoring intravascular volume status and cardiac output may
be helpful in managing this complex problem

Massive transfusion
1. Replacement of one entire blood volume within 24 h
2. Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h
3. Transfusion of >20 units of PRBCs in 24 h
4. Transfusion of >4 units of PRBCs in 1 h when on-going need is foreseeable
5. Replacement of 50% of total blood volume (TBV) within 3 h.
Definitions of MBT suggested for use in children are
• Transfusion of >50% TBV in 3 h,
• Transfusion >100% TBV in 24 h or transfusion support to replace on-going blood
loss of >10% TBV/min
Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian journal of anaesthesia. 2014 Sep;58(5):590.

Criteria to trigger the activation of an MTP should include one or more of the following:
 Persistent hemodynamic instability
 Active bleeding requiring operation or angioembolization
 Blood transfusion in the trauma bay
If MTP triggers are met:
• Begin universal blood product infusion rather than crystalloid orcolloid solutions.
• Transfuse universal RBC and plasma in a ratio between 1:1 and 1:2 (plasmato RBC).
• Transfuse one single donor apheresisor random donor platelet pool for each six units of RBC.
• Blood products should be automatically sent by the transfusionservice in established ratios.
• Subsequent coolers should be delivered at 15-minute intervals until the MTP has been terminated.
• The goal is to keep at least one MTPcooler ahead for the duration of the MTP activation.
ACS TQIP MASSIVE TRANSFUSIONIN TRAUMA GUIDELINES

Endpoints of Transfusion
 The ratio-driven massive transfusion may be discontinued or downgraded to goal-directed transfusion
based on the laboratory findings if surgical bleeding has been controlled by the surgeon in the
operating room OR there is radiographic and physiologicevidence of bleeding control after
angioembolization.
 The MTP should be discontinued when there is recognition that further resuscitation is futile.
 The following should be used as guides to cease therapy with blood and blood components in a
patientwho is not actively bleeding and still in the acute resuscitation phase
 RBC transfusions for hemoglobin ≥10 g/dL
 Plasma transfusion for prothrombin time (PT) <18 seconds
 Plasma transfusion for activated partial thromboplastin time (aPTT) <35 seconds
 Platelet transfusions for platelet count >1.5 lac/ml
 Cryoprecipitate or fibrinogen concentrate for fibrinogen level >180 mg/dL
ACS TQIP MASSIVE TRANSFUSIONIN TRAUMA GUIDELINES

• If standard thrombelastography (TEG®) is available, the following cut-
points for transfusion triggers may also be used:
• Plasma for r-value >9 minutes
• Plasma and/or cryoprecipitate (fibrinogen concentrate) for k-time >4
minutes
• Cryoprecipitate (or fibrinogen concentrate) and/or plasm for α-angle
<60 degrees
• Platelets for mA <55 mm
• Anti-fibrinolytics for LY30 >7.5 %
ACS TQIP MASSIVE TRANSFUSIONIN TRAUMA GUIDELINES

If rapid TEG is available, the following cut-points for
transfusion triggers may also be used:
• Plasma for ACT >128 seconds
• Plasma and/or cryoprecipitate (fibrinogen concentrate) for k-
time >2.5 minutes
• Cryoprecipitate (fibrinogen concentrate) and/or plasma for α-
angle <60 degrees
• Platelets for mA <55 mm
• Antifibrinolytics for LY30 >3 %

Disability
• Level of consciousness, pupillary size and
reaction, lateralizing signs and spinal cord
injury level ( ability to move all extremities)
• Glasco Coma Scale
• Careful in head injury patients
Exposure
• Completely undress the patient and inspect the
entire patient from head to toe both front and
back
• Maintain spinal precautions during logrolling
• Inspect both axilla and perineum
• Warm blankets.

Secondary survey
• The secondary survey does not begin until the primary survey (ABCDE) is completed,
resuscitative efforts are underway, and improvement of the patient’s vital functions has
been demonstrated
• Complete history and physical examination
• Reassessment of all vital signs
AMPLE History
Allergies
Medications
Past medical history (LMP, transfusions)
Last meal
Events leading up to trauma

Physical examination
• Stepwise, organized
• Every patient, the same way, every time
• Superior to inferior; proximal to distal
• Look--Listen—Feel
 Neurologic
 Head
 Maxillofacial
 Cervical spine and neck
 Chest
 Abdomen
 Perineum/rectum/vagina
 Musculoskeletal

ADJUNCTS TO SECONDARY SURVEY
X ray examination
• Haemothorax or simple pneumothorax.
• Spine fractures
• Rib, Sternum, and Scapular Fractures
• Limb fractures
• Suspected of having smoke inhalation injury
• Appearance of an elevated right diaphragm on
a chest x-ray may be the only finding of a right-
sided injury.

CT Brain
• To rule out head injury

CT scans of head, chest, abdomen and spine
Contrast angiography
• Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal
bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or
penetrating trauma
• Abdominal CT scan with IV contrast can document the presence and extent of a blunt
renal injury
• Suspected urinary system injuries are best evaluated by CECT. Intravenous pyelogram
(IVP) provides an alternative
• Some fractures traverse the carotid canals and can damage the carotid arteries
(dissection, pseudoaneurysm, or thrombosis.
• For detecting fractures of the posterior elements (pedicles, lamina, and spinous
processes) and determining the degree of canal compromise caused by burst fractures.
• CT angiography may be used to evaluate extremity vascular injuries
• Do not perform CT scanning if it delays the transfer of a patient to a higher level of care.

Bronchoscopy
• Tracheobronchial injury is a fatal condition
• The majority of tracheobronchial tree injuries occur within 1 inch (2.54 cm)
of the carina.
• High mortality rate from associated injuries, inadequate airway, or
development of a tension pneumothorax or tension pneumopericardium
• Patients typically present with hemoptysis, cervical subcutaneous
emphysema, tension pneumothorax, and/or cyanosis
• Smoke inhalation is a potential cause of airway obstruction from
particulate and chemical injury.
Esophagoscopy for suspected Oesophageal tear/ injury

Course of stay
Evaluate and manage
• DVT
• Infections
• Surgical management
• Nutritional management
• Pain relief
• Long term rehabilitation

New recommendations
Initial assessment Restriction to only 1 L of crystalloid fluid during initial assessment.
Airway & ventilation Drug-assisted intubation has now replaced rapid sequence intubation (RSI).
Video laryngoscopy highlighted as useful.
Shock Early use of blood products advocated.
Tranexamic acid is now recommended within 3 hours.
Thoracic trauma Flail chest replaced by tracheobronchial tree injury as a life-threatening injury.
5
th
ICS for needle thoracocentesis in adults
Modified FAST recommended for identification of pneumothorax.
Traumatic circulatory arrest algorithm (thoracotomy/pericardiotomy if no ROSC)
Chest size tube smaller 28-32F (previously 36-40F)
Abdominal & pelvic trauma Prostate examination no longer recommended as part of the evaluation.
Preperitoneal pelvic packing included in hemorrhage protocol.

Head trauma Anticoagulation reversal table is now included in the guidance.
Revised version of the GCS introduced.
Spine & spinal cord trauma CCR and NEXUS guidelines are now recommended.
“Spinal immobilisation” has been replaced with “spinal motion restriction.”
Prolonged backboard usage (>2 hours) should be avoided.
Musculoskeletal trauma The use of a tourniquet to control severe extremity bleeding is now recommended.
Antibiotics dosing regimens for open fractures introduced. Use weight based regimen
Thermal injuries New fluid resuscitation formula (2 ml/kg/%TBSA)
Paediatric trauma The PECARN traumatic brain injury algorithm now recommended.
(CT head- LOC >5sec, abnormal behavior, scalp hematoma, vomiting, headache)
Geriatric trauma Lower threshold for imaging in the elderly population is now recommended.
High-risk pre-existing conditions highlighted.(Cirrhosis, Coagulopathy, COPD, IHD, DM)
Trauma in pregnancy Vaginal fluid pH greater than 4.5 is an indicator of amniotic fluid leakage.
Transfer to definitive care CT scans should now be avoided in the primary hospital.
SBAR communication tool now recommended.

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